by Chips Mackinolty.
The first that staff and Members of the Aboriginal Medical Service Alliance Northern Territory [AMSANT] heard about the Centre for Independent Studies researcher Sara Hudson was that she had written a piece on Aboriginal Health Workers [AHWs] for the ABC’s The Drum, and that she had quoted AMSANT in her research paper, Charlatan training: how Aboriginal Health Workers are being short-changed.
A large number of our Members, and others in the broader AHW community—universally astonished and offended by her piece—contacted us about the quotation: was it accurate?
Well, yes and no—but more of that in a moment.
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In the short term, AMSANT issued a statement which was circulated throughout the sector, pointing out that while it was supportive of well informed discussion about AHWs, Ms Hudson had disappointingly never been in touch with AMSANT, and that there were inaccuracies in her pieces.
There was, of course, considerable anger at the insulting tone of her work. In calling AHWs “charlatans” operating in “a charlatan role” provided with “charlatan training” was clearly derogatory. Her libel of the profession was nothing if not deliberate, with the dictionary meaning of charlatan having a specific medical dimension: “someone who professes knowledge or expertise, esp in medicine, that he or she does not have; quack” . The libel, we are told, is thanks to “(a) woman I met in Western Australia”.
But the real astonishment and offense was not so much that Ms Hudson had not spoken to AMSANT, nor even the inaccuracies in her work, but was at her mendacious use of much of the material she cites.
Let’s start with her citing of AMSANT material, and in particular the organisation’s claim of a 30 per cent decline in the AHW workforce over a decade. Although it’s a figure she uses to benefit her arguments a number of times, she admonishes AMSANT for not providing “numbers to back up its claim”.
Hello? This, the only AMSANT source she quotes, was drawn from a media release—not the usual place where it is expected to footnote references. Nevertheless, a simple call would have shown her this data was drawn from the Allen and Clarke evaluation of the Intervention’s primary health programs. In fact, Allen and Clarke used the same data set Hudson herself uses—ironically she could have done the sums herself without, as it will be seen, misquoting others.
But Hudson wants to cite an Aboriginal organisation to back her argument even, if necessary, through misquoting and verballing:
The Aboriginal Medical Services Alliance Northern Territory (AMSANT) claims there is a crisis in Aboriginal health work because the number of Aboriginal people electing to become AHWs is falling [emphasis added].
In fact, AMSANT said nothing of the kind in the media release as can easily be seen. What the media release did say was something that Hudson will not admit, and which is stated quite clearly in that document, quoting AMSANT CEO John Paterson:
The number of Aboriginal Health Workers has dropped by 30 per cent in the last decade.
76 per cent of the profession is over the age of 40, and heading for retirement over the next couple of decades.
These statistics would be regarded as a scandal if it were to occur in mainstream health practices.
It is just as much a scandal in Aboriginal primary health care.
Given that all Australians know that the health outcomes of our people are so appalling, the fact that we are seeing the slow starvation of your profession makes it an even greater shame job.
But that’s because Hudson in fact wants to see the AHW profession abolished altogether: she is entirely happy that the profession is in decline. The fact that a valuable resource in Aboriginal health is being allowed to wither concerns her not at all—she reckons they are charlatans in any case.
Of course, Aboriginal people are judged responsible for the decline in numbers of AHWs through lack of interest in AHW work, according to Hudson:
The drop in the number of registered AHWs in the Northern Territory and the low numbers of AHWs completing their training are not the result of a lack of RTOs or government funding but the lack of education and interest among remote Indigenous people to become AHWs.
She produces no evidence for a lack of willingness to become AHWs, but to this end Hudson footnotes an ABC Stateline NT report, and yet again provides her own spin in the hope that no one had seen the original report—or would check it later. There is nothing in this report that evidences Hudson’s alleged “lack … of interest among remote Indigenous people to become AHWs”. The television report says it is a tough job, and not one that everyone can do—but critical nevertheless to the running of Aboriginal health services. One interview in the television segment points specifically to shortcomings in the structure of training, and another into the racially discriminatory nature of work conditions. No interviews or editorial in the yarn point to a “lack of interest”.
At times, this mendacious approach borders on dumb if not willful misinterpretation of reality. Hudson again gloats at the use of an Aboriginal newspaper source, not to mention a “real” health worker, when she claims:
Thirty years of welfare dependency has sapped the motivation to seek employment among many remote Indigenous residents. For example, one young woman had to be literally dragged off the Community Development Employment Project (CDEP) to undertake a traineeship in AHW:
“I remember when I was just turned 18, I was always very negative about things and wasn’t interested in nothing … There was this lady there who helped workers get full-time jobs. She came to me one morning saying she had a traineeship for Aboriginal health workers that I could apply for, but I said no. She still dragged me along and helped me fill out the forms and got me clothes for the interview. When she dropped me off I remember giggling the whole way. Two weeks later a man from Wurli called me and said I got the job. I remember my whole family coming and congratulating me on my job. I could see they were proud so I thought I would give it a shot.”
Aboriginal Health Worker Leitisha Jackson
For anyone who was present when Leitisha Jackson delivered that speech at the launch of the Year of the Aboriginal Health Worker nothing could be further from the truth about “sapped … motivation to seek employment”. Any decent reading of the Koori Mailarticle would see that this was the story of a wonderful young Aboriginal woman who is succeeding despite many obstacles. Hudson’s deliberate selective quotation insults Ms Jackson’s intelligence, not to mention commitment to her work, and who elsewhere in the Koori Mail article is quoted as saying:
Being an Aboriginal health worker has given me so many opportunities that I wish other young people my age can have. I had the best senior Aboriginal health workers as mentors. I feel so privileged to have worked with them.
Nor is Hudson interested, in the same Koori Mail edition, of the words of AHW stalwart with a 50 year career behind him, Jack Little, when he said that it was “good to see young health workers following in our footsteps.”
There is a simple reason for this. Hudson’s ideological position is that—despite any evidence to the contrary—the existence of AHWs is part of a “separatist” creed that is by definition doomed to fail:
Like previous research undertaken by the Indigenous Affairs program at The Centre for Independent Studies, this monograph examines the unintended consequences of having race-based policies and whether the problems faced by AHWs are symptomatic of this separatism.
Of course, according to Hudson, it is because
Among the Aboriginal health industry, there is the widespread belief that Aboriginal people feel more comfortable dealing with a health service provider who understands their culture and beliefs.
AHWs at Katherine NT, 2011The clear inference from this is that this is dangerous separatism, rather than ordinary common sense, and that it is being led by yet another “Aboriginal industry”.
In fact, if you go back to the report she cites, the evidence led to the exact opposite of her conclusions, and ideological position. Again she seems to trust that no one will look at her sources, let alone the “evidence in private” she has apparently discovered. The Legislative Council inquiry, on the evidence they gathered, in fact recommended greater resourcing for AHWs, with increased responsibilities, training and accreditation. It specifically recommends accreditation based on the Northern Territory model of registration.
It is worth quoting the “evidence in private”—as if such mysterious evidence is especially revelatory and otherwise subject to suppression—that Hudson suggests is evidence of an “Aboriginal industry” conspiracy to maintain separatism:
You have to understand that Aboriginal people will listen to their own. They have got confidence in their own persons, in their own ranks, and they will not tell another white nurse their problems to the fullest. They will tell them the good things but they will not tell them really what is wrong with them and this is where the decline in health has deteriorated within the last 10 years because most of our health workers have gone and been replaced with more nurses.
From the same page of the Legislative Council report, Hudson conflates the commentary of the Inquiry, with that of a group giving evidence with another quotation from this separatist “industry” in discussing “culture and beliefs”, but deliberately ignores what is being presented:
There is anecdotal evidence and some qualitative research indicating significant problems with the cultural safety of many mainstream health services for Aboriginal people. At worst this can result in personal discomfort and late presentation of sick Aboriginal clients; at worst, overtly discriminatory treatment and unnecessary morbidity and mortality.
Yet again, Hudson’s willful misinterpretation is an important part of her methodology and the quotation above is a case in point. Where she argues in Charlatan Training that the AHW profession should be abolished because cultural brokering is an anachronism, Hudson happily quotes—or misquotes—material antithetical to her position, and trusts she will get away with it.
And make no mistake about it. Hudson wants rid of Aboriginal Health Workers, and claims that proponents of the profession are merely atavistic:
Those who claim there is a crisis in AHW are clinging to the past; they cannot see that change is inevitable. The future and real self-determination does not lie with the creation of yet more ‘culturally appropriate’ courses and career paths specifically for Aboriginal people but with decent schooling and education that will enable Aboriginal people to become whatever they want to be.
Just as long as you are not an Aboriginal person that wants to be an AHW!
What Hudson proposes is:
- Abolish AHWs and convert the clinical role they carry out to one of “nurse assistants”
- Convert the “community” work of AHWs to “community workers” with no clinical role at all
- Converting the cultural brokerage aspect of AHW work to that of “Aboriginal Liaison Officers” to “act as a translator for visiting health care providers. … and the role extended to cover interpreting for all non-Indigenous visitors to the community”.
This is Hudson’s solution but, like so many desktop research projects, has little to do with reality.
For a start, what is to be done with the Aboriginal health centres that are managed by senior AHWs who have current management control over nurses? Are they now to be run by “nurse assistants”? Or is it inconceivable that Aboriginal people can “manage” whitefellas, just because they are AHWs?
In this, she takes no account of the fact that, in the Northern Territory, there is a link between wage parity and qualifications with job roles and scope of practice. She doesn’t appear to realise that to become an AHW in the Northern Territory is now only possible through a Certificate IV ATSI PHC (practice) which takes up to 2.5 years and includes mixed mode delivery which means the trainee does some block intensives and then clinical practice with on the job learning back home in their community.
In any case, Enrolled Nurse training is at a much lower level of clinical competence than an AHW and not in line with the Primary Health Care practice that is imbedded within the role of the AHW.
Hudson belittles the skills base of AHWs in aid of her ideological thesis that AHWs should be wiped from the workforce. In other words, Hudson reifies the work of a non-Aboriginal work classification as being superior to an Aboriginal qualification—even if that is not true.
In general, Hudson’s position appears to be that the capacity of Aboriginal people to perform clinical work as AHWs is simply impossible—despite the fact that, in the Northern Territory, they are qualified to sign off on Medicare item numbers, and all that this implies in terms of skills and legal competencies. Her solution is to abolish AHWs in place of job classifications such as “community workers” and “Aboriginal Liaison Officers”—and mere assistants to Florence Nightingale.
Hudson is right that in saying we have a crisis in education for many Aboriginal people, and that there are significant literacy/numeracy challenges which compromise training in areas like AHW training. But it is not as if Aboriginal people—as she tangentially acknowledges—have not recognised this. . That is throwing the baby out with the bathwater. She is totally misguided in her recommendation to get rid of the AHW profession and replace it with a model of nurse assistants. This would be unacceptable to the Aboriginal community and profoundly misses the point about the skills and knowledge that AHWs bring to the health team.
Hudson is right, as well, that too much was perhaps expected of many AHWs in the 80s and 90s given the limited literacy and numeracy skills that many AHWs possessed. It was simplistic and wrong-headed, if indeed ever espoused, to think that AHWs would be able to take over health care in their own communities without the involvement of other on-site or visiting health professionals like nurses and doctors. In particular it was mistaken, if anyone actually claimed it, to think that AHWs could simply replace nurses to become the key clinicians in their communities—but that is not what has been argued by the Aboriginal community controlled health sector in the last quarter century.
What has been argued by the sector is that it is equally mistaken to propose that Aboriginal people do not have a critical role required in the primary health care team, and that AHW clinical skills not be enhanced. The notion that an endless cycle of non-Aboriginal health professionals would be sufficient to meet community needs, or even to meet the needs of the temporary nurses and doctors themselves in remote communities, would have been as ill-conceived 20 or 30 years ago as it clearly would be today. The turnover of non-Aboriginal staff in remote communities continues and may be worsening: Aboriginal health workers and other Aboriginal staff are key to ensuring high quality culturally and clinically safe service delivery.
Put simply, AHWs are the one part of the primary health care workforce that cannot be replaced by “section 457” imports—let alone FIFO locums.
What Hudson does not recognise is that—despite her regular quoting of relatively ancient documents—things are somewhat different today as we head towards national registration of AHWs, and that AHWs and Aboriginal community controlled health services are at the forefront of the debate. They, unlike Hudson, are not locked into the past, and the quotation of decades-old positions. In Charlatan training, Hudson comprehensively refuses to engage with the Aboriginal health sector’s contemporary critique of the place of AHWs—and its analysis of massive neglect of governments, particularly in the realm of literacy/numeracy.
Whereas in the distant past only limited English literacy and numeracy capacity was required for AHW training, the new Certificate IV in Aboriginal Primary Health Care [PHC] training required for registration requires a much higher standard of functional literacy. And herein lies the problem for the Aboriginal PHC sector, particularly in many remote areas of the country. Many people in remote areas simply don’t have the literacy to undertake the Certificate IV training and as a consequence the AHW profession in places like the NT has been in decline over the past decade.
Hudson is again right that English literacy and numeracy deficiencies for people living in remote communities present serious challenges for people wanting to take on a variety of occupational roles relevant to their communities—and this is hardly limited to health care.
The education system over recent decades has clearly failed Aboriginal people in many regions and this national disgrace requires serious effort and reform. Hudson rightly points out the 1976 proposal from the Institute of Aboriginal Development for on-site literacy/numeracy programs in remote communities to compensate for the lack of literacy attainment in schools. But, even though this problem was clearly recognised 35 years ago, nothing of any substance eventuated. We haven’t had effective education in schools, and we still don’t have accessible or quality literacy/numeracy programs for adults in communities. It is hardly the fault of Aboriginal people that this basic requirement was not met then, and is not being met now.
In these terms, remote Aboriginal people have been left to rot and so we arrive at the difficult circumstances of the current day. Of course, we could blame these Aboriginal people themselves for this outcome, as is clearly the bent of many of the responses to Hudson’s The Drum opinion piece. This would be fine for the Anglo-Australian tradition of blaming Aboriginal people, but not one with any merit or any solution in prospect.
The current Certificate IV in Aboriginal PHC, the certificate required to become a registered AHW in the NT (and what will be required right around the country to become nationally registered as an AHW on 1 July this year), is a tough course. It is tough because of the amount of content. Students have to do pre-requisites prior enrolling in Certificate IV PHC – which generally takes six months. Once successfully completed, they then enroll in the Certificate IV PHC but they must have a clinical placement and undertake 900 hours clinical work within the Certificate IV which they are expected to complete within 18-24 months.
But it is tougher for remote area people because of its literacy/numeracy requirement. That’s a significant reason why in the NT in 2009 only nine people graduated as AHWs in the NT, whilst another 35 dropped out of their AHW studies. Literacy/numeracy requirements are not being compromised here, but it’s still enormously problematic that too many Aboriginal people can’t meet these requirements.
And, again, it is not the fault of the many young Aboriginal Territorians who want careers in health that literacy/numeracy has not been achievable.
Clearly immediate and concerted action is required to develop and provide serious literacy/numeracy programs for remote Aboriginal adults seeking to gain qualifications to enter the workforce, not to mention for those still in schooling.
We have never genuinely tackled this problem in the NT and as a consequence large numbers of Aboriginal people have been left in no man’s land in relation to potential employment. This is not to say we should be starry-eyed about the impact of intensive literacy/numeracy work—it is very difficult to make up for deficient school education—but with appropriate assessment it should be possible to get a significant number of motivated people over the line with literacy with focused effort. This will be too difficult for some, but very possible for others.
Having said all this, there are definitely roles for Aboriginal people with limited literacy/numeracy in Aboriginal health care, but these roles are not those of the registered AHW. There are roles in community liaison, health promotion, cultural mentoring, all legitimate roles that will all add to the capacity of the comprehensive PHC team. But no one pretends that poorly literate people can gain registration as clinical practitioners.
It’s a furphy Hudson simply asserts, with no one supporting such a position in contemporary times. It is acknowledged that current AHWs seeking national registration without the Certificate IV qualification (grandfathering) should be offered focused support to improve their literacy/numeracy.
Hudson’s point that nursing qualifications offer far more work flexibility, and are transferable around the world is reasonable at one level and indeed many AHWs take up this option of nurse training after a period as AHWs. But her suggestion that we should get rid of the AHW profession and create nurse assistant roles preparatory to eventual nurse training essentially misses the point for many regions, particularly remote contexts.
And does nothing to solve the literacy problem—which she rightly identifies but offers no solution beyond the abolition of AHWs and replacement with nurse assistants, with the same presumed lack of literacy/numeracy skills.
Indeed Hudson doesn’t even make the right connections with the importance of literacy/numeracy in her over riding obsession with the elimination of a “separatist” Aboriginal job position:
Instead of pouring more money into an unfixable problem—AHW qualification and training—government should invest money in quality literacy and numeracy education for remote Indigenous residents.
The real link is literacy/numeracy for a critical employment category, Aboriginal Health Workers—which she acknowledges in her discussion of IAD’s bid for funding to carry out precisely that work—not the elimination of the job category itself. She offers no evidence that the problem is “unfixable”—merely rhetoric about a job category she finds ideologically distasteful because it has the word “Aboriginal” in front of it.
Firstly, the AHW profession, despite the challenges of training, offers people a viable entry into the health industry. Many are promoted into supervisory and management or governance roles. They can train close to home and live and work in their own communities. Entry into nurse assistant training would be less accessible or less attractive to many, although it could be an option offered to some people. Physician assistant is also a potentially developing role.
Secondly, Aboriginal people as assistants to non-Aboriginal nurses is not what is required and fails in a fundamental way to understand the different skills that nurses and AHWs bring to the PHC team. Both nurses and registered AHWs are clinicians. In some circumstances it could be considered that nurses provide higher level clinical skills than AHWs, and are relative leaders in the clinical sense. However, in most circumstance it could be considered that AHWs have far greater knowledge of community and social determinants of health, and are relative leaders in the application of health care. And this is fundamental to the success of primary and preventive health care.
These two clinical professions bring different skills, and both are required in the workplace in complementary roles. They both assist each other, but should not be considered as assistant one to the other. This dynamic would fail to recognise the different skills they bring to the table, and would not work in the socio/political context of Aboriginal health delivery.
Having temporary non-Aboriginal people in charge of services in remote area communities as a permanent way of doing business locks us into all the old social arrangements and limitations of Australia over very many decades. Indeed, given recent work on high stress levels for Remote Area Nurses, especially in the context poor orientation and of working with high turnover/short term and agency staff , the importance of strong Aboriginal Health Workers as fellow clinicians is even more critical.
Desktop commentators such as Hudson pay no attention to what is really happening on the front line of Aboriginal health. Hudson refers to what she describes as a “cultural relativism” that “has promulgated many myths, namely, that Aboriginal people are unable to cope in mainstream health positions, and that they are turning their back on Aboriginal people and traditional medicine if they become nurses and doctors”.
That “myth” is her own—and one she does not footnote. She is the one that denigrates AHWs as being inferior, for example, to Enrolled Nurses. She also denies the pride in the Aboriginal community in those that achieve the rank of AHW, or nurse, or doctor, and the status each of these roles entails.
But let a GP—the pinnacle of Hudson’s primary health care hierarchy—speak:
When my job was working almost full time as a doctor in remote Aboriginal communities, I used to say (to) people that I could not do my job competently without Aboriginal health workers. Many of our clinicians now have to try to do their job competently without Aboriginal health workers, because we do not have the workforce.
Aboriginal Health Workers as charlatans? Tell that to the AHW who administers to me—as a whitefella—and who tells me of occasions of reviewing patient files and picking up life threatening conditions that were missed by the doctor, and resulted in life saving interventions. He is the kind of health professional I feel happy to be with.
The dictionary definition of charlatan describes someone who falsely professes knowledge or expertise, especially with regard to medical matters. Come on down, Sara Hudson!
Chips Mackinolty is a Darwin-based writer, and is currently employed by AMSANT as Manager Research Advocacy Policy.
Want to read more views on Sara Hudson’s report – see the response from the National Aboriginal and Torres Strait Islander Health Worker Association (NATSIWA) response here and this Media Release from the National Aboriginal Community Controlled Health Organisation (NACCHO) here.
For a copy of this paer with complete references and footnotes see the AMSANT website here.