Two ways to healthClosing the gap on health in the Northern Territory

Alice Springs

Tennant Creek

Newcastle WatersNewcastle WatersElliotElliot

Utopia HomesteadCamel Camp

Amperlatwaty

Ti Tree Alparra

DarwinDarwin

WALPIRI language group(approximate area)

ALYAWARR language group(approximate area)

ANMATEYERR language group(approximate area)

EASTERN ARRERNTE language group(approximate area)

WESTERN ARRERNTE language group(approximate area)

CENTRAL ARRERNTE language group(approximate area)

Map of Australia © Com

monwealth of Australia (Geoscience Australia) http://creativecom

mons.org/licenses/by/2.5/au/.

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Road sign showing direction to a few of the16 Alyawarr communities in the Utopiahomelands. © Mervyn Bishop/AI

Map showing Alyawarr and AnmatyerrAboriginal communities in Australia’sNorthern Territory.

Indigenous Peoples have

rights to specific measures

to improve their access to

health services and care

In Australia, the life expectancy of Aboriginal and Torres Strait Islander Peoples isaround 17 years lower than that of non-Indigenous Australians. The infant mortalityrate for Aboriginal and Torres Strait Islander Peoples is twice that of all Australians.And Aboriginal and Torres Strait Islander Peoples are three times as likely to reportsome form of diabetes than non-Indigenous Australians.1

The Federal Government has committed to improving the health outcomes of Aboriginaland Torres Strait Islander Peoples and closing this life expectancy ‘gap’ within a generation.

Significant political and financial investments in one-size-fits-all solutions, researchproves that blanket policies cannot deliver the desired results. Instead, an integratedhuman rights solutions – one that empowers people and engages them to takeresponsibility for the solutions – is required. The success of this approach isexemplified by the Urapuntja Health Service, a community-controlled Aboriginal healthservice provider on the Utopia homelands in remote Australia.

The Utopia homelands comprise 16 dispersed communities (or suburbs) spread overroughly 3,000 square kilometres north of Alice Springs in the Northern Territory.Amnesty International began working with the Alyawarr and Anmatyerr Peoples inUtopia in 2008. Over a period of three years, comprehensive research was conductedwith the free, prior and informed consent of communities and using a participatory model,with Alyawarr and Anmatyerr people working alongside Amnesty International staff.

The right to health under international lawAll people have the right to the highest attainable standard of physical and mentalhealth under Article 12 of the International Covenant on Economic, Social and CulturalRights. The right to health does not necessarily translate as a right to be healthy, butstates do have obligations to provide the conditions and services to ensure that peoplehave the best chance to be healthy.2

The Committee on Economic, Social and Cultural Rights defines how this right shouldbe implemented:

• The state has a duty to make available adequate healthcare facilities, with trainedprofessionals and essential medicines.

• Health facilities, goods, services and information on health must be physically andeconomically accessible to everyone, without discrimination.

• Health facilities, goods, services and information on health must also respect medicalethics, be culturally appropriate and sensitive to gender and life-cycle requirements.

• Delivery of health services requires, among other things, skilled medical personnel,scientifically-approved and unexpired drugs and hospital equipment, safe andpotable water and adequate sanitation.

Indigenous Peoples right to healthUnder international law Indigenous Peoples have rights to specific measures to improvetheir access to health services and care:

• Services need to take into account traditional preventive care, healing practicesand medicines – recognising and protecting the vital medicinal plants, animalsand minerals necessary for the full enjoyment of health for Indigenous Peoples.

• In Indigenous communities, the health of the individual is often linked to thehealth of the society as a whole and has a collective dimension. Any displacementof Indigenous Peoples from their traditional lands against their will denies themsources of nutrition and breaks their connection with the land. This has adeleterious effect on their health.

• Importantly, resources should be provided for Indigenous Peoples to design,deliver and control health services.3

1. Australian Human Rights Commission 2008 Face the Facts AHRC, Sydney.2. Committee on Economic, Social and Cultural Rights, General Comment 14, The right to health, UN Doc. E/C.12/2000/4.3. Committee on Economic, Social and Cultural Rights, General Comment 14, The right to health, UN Doc. E/C.12/2000/4 para 27.

Amnesty International May 2011

THE RIGHT TO HEALTH ON ALYAWARR HOMELANDS

Urapuntja Health ServiceThe Urapuntja Health Service is an Aboriginal CommunityControlled Health Service that was established at Utopia in theAlyawarr homelands in 1978. It services approximately 1,400Alyawarr people living on their traditional homelands acrossmore than 3,000 square kilometres in the central desert regionof Australia. The clinic is overseen by a board of elders andcommunity leaders who govern the clinic and appoint staffincluding the CEO, doctors, nurses, Aboriginal community healthworkers, administrators and drivers.

Protecting, respecting and fulfilling the human rights of AboriginalPeoples is fundamental to the philosophy of the health serviceand informs how health services are delivered in the Utopiahomelands. The Alyawarr Peoples describe it as ‘two way’.

Two way reflects a genuine partnership between Aboriginalpeople and health service providers. It combines Western,scientific and Aboriginal knowledge of health and healing, usingboth modern and traditional medicines. Services are deliveredby doctors, nurses and Aboriginal community health workers ina way that reflects the reality of Aboriginal lives in remoteAustralia and respects Aboriginal culture and law.

Two way also refers to the control of health services beingshared between Aboriginal governance structures and the healthservice providers. This model is the embodiment of a rights-based approach to healthcare delivery.

Joycie Jones Petyarr and driver in a four-wheeldrive used to deliver health services to the remoteUtopia homelands communities. © Mervyn Bishop/AI

Roselene from the Urapuntja Health Service clinic.© Mervyn Bishop/AI

The Royal Flying Doctor Service transports apatient from Utopia. © Mervyn Bishop/AI

Sarah Doherty, CEO of the Urapuntja HealthService. © Mervyn Bishop/AI

Dorrie Jones Petyarr and Joselyn Jones Petyarr ofSoapy Bore winnowing seeds. © Mervyn Bishop/AI

“We show the nurses two way”

Joycie Jones Pitjara, Ngangkar, traditional healer and community health worker, Urapuntja Health Service

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A DAY IN THE LIFE OF THE URAPUNTJA HEALTH SERVICE

A trip to the suburbsEach day the Urapuntja Health Service visits one of its 16homeland communities. A doctor, nurse, community health workerand community driver set out in a four-wheel drive and travel asfar as 150 km over rough dirt roads. Each community has itsown clinic building where consultations are held. The two wayphilosophy means that community health workers act as liaisonsbetween members of the community and the other medical staff.They interpret between English and Alyawarr and manage kinshiprelationships and men’s and women’s health needs. This meansthat trusted conversations are held in the Alyawarr language andensures that women speak to women and men to men.

Back at the clinicRoselene looks after the clinic. Her workload would probably fillthree jobs in the city. Roselene knows everyone and knows wholives where – valuable knowledge in a sparsely-populatedcommunity scattered over thousands of kilometres with dustycorrugated roads and few telephones.

She works closely with the Alyawarr drivers who pick up communitypeople for clinic visits and sometimes take others to the Alice Springshospital 260 km away. She also organises Royal Flying DoctorService evacuations of patients to hospitals in Darwin or interstate.

Roselene is an important bridge between members of thecommunity and the government bureaucracies. She helps

patients with Centrelink and medical forms and phones the AliceSprings hospital when families need to check on relatives.

She says that it helps to be local and Aboriginal. And she lovesher job.

Joycie Jones Pitjara is a community health worker. She loves herjob because it helps her work within the two way philosophy andhelps her people. One of the ways she works two ways is bymaking bush medicine the way she learned from her grandparents.

She says that in order to keep making and using bush medicine,Alyawarr people need to live on their traditional lands.

“We need country to work both way,” says Joycie Jones Pitjara.“If we move out somewhere else we forget about bush medicine.It’s important for us to know. Bush medicine help both way.Bush medicine is good for them [non-Aboriginal people] too.”

She is concerned about losing the traditional knowledge that hasbeen passed down to her, especially if people move off theirtraditional homelands. “How will little kids know?” she says.“Move into town, we lose it.”

Joycie Jones Pitjara’s other important role is to help the doctorsand nurses, “to know the Aboriginal way, to know Aboriginal law”.She knows what’s happening on homelands and goes out onvisits with the other medical staff. She makes them aware ofcultural protocols. She says that she “shows nurses two way”.Most importantly, Joycie Jones Pitjara says her relationship withthe doctors and nurses is about mutual understanding and respect:“People who come to help us, we help them too," she says.

Amnesty International May 2011

THE ORIGINS OF ‘TWO WAY’ HEALTHCARE

The two way health philosophy emerged at the Urapuntja HealthService in the 1980s, when Alyawarr Peoples and Western doctorsbegan working together. Since then, the Board has been vigilantin maintaining it.

Dr Kamandra Suraswati (Dr Kam) has worked with the health clinicsince 1984. Dr Kam works closely with his long-term friend andmentor, Aboriginal elder and chair of the Board Albert BaileyKemarr. Together they train new doctors and nurses and encouragethem to embrace the Alyawarr worldview and two way philosophy.

“This is a viable Indigenous culture with the warmth and thespirituality and the incredibleness of that culture,” says Dr Kam.“No-one feels that, no-one understands that unless you sit down in it.

“There’s all the very complex, obscure, tertiary-level medicine.It’s not that that’s going to save people … [it is] getting out there,working on the relationships, doing the basic primary healthcare… vaccinations, weights, de-worming, chronic medications,blood tests … that’s the kind of stuff that’s going to close the gap.

This … is a different kind of speciality and we need spirited soulsto take it on.”

Sarah Doherty is the Chief Executive Officer of the UrapuntjaHealth Service. She is also committed to the two way philosophy:

“When I deal with the Board for the Urapuntja Health Service,I’m working for a council of elders that have complete authorityover what happens here at Utopia,” she says. “My philosophyaround my role is to support community authority and ensure thatthe voice of Utopia is in the mix and in the wider conversationsaround health.”

Success of two waysA study by the Medical Journal of Australia published in 2008found that despite the steady rise of obesity and diabetesnationally, the people living on the Utopia homelands weresignificantly healthier than other Aboriginal and Torres StraitIslander Peoples. Alyawarr Peoples have worked to address theproblems of obesity, diabetes and smoking so successfully thatadult mortality rates from all causes have been consistently 40per cent lower in Utopia than among Aboriginal people in theNorthern Territory generally. Deaths from cardiovascular diseaseare 50 per cent lower.4

The study concludes that contributors to lower than expectedmorbidity and mortality are likely to include the nature ofprimary healthcare services as well as the decentralised mode ofliving, with its attendant benefits for physical activity, diet andlimited access to alcohol. Connectedness to culture, family andland are also important factors.

The evidence shows that living on homelands and using a two wayapproach to the design, delivery and control of health serviceshas tangible health outcomes that close the gap in Aboriginaland Torres Strait Islander life expectancy. As Dr Kam explains:

“It [the study] demonstrates that if people are given a chance tobe in charge in their own context, there is the capacity withinthat culture to make life-affirming decisions; healthy decisionsabout the way that they do things. This is a living example that itcan. It doesn’t mean there are not a lot of problems; there’s stilla huge [life expectancy] gap. But we’ve shown that our gap is30 to 40 per cent less that the gap anywhere else. From apurely pragmatic point of view, 30 to 40 per cent less chronicdisease … that’s 30 to 40 per cent less hospital time and lessmoney spent.”

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The Urapuntja Health Service model is an example of a rights-based approach to health. The evidence shows that whenhealth services are accessible, available, appropriate, of a goodquality and function in true partnership with Aboriginal peoples,it is possible to close the health gaps that exist betweenAboriginal and Torres Strait Islander peoples and other Australians.As Sarah Doherty says:

“I’m not talking about anything new but what I’m saying is thatto close the gap … it’s not about more pills, more vaccines,more emergency nurses. It’s about more people who are willingto sit down with people and ask them what their health needsare and how they can meet those needs. That’s what will closethe gap … working with community and deeply listening to thecommunity and developing a health service that’s appropriatefor that community, because you can't do one model that fits all”.

CONCLUSION

It is incumbent on all levels of government to realise that closingthe gap is not simply a health issue. It requires a whole-of-government approach – an approach that places human rightsat its centre and allows Aboriginal and Torres Strait IslanderPeoples to exercise all their rights. Active engagement for long-term solutions must be made local, personal and perennial.

A rights-based approach is inclusive of Aboriginal and TorresStrait Islander governance and the two way philosophy for allareas of service delivery. As Alyawarr elder Rosalie KunothMonks says:

“What we need and demand is our dignity and rightful situationin Australia. We are Australians. We are not reluctant to take upthe challenge and own a journey which might take us closer toclosing the gap which the Prime Minister talks about. But theydo not have to destroy the spirit or ethos of who we are.”

RECOMMENDATIONS

That the Federal and Northern Territory governments recognisethat one-size-fits-all health service delivery does not work andcommit to designing health services in partnership withAboriginal communities, based on the realities of the location in which people actually live.

That the Federal and Northern Territory governmentsacknowledge that Aboriginal people are committed to theirhomelands and support those communities in closing the gap in the Northern Territory.

Urapuntja Health Service staff. © Mervyn Bishop/AI

Dr Kamandra Saraswati, one of the doctors workingwith the Urapuntja Health Service. © Lucas Jordan/AI

Alyawarr elder Rosalie Kunoth Monks. © MervynBishop/AI

Albert Bailey Kemarr, Chair of the UrapuntjaHealth Service Board and senior elder of theAnterrengeny homeland. © Rusty Stewart/AI

4. Kevin G Rowley, Kerin O’Dea, Ian Anderson, Robyn McDermott, Karmananda Saraswati,Ricky Tilmouth, Iris Roberts, Joseph Fitz, Zaimin Wang, Alicia Jenkins, James D Best,Zhiqiang Wang and Alex Brown 2008 "Lower than expected morbidity and mortality for anAustralian Aboriginal population: 10-year follow-up in a decentralised community" MedicalJournal of Australia 188 (5): 283-287

Amnesty International is a global movement of more than 2.8 million people in morethan 150 countries and territories who campaign to end grave abuses of human rights.

Our vision is for every person to enjoy all the rights enshrined in the UniversalDeclaration of Human Rights and other international human rights standards.

We are independent of any government, political ideology, economic interest or religion– funded mainly by our membership and public donations.

Publication date: May 2011

Amnesty InternationalABN 64 002 806 233Locked Bag 23Broadway NSW 20071300 300 920

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Cover: Joycie Jones Petyarr, community healthworker with the Urapuntja Health Service,showing traditional bush medicine she producesas part of the ‘two way’ health philosophy. © Mervyn Bishop/AI

The Urapuntja Health Service Clinic, Utopia.© Mervyn Bishop/AI