Dr Maureen Davey

It’s true, Aboriginal health is much worse than that experienced by other Australians. Whether Aborigines live in urban areas or remote communities they are likely to die 17 years before their non-Aboriginal contemporaries. Closing this gap requires better government investment in health services, as well as in interventions that address land, social, educational, housing and employment disadvantage.

I acknowledge the pakana amongst us on whose land we stand, and thank you for inviting me to speak.

Over the last week, I have been feeling stunned, disbelieving and not knowing what to say or do. Is this really happening? Is it true that in 2007 we are really sending in police and army to Aboriginal communities without the consent of those communities? Does someone really think that the way to fix sexual abuse involves medically examining children? Or that flying in whole armies of white doctors for a week or two will enrich anything other than the pockets, CV’s, cultural experiences and armchair expertise of those white doctors?

I have felt powerless, hopeless, despairing, unable to talk about it – and I live almost as far away from the Northern Territory as is possible to do and still be in Australia.

But then the conversations started. Conversations with friends. Tentative. Exploring. All of us knowing that there is and has been a crisis in Aboriginal health for more than 200 years. That still there is nearly a 20 year gap in life expectancies all over Australia, including between the babies born to my Aboriginal friends and those of my white friends. We wish there were a simple answer. Something that would really fix all the problems in 6 months. But we know that the action needs to be urgent and sustained – that there isn’t a single recipe answer.

We know this week’s crisis is one of political desperation – a crisis of political imagination rather than anything new about life in Aboriginal communities.

And then I remembered that hopelessness and despair is only part of the picture. There are Aboriginal communities doing fabulous things all around the country – to make things better for themselves, their families and other Aborigines. We can be inspired by these activities. Support them. Fund them. Publicise them. Adapt them for use in other places.

As a GP and public health physician with nearly 30 years of medical experience, over half of which I’ve spent working in Aboriginal health, I’ve learnt that it is possible to make a positive difference to Aboriginal health.

• I know it helps to provide health services to Aborigines in a place that is their own, where the services are used by community because the staff are familiar because they are part of the community, or have been employed by them.

• I know it helps to provide health services of excellent quality that deal with the health issues that are causing the most problems in the community. Health services that deal with the sick as well as figure out how to best prevent illness and injury, including the sexual abuse of children.

• I know that the way to keep children safe and healthy is by supporting the kids, parents, grandparents and other community members to be healthy and look out for each other. It helps to integrate health services with family support, youth, aged care and children’s services so that everyone in the community is aware and taking responsibility for keeping kids safe from abuse. Supporting pregnant women and young families does make a difference. Having workers able to support kids, parents or grandparents when problems occur makes a difference.

I have worked for most of my professional life in Tasmania, and although I have visited several remote Aboriginal communities in central and northern Australia, attended many conferences, read many reports and had long conversations with many colleagues who have worked for years in different communities, it is hard for me to imagine how it would be to live and work there.

I do know that Aborigines reckon it is the whitefellas not the Aborigines who are now the nomads – white professionals and bureaucrats who work for a short while in Aboriginal organizations or bureaucracies before moving on. This is what they say about the white people who stay months or years. I don’t know what the word would be for the doctors from lower Sandy Bay who plan to go for 2 weeks and leave again. It is beyond my comprehension how anyone could believe that this would help.

Now to talk about sexual abuse.

I do know how complex and time consuming it is to work on sexual abuse in Tasmania.

I’ve worked as part of a roster of doctors on call to do forensic examinations of adults who have been sexually assaulted – rosters that are not working, even in a city as well resourced as Hobart. There are not enough doctors able and willing to undergo the training, to be on a 24 hour roster to examine people who have been sexually assaulted, or to go to court to present the forensic evidence. Which of these rare specialist doctors and lawyers will train the doctors volunteering to go to the NT on how to conduct a forensic examination on a child? How and where will this evidence be collected and analysed? Who will maintain the chain of evidence? What happens when the doctors are required to give evidence in court, perhaps months or years later? What about the ethical training?

Until a year ago I worked for 15 years as a GP and public health physician in Aboriginal health. Prior to this time I worked in general practice in Launceston, and recently I’ve been doing rural and urban locums in southern Tasmania. Over the years, I have also worked in sexual health services here, interstate and overseas. Mal Brough seems to think it unusual that sexual abuse has been reported in every community in the NT. I have yet to come across a geographical or religious or educational community where there is no abuse. In all of the places I have worked I have seen children who are being abused, and children who are at risk of being abused. I have seen adults still struggling with the long term effects of being abused when they were children. Some of these adults have gone on to suicide, some have huge problems with alcohol and drug abuse, most of them have physical and mental health issues. Many of them have become parents, and some have become perpetrators of sexual abuse, usually of children in their extended families. Other survivors of abuse have been on long journeys of personal healing along with the help of various professionals such as counsellors and doctors. As a result of their healing they have written books, run support groups and led community efforts to prevent further children from being abused.

We know that children are abused everywhere – in middle class and working class suburbs, at home, at church and youth groups. We know that it is so common that all our children are at risk. It is a terrible thing, and it should stop, now.

I was asked to talk about what is involved in a medical examination of a child who might have been abused. Some of what is involved includes:

• Building trust. The child or someone in the family or community trusts the doctor or health service enough to disclose their concern about the possibility of abuse.

• Talking. With the adult(s) who are concerned. Sometimes this is straightforward. However, sometimes it is very complex and takes enormous amounts of time and skill to untangle. The parents may be estranged, fighting, one accusing the other of abusing the child. Sometimes it is another adult who is concerned about the child. Perhaps a member of the extended family. Perhaps a child-carer. The parent/s are usually distressed. Perhaps it brings up their own childhood memories of being abused. They are worried about their child. There is the possibility that their other children may also have been abused. They feel guilty that it happened.

• Talking with the child. Other adults the child trusts may need to be enlisted to support the child as they tell the story.

• Engaging the parent/s and child with the process of unraveling the story, getting physical examinations, reporting to child protection agencies and police.

• Examining the child is important, but is only a part of the process of detecting child sexual abuse. Consent for examination needs to given by parent or guardian, and should be in writing. Current legislation in most states requires this examination to be done by specialist paediatricians who are recognized by Child Protection Agencies and the Courts as having specialist expertise in the diagnosis of sexual abuse. These specialists are only available in major cities and so in Tasmania children are required to travel to the specified paediatrician in Hobart or Launceston. GP’s like myself, though we have specialist training in the forensic examination of adults and see many children in general practice, have to notify the children to government Children’s Services and police, and refer the children on to the specialist paediatrician who has had specific forensic training. There are specific protocols for taking and recording the history and findings from physical examination. If the abuse is suspected to be vaginal or anal then the child will need to have their vulval, vaginal and anal areas examined for evidence of penetration and infection, often with the aid of a coloposcope. Colposcopes are the specialist equipment used by gynaecologists to examine women with abnormal Pap smears. Equipment and training is not usually available outside of major hospitals. It can be very difficult to assess whether or not there has been any genital touching or abuse, and even where there is a definite history of abuse it can be difficult to detect on examination unless there has been an acute injury immediately prior to the examination which has caused lacerations or bleeding.

• Examining the child risks adding abuse and re-traumatising the child and so needs to be done by specialist and experienced teams.

• Finding and engaging counselors (social workers, psychologists) for short term crisis intervention for the child, for the parent, for other family members.

• Finding and engaging counselors (social workers, child psychologists, child psychiatrists) for long term therapy. As well as for the identified child, there may be other children affected, and parents who are now ready to deal with their own abuse.

• What about the perpetrator/s? Mal Brough says they are going to removed from the communities. At what stage will this happen? What community and legal processes will be used? What about therapeutic interventions for the perpetrators? These kinds of services are difficult to access anywhere in Australia, and as we heard on Message Stick a few weeks ago, services are folding because of the lack of continuity of funding.

• Where are all these services for children, their families and the perpetrator?

• What happens to families where a child discloses or is found to be sexually abused? It is almost always complex. Distress. Disruption. Scapegoating. The impact on parents and grandparents who may have been stolen. And this is here in Tasmania. How must it be in a smaller community?

The above is a single scenario – some of the resources in terms of time and people that are needed for just one child who has been abused. What happens when there are several children over time, or at the same time? What happens when all this occurs in an area isolated geographically from specialist paediatricians and child counseling services? My experience is where all the parties speak English as the first language. Imagine how much more complicated it would be do it in a cross cultural environment where there is only limited language in common. No wonder there is a crisis.

And what’s more, we already know several of the children in these (and other communities, whether Aboriginal or not) have been abused. In the case of the NT Aboriginal communities, there was enough trust in Pat Anderson and Rex Wild that the families and communities told their stories, as outlined in the ‘Little Children are Sacred’ report. Examining kids won’t tell us a lot more. It risks re-traumatising them and their family. What’s important is to stop the abuse. And to provide long term supportive, therapeutic interventions for the children and adults who have been abused in the past.
We also know that single health checks are singularly unhelpful. That’s part of the reason why the State government stopped providing them to Tasmanian schoolchildren many years ago. Improving children’s health needs more than a check. It needs to include appropriate treatment, followup and health promotion. It works much better if the rest of the family are included. It’s important to keep the parents and grandparents alive and well so they can be there to support the children. Therefore the health services will need to address chronic conditions such as diabetes, heart disease, chronic lung disease, as well as smoking and grog.

If we really want to make things better we need to find out what resources are already in the community. Which of these resources are there for the long-term? What are the most effective ways to strengthen these resources so that they will be able to work more effectively over the long-term with children and families in which there has been sexual abuse?

What do the people who have been working hard in these Aboriginal health and children’s services have to say about the measures needed to make their communities healthier? How can government find out what these people have to say?

What are some of the success stories in Aboriginal communities? How can they be extended, adapted and resourced for other communities?

It’s true, Aboriginal health is much worse than that experienced by other Australians. Whether Aborigines live in urban areas or remote communities they are likely to die 17 years before their non-Aboriginal contemporaries. Closing this gap requires better government investment in health services, as well as in interventions that address land, social, educational, housing and employment disadvantage.

We need programs that will strengthen Aboriginal families and communities, supporting them to confront and resolve the problems they face.

Dr Maureen Davey
Public health physician and GP

Speech delivered at a rally organised by the Tasmanian Aboriginal Centre to protest about Prime Minister John Howard’s intervention in the Northern Territory. The brief: to cover the health and sexual abuse issues.