My Rural Story

AUSTRALIA’S RURAL, REMOTE AND INDIGENOUS HEALTH #MyRuralStory

Featuring Interviews from the brand new 3rd edition of Australia’s Rural, Remote and Indigenous Health by Janie Dade Smith

Share your rural experience now to win a copy of the book @ElsevierAUS #MyRuralStory

Jacinta Elston Professor and Associate Dean of Indigenous Education & Strategy at JCU. Co-Director of the Anton Breinl Centre for Health Systems Strengthening at JCU. Corey Stone Second Year Medical Student Bond University

Amani Savi Registered Nurse Fifth Year Medical Student Bond University Allegra Boccabella Third Year Medical Student Bond University

Robyn Williams Bachelor of Health Sciences Coordinator Charles Darwin University

Shannon Springer GP for the Aboriginal Medical Services on the Gold Coast and in Charleville

Sue Lenthall Associate Professor and Academic Leader, Central Australian Remote Health Education, at the Flinders University Centre for Remote Health in Alice Springs.

Regan Jane Sharp Community Psychologist working in the field of youth mental health, South East Queensland

Janie Dade Smith Professor of Innovations in Medical Education, Bond University.

JacintaElston

What is different about working in rural and remote areas?

My name is Jacinta Elston. I’m Professor and Associate Dean of Indigenous Education and Strategy in the Division of Tropical Health and Medicine at James Cook University. I’ve been working in Indigenous health for all of my career and I guess I came to Indigenous health and working in areas relating to indigenous and remote health because I grew up in North Queensland in a regional centre. As a child I spent a lot of time in rural farming and agricultural communities with my family. From this I have a natural attachment to the beauty of being in small, rural communities.

The difference about working in rural and remote communities, from the context that I’m coming at this from, is really to do with the indigenous health aspects of it. It’s the fact that when working in rural and remote communities, you’re going to see Aboriginal andTorresStrait islanderpeople at amuch higher portion than you would if you were working in a large urban centre. In a large urban centre, you might not come across many Aboriginal Torres Strait islander people at all in the hospital care system, but in rural remote communities,

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they’ll make up the large proportion of people that you’ll see and care for.

really important, when you go to these places, to be open to learning about that history and to hear it and understand it. The second thing I think people need to understand, or have some reflection about for themselves, is racism. I think we’ve reached a point in our country where racism is becoming a bigger and bigger issue. We saw through the Adam Goodes saga the impact that this is having on society. You can’t go to a barbeque and have a conversation about things like Aboriginal people without there being comments made. It’s really important when you go to places to be open to learning about that history and to hear it and understand it. Where do you stand on those comments when they come up? A good place to start would be to have a look at Stan Grant’s recent speech and racism IQ seminar series that was held at Sydney University at the end of 2015. He makes some really useful points about how we as Australian’s all embrace our history together. And I guess the last thing is that people do need to be willing to ask for help when they get stuck. When they’re feeling lost or isolated. In rural communities there’s a lot of connection and connectedness, if you feel you’re

What advice would you give to students going on a rural or remote placement? The fist thing I would advise is that they need to really understand the history of the community that they’re going to. Students need to understand what has happened to the Aboriginal Torres Strait Islander people in this country as a whole since settlement. Policies and government processes, the acts of genocide that happened and impacted on people in the communities. Things that have happened at a global or national level. There’s also been things that have happened in communities they’re going to be working in that people have a memory of, people still have connections to, and I think that it’s ‘I think we’ve reached a point in our country where racism is becoming a bigger and bigger issue. We saw through the Adam Goodes saga the impact that this is having on society.’

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settings when there’s a lot of turnover of staff. People who work in these areas are committed to the cause and they’re there for the long term often, so relationships and connections topeople, that’s amazing. In rural communities there’s a lot of connection and connectedness, if you feel you’re outside of that and you don’t understand things look for help; look for a mentor, look to the leaders and ask for advice. And then on top of that you’ve got opportunities to sit, some times in really beautiful places, quietly. At the side of one of the mountains out in the lake Argyle region of Kununurra where

outside of that and you don’t understand things, look for help; look for a mentor, look to the leaders and ask for advice. What has been one of your best experiences working in these remote communities? I think it’s hard to pinpoint my best experience when working in a rural and remote community because there’s been lost of best experiences and lots of really unique opportunities that I’ve had. But if there was one great thing that’s come out of the couple of decades that I’ve been working in this space, it’s the relationships and the connections to people. It’s knowing that all around the country I’ve got relationships, friendships, associations that are real and meaningful. They’re relationships that have lasted the test of time. And I guess that’s more than yougetwhenyou’reworking in largeurban

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there’s nothing in sight except for bush and hills and land and the water, and to be able to just sit and feel the country and hear it breathing around you. So there are those sorts of opportunities. What have you experienced in remote Australia that has changed your world view? One of the big ‘aha’ moments in working in Aboriginal health and rural remote health was probably the first time I went to Thursday Island, to the Torres Strait, and I was only going there from North Queensland but it was a saga to get there. You spent the whole day, you’d be on the plane then you’d be on the bus, then you’d be on the ferry, and it really brought home to me the cost of traveling in rural and remote communities for peoplewho aren’t on the tax payers dollars, who aren’t part of health care systems or service providers who are paying for them to get out there. And so for people in rural remote communities, the cost of getting back and forwards to regional centres for health care, for family community business, for funerals, for bringing somebody’s body home after they’ve passed away - all of those things are immense costs to our communities and they take a toll and people make choices about whether or not they will get care based on those costs often, and based on what their families can afford.

And so we’ve got to remember that a lot of people living in rural and remote communities, particularly the Indigenous people, have poorer education standards, poorer opportunities for employment, often living ingreater situations of poverty. And so their health is worse and that’s a large burden on the health care system. But giving people more help to get to the health service, to be able to engage it, I think is critically important and I think that was one of those ‘aha’ moments for me. The other thing that I’d like to add about working with Aboriginal Torres Strait Islander people is understanding and having a commitment to the principles around self-determination and sovereignty for Indigenous peoples. Aboriginal and Torres Strait Islander people have been really powerless over ‘Out in the lake Argyle region of Kununurra, where there’s nothing in sight except for bush and hills and land and the water, and to be able to just sit and feel the country and hear it breathing around you...’

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the last 200 years in terms of making any decisions about themselves, and so there’s some huge issues that are facing us with AboriginalandTorresStraitIslanderhealth, and if we’re going to see any improvement at all, Aboriginal and Torres Strait Islander people have to be leading that. So working with them, bringing them to the table at the time that programs are designed,decisionsarebeingmade,letting them take the run on delivering on these programs becomes critically important. And so I think that for any health service provider in the future, understanding that you won’t go anywhere, we won’t go anywhere as a country in improving Indigenous health, unless we have this being achieved in partnership with Aboriginal Torres Strait Islander people.

If we’re going to see any improvement at all, Aboriginal and Torres Strait Islander people have to be leading that.

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Corey Stone

I’m Corey Stone, I’m 26 years old and I’m a second year medical student at Bond University. Prior to studying medicine, I studied commerce. I did majors in accounting and finance and I worked in that industry up in Brisbane for two years. I’ve lived in the city my whole life so I hadn’t really had much exposure to rural or remote lifestyle until I went up to Kununurra. In my first year of med school I took the opportunity to participate in a student philanthropic trip out to Kununurra where we spent two weeks with the local kids running, or assisting, an organisation called Save The Children with a holiday program. During the holiday program, we organised

sporting activities for them, cooking classes, boys nights, girls nights, lots of sports - they love their sports out there. I have to say, it was the most eye opening experience I’ve had inmywhole life, seeing the difference, the contrast between rural and remote and metropolitan and city lifestyles and it probably was the most rewarding two weeks of my life.

What is different about working in rural and remote areas?

Working in Kununurra, in a remote community, is incredibly different to working in a metropolitan area. There’s a real sense of community out

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‘There’s a real sense of community out in these rural areas that you don’t get in the city.’

in these rural areas that you don’t get in the city. There’s a genuine care for one another that I’ve never experienced before. Everyone knows each other’s business, but in a good way, they’re looking out for each other. You also get to know people a lot quicker. I only spent two weeks out in Kununurra but I built some incredible relationships whilst out there and I feel like I really had an influence on some people’s lives while I was there, even though I was only there for a short amount of time. And I don’t think that sort of thing happens, or is as likely to happen, in the city as it is out there. What advice would you give to students going on a rural or remote placement? Going out with an awareness that things are very different out there. Resources aren’t as easy to come by as they are here. Everyone knows each other’s business, but in a good way, they’re looking out for each other. In the city we take for granted just being able to walk down to the shops and pick up a newspaper and that sort of thing. But, it’s not like that out there. We have a great understanding of what’s good for us and what’s not

good for us and, in my experience, out there they don’t have that same level of understanding and education. So, I asked kids a simple question like ‘name for me two green vegetables’ they couldn’t name two green vegetables which was quite astounding for me. Again, having an appreciation for education is key. Out in this area the absentee rate is something around 90% so these kids aren’t going to school and they don’t appreciate the importance of education. So I think going out with an open mind and appreciating that there are these differences in these communities is very, very important. What has been one of your best experiences working in these remote communities? My best experience working out in Kununurra is also quite a sad story. We were playing basketball one day with a group of kids. They were all aged between six and 15 and one of the eight

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year old girls got hit on the back of the leg with a rugby ball and she started crying. We couldn’t work out why, the ball didn’t hit her that hard and she wouldn’t explain to us what happened. She turned around and she was bleeding quite profusely from the back of her leg through her shorts, but we couldn’t really touch her to see what was there. So, we took her to the Elder and asked her ‘what can we do? Something needs to be done.’ The Elder said to us, well, she didn’t really say to us, she said to the girl ‘just go home’. We had been to this girls house the previous day and she lived in a tin hut out on the reservationandwe knewthat noone would be home and that the home wasn’t

a sterile, safe environment for her, so we ended up taking her inside to the nurse and she dressed the wound up and gave her some pain killers for children and after that she was fine. She was running around on the basketball court and she was happy. It was a very rewarding thing for me, seeing that the girl was helped rather than sent back to her house where nothing could be done, and nothing would be done, and it got infected. So while it was really sad to see that that’s how they deal with those issues out there, it was also very rewarding to know that we were able to create a positive outcome for that girl.

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What have you experienced in remote Australia that has changed your world view? The experience that really changed my world view when we went out to Kununurra was when we set up this scavenger hunt and I set up what was called the ‘Education Station’. The kids would come around in groups and I had a little blackboard set up and I would ask them some general knowledge questions that someone in their age range would be able to answer for me. So, I’d ask the 15 year old kids something like ‘what’s 7 x 7’ or ‘name two pieces of fruit’ and it was astounding, they couldn’t

answer these basic questions for me. The first thing I asked them was ‘how old are you?’ so that I knewwhat sort of general questions to ask them. But the question I really should have asked them is ‘how many days a week do you go to school?’. It was a real ‘aha’moment for me because I didn’t realise that they didn’t go to school, these kids, or they went to school once a year or once a term. So that reallymademe wake up and realise how lucky we are here to have such a big emphasis on education and how good our education is here. They don’t have those facilities available to them out there and there’s not people telling them to go to school and telling them how important education is.

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W hat T o T ake O n Y our R ural P lacement BRING

Toys Make sure that you bring toys with you. You’ll be dealing with lots of little kids!

Knowledge of the Community It’s not just about the patient and the medicine, it’s everything wrapped around it.

An Open Mind While we like to think that medicine and science is an absolute and that wherever we go it will be the same, it’s not

Something to Fill Your Quiet Times There are no cinemas, often no pubs so explore your hobbies and spend that time learning to develop yourself

Reference Texts Because you can’t leave home without them!

Contact With Home It can get stressful so make sure you keep in touch with friends and family

Your Favourite Snacks Be sure to pack yourself a care packa ge

Amani Savi

My name is Amani Savi. My background is that I’m a registered nurse. I worked in Mackay for five years as a registered nurse and it was there that I decided that I wanted to go back and do medicine. I’ve been at Bond University for five years, this is my final year as a medical student. Since I’ve been here, I’ve been contributing to my passion with rural and remote medicine by being part of the Rural Health Club. I’ve served as the Vice President, President and Treasurer. The Rural Health Club, here at Bond University, is reallyjust tohelptrytoengage students inwhat ruralmedicine isall about. Trying to get them to go out and network with doctors that live rurally, getting them to see a different type of medicine.

When I was a nurse working in Mackay, there was not one qualified Australian trained doctor in the entire hospital and I thought that was pretty poor. Considering Mackay is not even really that rural, it’s more regional and I thought, if we don’t even have Australian qualified doctors in regional areas, what have we got rurally? So, that was my big drive to come back and do medicine so that I could give back to the bush and help close the gap which is something I’m very passionate about. I’ve decided to spend my last year as a medical student in a town called Inglewood, which is a town three hours west, which for a lot of people seems a long way away. I think of it as just a bit of a stones throw away. It’s a town of 1,200 people, it’s a two

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GP town at the moment. It will be two GPs and a student when I’m there so I think I’ll get a lot more experience there. I’m the only student who’s taken up the opportunity in my final year to go rural, but I just think it will be fantastic. I’ll feel like I’m already there, I’ll feel like I’m making a difference. I’ll have started building community ties with an area that I would hope to go back to when I’m finished and I’ll still see everything that everyone in the city will see. In fact, I’ll probably see more. What is different about working in rural and remote areas? I think there are lots of differences between working rurally and working in a metropolitan area. I personally think there are a lot of advantages to working rurally, some would disagree. The biggest advantages I see for living in a rural area would be the fact that you’re part of a community. That sense of close-knit community. That’s a big draw card for me. It helps with the continuity of care with your patients. You’re actually able to look after your patients, not just fromwhat they present when they come into the clinic, but because you know who they live with, where they live, what their background issues are with the family; you’re able to treat them much more holistically. You obviously also see those same patients coming through the clinic, it’s

‘When I got there I had a real, oh my goodness am I still in Australia moment. It was like I’d landed in a third world country, it was just heart wrenching...’

not a GP bulk billing, in-out sort of situation, so I love that. I also love the fact that you make a real difference when you’re somebody of this profession in a small community. I love the fact that you don’t sit in traffic for three hours. I must admit that gives me more time to horse ride, so that’s a big plus. You can live in the city and be 5km away from the hospital, but be in traffic for an hour each way. That’s just wasted time to me. I’d rather be practicing medicine or spending timewithmy family. I guess because I lived rurally for those first few years of my life and, although I only have a few memories of it, they were the best memories of my life and I’d like to be able to recreate that for my daughter, so they’re the big drawcards. There are also disadvantages with working rurally. Sometimes your access to resources is not as good. Your ability to promote yourself within your chosen career can be somewhat stunted. But I think if you’re passionate to be there, and you’ve got the drive, then you’ve got

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the ability to continue your profession wherever you are. And I think it’s a big blessing that you can give to people in rural areas, and they can involve you in their personal life; so in saying that, that’s an advantage and a disadvantage. People will be your patients, but they will also be your friends so you do have to be able to draw that line between being their doctor and being their friend, but at the same time it’s such a privilege. What advice would you give to students going on a rural or remote placement? If a student was to come to me and ask me ‘what are the three things I need to know to go rural?’ I would say this: One, get involved in everything you can when you’re out there. Get involved in the local sporting club. Say yes to every experience, if someone says come and muster my cattle for the weekend, do it. That’s the best thing you can do, get

involved in the community. Because it’s the sense of community and that close-knit environment that’s a real drawcard for anyone who goes rural and if you don’t experience that, you’ve gone out there and missed out on that. The second thing I would say is take something to do in your quiet times, because there are going to be quiet times. There are no cinemas, there’s no bowling alleys, there’s no pub or clubs generally. So, take some creative writing, take some music, take some paint, do some artwork. Findyourself inthebushandactuallyspend that time learning to develop yourself. The third thing I would say is be on the ball with your clinical knowledge. You don’t have a lab down the road. You don’t have an MRI machine or a CT scan down the road. Your patients will have to travel maybe two or three hours to get to those types of things. So, be up to date on your clinical knowledge. Know how to diagnose from clinical signs, really listen to your patients and know how to

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do a good history because 80% of your diagnosing can be done from a history if you do it well. They’d be the three big things I’d tell a student going rurally. What has been one of your best experiences working in these remote communities? The best experience I’ve had in a rural setting is when I worked as a student on placement with a GP at St George. St George is a small town six hours from Brisbane and I was lucky to work with a GP who had worked in the town for 40 years. The best part of working with her was that I got to see how she approached her patients and their care. As an example, a patient came to see her who had amental health issue. Shewas not just able to treat that personwithwhat they toldher intheactual interview, shewas able to treat them from a holistic point of view. She knew their mother, their father, their brothers their sisters, and she was able to globally, in a way, look after this patient. And it just astounds me at the end of the day that we saw about 20 patients, every single patient had a different issue - there was not one issue that was repeated. So people who say when you go rural you only do the same thing over and over, they’re definitely wrong. Every patient we saw was different, but every patient we saw, she knew their background. She knew, they’re the teacher that worked at such and such and it’s been really tough

down at the school lately so that’s probably why she’s come to us with that problem.

The biggest advantages I see for living in a rural area would be the fact that you’re part of a community. That sense of close-knit community, that’s a big draw card for me . That ability to have the knowledge of how to treat her patient better and how to look after her patient, the ability to holistically look after them and the continuity of care that you could see she had for all of her patients. That was a big wow moment for me, that’s what really cemented my idea of being a rural GP because, you just can’t do that in the city and so that was a really big moment for me. What have you experienced in remote Australia that has changed your world view? Something that really changed my world view was when I was on placement in a little island called Elcho Island. It’s a little island off the top coast of Australia, about a two hours flight from Darwin. It’s a community of about two and a half thousand Aboriginal people and when

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I went there I was so excited. It was the first placement I was doing in a real rural Indigenous community and I was excited to see all the different health challenges that they face and the way that I was able to make a difference. However, when I got there I had a real, ‘oh my goodness, am I still in Australia?’ moment. It was like I’d landed in a third world country, it was just heart wrenching. It was so sad to see people who are Australians not having access to health care, not having the types of services that urban Australians have, and just being so far out of the way. So, yes it was a two hour flight away but there were hardly any fruits and vegetables on the island. The ability to have a nice house on the island, the ability to have clothes and shoes that were appropriate for the weather, all of those things were just lacking.

It really opened up my eyes to, oh yes, we really do have a gap and we have this Close the Gap campaign and it’s there for a reason, but we really need to be working on it a lot more than what we are. We can keep saying that we’re working to close the gap, but we really do need to be working to Close the Gap because it’s just not happening at the moment. So that was a real moment for me and I think that is, again, the reason I want to go rural because, not only do lots of Indigenous populations and communities not have access to health services, there’s also lots of farming and mining communities that also don’t have access. So, it goes across the board that we need more doctors off the east coast of Australia to go west and if I can be just one of those GPs that does that, then at least I’ll have made some difference.

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Allegra Boccabella

My name is Allegra Boccabella and I’m a third year medical student at Bond University in Queensland. My remote experience started in 2012. I was on a gap year and I can’t really remember why I decided to do it, but I wanted to experience something different. So, we had a family friend who was an Ear, Nose and Throat Surgeon who did specialist outreach in Cape York in Queensland. So, I asked him if I could come along for a trip and he said yes and I’d be coming along as the Audiological Assistant. So, I did that for a week and I absolutely loved it, it was great and I managed to convince him to let me go again. It’s been four years now and I’ve managed to go back six times into a whole

bunch of different communities. I’ve been to Arukun, Pormpuraaw, Kowanyama, Lockhart River and Napranum. Basically the setup is that we have the Ear, Nose and Throat Surgeon, the Practice Manager, the Audiologist and the Audiological Assistant, which is me, that goes up in the group. We basically fly into Cairns the night before the clinics start, and on the morning of the first clinic we get up nice and early and fly in a little plane from Cairns Airport to the first community. At the end of the first clinic, which is at the end of the first day, we fly back to Weipa, which is a remote centre, and we stay there overnight.

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On the second day, we fly from Weipa to the second community and we’ll do a clinic for the whole day and then at the end of that day, we fly back to Weipa. And then on the third day we fly from Weipa to the third community and fly back to Cairns at the end of it, and then we come home the day after.

Another thing that’s different is the investigations and the sorts of things that you can actually do. In a big urban hospital, you can send someone for scans and you can send someone for tests and you can send them for small procedures. But, when you’re actually making those decisions in a remote area you have to factor in: How far away is that test? Does that person have to fly to Cairns? Is that flight three hours? How much is that flight going to cost? And does this patient really need this or can we make do with something else? So, there’s a certain sense of compromise that you wouldn’t see in a larger tertiary hospital in a city. Another thing is the distribution of staff that you see. So, for some of these smaller communities it will actually be a small primary health care clinic and often there won’t be a single doctor in the actual clinic. So, you’ll have a mix of Indigenous Health Care Workers, Nurses, Nurse Practitioners, and other staff. You’ll also have a lot of specialists that fly in and fly out so they’ll just be there for the day, just like we are, in our specialist outreach team. I think that’s really different because you’ve really got that different team dynamic but it’s also smaller and a lot more friendly, so you get to know a lot of faces, you see people regularly. Sometimes with the fly in - fly out, you actually fly into one community with a group and then see them two days later at a different community, so it is quite fun and you do end up on a similar circuit.

What is different about working in rural and remote areas?

The first thing would be that you’re really working under a strict time frame. Not to say that things aren’t busy in urban hospitals, they definitely are, but in remote areas, when you’re flying in and flying out of a community, you have to be finished by a particular time at the end of the day so you can fly out. So there is that time pressure to make sure that you’ve seen the children, because most of our patients are children, and have everything done within that time frame. So, I think that is quite different.

‘If you want to see the social determinants of health in practice then going to a remote Indigenous community is a really great thing to do.’

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And I think that in an urban context, even though you will see the same people every day, the comradery isn’t the same as you see when you’re in the remote fly in - fly out circuit, and that is quite exciting. What advice would you give to students going on a rural or remote placement? Make sure that you bring toys with you. Particularly, plastic ones that you can easily clean, because often you’re dealing with lots of little kids, certainly in ear health, that’s something that we deal with a lot. So, you need to have something to entertain the kids and then the parents are happy and you’re happy and the kids are happy. And also, stickers and that sort of thing. Just having that with you at all times means that if you do have a patient and you are a bit nervous you can make the atmosphere a lot less tense, and you feel more comfortable,

and you obviously build rapport at the same time, so that’s quite good. The second piece of advice I would give is to make sure that you walk in and introduce yourself to all of the local staff that are working in the health clinic. Whether that be the Nurse, the Indigenous Health Worker, the Doctors or even the cleaner, the locals really do know so much about their community. This can range from practical questions like ‘have you seen this child?’ to ‘I didn’t really know if I could ask this patient this question’ or ‘they looked a bit strangely when I said that, is that ok for me to say?’. Often I’ve found in all of the communities I’ve been to they’ve been really helpful and always really happy to help out whenever you ask. It is really important to remember, in these clinics, that for a lot of these communities, they have different health services coming in

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every single day and sometimes people come and can be short and not very respectful, that this is their clinic. They often appreciate that you’ve made the effort to introduce yourself and get to know a little bit about them. I would definitely say do that, because it’s the respectful thing to do and also, they really help you out when you need them. Ask questions, be happy to be there, be enthusiastic and don’t be worried about getting out of your comfort zone... The third piece of advice would be to make sure that you’re really open with the parents and the community in general. Ask questions, be happy to be there, be enthusiastic and don’t be worried about getting out of your comfort zone and doing that sort of thing. If you talk to the parents, if you ask them questions, if you join in on their jokes, that’s going to make you feel more comfortable and that’s going to make the experience much better for you. What has been one of your best experiences working in these remote communities? We were on a clinic up in, I can’t remember the name of the community, it

was probably Arukun, but basically there was this gentleman who came in with this large sebaceous cysts and the option was that we sent the him to Cairns or that the surgeon did the operation that day. I think I was first year medical school, really excited, but I’d actually never seen a procedure like this done before and the surgeon said ‘we’ve got a medical student, let’s get her in’. So I got to stand in and just before he was like ‘It’s ok, it’s going to be good, I’ve done this surgery so many times, this is not a big surgery so I want you to be able to see everything. This is really going to be something exciting for you.’ So, I stood in there and watched the whole procedure andhewas askingmequestions and drilling me. As a medical student, that’s a moment you dream about for your entire life until you get to that point and being in that situation, that it was just me, him and the patient, was so special. And actually, I’d never considered doing surgery up until that point but we got to the end and I thought: yeah, maybe I could do that. I think if my first experience was in a big hospital with a whole bunch of nurses, a whole bunch of doctors, a whole bunch of people in the room, I wouldn’t have felt as comfortable. I wouldn’t have been able to see so closely, I wouldn’t have been so involved. So, that really was a really special experience that I don’t think you can get outsideof the rural andremoteexperience.

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What have you experienced in remote Australia that has changed your world view? My first experience seeing remote Australia was probably the biggest life changing moment, in terms of my experiences with rural and remote health. I was raised in Brisbane, I’m a self- confessed city girl, that’s something that I really like and I’d never been anywhere like that before. If you want to see the social determinants of health in practice, then going to a remote Indigenous community is a really great thing to do. However, it can be really sad and I certainly found that it was really sad. We live in Australia, that has so many things to offer, and we have this huge inequality in terms of health and educational outcomes with Indigenous Australians and yeah, you hear about it and you read about it, but it’s so different to actually seeing it. The communities that we were going into, some of them are classified as being the most disadvantaged communities in both the state and Australia. So, you really do see a lot of poverty. From the moment we actually got off the plane and went to the health clinic you could really see it. You could see that the houses were run down, some of the places didn’t have doors on them, therewas a lot of pollution, there were a lot of mangy dogs running around and they looked quite sick.

Then when we got into the clinic, I remember that there was a scabies outbreak at the time, so a lot of the kids had scabies. I saw a lot of head lice, not that you don’t see these sorts of things in Brisbane or in urban contexts, you do, but it was much more prevalent there. That really changed my world view and, with a lot of the kids, you saw that certainly they were quite sick and you could really see that there was a disparity in health. Another thing that I remember is that you didn’t see a lot of old people. I didn’t really understand why until I was driven, from this first experience, to go and study public health and I learnt that I didn’t see any old people because Indigenous Australian’s don’t tend to live until they’re very old, particularly those who live in those remote communities. So, I think it’s quite interesting that my first experience was also my most life changing.

‘These communities, some of them are classified as being the most disadvantaged communities in both the state and Australia. So, you really do see a lot of poverty...’

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As a result of working in a remote area, what are your future plans? My plans are to be involved in remote health for the rest of my career at varying levels. After studying public health, I definitely have a strong interest in that side and I really do hope to go on to become a specialist. I hope to participate in specialist outreach, similar to the outreach model that the Ear Nose and Throat Surgeon I’ve worked with does. I don’t want to be an Ear Nose and Throat Surgeon, so it will be something different. But I definitely hope to be able to do that and I wouldn’t mind doing some time even before that as a Registrar or as a

Training Doctor, doing some remote work and maybe some work with the Royal Flying Doctors in the future as well. I would also like to get involved with health policy, particularly in terms of remote and Indigenous health. I think I do have a reasonable understanding of what it feels like to be on the ground and not many people have that experience of actually beinginthosecommunities,beingadoctor and then also having the policy aspect of it. So, that’s all a bit of a dream. I don’t know how much of that I’ll actually get to be involved in but, definitely, I would absolutely love to continue going on with the specialist outreach and really can’t wait until it’s me there in the Doctor position.

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I was workingwith a couple of women who were managing a diabetic support group, a support group for people with diabetes. We were going up to the other end of the island that was about two or three hours drive. Somehow, I ended up driving the big troop carrier. Amazingly enough, we started with three people, ended up with about 15 including my two kids - they were always coming with me. Anyway, driving, driving, driving, we get to this big, what we call a jump up, a bit over a sandy rise. BANG! Straight into this wallaby, killed it. I was traumatised! I was a vegetarian, my oldest son was traumatised because he hated seeing things hurt. But the rest of the peoplewhowere therewere so happy. That story is still told today, how after all those years, Robyn finally did something useful. That was a real wake up, I thought they were just laughing at me, which they were, but the council president came around and said ‘finally, Yapa, you’re doing something useful, thank you, thank you, thank you’. I went: ‘OK, if I’d have known it was that easy I would have run over a few kangaroos a bit earlier!’ ‘

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Robyn Williams

@ElsevierAUS My name is Robyn Williams and I have lived and worked in the Northern Territory for the better part of 35 years. I first went to Darwin to do my nursing training over 35 years ago, because I had an interesting but useless Arts Degree, and I didn’t want to be an Anthropologist, still don’t. I wanted to do something that was both practical and useful, being a third generation do -gooder, and that seemed to be the best and quickest way to do it. In those days, Nurses were the main work force apart from the Aboriginal Health Care workers. So I did that for a few years, came back into Darwin to do my Graduate Diploma of Education, went back out bush teaching, then combined both

of those at what was Bachelor College teaching Aboriginal Health Workers, writing the original Aboriginal Health Workers courses and teaching those for a few years. So, it all came together like some grand plan but, wasn’t actually. I think it was also a matter of knowing what I didn’t want to do but broadly where I was working. So, I’m now coordinating the Bachelor of Health Sciences at Charles Darwin University and again, that’s another nice amalgamation of my experiences from my time, and one of those units is Rural and Remote Health which I just love.

What is different about working in rural and remote areas?

who you are, that doesn’t necessarily mean knowing where you come from or how you are, not the prosaic stuff, but more knowing who you are. Your professional, cultural identity, that’s really important because things tend to be heightened in a rural or remote context and you need to know who you are because you’ll be thrown into situations where you need to be able to fall back and know yourself and be strong. You need to be strong and be independent and be a culturally safe practitioner; it’s absolutely crucial. So that would be the first thing, to know yourself and know who you are. Secondly would be to find out a bit about the place where you’re going. Do your homework, do a bit of research. Is it a farming community, a mixture of hippies and farmers and rural politicians that only visit come election time or is it an Indigenous community? Was it a reserve? Just get to know a little bit about it so you know what you’re getting yourself in for. So you don’t get there and find out, much to your shock and dismay, that there are no caravan parks of hotels or shops with interesting little bits and pieces in there. The third thing would be, to mind your manners. By that I mean to be respectful. Most of the things that you will think of when you go out there, people would have done before or at least thought of. So it’s part of finding out the history.

There’s a lot of differences. I think probably the main thing, at least for me, and the people that thrive in those situations, is the fact that in a rural and remote context, you have the opportunity to develop relationships and engage with the community. In fact, it would be really hard to avoid that when working in a remote context. In an urban context, you tend to be in your little work bubble and then you’re home or your social life bubble, and the two don’t often connect. It’s easy to stick with your own kind in an urban context. What advice would you give to students going on a rural or remote placement ? Number one, know who you are and have a strong sense of self. Know exactly ‘After spending long amounts of time in rural and remote communities I realised that I actually knew less than when I started. I think that was probably a key moment.’

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That was a real wake up, I thought they were just laughing at me, which they were, but the council president came around and said ‘finally, Yapa, you’re doing something useful, thank you, thank you, thank you’. I went: ‘OK, if I’d have known it was that easy I would have run over a few kangaroos a bit earlier.’ Did you have any ‘aha’ moments working in rural and remote areas? When I realised reasonably early on ‘actually I know very little’. Certainly, after spending long amounts of time in rural and remote communities, I realised that I actually knew less than when I started. I think that was probably a key moment. I think also, in order to be a culturally safe practitioner you have to be respectful. That can be really hard because not everybody is nice and not every person you’re meeting with and engaging with is going to give you the same courtesy...

Be respectful of other people, they might not do or think or look the same as you. But, none the less, mind your manners and be respectful. Listen. Shut up and listen. I thinkthatwouldbemythirdpieceof advice. Something I find surprisingly easy to do. What has been one of your best experiences working in these remote communities? One of the experiences that was the most salutary forme in terms of going, ‘aha!’was having a little epiphany was many years ago - probably about fifteen years ago. I was in a remote Indigenous community, about 500ks north east of Darwin; a big community, about 3,000 people. I was working with a couple of women who were managing a diabetic support group, a support group for people with diabetes. We were going up to the other end of the island that was about two or three hours drive. Somehow, I ended up driving the big troop carrier. Amazingly enough, we started with three people, ended up with about 15 including my two kids - they were always coming with me. Anyway, driving, driving, driving, we get to this big, what we call a jump up, a bit over a sandy rise. BANG! Straight into this wallaby, killed it. I was traumatised! I was a vegetarian, my oldest son was traumatised because he hated seeing things hurt. But the rest of the people who were there were so happy. That story is still told today, how after all those years, Robyn finally did something useful.

Which is a good thing because it takes the pressure off and it also means that, you know, non-Indigenous people have a

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shelf life in Indigenous communities. Like a celebrity sports star, you need to know when it’s time togo, when it’s time to retire. The other thing that came with that was, I knew that leaving a particular community wasn’t the end of my relationships. We’ve had a long many decades, three decades of family connections with many communities, and we still have those connections. One of my favourite brothers is a Yolngu man from one of the communities. My kids grew up out in these places. They’ve had experiences no one else would have. In fact I think the youngest at 21 is convinced, well he’s not convinced that he’s not Aboriginal, just because that was the way he was brought up. How can someone ensure that they are working towards being culturally safe? Being a culturally safe practitioner is about first and foremost, knowing who you are and the impact of that on the people that you are engaging with. Whether it’s working or they’re your clients or it’s just on a day to day interaction. So, knowing who you are and the impact of that. For example, I’m a third generation do- gooder, I’m also a Collingwood tragic for those of you who know or care about AFL, that absolutely has an impact on who I am and the way I can engage with people. I remember going out to an Indigenous

community many years ago and the entire community were Collingwood fans and I thought, ‘Yes! Give me a job, I’m coming to work here.’ So, knowing who you are and the impact that has. I think also, in order to be a culturally safe practitioner you have to be respectful. That can be really hard because not everybody is nice and not every person you’re meeting with and engaging with is going to give you the same courtesy, particularly if you’re in a stressful or an acute clinical situation. It can be really hard to be nice to someone, and be respectful and acknowledge what they bring to the table. Can I just give you a classic example? When I was teaching the Aboriginal Project Officers course, it was mostly urban Aboriginal people and I’m an interactive teacher so I’d say to them ‘what do you think?’ And, this young man who had come in from one of the mining

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communities, an Aboriginal man, he was earning a lot more money than I was as a mechanic. He came in to do the course because he wanted to change his work and he just slammed his fists down on the table and he said ‘I didn’t come to university to be asked what I think! You need to tell me, that’s your job!’ I thought, OK, here I was thinking that I was being culturally safe but no, I hadn’t actually engaged the person, the recipient in the sort of care or the sort of education that they wanted. That for me was a big moment and that was when I first really started thinking about how it doesn’t matter if you’re

teaching nursing or landscape gardening, you need to work in a culturally safe manner so it’s actually engaging with the person and negotiating with them. I think it’s absolutely critical. Certainly, as health professionals we’re taught, in particularly if you’re a medical practitioner, you’re taught that you’ve got the answers and you tell people what to do and I think it’s unlearning that in many ways and taking that on board.

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Shannon Springer

My name’s Shannon Springer, I was born andraisedinMackayinNorthQueensland. I’m an Aboriginal, South Sea Islander man from there, and spent a few years, my younger years, in Longreach which is in fromRockhampton. I went to school there for about four years before moving back to Mackay. I spent most of my life there. Originally I didn’t start out to be a Doctor or to be a GP, which I am today, or an academic for that matter. I was really interested in playing rugby league and I had a scholarship to play football and after I finished year 12, I moved to Brisbane to try and pursue that career. Whilst I wasn’t that good at football, I was also enrolled at university and I studied a degree in Indigenous Primary

Health Care which I studied around a whole range of people, a whole range of Aboriginal, Torres Strait Islander people, which were really inspirational for me. Afterfinishingthatdegree Idecidedtostart studyingmedicine. It was through a whole bunch of encouragement and support from a whole lot of non-Indigenous people as well, that I enrolled in James Cook University in Townsville which had a strong focus around rural, remote, tropical health and Indigenous health. So, I studied there, it was a six year course and I really enjoyed it. It had lots of placements in rural, remote areas in Kowanyama and The Cape, Ayr, Mount Isa, Charters Towers, so it

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I knew very early on that I wanted to be working in community medicine. I loved getting out of the hospital context, around health promotion, disease prevention and particularly trying to make some in roads around Aboriginal, Torres Strait Islander health outcomes. So I completed my hospital bare minimum and got straight out into general practice. Just before I finished my fellowship training I moved back to Mackay and worked at the Aboriginal medical centre where I was for the last six years, working with my own community. That was really inspirational, working with your own family and cousins and relatives and seeing them as patients. That’s something that can happen working in rural and remote, you can’t have that professional divide.

‘It’s the environment, it’s the people and I think it’s the journey on the way to the patient. It’s not just about the patient and the medicine, it’s everything wrapped around it.’

was really, really inspirational for me to do that and stay connected, being in North Queensland, and I’d get to play football as well which was also important. Finishing that degree, I moved to Brisbane, I actually moved to the Gold Coast first to complete my internship, then went to Rural Brisbane Hospital.

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