The unique challenges of outback nursing: it's not every nurse who could cope with the isolation, heavy workload and minimal health gains of working in a remote Aboriginal community.

FOR ZEALAND-TRAINED nurse and midwife Theo Allan, working in the Aboriginal community of Utopia--three to fours hours by road north east of Alice Springs in Australia's Red Centre--was an experience she wouldn't have missed for the world. However, she warns that it's not a job or lifestyle every nurse would feel comfortable with. The work is physically and mentally demanding, and the burn out rate among the nurses and doctors who choose to work among Aboriginal communities in the outback is high.

"Nurses are well paid--up to A$80,000 a year--and well housed, with cheap rent, good houses and other incentives, but nurses need to have a real sympathy for Aboriginal people and be prepared to work independently, with little support or supervision," she said. "The key to the work is the relationships you build with the community, but the health results are few and far between, and difficult to assess."

Allan trained at Wellington Polytechnic from 1978 to 1980 when she was 17. She has worked at Wellington Hospital, in London and Saudi Arabia, before returning to New Zealand to do her midwifery training at the then Auckland Technical Institute. She worked at Taranaki Base Hospital, then moved to Australia in 1992, spending a year rural nursing just out of Darwin before eventually accepting a nursing position in Utopia where she worked from 1997 to 2000. She is presently working in Alice Springs as an independent midwife, as well as on call for the Alice Springs Hospital.

Utopia, a 100-square kilometre area somewhat ironically named, is home to about 900 Alyawarr people, as well as some other smaller language groups. The health clinic is one of around 50 clinics that have been established in Aboriginal communities in Central Australia since the mid-1980s. Some are government-funded and run by the Aboriginal Medical Services; others are funded and run by the Territory Health Services. Allan believes the former model is generally more successful, as the community has more autonomy and control over how the service operates, although this is ultimately dependent on how well the community itself functions. The Utopia health clinic is run by an Aboriginal health board that has a large say in the appointment of the two nurses, one doctor and six health workers who staff the service. The clinic is responsible for 18 outstations, the furthest of which is 100 kms from the main clinic.

"Some of these outstations are just little sheds in the middle of the bush, others are simply a medical box looked after by the local people," said Allan. The work is very demanding, with the nurses working as independent practitioners and often on call every other night. As a result, recruiting and retaining suitable staff is a real challenge. Every three weeks, the nurses return to Alice Springs for a much-needed weekend break.

The health workers are all local Aboriginal people who undergo an 18-month training course at either Alice Springs or Darwin. Their ability to assist the nurses, says Allan, is very much dependent on their literacy and numeracy levels. Some are able to perform tasks like taking temperatures, weighing babies and giving out medications, while others are more cultural brokers, forming a link between the nurses, doctors and the community. "Engaging with the local health workers, rather than trying to bypass them, is important for building meaningful relationships within the community. If you are lucky, a health worker will adopt you and be your guide. They have a lot of demands on them too, both from the health professionals and from their own people. Some health workers also feel they are not recognised or properly recompensed for their cultural skills.

"The role of the health worker is constrained by their own community demands. For Aboriginal people, the family is the priority and they will not come to work if there's any social disharmony within their family group. Children are central to their lives and mothers are not meant to make their children cry. As a result, they are often reluctant to give them medication in case it might cause them any distress. They would prefer the nurses gave their babies an injection rather than administer the medication themselves. It's OK for a nurse to make a child cry.

"Rituals around death play a major role in their lives. When a family member dies, the family will leave their homes and live in a "sorry camp" out in the hush in humpies [temporary shelter] for two or three months. This makes it very difficult for a nurse or doctor trying to treat a patient. A patient with chronic heart disease will not be interested in coming to the clinic to get their blood pressure checked nor will a diabetic want to attend an education session if they are in a "sorry camp". This apparent non compliance can be very frustrating for the health professional, but you have to accept that Aboriginal priorities are very different from those of 'white fellas' and that their tribal law will take precedence over any other laws or white fellas' expectations. You can't force people to come for their treatment. You just have to be supportive and creative in the way you work."

Allan was determined not to be another white person coming into the community and trying to boss the people around--"They are so vulnerable to this sort of treatment". She also tried hard not to be disheartened at the lack of real health gains she observed. "We were dealing with some very sick people--people with pneumonia, heart failure, anaemia, diabetes and renal failure. The death rate among younger people, from traffic accidents and suicide, is also very high. We did have some success with children who were failing to thrive and we were able to get food to families that were struggling. We made some difference but that difference was very small. It's great to have the services out in the communities, but as yet, there has been little improvement to the lifespans or health status of Aboriginal people."

The deeply embedded health disparities between Aboriginal people and other Australians are reflected in the Territory Health Services' 1990 Aboriginal health indicators. (1) These show that deaths from cardiovascular diseases were over three times that of non-Aboriginal Territorians; deaths from respiratory diseases almost six times higher; deaths from diabetes almost eight times higher; deaths from renal failure almost 11 times higher and death rates from infection in young Aboriginal children were 15 times the non-Aboriginal rates. Over the last 13 years, there has been little or no change in these statistics, with an 18-year gap in life expectancy between Northern Territory Aboriginal males and non-Aboriginal Australians, and a 20-year gap between females in these same groups.

The Utopia health clinic has its own ambulance and staff are able to transport people into Alice Springs in emergencies, for x-rays and treatment like dialysis. For the most urgent cases, the nurses call on the Flying Doctor Service, which is able to transport people to hospital in half an hour. Pregnant mothers are encouraged to go to Alice Springs Hospital to have their babies, though Allan, being a midwife, was happy to assist with births in the community. "I delivered five babies in the two and half years I was there." Few nurses working in Aboriginal communities, however, are able to offer a midwifery service and have little experience working with pregnant women.

"Aboriginal women are given accommodation in Alice Springs as the time of their babies' birth approaches. However, coming into the town is a very alien and frightening experience for them and some will run away before their baby is due. Others are induced because they do not want to wait any longer. Being taken away from their families is also very disruptive for the whole family. Although many Aboriginal women have complicating diseases, many are healthy young women who should be able to have the support they need to birth in their own communities. At Alice Springs Hospital, there is a 25 percent caesarian rate among Aboriginal women and the infant mortality rate is three times higher than the rest of the population. Maternal mortality rates are also very high."

Allan, now living back in Alice Springs, is finding it difficult working as an independent midwife. The medicalised model of birth is still predominant in Australia--"New Zealand has a much more advanced midwifery service"--and only one percent of Australian woman have their own midwife. The pay is also poor compared to rates in New Zealand. Allan is considering doing some relief work back in Utopia next year. Then she may return to New Zealand where she expects to gain greater satisfaction in her chosen midwifery field.

"Working among Aboriginal people has given me a unique perspective on nursing. My outlook on life has been broadened and I learnt greater confidence to use a partnership approach in health care, not top down. For the Utopia people, relationship was more important than how well qualified the nurses and doctors were. They valued the heart connection and having a laugh (if they were not acutely unwell of course) above anything else. I shall always be grateful to have had these experience."

REFERENCE

(1) Devanesen, D. (1997) Intersectoral Action for Aboriginal Primary Health Care. Paper presented at the Ninth national health promotion conference. Territory Health Services: Northern Territory Government.