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5 Case Study – Indigenous Life in Australia

5 Case Study – Indigenous Life in Australia

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house indigenous peoples who may have lost land, become sick or suffered from

violence were at times overcrowded and unhygienic, and efforts to dress indigenous

people in European clothes in situations where water for washing was scarce could

promote infections (Mitchell 2007). In government compounds and reserves residents complained of head lice, bedbugs and fleas and suffered epidemics of infectious disease (Mitchell 2007). Claims were made that thousands of indigenous

Australians died on government reserves from hunger and cold (Mitchell 2007).

Research on living conditions of indigenous Australians in cattle stations in the

1940s found that medical care was in short supply. A view of the dominant white

population was that it was a waste to spend resources on treating sick indigenous

workers and most hospitals in rural Australia refused to accept indigenous patients

(Mitchell 2007). For some conditions the treatment was in effect imprisonment. Up

until 1955 in the Northern Territory those suffering from leprosy could be transported in neck-chains to leprosaria for permanent incarceration (Mitchell 2007).

Overt and covert forms of discrimination are ongoing experiences for indigenous

Australians. In the 1960s in one New South Wales town indigenous Australians

were banned from the local public swimming pool because of prejudicial concerns

that the children would spread syphilis and gonorrhoea and that the men would

ejaculate in the pool and so impregnate white women (Mitchell 2007). The level of

active discrimination against indigenous Australians was apparent in legislation.

The Australian constitution of 1901 included clauses that stated that laws of the

Parliament would apply to people of any race, with the exception of the indigenes

as special laws would apply to them, and that indigenous people would not be

counted in any Commonwealth or State census. Indigenous Australians were then

not considered as citizens in their own country (Anderson 2007a). This led to the

situation where indigenous Australians were not able to access Commonwealth

social welfare provisions available to other Australians including old age pensions,

maternity allowance, unemployment and sickness benefits (Walter and Mooney

2007). This form of legislative discrimination relating to social welfare survived in

some form until 1966 (Anderson 2007a).

In Western Australia a 1944 act granted citizenship to indigenous peoples if they

abandoned “their family and cultural connections” and lived like Europeans

(Mitchell 2007, 51). Even if indigenous Australians conformed to this standard they

were not eligible if they suffered from particular health conditions, including leprosy and syphilis (Mitchell 2007).

Negative impacts on the health of indigenous Australians continued throughout

the twentieth and twenty-first centuries. As discussed in Chap. 3, poor health outcomes are strongly associated with poverty, and in 2002 the household income of

indigenous Australians was 59 % of non-indigenous households (Walter and Saggers

2007). But even a good income is less protective for indigenous Australians:

whereas a higher level of personal income is associated with higher self-assessed

health ratings for non-indigenous Australians this is not the case with indigenous

Australians for whom the ratings across different income levels remain about the

same (Walter and Saggers 2007).



5.6 Maintaining Disparities



57



It has been argued that differences in socio-economic status explains up to half

the gap in self-rated health status between indigenous and non-indigenous

Australians (Walter and Mooney 2007). Indigenous Australians are more likely to

live in poor housing conditions, especially in remote areas where 20 % of the population are in overcrowded households, and far fewer indigenous Australians own

their own homes compared to other Australians (Bailie 2007). Nearly a quarter of

all homeless people in Australia are indigenous Australians (Muthu and Grzeszczyk

2011).

Indigenous Australians are also disadvantaged in the education system – another

determinant of health. Most of the land legally owned by indigenous Australians is

in remote areas and few students may have access to secondary schools in these

locations. Participation of indigenous Australians in tertiary education has been low

and even declined in the 2000s (Dunbar and Scrimgeour 2007). Western forms of

education have further disempowered indigenous Australians and had a negative

impact on their social and emotional well-being through devaluing their language

and culture (Dunbar and Scrimgeour 2007).

Paternalistic responses from government to poor indigenous health outcomes

and health-deleterious environments have continued. For example, in 2004 an indigenous community group in Western Australia signed an agreement with the

Australian government under its affirmative action policy where, in order to secure

funds for petrol dispensers, the community agreed to such things as ensuring that

their children would wash their faces twice a day, rubbish bins would be emptied,

that houses would be kept clean and rates would be paid (Baum 2007).



5.6



Maintaining Disparities



In Chap. 3 the relationship between poverty, social class and health outcomes was

discussed. Higher proportions of indigenous peoples live in poverty and social

deprivation than the descendents of settlers and colonizers. This class difference has

a major impact upon health outcomes. But economic differences alone do not

account for differences in mortality rates between ethnic groups (Tobias et al. 2009).

Indigenous peoples have been forced into the market economy through displacement from traditional sources of food as their land has been altered or taken in the

name of economic development (Lambert and Wenzel 2008). In this context, diseases of poverty have been called diseases of colonization and racism as the experience and consequences of poverty are different for indigenes and settlers (Robson

2008). For example, an indigenous person in poverty is likely to be exposed to

poverty for longer, have fewer assets, have less choice in relation to housing, be

more likely to come under the surveillance of the police, and so on (Robson 2008).

Anderson (Anderson 2007b) argues that the assumptions underlying social epidemiological explanations of unequal health outcomes need to be critically assessed

for their relevance to indigenous peoples. For example, the centrality of work in

health outcomes argued by Marmot and colleagues as a result of the Whitehall



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Studies, noted in Chap. 3, may not apply for communities where labour force participation is low and extended families may play a more significant role in sociality.

Anderson (Anderson 2007b) also notes that more research attention should be paid

to the reproduction of disadvantage across generations. Historical trauma theory has

been used by indigenous scholars to critically reflect on the history and impacts of

colonization across time. This theory originally developed in relation to holocaust

survivors and survivors of Second World War Japanese concentration camps

(Pihama et al. 2014). Historical trauma theory emphasizes the intergenerational

impact of trauma that promote dysfunctional behaviors like substance abuse and

interpersonal violence. Historical trauma has been defined by Lakota scholar Maria

Yellow Horse Brave Heart as “cumulative emotional and psychological wounding,

over the lifespan and across generations, emanating from massive group trauma

experiences” (cited in Pihama et al. 2014, 251). It is argued that this wounding can

result from a number of mechanisms, including an identification with the suffering

of deceased ancestors and unresolved grief for the loss of land and kin (Pihama

et al. 2014). A challenge from this perspective is to introduce new diagnostic categories into psychological classification systems that point to the distal causes of

dysfunctional behavior, for example, “acute and chronic reaction to colonialism”

(Duran and Duran cited in Pihama et al. 2014).

Gaps in life expectancy between indigenous groups and settler groups change

over time with the example of New Zealand being illustrative. Variation can be

explained by significant social and political changes, like shifts of populations from

rural to urban areas, the impact of economic restructuring and how it differentially

impacts on indigenous and non-indigenous groups, and so on. For example, between

the 1940s and 1960s the differences in mortality rates between Māori and other New

Zealanders decreased sharply. This was a period in which there was increasing

investment in public services (Woodward and Kawachi 2000). It was also a period

in which income inequalities in New Zealand diminished (Howden-Chapman

1999). The improvements in Māori health status relative to that of other New

Zealanders did not continue. As a result of neoliberal economic reforms of the mid1980s incomes for Māori declined in relation to those of other New Zealanders

(Brown 1999). The reforms had a worse effect on Māori than other groups.

Traditionally Māori have been found to concentrate in manual occupations such as

meat works jobs and process work in factories, and these manual jobs were negatively affected by the impact of the economic reforms. The loss of income from the

changing nature of work arrangements and increasing unemployment in New

Zealand in turn led to increased chances of Māori dying from premature death,

particularly for the middle-age group.



5.7 Evolving Health Initiatives



5.7



59



Evolving Health Initiatives



Settler societies have responded in different ways to indigenous health and indigenous health practices over time. Settlers and colonizers could actively suppress or

discourage the health practices of indigenous peoples. In New Zealand a Tohunga

Suppression Act of 1907 restricted the rights of Māori to go to a traditional Māori

healer, the Tohunga. Tohunga were specialists in health care practices, and with the

passing of the Act they could be imprisoned if they continued to practice (Belgrave

1985). The Act was established, in part, to direct Māori towards Western systems of

treatment. This was despite the fact that most Māori were living in rural areas with

very poor access to Western medical facilities, and that hospital boards were reluctant to admit Māori patients (Lange 1999). The Act was not repealed until 1962.

This led to the loss of indigenous systems of knowledge in a range of areas, including childbirth practices (Kenney 2011). In other countries cultural traditions were

banned for health reasons. In Canada ceremonial gatherings like the potlatch and

the sun dance were at one time banned for fear of spreading tuberculosis (Kelm

2010).

Conversely, indigenous health practices could be taken up by the colonists.

Native American medicine had a variety of techniques to combat injury and disease,

such as splints for broken bones and moss to stop bleeding, and a number of herbal

remedies were taken into the European pharmacopeia, including ginseng, ipecac

and sassafras (Breslaw 2012).

In more recent times measures have been taken by health authorities in an effort

to empower indigenous groups. During the interwar years, public health interventions in rural areas of Europe and the Americas supported indigenous development

(Murard 2008). Since the 1970s there has been increasing interest in drawing on

indigenous health understandings to respond to health problems in the indigenous

community, with a particular flourishing of healing and spiritual practices in drug

and alcohol treatment programmes in Canada and the United States (Brady 1995).

This can broadly be positioned within a process of cultural revitalization amongst

first nations’ peoples. For example, the high rates of alcohol-related illness and

death amongst indigenous populations in North America and Australia have led to

a restoration of healing practices which are grounded in the view that substance

abuse is at least partially an outcome of cultural disruption, or a result of a rejection

of the “culture of the colonizers” (Brady 1995, 1487).

Developments in North America have been taken up by other indigenous peoples, such as indigenous Australians, although the Australian government was far

more reticent in embracing such moves than the Canadian government (Brady

1995). Concerns have been raised that the way that the concept of culture that has

been used in treatment programmes equates more with the idea of an authentic traditional past frozen in time, and that as such this constrains and narrows the options

for the social practices of indigenous people (Brady 1995). That is, culture has been

viewed as something static that needs to be recovered as opposed to something that

is dynamic and constantly evolving.



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Traditional healing practices and therapeutic regimes unsurprisingly differed

across different first nations and indigenous peoples. In Australia healing practices

were usually private matters commonly involving the “removal of foreign objects

and alien forces from a person” (Bell cited in Brady 1995, 1494) or land-based

approaches such as going ‘out bush’. By contrast in North America therapeutic

practices could take the shape of group events and there are differences between, for

example, indigenous peoples of the North American plains and sub-Arctic huntergatherers (Brady 1995). But through cross-fertilization between different First

Nations and indigenous groups there have developed syntheses and hybrid practices

in therapeutic approaches, that may also include Western elements (Brady 1995).

Programs can combine elements of First Nations and Western systems, such as the

process used by Alcoholics Anonymous and Native American sweat lodges, through

to systems based entirely on the medico-religious systems of First Nations (Brady

1995).

Some research has demonstrated the positive impact of enculturation on health

indicators. Enculturation has been described as “a process of learning about, identifying with, and practicing one’s traditional culture” (Bersamin et al. 2013, 257).

Bersamin and colleagues (2013) explore how Alaskan natives, with higher levels of

enculturation or traditionality, identified by such items as whether they spoke their

native language, used traditional medicines and engaged in spiritual practices, had

higher rates of physical activity than other Alaskan natives. The Yup’ik people were

the focus of this study and they have a tradition of physical activity that includes an

emphasis on walking and hunting. Those with higher levels of physical activity had

lower body fat measures. Findings in North America that the HIV/AIDS epidemic

has been slow to affect the aboriginal population has led to suggestions that stronger

American Indian identity could be a protective factor in some way, such as the

engagement in community activities decreasing other risk behaviors associated with

HIV/AIDS such as alcohol use (Kelm 2010).

There is however a danger in homogenising the experience and outcomes of

indigenous peoples. To illustrate, traditional Kānaka Maoli in Hawai’i, who strongly

identify with their ethnic group, are significantly more likely to have a diagnosis of

diabetes than integrated Kānaka Maoli, who identify with the mainstream culture

(Kaholokula et al. 2009). Similarly traditional Kānaka Maoli youth are more likely

to attempt suicide. A possible explanation for this is the higher levels of cultural

conflict and racism that traditional Kānaka Maoli may experience leading to these

poorer health outcomes (Kaholokula et al. 2009).

Efforts have also been made to involve indigenous peoples in the management of

health service provision so that indigenous peoples have a more influential role in

decision making processes and the implementation of decisions (Kelaher et al.

2014). Community involvement in governing bodies has been linked to improvements in health equity (Kelaher et al. 2014). For example, Aboriginal communitycontrolled health services have provided care to Aboriginal communities in remote

areas and the slowing down of mortality rates from diabetes and ischaemic heart

disease has in part been attributed to their work (Lau et al. 2012).



5.7 Evolving Health Initiatives



61



But the level of involvement of indigenous peoples in the management of health

services can change with the political currents. The Aboriginal and Torres Strait

Islander Commission, established in 1989 by the Australian Federal Government to

improve the conditions of the communities of indigenous Australians in cooperation with elected leaders of Aboriginal communities, was seen as a step towards

self-determination. It was abolished in 2004 and replaced with a government

appointed council (Muthu and Grzeszczyk 2011). Then again in 2008 a “Closing

the Gap in Indigenous Health Outcomes” agreement was made by the Council of

Australian Governments to address the life expectancy gap between Aboriginal and

other Australians. A major plank in this agreement was for government to work

with Aboriginal communities to overcome health inequities (Kelaher et al. 2014).

Māori health models have been developed in New Zealand with common components including a focus on self-determination, a focus on Māori collective structures such as whānau (roughly commensurate with family), hapū (a subtribe) and

iwi (a tribe), promoting Māori identity and promoting social justice (Boulton et al.

2011). Since the 1990s in New Zealand many Māori health provider organizations

have developed that have incorporated Māori principles of health practice – known

as hauora. Examples of how Māori principles could work in practice can be seen in

patients attending a youth alcohol and drug rehabilitation service taking the main

part in discussions with agencies auditing the service. This was an expression of

rights to self-determination, that was promoted in those young people using the

service (Chant 2011).

An attempt over many years to respond to some of the concerns raised in relation

to indigenous people’s access and use of health care services is to promote cultural

competence programmes in the education of health professionals. The goal of cultural competence programmes is to acknowledge the cultural and social influences

on the consultation between the health professional and the patient and to consider

or devise ways that takes these influences into accounts so as to facilitate better

patient outcomes (Paul et al. 2012). Paul and colleagues argue that to perceive oneself as culturally competent is in fact an indication of cultural incompetence. They

argue this on the basis that such a view assumes that complex historical and social

processes that are constituted under the term culture cannot be reduced to a specific

learnt technical skill (Paul et al. 2012). ‘Having competence’ suggests an achieved

endpoint, as opposed to an ongoing process of learning and reflection. The concept

of cultural competence has also been criticised for essentializing cultural differences, as opposed to promoting connections between peoples. This is not to abandon the goals of understanding in positive ways, but signals the complexity of

interactions between peoples (Paul et al. 2012).



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5.8



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The Health of Indigenous Communities



Conclusion



The history of colonization and its effects shows how devastating this process was

on the health of indigenous peoples throughout the world. Hundreds of years later

the effects of colonization are on-going. In addition to the experience of racism and

stigma that may be felt by anyone who is not part of the majority group, indigenous

peoples have faced the extensive loss of land and attempts to eliminate their culture.

In more contemporary times efforts have been made to try to redress some of the

wrongs of the past, which in the health sector has meant a process of experimentation with the revitalisation of indigenous health practices and modes of delivery and

some effort to recognize the role that indigenous peoples should play in the management and oversight of health services that are targeted at them. These are ongoing

developments and will no doubt continue to ebb and flow on the basis of political

circumstances and social policy developments.



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Chapter 6



Institutions of Health Care



Abstract The organization of health care institutions is not one of stability, but of

constant change. It varies over time and from country to country. This chapter

explores the development of the hospital and primary care in the community through

a range of examples. A case study of how care for the elderly is provided in China

is developed. The chapter addresses debates around the price and cost of health

services, evidence-based medicine, rationing debates and accountability, and concludes that the international trend of rationalizing our institutions of health care may

lead to greater efficiency or a more equitable distribution of services; however, it

may also give rise to debates around humanitarian ethics and our sense of moral

justice.

Keywords Hospitals • Primary care • Complementary and alternative medicine •

Medical training • Heroic medicine • Clinical gaze • China • Health rationing •

Evidence-based medicine • Quality assurance



6.1



Introduction



The organization of health care institutions is not one of stability, but of constant

change. This chapter focuses on the development of the hospital and primary care

sectors and efforts that have been developed to control growing expenditure on

health services and to ensure the quality of services. Although there are a variety of

ways of funding hospital and primary care services and differences across countries

in the mix of public and private provision of services, there are some commonalities

in the influences on health care delivery. One commonality is the requirement to

ration services, which in turn has provided an impetus to determining what types of

treatment are effective and to standardize the delivery of health care practices.



© Springer International Publishing Switzerland 2016

K. Dew et al., Social, Political and Cultural Dimensions of Health,

DOI 10.1007/978-3-319-31508-9_6



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6.2



6 Institutions of Health Care



Hospitals



The hospital is in many ways the centrepiece of the health system. Hospitals are

viewed as the pinnacle of scientific achievement in medicine, and they attract the

most spending on health care (Mooney 2009). Hospitals also perform a cultural or

social function in that they powerfully represent the specialisation of knowledge

and the reliance on sophisticated medical technology. They foster a philosophy of

intervention that pervades other sites in the health care sector (Davis 1981).

Hospitals did not always have this status. It was not until the nineteenth century

that hospitals became doctor-centered (Granshaw 1989b). Medieval hospitals were

often founded by churches and served the charitable and other functions of churches,

and could be leprosariums or almshouses. Inhabitants led a semi-monastic life with

the sick cared for by lay people or servants and an emphasis on “bed rest, warmth,

cleanliness, and an adequate diet” (Carlin 1989: 31). In the late 1700s attempts were

made to distance the hospital from the almshouse, with the term ‘infirmary’ being

used to denote newly established voluntary hospitals. Philanthropy of the propertied

classes increasingly replaced church charity as funders of these institutions (Porter

1989). Historian Roy Porter (1989: 152) argues that in these early stages of capitalism the infirmary “threw a cloak of charity over the bones of poverty and naked

oppression”.

In the United States prior to the early twentieth century hospitals were places for

people who had no one to care for them – “the homeless, paupers, travelers, seamen

in a strange port, unmarried pregnant women” (Breslaw 2012: 180). Specific curing

institutions, such as The Pennsylvania Hospital in Philadelphia, started to appear in

the late 1700s, but prior to this few Americans would have seen a hospital (Rosenberg

1987). An impetus for the founding of hospitals in America was to distinguish

between the undeserving poor – who would be confined to the almshouses, and the

worthy poor whom philanthropists were willing to support (Rosenberg 1987). In

addition hospitals could act as institutions of medical training and so keep American

physicians from having to travel to overseas destinations such as Edinburgh and

London to further their education. Another bonus was that the skills learnt in hospitals where the wards were filled with the worthy poor were transferable and would

benefit the wealthy who would be attended by physicians in their homes (Rosenberg

1987).

From the eighteenth century hospitals increasingly came to be used as centers of

medical training, laboratories of medical research and then as an institution of healing (Seidler 1989). The medical profession itself took on a greater role in establishing medical institutions (Granshaw 1989a). Hospitals added to the prestige of

clinicians and provided opportunities for them to enhance their clinical skills

(Breslaw 2012). Medical practitioners could also gain teaching monopolies through

hospitals. Consultants received large incomes from teaching and from the ability to

establish private practices as a result of reputations gained at the teaching hospitals.

Consultants also gained a monopoly over access to research facilities (Waddington

1977). Those who occupied hospital posts came into contact with the philanthropists



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5 Case Study – Indigenous Life in Australia

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