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    Jennifer Doggett

    Jennifer Doggett

    Great piece – what this highlights for me is the importance of consumer and community consultation in the development of health promotion, preventive health and primary care policies and programs, where this consultation specifically involves people from culturally and economically marginalised groups. No matter how well intentioned, a group of middle class public servants, academics and clinicians are never going to be able to solve these problems on their own.

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    Government cut backs in funding to aboriginal medical services (AMSs) have already begun. However the proposed $7 co-payment and the soon to be introduced inability to bulk bill indigenous patients for management of an acute illness along with a chronic disease plan at the one consultation starting in November will lead to widening of the gap in survival between indigenous and non-indigenous people.
    I work in an AMS in the remote north of Australia. Our clients only present to the clinic when they feel ill. I don’t see ‘worried well’ Aboriginal and Torres Strait Islander (ATSI) people. Many ATSI people don’t understand the concept of subclinical illness. When I first started working with ATSI people I managed indigenous people like I had my non-indigenous clients in the outer suburbs of Melbourne. I would attend to their acute problem or the most important problem on their list of complaints and ask that they see me again for management of non-acute and less urgent problems. The non-indigenous clients in Melbourne would return for follow-up and be interested in returning for preventative activities such implementing measures to address chronic disease, immunisations and smears. This is not the case with ATSI clients. Most ATSI clients never return until they are symptomatic again. I have therefore found that when they attend I have to address every complaint on their list, perform a complete health check and ensure preventative activities are completed to ensure better health in the future. This means consultations regularly take over an hour. Thus apart from managing the scabies or impetigo they present with, I commence management of the previously undiagnosed diabetes, treatment for the asymptomatic STI or renal disease, and counselling and or medication for suicidal depression and other psychiatric illness. These problems left undiagnosed and untreated not only increases death rates in our ATSI clients but increases the public health risk to others who contract these asymptomatic infections.
    Those of you who don’t work with these clients possibly don’t understand the barriers to their more regular attendance. This includes ATSI patient ignorance of the importance of addressing asymptomatic illness before complications develop. Other barriers include embarrassment and many clients not having developed trusting relationships with doctors who often only stay in these communities for a short period of time. Some clients have no transport to get to the clinic (we have insufficient very poorly paid drivers who attempt to find clients and bring them in to be seen), some clients are not contactable (no phone or no service where they live remotely) or combinations of these impediments. Some of the very remote small communities are only visited by doctors every few weeks in the ‘dry’ season. It is crucial that all patient problems are addressed during these visits. However, now the government wants to introduce another barrier – the $7 co-payment. AMS’s already have difficulty recruiting doctors as better remuneration exists in the hospital system (where only acute problems are addressed). Taking another loss of income will surely be the death of AMS’s whom I believe are vitally important to fund appropriately if we are to have any chance of ‘closing the gap’.
    Dr Andrew Beveridge
    SMO, Ord Valley Aboriginal Health Service


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