” Ultimately, health outcomes – including frequent presentation to hospital – are reflective of social conditions, especially homelessness.
Health, as we are witnessing in remote Indigenous Australia, is a reflection of individual, community and life circumstances.
By taking a socially-focused and compassionate approach to medicine, Katherine Hospital staff hope to alleviate unnecessary presentations to an already overburdened “
Geordan Shannon PhD Candidate, Institute of Global Health, UCL
Without anywhere that is home, Indigenous people have been without a physical space to reinvent themselves and their culture in modern Australia.
Since colonisation, Aboriginal people have been internally displaced from their country. The doctrine of terra nullius – a land without people – was established under British colonial government and persisted in Australian law until 1992). It served to reinforce the concept that Indigenous land was “empty”; it belonged to no one and so could rightly be claimed for Western exploitation or settlement. This doctrine arguably still persists in the collective Australian psyche, evidenced by social policies and government interventions which impact harmfully on Indigenous people and their connection to their land.
The Stolen Generation, in which Aboriginal children were forcibly removed from their families between the 1900s and the 1960s, is one government policy that led to Indigenous dispossession in the broadest sense of the word. Important Indigenous constructs around family, culture, community and the physical land were affected, and the impact was inter-generational . The Northern Territory Emergency Response Act (NTER) 2007 – often referred to as “The Intervention” – represented a suit of legislation that was enacted to address child abuse in remote communities through mandatory changes to welfare provision, land tenure, child health checks and law enforcement. It has been criticised nationally and internationally for ineffectual, non-consensual and mandatory measures, impacting on the autonomy of Indigenous people and causing humiliation, fear, and confusion among Indigenous communities. Evidence suggests that the intervention has also “increased levels of itinerancy and homelessness among Aboriginal people who have left their home communities in order to avoid the punitive and paternalistic aspects of the NTER”.
Warlpiri Transient Camp, established near the town of Katherine in the Northern Territory, has an interesting history that reflects Indigenous dispossession. In 1949, Lajamanu was forcibly established as an Aboriginal settlement on land that traditionally belonged to the Gurindji. Several hundred Warlpiri people – Australia’s largest tribal group – were trucked there against their will due to government concerns about overcrowding in Yuendemu, 600km to the south. Many simply walked back, with multiple walk-backs happening until 1968. Amid this, a large number of transient Warlpiri “mob” began coming to Katherine to camp, disconnected from their land.
A large number of homeless and itinerant Indigenous people now live in Katherine in town camps such as Warlpiri Transient Camp. These camps serve as a halfway house in towns, away from dilapidated and overcrowded housing and social decline in remote communities.
Conditions are unhealthy, overcrowded, and, at times, dangerous. Violence is common: cases such as the murder of a mother of five occurred in 2014 in Warlpiri Camp. Infrastructure is severely limited and neglected. This led to legal action by residents of Santa Teresa earlier this year.
Lack of a future
Imagine being a young person in Ngukurr, on the Roper River in Arnhem Land. There are very few employment opportunities and limited community infrastructure and housing. If you want a way out, Katherine is your next stop. However, there is a prolonged waiting time for public housing. According to the Northern Territory Department of Housing, the wait is now at least five years – that is to say, if you know how to apply. In reality, if you are a young person wanting to move to Katherine, then you are likely to end up homeless.
The situation has become so normalised that this is exactly what young people do on a regular basis. And while such issues are widely known, they are rarely spoken about.
Between neglected housing in remote communities and dangerous town camps, Aboriginal people live displaced from their land and culture. As Simon Quilty, head physician at Katherine Hospital, put it: “Indigenous people are like long-term refugees displaced on their own land. Nothing has changed and nothing has been done about it.” The staff also found that Indigenous people were attending the hospital with worrying regularity.
Under the leadership of Quilty, Katherine Hospital is addressing homelessness as a health issue using a socially oriented approach. A team of doctors, nurses, social workers and Aboriginal liaison officers are looking at the factors behind why people are driven to attend the hospital so frequently. Using retrospective emergency department admission data, a recent paper published by the team found that some people attended the emergency department for non-medical conditions as frequently as every two weeks.
Such people were driven by issues such as homelessness, alcohol use, weather (including rainfall) and Indigenous identity. The study showed that people who frequently presented to the emergency department were more than 16 times more likely to live in temporary accommodation or be homeless. They were 2.2 times more likely to identify as Aboriginal, and 2.7 times more likely to have alcohol linked to their admission.
Although alcohol is commonly labelled as responsible for “the problems” in the town of Katherine, the study clearly showed that the fundamental issue was homelessness. Other recent research demonstrated that homelessness was a profound problem across the Northern Territory. Homelessness rates in the territory are 15 times the national average: 12% of all people in the Katherine region are homeless; six of the ten regions with the highest homeless rates in Australia are in the Northern Territory, regions that cover almost the entire state. An astonishing 28% of the population of East Arnhem are considered homeless.
Following these findings, the Katherine team is now implementing a social care pathway that provides a culturally appropriate intervention that addresses the whole range of problems experienced by those who present to the emergency department. The programme builds on existing evidence that social interventions for frequent presenters and homeless people, including housing provision and case management, reduces the number of people who attend emergency departments.
Patients who present themselves at the emergency department on more than five occasions within a year will trigger a “frequent presenter pathway”, where social, medical, drug and alcohol problems will be identified and addressed by trained professionals prior to discharge. This model of care has been investigated in urban, predominantly non-Indigenous settings only and this will be the first time such an investigation takes place in a rural Indigenous setting, with a large randomised trial planned for later in 2016.
Ultimately, health outcomes – including frequent presentation to hospital – are reflective of social conditions, especially homelessness. Health, as we are witnessing in remote Indigenous Australia, is a reflection of individual, community and life circumstances. By taking a socially-focused and compassionate approach to medicine, Katherine Hospital staff hope to alleviate unnecessary presentations to an already overburdened system, and focus on the drivers of overall health and community well-being.