On being familiar

Familiarity breeds contempt.  Did you learn that at school as well?  I don’t reckon it’s true.  Back in Wadeye for the third time has been wonderful.  Feeling that everything isn’t strange, understanding a bit of the system, it’s all good.  But the best is when a local say’s “You’re back”, with a bit of a grin.

The house is familiar – the light that doesn’t come on straight away, the louvre that doesn’t close properly and the rush to get the dishes done before the water drains out.  We had patients to see as soon as we arrived.  On the first day, a lady rushed into my consulting room.  She had a big smile, and told me about her family.  The fact that she wanted to sell me a painting didn’t really detract.  It is good to be back.

Probably the most enthusiastic about us being here is the Culiocoides family – better known as the midges or sandflies.  They have celebrated in style...

This is a bit representative, and I'm not going to reveal all.  You could make a loud sympathetic sigh at this point.  But it's got me thinking.  I'm more of less used to it now, and that helps me understand some issues of health care here.

I've been wondering what happens to people who live here all the time.  The locals live with midges, scabies, nasty bacteria and the rest.  That's life.  Why would you go to the clinic with skin sores.  They're a part of life that won't go away.  It hasn't occurred to me to see someone about my itches.  But they're not really that bad, and I have some idea of what can be done and what can't.  

The hardest part of our first week is feeling that there is reasonably good provision of health care but terrible implementation.  Bad skin infections have made diabetes control out of control, back aches have caused misery and poor mobility.  We have cleverly given medicines and even packed them in dosette boxes.  We have documented the ways we are dealing with the problems.  But only to find at the end of the week that the medicines are untouched and the problems are worse.

Today I gave some antibiotics to a family member of a child who was bitten by a dog.  I explained how to give them.  She then asked me what they were for.  I had made all sorts of assumptions.  People do want to understand, and I am understanding slowly that unless I can engage at that point, there is a lot of wasted energy.

There are some good things going on here.  We have heard an estimate of 650 people with jobs - not bad in a community of 3,000+.  Education provision seems more flexible and relevant.  There's a good feeling in town.  It may be that it's bush holiday time, but I think there is more.  I just wish for a health care system owned and operated by locals.

Wadeye 2013

We are in Wadeye for a 5 week placement. It's good to be back - it feels like coming home! I appreciate many things about this place: the bush, the birds, natural beauty. It's good to renew connections with people too. There are many familiar faces, and some remember us.
There's a cardiology clinic this coming Tuesday (tomorrow), and I was again given some responsibility for checking people with RHD - rheumatic heart disease, now so rare in mainstream medicine, but so devastating to people here.  RHD is one of the symbols of  "The Gap" which needs to be closed.  It's a disease resulting from many infections over a long time, and episodes of acute rheumatic fever where the heart is damaged. Patients diagnosed with this condition need to have a monthly injection of long acting penicillin, to prevent further attacks.  Some seem to understand, and have their injections monthly. Many avoid the injections, and I wonder why this is, when so much is at stake.  I wonder if "we" have failed in the process of communicating what it's all about.  On Tuesday, Felicity, the RHD support nurse, will be here from Darwin. I hope there's time to talk with her about these issues.
One of the factors is the turnover of the team - so patients often have a new nurse to get to know. There are only 2 nurses here now, who were here last year. They were also here the year before - so this is some continuity, at least.  One of them works as a midwife in antenatal care, the other is now managing the chronic disease program and networking with other agencies working here. A big job.
And the team is about to turn over again - in 2 weeks one will be back from leave (oh yes, she was here last year), but everyone else will be new.
Apart from catching up with people with RHD, I have a long list of people with chronic disease who are overdue GP checks.  So I have plenty to do!  And not enough time to do it in!  We're here for 5 weeks, which is really just a drop in the ocean.  We'd like to make a difference here, even if it's in the lives of a few people, rather than impressive results.
On another note, the swimming pool is open from 7-8am for laps.  Work starts at 8, so it's a bit of a scramble, but I've been enjoying a morning swim.

snippets

While out doing home visits: young children in the family were playing with a hairless joey they'd had since the day before.  Leanne, a RAN (remote area nurse), took it to the rangers, while I waited with Rosemary, a RAN back here to be the chronic disease coordinator.  It may be too young to survive, but the family had no bottle or syringe.

Rosemary knows the community well, and it's great she's back.  She and Kirsty, another RAN, have been coming for many years.  The team is about to change dramatically, as at least 5 RANs are leaving withing a few weeks.  Continuity is so important here, but so hard to maintain.

The fruit and veggie shop didn't open on Tuesday (the day the fresh supplies come in) - "not enough staff"

Last Friday (27th July) was a public holiday for Royal Darwin Show day.  We weren't required to work, so we drove to Daly River.  Some of you may have been there.  We stayed in a caravan park right on the river.  We'd arranged to meet up with Nick & Rosie & family - they were on their way to Broome.  We had a great time catching up with them, and we also caught 2 freshwater sharks! Enough to feed us all.  Daly River is on the road to Wadeye.  So we came from the west, and the others came in from the east.  


We brought a sprouting coconut back from Daly River, hoping it might grow in the garden.


Going out of the clinic one night after work, we met a lady.  She told us that her husband had passed away a few months ago, and she felt lonely, so she would pray.  She said she was the designer and printer of the material I'd bought from the women's centre, and the money from the sale would help her when she goes to Darwin for an operation.  It was good to sit and chat.


Not a drop of rain during our time in Wadeye!  We're back in cold Victoria now, having left yesterday.  I'd hoped we'd have time on our last day to be a bit relaxed, saying goodbyes etc.  But it was a busy medical day, starting off with a really sick baby who Tim was involved with,  intraosseous fluid resuscitation and then transfer (a similarly acidotic child had died in the clinic a few weeks back, before we arrived).  Then in the afternoon, I helped organise the transfer of two patients with serious infections, one a wound on his foot, that had been discharging for months, the other probably had a foreign body in his foot.  All the plane seats were taken, it being another long weekend (NT Picnic Day this time) so a special charter came for them.


We've been thinking about The Invervention, and Stronger Futures..  those thoughts are not quick snippets!  The issues are not simple, and we see many aspects to it all.  Hopefully the subject of another post.


As the call came over the clinic PA, "The car is ready to go to the airport," we gathered with the staff.  One of the RANs is a Zulu.  She got us to hold hands, and she sang the 23rd Psalm.  It was very moving, and a lovely send off.  We're sad to leave.  We feel that we've been able to build on last year's experience, and also continue some relationships.  We hope to be back some time! 


It's great to be home now, despite the temperature.  It's special to see family again (what lovely smiles Isabel gave us, and what fun with Georgi!).  We have a week before starting back at work here.

RHD

RHD... Rheumatic Heart Disease.  I've been given the job of reviewing these patients, in preparation for the cardiologist's visit in October.  Many of you (those a bit older - say no more) will remember rheumatic fever, and how it can affect the heart.  It's not common in mainstream medicine, but is a reality here, as people have many streptococcal infections and some develop rheumatic  fever.  They then require a monthly injection of long acting penicillin, to prevent recurrences which may make the heart effects worse.  The team here have found that it's sometimes easier for them to go out and see the people in their homes.

Reviewing the patients has pushed me out of the comfort of the ivory-tower clinic.  I've taken the nurses' maps of the community and driven round the streets, stopping at the relevant houses and asking if the person is there, then sitting on the verandah or the tiled floor inside, and doing a check up.  I've found people generally helpful and welcoming, and I've had some good times with them.  Sometimes I've needed to go back to a home several times before I connect with the person concerned.  I've realised that people have their English name, that we know them by, and they also have a name in their language,  that they call each other by.  They all know the English names as well.  It's another example of how much the people need to know, in order to work within systems that are so white-mainstream-western.

Anyway, we leave on Friday, and I'm not sure I'll have seen everyone I need to.  That's chronic disease - the work goes on and doesn't finish.  I'll be able to leave a list for Dr Simon to follow up.  It's good to know that he's here 3 days a week, working with chronic disease patients.  This week, Rosemary came back.  She's been coming for 10 years.  She's come back to be the chronic disease coordinator.

Meanwhile, Tim has been working on the acute side.  Hopefully he'll write something!

Hope?

I've just finished reading "Listening to Country" by Ros Moriarty. I highly recommend it! I found it inspiring and very moving. I wonder, is there hope?

Briefly:
Ros is a white woman who married John Moriarty, a man from Borroloola, who was stolen from his family, and reconnected much later. She describes the journey of connection with family, traditional Law and culture, and what it means that the young people haven't wanted to embrace the traditions. She describes richness of family life in the midst of poverty and the gradual but inexorable breakdown of culture. Interwoven with this story is the story of their family life and their business, Balarinji, now an international design agency, with well known Indigenous designs - the painted Qantas planes, for example.

As a newcomer here in Wadeye, a different community, I can only guess how the principles apply here. But - it does seem that traditional culture isn't strong in the town here.

I'm struggling to see how Indigenous cultures can flourish and progress in the context of white/mainstream/dominant culture, which sets the agendas and the rules. Is it possible for these two cultures to live side by side with mutual respect, and openness to the other?

Is it too late to undo the damage of European settlement and takeover?

Andy sent us a link to an article suggesting that we, the white community, need to become powerless, in order to make a difference, to allow Indigenous people to develop appropriate community programs.

http://blog.whywarriors.com.au/2012/letting-go-of-our-power/

It makes interesting reading. Is this a hopeful way forward? To trust Indigenous leadership enough, and to take a supportive role?

Ros Moriarty says, "Talk is cheap and words and symbolic gestures, while vital to the effort, will ring true only when we write a new Australian story that is scripted for John's family as well as mine. Pragmatism and empathy in balance might begin to turn the tide."

In the meantime, we are here in Wadeye, doing a medical job as part of a clinic team. I hope that as we go about it, we communicate respect - and I hope we empower people in their health. That's our goal in mainstream Leongatha medicine! It's not always easy there! So spare us a thought, and write them down!

When is obsessional, well...obsessional?

Like Joy said, it's good to be back.  I'd forgotten the dogs though!  They don't sleep, and sometimes it seems that no-one else does as well...  They really do howl when there is a full moon.  Despite them,  we are feeling like this is home for this brief time and are very happy here.

The dogs remind me about "Jack".  He was the first indigenous patient I met last time we were here.  He sticks in my mind - a big, broad, healthy looking man with a bad cough.  We arranged for him to be checked in Darwin.  Sadly, his chest XRay showed a nasty cancer.  I asked about him this time.  Apparently his health declined quickly.  Back for a while in Darwin, but no useful treatment available. The staff told me with some emotion about his return.  He was loaded in Darwin onto the Careflight plane unconscious for his trip home and palliative care.  The plane landed at dusk.  A few minutes later, there were people everywhere waiting respectfully, some quiet, some crying.  No-one quite understood how everyone knew to come.  Somehow they just did, as if they had a sense that he was coming home.  And even his dogs and a lot of other dogs came and sat on the tarmac while he was unloaded. Even though he wasn't responsive, a nurse said "Jack, welcome home".  To her amazement, tears ran down his face.  Five hours later he passed away.

Not all the stories are sad.  It has been wonderful to be able to talk and laugh with local people we remember from last year.

The first morning we were late to work.  Only 3 minutes, but the 8 am team meeting was well underway.  Oops!  That and a myriad of daily events highlights to us the challenges of running a health service here.  Rigidity about rules concerning time in a cultural context that sees time very differently is tricky.  Sometimes it feels that the more local people seem relaxed about the clock, the more white people live by it.  But not just time.  Our program is vast and complex.  There are numerous health plans, care plans, review checks, consultant recalls, and complex audits of them all.

Overlying that is Medicare.  Our health system was not designed with the Northern Territory in mind.  I guess that makes sense.  Only 200,000 people live here.  While my brain is barely coping with what care plan to do when, I have to remember whether the medicare number is a 715, 732, plus a 23 or 36 plus a 10991 incentive item, or perhaps a 721 or 723 bearing in mind that the last 2 can only be done once in 12 months, the 715 once in 9 months, or it could be a 703 or a 705, plus a number relating to other services given.

Last time, we commented on the lack of Indigenous Health Practitioners.  That hasn't changed.  Maybe we should scrap the clinic and have a yarn with people under the nearby gumtree.  Would that change our impact?  We certainly wouldn't be able to get the care plans done!  Is it realistic to expect local people to come to work at 7.55am, sit in an office and share the consultation with a patient and a computer screen?

Having said all that, I'm sure we are helping.  I met a teenager this week who talked about his family.  His cousin plays football at an elite level in Darwin.  He's pretty proud of him.  This bloke can't do that.  He had rheumatic fever when he was 10, and already has significant heart problems.  He inspired us to want to do all that we could to prevent this sort of disease.  And there are lots of good things happening.  Some great strategies for health, good care of people of all ages, and really caring people doing it.  It has to be worthwhile...  But maybe being obsessional isn't always the answer.

A CareFlight arriving to take someone to Darwin for treatment

Back in Wadeye

We've been here a week. It's good to be back: so much is familiar. We're earlier in the season this time, and some of the gums are flowering, stunning orange blossoms. Little corellas screech and nip off the buds. It's been cooler overnight - rather nice. (but it's all relative)

We have 5 weeks here this time. It was great to have a week in NT before starting - we hired s campervan and enjoyed Litchfield National Park & Berry Springs, especially the chance to join with Tim's brother Nick and his family for Nick's 40th. Jerry came up as well. What a great time! Nick & Rosie looked after us really well, and how their 4 have grown! It was special to renew connections. Josh is into fishing, Matt is always seeing birds before anyone else and knows what they are! Zach loves crocodiles (not quite sure why), and Abbey makes friends wherever she goes.

So back to Wadeye. Some of the staff are the same, and also we new ones to meet. The team seem to be working well together, and morale is good. Saturday night we cheered for the clinic at a basketball game, Clinic vs Police - clinic lost, but tried hard! We had a BBQ together afterwards.

There are still no indigenous health workers, and I miss the opportunities this would bring: help with understanding people's issues, and help in explaining medical concepts of disease and treatment. This is important in all our work at the clinic, and I'm very aware of it - I'm working in chronic disease again this year, and I often feel the lack of communication skills. Part of it is basic language difficulties, but I know there's more to it. I'm still not sure how to "do" chronic disease, especially as I'm so short term. I feel humbled when people share their lives with me - it feels like an unexpected gift.

It's good to be back. We hope our being here is worthwhile for team and community. We appreciate the opportunity to slow down a bit in the work context, even though there are busy patches. We appreciate the working day finishing earlier, and evenings without the usual demands of home. We appreciate the beauty of the bush around us. We had a great walk on the beach at sunset last night, with some others from here.

So we will post!

the dry season burn