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Saturday, 19 October 2013

2 The role of traditional medicine practice in primary health care within Aboriginal Australia

Established primary health care clinics

Clinics offering TMP alone or in combination with biomedicine

The Office of Aboriginal and Torres Strait Islander Health (OATSIH) report on provision of health-care services in 2010–2011 includes traditional healing and bush medicine service provision [9]. Questionnaires were distributed to all participating Aboriginal and Torres Strait Islander biomedical health services that receive funding from OATSIH for provision of primary health care. Nearly 100% of services responded. The results showed that in the year 2010–2011 the percentage of health clinics that offered services of traditional healers was 19.7% and that of bush medicine 12.4%. This compares with previous years – 2009–2010 at 14.8% and 9.9% and 2008–2009 at 17.9% and 10% respectively, showing a slight increase in the 2010–2011 periods. Therefore statistically within government funded established primary health care clinics in Aboriginal Australia roughly one fifth offer traditional healers and one tenth offer bush medicines as part of the healthcare service. There is however a lack of detail within the report surrounding this service provision. Details such as how often these services were provided, when, why and how they were provided with respect to biomedical healthcare and if these service provisions resulted in employment within the health service were not reported. Clearly more descriptive analysis is required to gain better understanding of TMP in PHC.
Apart from the OATSIH report, no formal studies were found for the use of TMP within PHC clinics in Australia. However there were written anecdotal reports from Aboriginal health workers and nurses employed within select health clinics for the storage and use of bush medicines, and sometimes THs, within the clinic [10,11]. These anecdotal accounts of TM use were all based in the Northern Territory and describe that bush medicine plays a role in the ‘treatment of medical, surgical and spiritual ailments’ [10], for ‘infected sores and scabies’ [12], that ‘bush medicines were kept at the back of the clinic’ [11] and that bush medicines plants have been established in the front of the health centre and that ‘soon we (Yolngu) will be using it with the western medicines’…‘working together with ‘balanda” (non-Aboriginal people) [13]. Observation of a TH visiting to the clinic (i.e. not resident) to heal a girl successfully with fits was also made by one author [11]. These anecdotal accounts give us little information regarding the extent of use or the reasons for use of TM, and are unreliable as sources of current practice as all three accounts were written 9 years or more ago.
The Akeyulerre Healing Centre in Alice Springs offers stand-alone TMP (THs and bush medicines) in a culturally safe place where traditional knowledge and practices can be shared and practiced. An Australian Broadcasting Network (ABC) interview conducted with an ethnobotanist researching the use of bush medicines and a local elder women discussed the use of specific bush medicines made by local community people provided at the centre [14]. It was explained that many people in the local community, as well as visitors from other communities, come to get the bush medicines for a range of ailments such as colds and flus, sore muscles, wounds, headaches and skin rashes, and that the elders are passing on this knowledge to young people, and that (bush medicines’ have ‘always been used’ While this interview may tell us that bush medicines are being widely used, qualitative and quantitative data was not investigated to understand the ‘why’, ‘how’, and ‘when’ of TMP.
Similar to Alice Springs local elder women in the Western Australian Kutjungka community Balgo Hills (Wirrimanu) have formed the Palyalatju Maparna Health Committee which provides bush medicines to the local biomedical health clinic at Balgo, the local community and surrounding communities [15]. The elder woman who was interviewed for Indigenous newslines, describes that
the beauty of bush medicine is it makes us feel good, and it feels good using our own ways to make community strong’, and
blackfellas and whitefellas come and tell us, ‘Im feeling better from your bush medicine, can I get some more?’
The article describes that bush medicine is used on its own or in combination with modern medicine and types of ailments that it is used for include headaches, diabetes and wounds to name but a few. In April 2011 the funding was ceased and the committee dissolved [16]a. The incorporation of the Palyalatju Maparna Health Committee could be seen to play an important role in the community for access to bush medicines for primary health care. Whilst further research is justified in assessing this role both qualitatively and quantitatively the article does give us an indication that the provision of bush medicines by local women elders improved TMP for the Balgo community.
Not yet published a pilot study is under way to assess the combination of use of THs and biomedicine with a two-phase qualitative project in Queensland, after studies of Diabetes Type 2 in four regional/rural Aboriginal communities found that a number of patients still utilised traditional healing practices [17].

Clinics offering only biomedicine

A qualitative survey by way of a questionnaire was developed in Aurukun Health clinic, Cape York Peninsula in far North Queensland, to determine the extent of use of bush medicines by clients of the health service and for what types of illnesses medicines were used for [18]. Permission for the survey was gained from the Queensland Health Ethics committee and the survey was conducted and filled in by clinic staff due to low literacy levels of clients. As a consequence the survey did not go well and no understanding of bush medicine use was gained as a result. The set up of this survey could be seen to fail on several levels – identification of some of these reasons has been made by reviewers of the research project [18]. Cross-cultural communication, cultural sensitivities for sharing of knowledge and re-enforcing of negative colonialist experiences through the research process were reasons identified. This highlights difficulties in qualitative field research, and the need for sound cultural understanding and putting time into the design of research and building trust relationships with community before attempting research.

Primary health care in the household or community

Traditional healers (THs)

The Ngaanyatjarra Pitjantjatjara Yankunytjatjara (NPY) Women’s Council Aboriginal Corporation employs traditional healers as part of the services offered by the organisation. The ‘Ngangkari program’ offers health and mental health outreach services within NPY lands which covers about 25 communities in the tri-state area of NT, SA and WA [19]. Both a book has been published about these traditional healers, or Ngangkari [20], and an interview was recorded on ABC which examined the role of the THs [19]. It is reported that Ngangkari work hand in hand with the mainstream health services both in primary and tertiary health care and are recognised by the mainstream medical doctors, working alongside and in co-operation with them. From the report of one TH, the role of the TH is in combination with biomedical care;
Often a doctor will say, ‘listen, weve got this sick child here, could you give this child a treatment and after youve done a treatment well give it appropriate medicine’…theres a lot of cooperation these days and respect.”
The sequence of these events is noted. First line, the patient is seeing the ‘western’ doctor. This doctor then refers to the TH for a treatment who then refers back to the western doctor for pharmaceutical medicine (rather than traditional herbal medicine). No information is given surrounding this process that informs the reader of the extent of this practice, such as was it the western doctor who felt that the patient would benefit from the TH, is this process used on every patient or was it at the patients request? What we can determine from this account is that there is mutual respect between the western doctor and TH in this situation. As one TH states [20];
‘..today it is recognised that a ngangkari is a doctor too. Doctor, ngangkari. Ngangkari, doctor. Same thing.’
An ethnographic account of THs in the Kutjungka region of North Western Australia by observation of artistic description of healing practices was made by McCoy [21]. The account sought to understand by way of this observation as well as conversation with community members about health behaviour (after their permission was sought). The THs of this region are known as ‘Maparn’, that is ‘men or women who respond to people’s sickness using a traditionalist model of diagnosis and healing’. Observational reports stated that many people visit the Maparn first, especially if they consider their sickness to be serious, and that sometimes Maparn will visit the clinic, especially if a family member requests their presence. An account of a young man in his twenties who used services of both the Maparn and the health clinic concurrently was described – the young man would visit the Maparn in the morning and the clinic in the afternoon. The availability of Maparn may affect the role that TM plays – in some communities Maparn have passed on and in others they have given up their practice, which means that Maparn from other communities will need to travel. Although this type of research provides detailed and accurate description, it does lack objectivity and does not give us a reliable indication to the extent that Maparn are incorporated in health behaviour of the community, for example a percentage of community members that use Maparn, and if this use is associated with cultural affiliation.
More ethnographic research was completed within the Warlpiri community in the Northern Territory, specifically on two recorded illness episodes to examine health behaviour of people using ngangkari’ [22]. In his observations the author discovered that the use of bush medicine was used to treat specific symptoms of illnesses and included coughs, colds, wounds and sores, and that every adult and many children had some knowledge of bush medicine. If the disease however was caused by sorcery then an Ngangkari was consulted. Two illness-related cases were followed to examine health behaviour. The first case was a 44yr old male who consulted several Ngangkari over a period of weeks before finally visiting the clinic (biomedical) after his condition was not improving and becoming worse. The second case was a 33yr old girl who after years of biomedical healthcare ceased visiting the clinic (except to collect her long-term medicines) to engage with an Ngangkari. These two cases give an example of different age and gender who both utilised THs in different sequences, and whilst the same subjectivity may apply as for the above ethnographic study and lack of understanding of the level of the community who engage with Ngangkari, it does give us an indication of the role of the TH based on health beliefs of illness causes.

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