Aboriginal health workers: agents of change?

It is not possible to do justice to a topic as broad and as complex as roles of Aboriginal health workers in an editorial1 of this length, so I shall start by drawing readers’ attention to the monograph, Rhetoric and Reality, recently published by Central Australian Aboriginal Congress. ’ This study is probably the first comprehensive attempt to analyse what Aboriginal health workers themselves, their communities, as well as their employer organisations, perceive to be the main roles and functions of health workers, albeit in one specific region, Central Australia. I urge those of our readers who are interested in finding out more about the work of health workers to take time from their busy schedules and visit health worker employer organisations, especially community-controlled health services, not only to familiarise themselves with what health workers do, but to obtain a better insight into the structure and organisation of health service provision to Aboriginal people. As with the concept of the village or community health worker in Africa, Asia and South America,’ the roles and responsibilities of Aboriginal health workers can be understood properly only within the context of the philosophy and practice of primary health care, an issue to which we shall shortly return. For the rest of this editorial, I shall focus on a recurrent theme in Aboriginal health: the notion of health workers as agents of change, one of the many issues raised by Tony MacMasters in his article on pages 319-5! 0 of this edition of the journal. The aim is to highlight some of the barriers, in my view, that should to be overcome if the rhetoric of Aboriginal health workers as agents of change is to be translated into practice. So what exactly do people mean when they say Aboriginal health workers are agents of change? TO answer this question, it is important to remind ourselves of at least three issues regarding the origins and evolution of the concept of primary health care. The first onle relates to the nature of colonial health services. Throughout Africa, Asia and South America, colonial health services, at least until World War 11, were primarily designed to cater for the needs of minority elites, mainly of European origin; they were not meant to serve the needs of indigenous populations. When health services did serve indigenous populations, as did inoculation campaigns, for example, the ultimate rationale often remained the protection of the health of white people and/or control of specific diseases that directly threatened strategic aspects of the colonial economie~. ~ Thus, in many African countries, at the time of independence in the 1950s and 1960s, for example, no more than 10 per cent of the populations had access to modern health care facilities. This was largely the case for indigenous Australians until the 1967 referendum, which granted citizenship. The second issue relates to the obvious dilemma facing newly independent countries: how to extend health care facilities to the large majority of the populations that were denied access under colonial rule? The problem was complicated by the fact that these countries (also called ‘neocolonial’ states because of their continued economic dependence on the former colonial masters despite political independence) possessed neither the human nor the material resources to extend the existing health services to those without access. Even if funds were available to build hospitals, it was still not possible to train doctors and nurses over relatively short periods in response to the exigencies of the time. (This is the type of dilemma currently facing Nelson Mandela’s South Africa). Thus the concept of the village or community health worker developed as a cheap, and, in many respects, a more realistic alternative to the conventional hospital-based doctor or nurse. The idea was to provide some rudimentary training to dedicated groups of people to become health care workers in their own village communities. Because community health workers speak the same language and come from similar cultural backgrounds as the people with whom they work, they are generally expected to be more effective health care providers than the often elitist doctor or nurse. The third point to remember about the evolution of the primary health care concept is a growing awareness among health analysts and policy makers from the 1960s that access to health care, though an important factor in improving health, is only half the answer to poor health, especially among n e e colonial marginalised populations; an equally important factor in health improvement is the enhancement of social and economic opportunity for people in the form of education, income generation, and above all, pride in cultural identity. An important function of the health worker as agent of change is to ‘engage’ other agencies such as the schools and agricultural extension services (through what has been called intersectoral collaboration) to ensure that the activities of these agencies improve rather than undermine the structural position of the most marginalised elements of the population. This is an essential ingredient of the Alma Ata Declaration that is often, unfortunately, missing in most discussions about primary health care.4 As with their counterpart village or community health workers in neocolonial Africa, Asia and South America, Aboriginal health workers have played an instrumental role in extending modern health services to the large majority of indigenous Australians. The reduction in the infant mortality rate over the past 20 years is a good example of an area where health workers, in conjunction with other health professionals, are making a difference to Aboriginal health-although the infant mortality rate still remains three times higher than that of the nonAboriginal population. Such achievements have been made possible, largely, through a more effective management of infectious diseases. While improved access to medical services may be relatively effective for tackling infectious diseases among indigenous Australians, the same cannot be said of noncommunicable or so-called life-style illnesses such as hypertension, diabetes and renal problems.