Bennelong Society Conference 2004:
Pathways and Policies for Indigenous Futures

Problems Faced by Remote Aboriginal Communities in the Western Desert

James Back

[The following information is drawn from a thesis paper I recently submitted to the University of Western Australia. It is presented as a practical demonstration of the problems (health) intervention strategies and programs face when working within remote communities, as discussed at the recent Bennelong Conference in Sydney. This paper highlights the changes required by all people working within these communities, from the people themselves to the many organisations and departments that filter through these communities. Should you wish to discuss any of this information I can be contacted by phone (08) 99388 0077 or mail to james@edge.org.au / james@paliya.org]

I was originally introduced to the people of the Western Desert to explore the sustainability and effectiveness of a healthy lifestyle community intervention program for the prevention of Type II diabetes and other lifestyle related diseases in a remote Western Australian Aboriginal Community.

The morbidity and mortality rates for Aboriginal Australians are significantly higher than for all other Australians (Australian Bureau of Statistics, 1999 Deaths, Australia, cat. No. 3302.0). Aboriginal Australians demonstrate higher rates of smoking, hypertension, obesity, sedentary lifestyles and poorer diet and nutritional patterns than do all other Australians (Rosenberg & Lawrence, 2000). These five lifestyle factors contribute significantly to the risk of developing Type II diabetes, which is reported to have an incidence rate of greater than 30% in many remote Aboriginal communities (The Australian Institute of Health and Welfare & the National Heart Foundation of Australia, 1999).

It has been suggested that loss of traditional lifestyle and the rapid adoption of a Western lifestyle has contributed significantly to high rates of these risk factors (Braun et al. (1996), Gault et al. (1996) and the World Health Organisation (1994)). Further to this, living in a harsh and remote environment limits access to, and increases the cost of fresh fruit and vegetables within a community (Australian Medical Association, 1998). Low levels of Western education and little exposure to purposeful and productive work opportunities and roles, and poor health among community leaders, limits their capacity to work in the community's best interest. Recent research has demonstrated that more needs to be done to address this disparity from 'other' Australians (Rosenberg & Lawrence, (2000), Brownson et al., (1999)).

There is very limited available research that explores Aboriginal health from a holistic cultural perspective (defined by the Martu as healthy body, land and spirit) and few programs apply wide intervention strategies to impact the environmental, physical and mental health of the people of a remote Aboriginal community. There are only a few studies that have targeted specific components of remote Aboriginal community life and that have achieved significant gains in community health for the duration of the study. Based on this, future research and program development in this field needs to reflect the findings of these studies and embrace the proven methods of best practice. My study explored how effective different health adjusting strategies were and what the barriers to these strategies were.

Initially, the intervention was aimed at an individual level and focused on a registered cohort of 14 high-risk or diagnosed Type II diabetic individual from a community of 180 people (of which 54 (30%) are suspected by the Aboriginal Medical Service of having Type II diabetes) compared with a matched cohort from a neighbouring community. After three months, it became evident that a number of modifications were necessary to address the limitations and complications imposed by the location and logistics of the remote Aboriginal community and the resources available to the Program.

Anticipated Limitations of the Study

1. Participants have a transient culture and had been living in a Western styled community for only 21 years prior to this Program being implemented, thus were unaccustomed to the necessary management and lifestyle requirements of such.
2. Variables beyond the researcher's control may have influenced results, eg monopolies of supply in terms of resources and labour available to the Community.
3. Many of the participants could not provide traditional Western personal details such as date of birth, and familial links to disease.
4. Cultural activities could restrict access to the Program at certain times of the year.

Delimitations of the Study

1. Participants all belonged to the Martuwanka people, whose land is defined by the boundaries of the Western Desert.
2. A commitment from the Martu elders and leaders was made to endorse the Program and promote the achievement of the Program's outcomes prior to the implementation of the Program.

The primary focus of the study subsequently became the promotion of healthy lifestyles to those present in the Community. This second intervention comprised exercise opportunities, healthy lifestyle workshops and presentations, food preparation and presentation workshops, reorganisation of work-practices, cleaning of the store, and finally, structural changes within the Community to enable people to pursue a wider range of sport, exercise and leisure pursuits and to make healthy lifestyle choices. Further, the Program identified logistical strategies that enhanced the health of the Community and its population and then recommended changes to existing policies within the Community that do not facilitate good health. These interventions were actively managed for a period of 17 months before the Program was handed over to support staff and senior RAWA Community School students.

Thus the Program evolved to assess the barriers and issues faced by health practitioners when working in a remote Aboriginal community. The Program was extended to target all Community members to change their lifestyle behaviours to healthier alternatives by addressing appropriate structural factors that have a direct impact on the health of the Community and its population.

The impact of this intervention was evaluated in a number of ways. Interviews of support staff and high school students within the Community and chair-people of the Western Desert communities were collected at the Program's formal completion. Further, participation rates, knowledge retention rates, applied behavioural changes, minutes from Environmental Health Committee Meetings and results from a health and lifestyle audit were analysed to assess the impact the healthy lifestyle intervention had on the Community members.

Assessment of these results indicated that commitment from elders within the Community towards Program strategies and outcomes was low. Further, it was found that groups operative within the Community were not working towards a common Community-defined outcome, but all had individual and distinct agendas. The thesis explored how health, education and employment within the Community were often hampered by separate groups in the pursuit of their own agendas, thus limiting the viability of the Community itself and decreasing the quality of life of its members.

Community control and ownership, along with the direct support and assistance this intervention received from RAWA Community School were fundamental to changes in the health and well-being of community members. Financial support and the provision of services in kind from outside parties enhanced the scope and magnitude of the Program.

$30,000 were allocated to implement this healthy lifestyle intervention in a remote Aboriginal community for a 17 month duration. Any further resources and assistance were sought from local mine-sites in the region on a need-to basis.

A lack of resources to monitor and implement the Program among the transient participants substantially lessened the impact of the Program. Strategies were developed to make the Program more culturally holistic for the Martu, by addressing the components of their definition of health; those being the land, body and spirit. A number of significant parties within the Community made these strategies less effective by not supporting the Program, due to different organisational agendas, the political intricacies of which are beyond the scope of this article.

The strategies varied in effectiveness dependent upon the involvement of other community based organisations and how they were perceived to be contributing to the Community by the Martu themselves. Education can impact the knowledge, skills and attitudes of people, however if people are not then given the opportunity to support these new attributes then the recently acquired knowledge, attitude and skills are rapidly made redundant. For example, a number of workshops were conducted teaching people the benefits of eating more fruit and vegetables and the store implemented a subsidy to offset the financial burden of these goods but failed to order the fruit and vegetables to the people. The significance of the workshop messages were hampered by the lack of support demonstrated by the store as people could not practise their new behaviours.

The strategies that had the greatest impact on behavioural change were those that were marketed to, and participated in by only Martu participants. Developing sound relationships with other working parties in the Community, based on common outcomes was a slow, drawn out process as each seemed to demonstrate some degree of practised territorialism. I put forward two main reasons for this; firstly, there are too many agencies and government departments trying to work within the Community and those that are operating on a permanent basis in the Community can spend too much time in the ensuing bureaucracy than in delivering a service, and secondly so many programs are 'delivered' in the Community over such varied duration and with such diverse aims and outcomes that again the local working groups are guarded in their alliances.

However, I found that those strategies that utilised the staff and resources of the Community School had a greater impact on increasing participation rates. Given the limited resources of the project, it was an essential requirement to access the School and maintain a strong working relationship with them. Promoting health as a main topic within the curriculum framework, around which the School developed literacy and numeracy, was a significant key to the gains in health knowledge among the students and Aboriginal Education Workers about those issues pertinent to the Community.

With the hard won support of the Aboriginal Medical Service, the nurse was able to endorse the health messages promoted through the Program to participants, further enhancing their impact.

To illustrate my comment of too many cooks..... During a recent 24 day stint in the desert I observed 17 different departments or companies fly in/out of the Community in which I was located, each with some degree of overlap with one or more of the other groups.

In brief, a more co-ordinated and defined approach to what happens within each community must be initiated and managed by appropriate Aboriginal people within that community. I believe there is enormous scope to amalgamate many of the services that currently work within these communities to be not only more cost effective but also to minimise what is often seen by the local people as superfluous and fleeting visits . I propose further research should be done on exploring effective models of servicing remote communities. In my experience, data concerning servicing agency visits is neither managed nor reported to any peak organisation or government body and thus is lost in bureaucracy. Department representatives need to strategically communicate with each other to minimise the impact this has on the target community yet maximise the outcomes from all departments to ensure services and facilities are being delivered and utilised by the people they have been promised to .

In view of the above information, it is highly recommended that future programs should address the following criteria/areas:

1. Defining all the pertinent terms of reference in the study to establish the target Aboriginal groups interpretation of ;
   • community
   • commitment
   • active participation in community programs
   • health and pertinent health issues/afflictions
   • education and acceptable levels of education
   • cultural barriers
   • other barriers to Program strategies
2. Establish at the outset what outcomes the Community Representatives want to achieve, we as service providers need to sit back and observe, to listen and do things the 'blackfella way'---we need to collaborate further, more effectively with our target groups. This is not a redundant concept, it is simply one that has not been mastered effectively by the mainstream community.
3. Determine which strategies, from a community perspective, will be most effective towards achieving the stated outcomes
4. A commitment from the elders to manage change and participation in the arenas of health, education and employment
5. An accountable commitment from the people to actively participate in the program. with incentives and disincentives that promote recognition of existence within a broader Australian community, whilst holding strong their minority group status. Better management of the financial remuneration of remote living people may be a key to aligning the behaviour of this group of people more closely to that expected of main stream Australians, I refer specifically to payments for participation in CDEP and Education, and further the baby bonus scheme.
6. Alignment of goals and outcomes from each of the organisations/corporations working within the Community to achieve common Community objectives and fundamental gains in health, education and employment to bring these closer to the levels of mainstream Australians.

This short intervention does have its limitations, primarily that many of the Martu people from the Community lack the skills necessary to develop, implement and run such a health intervention program. This was partially addressed at the conclusion of the Program, by the provision of an extended training and hand-over of the responsibility and management of various strategies and projects to the support staff and the responsible volunteer high school students. The staff that took on these roles have been in the Community for significant periods of time, though will invariably leave the Community at some point. Furthermore, neither will the students always be in the Community, due to the inherent transient nature of their culture, thus the viability of such a Program is fundamentally flawed.

The people carrying on the Program, have maintained links with outside parties, who have endorsed their support for the Program through the continuation of services. As such, the University of Western Australia students have been able to continue practicum placements in the Community and provide workshops and health and fitness sessions with the people for up to 16 weeks each year. Furthermore, other service providers introduced to the Community, through the Program, continue to visit and conduct workshops within the Community, while the School carries on nutritional education, training and physical education sessions and opportunities for all Community members.

The Community Chairperson reported to the Environmental Health Committee on 27 June 2002 that "we need help with our vision. Our people need to show interest. Old people with vision have died and current leaders have no vision---we need to help our kids." He continued, "older people need to accept responsibility and give the kids a good future." Sadly, he does not demonstrate this in practise, as can be articulated in the following example:

At the completion of this meeting, the Chairperson committed to discuss these comments with the Martu elders within the Western Desert Region, at a regional council meeting being held the following day. He committed to report back to the Environmental Health Committee at a meeting proposed for 3 September 2002. At this meeting, the Chairperson conceded to not following through with this commitment of discussion with other Martu elders about what a good future is defined as for young people, and was resistant to discussing it any further. Thus I feel Martu leaders need to establish and adhere to realistic and defined health, education and employment boundaries within their communities and actively demonstrate they are committed to achieving these. This is a well worn track---but the broader Australian Community must now action incentives and disincentives towards participation and commitment to improved health, education and employment levels If specific minority groups over a demonstrated period of time cannot identify with or contribute to the broader Australian Community then should their eligibility to such community services not be questioned?

Given that the rates of morbidity and mortality are substantially higher across all age groups for Aboriginal Australians than that of other Australians, Aboriginal health will remain at the fore of contemporary social inequity debate. Health practitioners should now have the capacity to adopt methods of best practice, based on sound research over the past 15 to 20 years within this field. Bureaucrats need to now address how the fundamental problems that diminish a program's impact can be minimised at the community level. A firm commitment towards social reform, through the establishment of purposeful roles and a developed sense of ownership over tangible items that perform functional work in these modelled Western communities is vital if gains are to be made in health, education and employment for many remotely-based Aboriginal people.

Through my experience, I firmly believe the establishment of strong links with the people and with the organisations working within the Community is essential to ensure a successful intervention. Further, establishing a common Community vision amongst all parties is integral to achieving sustainable health gains amongst the people living a remote Aboriginal community. The foundation for this type of change is firmly entrenched in the holistic belief by which Aboriginal people view and value their health. That being, a healthy body, spirit and land, as defined by the Martu people themselves. A firm, voluntary commitment to the objectives and outcomes of a (healthy lifestyle) program needs to be demonstrated by those involved in the Program.

Programs such as this healthy lifestyle intervention are required to continue and certainly effect changes at a Community level addressing the social inequity faced by Aboriginal and non-Aboriginals living in remote regions. The limitations of such programs are readily identified and should be communicated to all parties if they are to achieve afore stated outcomes. However, there must be a ground swell of change, initiated by the people themselves to address the fundamental community flaws that are widespread in remote communities before substantial gains will be observed in health, education and employment.

Programs servicing remote communities need to begin addressing the social, cultural and economic complications remote Aboriginal inhabitants face at a community level and further, with individuals integration when in local towns. As such, these programs should be directed towards developing pre-employment skills coupled with a commitment to embrace mainstream standards of literacy, numeracy and health and hygiene. Government must give serious consideration to many misdirected tertiary programs being funded when the basic infrastructure existing within these communities exists purely at a superficial level with no capacity to sustain the intended impact of these programs. An example of this is Telstra's commitment to have all phones in regional and remote areas repaired within 48 to 72 hours after they have been reported damaged, regardless of the frequency or nature of this damage. Such charters, and Telstra are not isolated in this example, firmly endorse costly, anti-social vandalism as I witnessed on numerous occasions. Primary intervention programs need to be promoted and developed at a local level to explore meaningful employment for each working age Aboriginal individual inhabiting a remote community, to give them greater control over their environment; translating to better health and hygiene and substantial gains in the autonomy and sustainability of remote communities, whilst further, making a contribution to the broader Australian community.