Dr Lara Weiland . . . shattering letter to political leaders.

Letter to two leaders

Dear Prime Minister Howard and Premier Beattie,

This letter is to convey some of the issues affecting Aboriginal people on Cape York and some ideas on how they can be addressed. I have spent the last three years as a trusted and involved doctor in a Cape York community and have had a 10-year involvement in indigenous issues which has helped me gain an insight into the issues.

I make no apologies for any emotional or strong language as it is nigh impossible not to use it when you become involved in the endless tragic cases. Horror stories that would cause uproars and criminal charges elsewhere are so common that they are sickeningly part of the norm of everyday life, rarely anything coming of them. Children are caught in a nightmare which they cannot escape and something must be done to help them at the least.

I've laid out 10 important issues in point form, though they are all intricately interwoven. Please take the time to consider them.

Noel Pearson got it spot on when he said recently that we have to do things drastically different if we are to make a difference. (A colleague) and I had a 'slogan' for our thoughts on the Cape York situation: "We need revolution, not evolution!"

Twenty plus years of the same talk and bureaucratic ways of handling things has only plunged these people further into despair. It is time to get serious. There needs to be a serious investment right now to see a difference and salvage a future for the children of Cape York.

One can argue that this will cost a lot of money. I would argue that if all the layers of bureaucracy were stripped, and unwanted, unworkable ad hoc programs and projects, committees, working groups, feasibility studies and the pockets of grant monies etc. were cut out, there would be plenty of money that could be better used at the coalface.

In other words redirect money from the 'chattering classes' to the communities and grassroots workers. These workers are often in their jobs because they care and want to make a difference and if supported are willing to put in 120 per cent and work toward effecting change. I have seen this first-hand.

It would save taxpayers' money in the long run by preventing further long-term disasters. However no one seems to be interested in this, as it doesn't show a saving in this year's departmental budget which is what his or her performance is measured on.

If you could only look into the face of a child who has been raped, who tells you they have no dreams for the future and are thinking of suicide, then you would see that NOT doing something is not an option.

Please take the time to read my 10 points and my suggestion as attached.

Sincerely yours,

Dr Lara Wieland
(MBBS, FRACGP, Grad. Dip. Rural Medicine/Aboriginal Health)

Ten point on Cape York

1. Substance Abuse
Substance abuse has already been identified as a problem of epidemic proportions linked with almost every other issue. This has begun to be addressed by the Cape York Grog Strategy, which was an essential first step. However the resources are not in place to deal with what comes afterwards.
Adequate policing (see 9.) is needed to be able to enforce the laws regarding sly grog and drugs.
People who have spent many years "being drunk" will have little support in learning how to have sober relationships, how to be parents and how to socialise without alcohol. These things are available in the mainstream yet not where they will be most needed.
There may also be an increase in workload for clinics initially as people are sober enough to start feeling sick or caring about their health even though there should be a decrease in trauma.
There is also no provision for dealing with the aftermath in the form of Foetal Alcohol Syndrome/Effects (see 5.)

2. Mental Health/Social and Emotional Well-being
Indigenous people in communities suffer from much higher levels of psychosocial distress. I found in my time as a doctor that despite the high rates of physical disease I would spend the majority of my day dealing with social/stress problems. Almost every day I would see someone who had been contemplating suicide. The majority of mental problems are related to substance abuse but welfare & unemployment, relationship problems, domestic violence, witnessing violence, trauma and grief, lack of sleep, and overcrowded housing also play a part. It is stressful for any of us to raise children let alone trying to raise them in a crowded house where people steal your food and invade your privacy, with little money, sleep or support. A lot of these will be much less of a problem once the alcohol is gone but it won't change the things that people have experienced or witnessed. There will be a great need for help and counselling in this transition period.
I have also found that many people who did try to give up alcohol have underlying anxiety or depression disorders. Those who have the training to pick these up are rarely in the communities (ie. General Practitioners and counsellors). Not only does there need to be the people there with the skills and training they also need to be long term stayers that the community can learn to trust with their innermost feelings and problems. These kinds of people can be attracted to these jobs if adequately supported and not suffocated by bureaucracy in their efforts to make a difference.
The communities currently get a qualified counsellor one-two days a month. He is very good and people generally like and trust him but one day per month is nowhere near enough. In the community I work in there (are) enough patients to keep him occupied five days a week, and five busy days at that. This position is COMMONWEALTH FUNDED THROUGH DHAC AND IS DUE FOR REVIEW SOON.

3. Family Breakdown/Domestic violence
There is inadequate support/counselling for those with relationship problems and violence problems. There is no parenting support and child-care services are erratic.
Children have been witnessing domestic violence, proven to be psychologically damaging, and there is no counselling for this or relationship education for kids.
Over-crowding of the family house creates another plethora of problems. It is not uncommon to have 20 people living in a three-bedroom house with one bathroom.
There are more and more young single mothers who have no support and few role models, and what should be the most entrenched knowledge, basic child-care, is disastrously not understood in many young parents.
Many parents don't know how to control their children any more and have nowhere to turn for advice and support.
The elderly have also been abused and neglected with the increasing loss of respect for elders and family. In one community there were elderly people living in a hostel who were lying naked in several days worth of their own faeces and urine, malnourished and covered in dog ticks and lice. It was only after intense lobbying, for which I was criticised, that these services improved and aged care services in communities were reviewed. Clinic staff would be able to take much more of a pro-active role in aged care if given adequate staff and resources to do so but this is not the case.

4. Child abuse and Neglect/Child Protection
Child sexual abuse and neglect is out of control. If you consider the official definition of abuse, which includes emotional abuse such as having to witness violence, then almost every child has been abused. As I got to know my patients it has come out that the majority of the young women have been sexually abused.
Not many children get tested for Sexually Transmitted Diseases (STDs) as this is discouraged by Queensland Health (to the point where a pediatrician who worked for nearly 20 years in the Cape was going to be sacked over this.) Only doctors are allowed to test and there are rarely doctors in the communities. Even then they are told to only test when a child is symptomatic and even this is discouraged. Despite this I have had many patients as young as five and six test positive for STDs such as chlamydia.
There have been girls as young as six in communities who have been found to have Pelvic Inflammatory Disease — a condition where sexually transmitted chlamydia causes pus in the fallopian tubes of the girl leading to pain, fever and often future infertility.
There are grandmothers who tell me that on "drinking nights" they lock themselves into the bedroom with their grandchildren to protect them from being raped.
I felt physically ill as one person told me about a small girl who came to school unable to walk properly because she had been sexually abused. However I felt even more ill and wanted to cry but I was too angry, as another person told me that regularly on "drinking nights" they could hear a grandma down the road yell "Get off those kids."
Queensland Health don't want to know about this problem. No one is encouraged to report and doctors are the only ones mandated to report in Queensland (one of the few states left behind in this) and doctors in communities are not part of Queensland Health's plan (see 6.) One of the head detectives in the Cairns Juvenile Aid Bureau told me that they have real trouble getting cases reported even though they are aware of the prevalence. They said they have only been getting adequate reporting from my community and this has been directly related to having a long-term doctor there who knows the community and who is keen to detect and report abuse.
The Juvenile Aid Bureau (JAB) are keen to do something about all of this. The officers have funding to use staff to do monthly training in all the communities for health, police and school staff and to do education in schools. The officers are so keen to do this they have said they will drive around the communities and not claim overtime for their travel, yet they cannot do this as THEIR REQUEST FOR A VEHICLE WAS REFUSED. Now they can only visit when they can get a ride with another departmental vehicle, which is not very often.
The Department of Families (DFS) is next to useless. As in all other departments there are dedicated, well meaning, coalface workers but there are not enough of them and they are not adequately supported.
There have been months where we haven't had a DFS officer for our community at all. When we do we have to wait until the next monthly visit for follow up which is more often than not a quick flying visit. Officers are given no orientation, little support and don't get paid any more for working in what can amount to a warzone.
I have made multiple reports of abuse about children over months that have been ignored and nothing has happened. When a child discloses sexual abuse to me I no longer promise to make it stop as that makes me a liar. The last child I promised that to was put back in the same unsupervised situation. He was six years old and had contracted chlamydia.
I had assumed that when reporting a case of abuse to DFS that it was automatically passed onto the Suspected Child Abuse and Neglect (SCAN) team and the JAB. I now find that most cases I reported to DFS were never passed onto the JAB/SCAN and this has been the case in other communities also.
When children have been placed in foster care in the community it has often been within close proximity to the previous situation. No training or support is offered to foster carers and there is little follow up. This is a departmental problem as I have seen individual workers try to to this with few resources and little or no support.
I have seen children placed in a home more than once despite the department being notified by myself and others that community members suspected the father was a pedophile. Several children from that household have tested positive for STDs.
There is barely even crisis management where DFS is concerned and certainly nothing in the way of early intervention, prevention or support for families at risk.
Many of the children who have been abused are becoming the next generation of abusers. This is a well-documented phenomenon and is known to be happening throughout the Cape. We have 15-year-old boys who have been abused who are now abusing 6 and 7-year-old boys and will be the future's pedophiles if not helped. There is evidence that specialised early intervention and counselling can prevent this in many cases however there is nothing like this available anywhere near the north.

5. Child and Youth Development
There is a whole generation of children who have been left physically and emotionally scarred by the dysfunction of the last 20 years. We are yet to face the full aftermath in the form of hundreds and hundreds of children who will have some form of learning difficulties and/or behavioural problems as well as health problems, from Foetal Alcohol Syndrome/effects (FAS/FAE), or from years of neglect, witnessing family violence and being victims of sexual abuse.
Again services for children are pitifully scarce or non-existent.
There is a need for a full-time occupational therapist in each community to diagnose all the FAS/FAE kids and to initiate early intervention and support for them so they have some chance of a SEMI-normal life that isn't spent in jail. There will also need to be support services for these kids at school and perhaps even a 'sheltered workshop' situation for the more severely impaired children who will never be able to achieve any sort of education or gainful employment.
Again a children's counsellor/psychologist could be employed full time in the larger communities and be kept very busy with all of the psychological problems in the children. This is an important investment, which will save money and tragedy in the future.
Currently we have a child psychologist for one day a month and even that has only recently started.
With all these problems there needs to be more experienced and specialised teachers in the school to support the current ones, many of whom tend to be new graduates with little experience or interest in being there.
There are very few activities for children in the community. In one community for example, the playground is a wreck, the basketball court has long grass growing out of it and the swimming pool is empty. There is no sports and recreation and virtually nothing for children to do but get into trouble. There is also no youth worker or community development officer.

6. Health Services
People in communities do not have equal access to doctors and health services. One might argue this is because of remoteness but they don't even come close to the access to services enjoyed by other areas in equally rural and remote settings. This is appalling when you consider the years of rhetoric from governments and health departments about wanting to improve indigenous health.
Queensland Health thought it had the answer by introducing the Chronic Disease Strategy and recall systems for health screening. This is good theory and it is important to pick up disease early. However it is a program written by public health academics and administrators with no input from coalface workers. "A programme written by public health physicians with research papers as outcomes," as one of my colleagues, Dr David Rimmer, once put it. There has been no consideration of the extra time and resources that will be initially needed for the increased workload and paperwork. There also seems to be a lack of awareness that acute care will continue to be needed whilst all this health screening is going on. This strategy and the health department in general is focused on the individual disease not on the individual person which is not how real life works.
There is no understanding or allowance for how much of the medicine is social medicine and what skills or resources are needed.
Queensland Health does not know because they have never asked nor wanted to listen to the people on the ground who have tried to have input or offer solutions.
As these Brisbane bureaucrat-devised systems come in, long term health staff are leaving the Cape in droves as they become stressed out and frustrated with a system they can see doesn't address the real problems. This is a tragedy as long term staff tend to become trusted and accepted by the community, putting in them a position where they can be far more effective than any fly-in program.
Trust is a major issue for Aboriginal communities who have endured decades of broken promises, fly-by-nighters and self-interested con men. So many of my patients have emphasised over and over how vital it was that they knew and trusted the long term health staff in seeking help for medical and social problems.
When I first arrived there had been five completed suicides in the previous two years. In the last three years since I have been there, there have been none. This may be a coincidence but many of my patients came to see me for help early. My three years has been the longest a doctor has stayed in a Cape York Aboriginal community and I only left because of frustration with the system. Many community people have said to me that they appreciate having a doctor they can come to who is there all the time that they know and trust. They say that if they had had fly-in, fly-out doctors they would simply not come. Yet no one who makes any of the decisions has ever asked the people what they want or will use.

7. Sexual Assault
Cape York has extraordinarily high rates of adult sexual assault as well as child assault (covered in 4.)
Again this should improve with the banning of alcohol. However it will not change the fact that the majority of women in communities have been assaulted and have to live with that. They have no access to female or specialised counselling services despite other rural areas with lower rates of assault having this access. Until recently I was the only one offering this service and that was only in my community. This was one of many unrecognised roles never supported or understood by Queensland Health.

8. Sports and Recreation
As mentioned earlier there are virtually no functioning facilities or activities for children or adults. I have been to rural towns, which are one-fifth of the size of one of the communities, but with 10 times as much in the way of recreational facilities. Sport has the potential to become a real focus/source of positive energy.

9. Policing/Law & Order
Law and order is a huge issue as Noel Pearson has also pointed out. Hopefully this should very much improve with the alcohol laws too. However there will be an increased need for policing of sly grog and drugs if we are to really fight substance abuse.
Police numbers are based on population not workload. This gives my community the same number of police officers as Magnetic Island, an idyllic island retreat 30 minutes by boat from the major city of Townsville. This despite my community having the same recorded workload as the Innisfail district for example, which has 40 police officers!
The officers that do come here are, as with the other departments, often dedicated people who try to contribute to the community and really try to make a difference. They are also not very well supported. Their overtime is often restricted so if they respond to a call they are often not paid. This puts them in a position of deciding whether a call warrants their attendance or not.
In the three years I was there probably 40 per cent of the officers received some sort of stress counselling or treatment from me.
They have also felt poorly supported by the Department of Public Prosecutions whom they feel often makes it difficult to get appropriate convictions on violent offenders, making them feel they are wasting their time doing all the paperwork.

10. Capacity Building/Employment
A mistake in the past (and present) has been that when looking for locals to work in government run and devised programs and projects, they try to save money by using what they see as a pool of labour in CDEP (Community Development and Employment Program). There are two problems with this. Firstly these people are given little or no training or support in their new position. Secondly they continue to get the same wage. CDEP is locally known as "sit-down money" – meaning you still get paid even if you sit and do nothing. Hence another expensive program fails and bureaucrats say they have tried and it just won't work.
After years of substance abuse, social dysfunction, welfare dependency and poor education there needs to be a substantive investment in capacity building and training. Increasing the coalface workers as suggested can do some of this. Experience in my community showed that having long term dedicated nurses and a doctor benefited the local health-workers also. We had the lowest turnover and highest attendance rate. Despite everyone being overworked and time limited we tried to spend time encouraging, mentoring and training health-workers that worked alongside us. When I left, a couple of health-workers told me I had encouraged them to stay on and had helped them learn a lot.
Why not have outside workers in sufficient numbers who are well supported to stay on, who have to work alongside locals who are supported with training to increase their skills and qualifications?
A key component of all this is that funds and control of human resources needs to be 'bottom up', not 'top down' and controlled by the 'chattering classes' as it is at the moment. It is widely recognised that community control is vital in this setting and I have plenty of literature on this that I could share including papers by bureaucrats and government departments who know how to talk the talk, but not walk the walk.
Many people get nervous at the mention of 'community control' and envision mismanagement, embezzlement etc.
Sure but things can be done to address this. For example one region in the Northern Territory eliminated much of the health bureaucracy and went for community control. There was a board of community members who were trained in how to become board members. Capacity building was a key feature of the initial investment. There was also strict accountability and independent accountants monitoring things. The communities decided what services they wanted and needed and purchased them from providers such as state health and RFDS. The dollars were going to where they were needed and the Aboriginal people were having a say in their health. Accountable local councils need to play a key role.
I have attended a couple of conferences on remote and rural indigenous health where there were presentations of successful programs in indigenous communities in other parts of Australia and overseas. Not one of these success stories was a government run or devised program. They were all grassroots programs that had been devised and run by local health-workers and community people working together with dedicated doctors and nurses who were willing to listen to the people they served.
There is a lot of talk about community control in health and self-determination and empowerment but it seems to be only as it suits the bureaucrats. There needs to be a change in direction where funds and services are directed at the coalface or grassroots level in such a way that even the most disadvantaged community can access them. The health system needs to be overhauled to bring in accountable community control that assists and supports coalface workers rather than discouraging and burning them out.
A minimum start would be ensuring that there is access to Australian average numbers of general practitioners in all communities. Also adequate numbers of Registered nurses and a local health-worker to a population ratio of 1:150 as recommended by the AMA and NTRHWA.
There needs to be a substantial number of occupational therapy services available to diagnose and work with the huge upcoming numbers of FAS/FAE children. There also needs to be adequate access to hearing and ear specialist services for children and guaranteed ongoing access to a pediatrician and registrar.
There needs to be a full time adult counsellor and children's counsellor for each community and a part time sexual assault counsellor available.
There needs to be a youth worker, sports and rec officer and community development officer for all of the larger communities and perhaps a combined position for the smaller communities.
Part of the position description should include capacity building — i.e. support and training of locals, and community building. This is something that most people who comes to these jobs are interested in but don't normally get the time or resources to do.
There needs to be increased police numbers to police sly grog and drugs and to investigate and report child abuse.
This is not meant to be a comprehensive essay on all of these subjects as there are other people far more qualified to speak on some issues such as economic development which I know little about. However I have many more detailed ideas on what could be changed, how and why, particularly in the area of whole person health and well being and child protection but I have taken enough of your time as is. I would be very pleased to discuss this further at any stage in the future if you wish.

Thank you very much for taking the time to read this.

Dr Lara Weiland
6 August 2003

http://www.thecouriermail.news.com.au/common/story_page/0,5936,6871162%255E3102,00.html

home