Day 8 of the Australian Journey

Today I got up early and ran the length of the island/peninsula (I'm not quite sure which it is).   I saw too many kangaroos to count and numerous hog deer.   No wombats, however.   One kangaroo dashed across the path so close that he startled me.   I think I startled him also.   They're not used to people running along the path before dawn.   At a distance you can tell the hog deer apart from the kangaroo because they run with constant height while the kangaroo bounce up and down as the race across the plain.

The island is beautiful and full of vegetation that I've never before encountered.   It's more marsh-like than I had imagined.   There are areas reclaimed by the water where dead gummy tree trunks stand testament to the forest that once ruled there.   Intermittently, the trail opens into panoramic vistas of the lake. Ferns predominate on the forest floor.   The earth is rich and black.

After breakfast, we prepared to make the journey across the water to the headquarters of the Coop where Lily and Shadow and family from the Northwest Territories were going to demonstrate some of their ceremonies for the local community.   We had a marvelous barbecued lunch, met many people we'd seen in the last two years, and then watched Lily and Shadow do their "burning cure".   I wrote about this last year in my blogs which are still available on www.futurehealth.org.   Briefly they heat palm tree bark in a fire and apply that to painful areas of one's body.   This year I asked them to treat my left sacroiliac area.   I've been doing more intensive stretching and yoga to open my hips and pelvis (which a healer in Warburton told me were way too stiff) and I've discovered an old injury from 30 years ago which has become painful again as I have removed the armoring that had collected around it.   The heat felt wonderful and I enjoyed as much of it as I could.   Then they did the ritual where they put people on top of a fire on paper tree bark and throw water onto the fire with the people covered by blankets.   It's like a mini-sweat lodge that lasts only a couple minutes.   This is their cleansing/smoking ceremony.   I also wrote about this last year and Shadow and Lily used their children again.   Then they demonstrated spear throwing and it was time to go home.

On the way home, I interviewed Laura, an aboriginal patient advocate (in both senses of the term) from Western Australia who was part of Culture Camp this year.

Laura works the whole of Western Australia.   I asked her about her job.   She said, "We connect with go-to people in the region.   We promote people's rights in the health system.   I ask people if they have any problems we can assist them with.   I offer to advocate to services about an individual complaint or problem but also more systemic issues because we find that a lot of people don't want to make official complaints either because they have no faith that the service will address their complaint or that they'll get worse treatment if they make a complaint.   I think people don't realize that it is an official process that services are obliged to respond to."

I asked Laura about the kinds of problems she often encounters.   She said,   "People feel discriminated against because they are aboriginal.   A lot of what we are addressing is miscommunication and misunderstanding.   Often people feel that they get stuck or left in between services.   Often it's up to them to get from A to B and people don't know how to do that.   Also people have to travel ridiculous distances to access a test or a specialist or an operation.   I'd qualify by saying some of that happens in the regions.   A lot of times it's about it being available in a timely way.   Like the specialist might be coming back in another three weeks or six weeks.

"I hear the same stories so often.   One example of racism and discrimination is a young mom being told upon arrival to emergency that her small baby must be suffering from drug and alcohol withdrawal even though she had never drank or smoked or taken drugs.   I hear this story regularly.   By definition all aboriginals are drunk or doing drugs.   Sometimes when people are sent to Perth they might be given a taxi voucher to get themselves to the hospital.   They might be sitting in the airport for hours because they don't know how to get a taxi or they don't know what a how to get is a taxi or they're afraid to get into a car with a strange person or they revert to their original language because they're stressed and can't remember how to speak English.

"We do have a service that is just to liaise with aboriginal country patients but it isn't big enough to meet the needs and it's Monday through Friday 9 to 5 and a lot of things happen outside those times.

"In the hospitals even though we do have recently more aboriginal liaisons, often they'll only be liaising on certain wards in the hospital where the majority of aboriginal patients are.   You can still be in the hospital and be told you're not entitled to the aboriginal liaison."

I asked Laura for her perceptions of the failure of the health care system for aboriginal people.   She said, "Too often it assumes and doesn't communicate or ask the patient anything.   They don't ask if they understand.   There is a huge divide between services.   The assumption is that someone else is taking care of it and it falls back on the patient.

"I think the aboriginal medical services do an outstanding job but we don't have enough health services or health workers to meet the need, particularly outside of Perth.   We still have a lot of services in Perth but people can't afford them.   Few services advertise that you have no cost for your appointment or that you have a much smaller cost.

"In Perth we have one aboriginal medical service where people get a free medical appointment under the close the gap initiative.   Any aboriginal person at risk for getting a chronic disease gets free medication.   Private practice gp's can bill the government for aboriginal patients or not.   It's up to them.   Any patient can take their receipt from the doctor and get a rebate from Medicare.   A lot of people don't have the money to pay up front for the appointment.   A lot of elders will put them last and not have funds for their appointment or their medication or even their transportation.

"Renal dialysis is one of the saddest examples of that division.   A lot of places have no public dialysis services.   You can get a machine in your house that the government pays for.   You have to have enough space to house the machine and keep it away from children, etc.   You have to own your own home or be able to stay for a long time.   A lot of people are in Perth just to get their dialysis treatment.   80% are in Perth because there's no dialysis at home or they're waiting for people to die so they can get their spot on the machine.   Quite often we have patients who have absconded.   We get calls about patients who are not turning up for dialysis.   I'll find them staying in the park down from my office because there's not very much in the way of affordable accommodations.   That's where they find other countrymen who care about them and look after them.   Or they've been kicked out of hostels which care for aboriginal patients because drinking is forbidden and they've had a drink.

"We advocated for a lady getting dialysis for quite a while.   They gave her a tablet.   She stopped turning up for her dialysis appointments.   The service alerted us.   We found her.   She thought she just needed to take the tablet now and no longer needed dialysis.   She didn't understand that without a transplant she'd be on dialysis for the rest of her life.   We don't really have accessible interpreting services for a lot of regions.   Even in Perth there's a lot of ignorance that aboriginal persons speak languages other than English.   Often they let a grandchild do the interpreting.   A lady found out she had cancer in Perth.   They got her granddaughter to interpret.   By the time she found out what her options were, they weren't possible any more.   The cancer had progressed too much.   We've had quite a few cases in the past 18 months."

"What about mental health care?" I asked.

"One of the biggest things because we ask people what issues they have is the lack of counselors or accessible programs or culturally secure programs for aboriginals.   It's a huge void.   Namely, the commonest thing is a family member ringing the service for help for someone else.   Service says it's unethical to help without the person coming into their office or the gp making a referral.   Then the crisis is not managed and the call ends in suicide.   Yet they consider acting and preventing a suicide unethical.   I think for our population a family referral would be very valuable.

"When people do manage to access services, the family is very out of the loop.   A lot of services say that would be unethical because that's a breach of confidentiality.   I know that a lot of patients want their family to come to the appointments but the providers still say it's a breach of confidentiality.   The person is living with the family and even if they don't want the family involved, the people who are living with them need to be involved.   Sometimes the patient doesn't even understand English and the services are using an interpreter and still refusing to involve the family.

"It's difficult for aboriginal people to leave country when they are sick or for births or deaths because country is their place for healing and their source of spirituality and support.   For some remote communities, everyone knows where they fit and how they relate to everyone.   It must be very difficult to come to Perth where no one cares about you and you don't fit.   There is assistance for people who need to travel to give them an escort.   That's up to the gp.   Administrative stuff happens at the hospital and the hospital argues sometimes even when the gp says they need the escort.   I had a man who was 70 years old who hadn't been to Perth for 50 years and all that the clerk wanted to know was if he could walk or not to go to his appointment.   Particularly if people are going down for a test, they are outpatients so their accommodations are separate from the hospital.   We have very limited services to help people get from the airport to their accommodations to their appointments.   People lack the savvy to do this.   A family was given a voucher for the public transport but they had never seen a bus in their life so they walked a couple kilometers to the train and didn't understand how to pay and then they got a fine.   If they had a German accent they would have been tolerated but because they look aboriginal they were not tolerated.   A young family couldn't find accommodation in Perth.   The husband was from over 3000 km away.   We helped him transfer to Darwin because it was closer to home.   He was quite grumpy and bit snappy, but he was in his mid-30's suffering renal failure.   It's not reasonable to expect him to be nice under those circumstances and" In the end he went home to be with family when he needed to and got an infection and died.

"I remember when we first went into the region people said you get to Perth in a plane and you return in a box.   Our mob doesn't seek services until they're quite unwell which contributes to that perception.   The understanding may need to be two way."

Next I asked Laura about the relationship of health care to traditional community healers, She said,   "The aboriginal medical service because they're part of the community are able to link into traditional healers though they don't employ   them.   Often families do that off their own back [meaning pay for healers with their own funds].   Some willingness exists in mental health to work with traditional healers.   Coverage doesn't exist for the moment.   We have an expanding statewide mental health service.   It will take a while to filter out what that means.   We're not really sure what the status of their obligation is.

"It depends upon what region you're from whether or not you have healers.   Sometimes it's the willingness of a particular staff member to see something like that especially for acute mental illnesses.    The person might require an acute place to stay.   People have to go a long way from home to access anything.   That's hard for their recovery and for the family engagement.   A lot of services say that social emotional wellbeing is not a part of what they provide. For example, the 70 year old man who needs an escort being told he doesn't.   When someone doesn't have the means to get to the hospital for their appointment, that's a problem.   Culture is treated as a layer you put on the end to make it seem a little nicer.   They don't understand that people might not access service at all because it conflicts terribly with their own beliefs."

That seemed to be the theme of this week.   Culture is not an afterthought.   It is all important.   Here is where the health system and the community disconnect.   For the health system, culture is just cute art, because science has the answers and patients should just do as we say.   Of course, even the recent history of medicine reveals that what medicine believes to be absolute fact turns out to be incorrect.   We are curiously without history in medicine.   Whatever we believe today, we act as if we have always believed it.  

Here is an example from the United States.   The cost of treating people who have had at least one hospitalization for depression and are on public funding has increased by 30% over the 10 years from 1996 to 2006 in a study just published.   During that time no improvement in outcome was seen.   Hospitalization frequency dropped, and so did psychotherapy from 58% to about 35%.   Medication use increased from 81% to 87%.   The increase in cost was attributed to the use of more expensive drugs, such as the adjuvant use of antipsychotics to treat non-psychotically depressed patients.   Are we doing the right thing if costs go up with no improvement in outcome?

Implicit within the appreciation of culture is the understanding that medicine itself is just a story.   Theories are stories and stories change.   Treating the story is often more important than treating the disease because the disease is the story and the story is the disease.   Our stories about the world arise from our bodies and represent our bodies' ways of communicating internal states.   Change the internal state, change the story.   Change the story, change the internal state.   This is not obvious at all from within the biomedical paradigm.

Day 7 of the Australian Journey

The rain continued all night.   Before bed, we made offerings to the sky spirits to ask to hold the rain if possible in the morning so that we could light the sweat lodge fire.   As I awoke, that seemed unlikely.   The rain continued.   Breakfast came and just as we were putting our plates away from a marvelous Aussie brekky of bacon, sausage, fried tomatoes, fried mushrooms, and eggs, the rain stopped.   Quickly we ran out to the fire pit with all the dry kindling we could muster and got the fire started.   I have been taught that the sweat lodge fire cannot be started if it is raining because one doesn't intentionally combine two different types of purification.   If the rain starts after the fire is lit, that's ok because the thunder spirits have made a decision to augment the purification.   Then it's not hubris on our part.   We did manage to get the fire started with fairly damp wood thanks to some excellent dry kindling.

I'm not going to say much about the actual sweat lodge ceremony because I have written about this elsewhere and the details of sweat lodges are well known in the North America.   Bucko has written extensively about the various styles of inipi (meaning breath of life) ceremonies in a book called The Lakota Sweat Lodge, which is excellent reading.
The only surprise was to meet pelicans in my preparations and prayers and to hear that this lodge was under the auspices of the pelicans.   Later I learned that the pelican is the totem of this land where we stand.   I was guided to dedicate the lodge to two people who were struggling whom we had met on our last trip and to their families.

The lodge experience was powerful for all.   Marion, the aboriginal elder about whom Miriam spoke in Day 6, attended, which was an honor for everyone.   The CEO of the Coop attended along with some of his key assistants.   He talked about having visited Edmonton, Canada, where he learned about the summer ceremonies such as the sundance in which all the urban Indians are bussed up the road to Jasper for a week together.   I wasn't sure if he meant sundance, but it certainly could have been.    Jason told us how much he wanted to create a weeklong opportunity to bring his community together for ceremony and healing.   We invited him to join us in June for our annual sundance.

We began trying to light the fire at 8am and had finished the lodge by 4pm.   That included some schmoozing afterwards and a bit of snacking for dinner was yet to come.   Also the cameraman had to interview us for the documentary being made about Culture Camp 2012.

During the evening a man from Millingimby (also known as Crocodile Islands) in the Northern Territory spoke to us about his walking from there to Darwin, which is over 800 kilometers.   The walk required 3 months.   He took nothing with him and lived on what food he found or caught along the way.   That seemed normal to him.   He caught a boat back.   He did not speak English and was translated by an anthropologist who accompanied.   That man was working on aboriginal land claims with frequent court testimony and was fluent in the language of Millingimby.   The story of the walk was impressive and quite inspiriting.

Then Shadow, also from that community, and known to us from the last three years, regaled us with crocodile tales.   I suppose one cannot come to Australia without the requisite crocodile stories, many of which are exaggerated, but I doubted none of Shadow's stories.   He told stories of his kids catching a small croc and keeping it in their bathtub until it got to big and they had to let it go.   He said it recognized their voices and responded, knowing they were probably bringing it frogs, fish, or other goodies.   He told a story he told last year about a crocodile chomping a man on his head and the man managing to get free by sticking both of his fingers in the crocodile's eyes.   He told about a crocodile coming up under his dinghy and trying to push him and his mate out into the stream as they were just about to dock on the shore.   The took a running leap, jumped off the boat onto the crocodiles back, and leaped onto shore just an instant before the croc figured out what they were trying to do.   That was as close as he had ever come to being eaten, Shadow told us.   He told stories of several people being pulled under water and playing dead while the croc stuffed them into mangrove roots and then escaping as the croc went away in search of other pray.   Apparently the do eat fresh meat from time to time, but more often than not, they like to marinate their food under water for a week or two before eating it.   He told about cutting one croc open and finding a man inside who had been swallowed whole without a mark on him.   He told funny stories about throwing his kids in the water instead of the rock to see if there were any crocs.   The kids were there and laughed at that.   They certainly had an amazing life in nature living where they did.   Shadow told of a constant string of encounters with birds, spiders, snakes, crocs, and other wildlife as they went around trying things that he told them not to do.    Shadow told about him and a croc stalking each other.   They would play a game where he would come down to the shore and the croc would disappear into the water at which point he would run to high ground just as the croc surfaced and lunged at where he was standing an instant before.   I was convinced not to enter his part of the Northern Territories without his protection and guidance.   Crocs sound dangerous.   Shadow said they were the most perfectly designed predator in the world.   They were silent and fast.   A man didn't even have time to shout when attacked by a croc.   He was already underwater.  

We spent more time talking to Miriam the physician about her work in the community with people on benzodiazepines and narcotics and sleeping aids.   She mentioned that many of the elders were taking benzo's and sleeping pills to help them cope with the stress of their role in the community.   We reflected together on our health care system's promotion of magic potions and pills for every woe.   In her community as in mine, people are trained to believe in instant relief instead of learning the slower techniques that are more long-lasting.   We see that in television commercials with instead abs (abdominal muscles), instant fitness, instant relief from sadness, and the like.   Her patients were in the same boat as mine.   I talked about my pain group which seemed to interest her.     I make as a requirement for receiving pain medications from me that people attend pain group at least once monthly.   They must also do something physical at least once weekly.   That could include taking a yoga class, going for physical therapy, taking a t'ai chi or chi gong class, or something like this.   Most of my pain patients are reporting back pain.   They are under the mistaken impression that their X-rays correlate with their pain (which they do not). We talked about whether or not Miriam could implement such ideas into her practice at the Coop.   Talk continued late into the night, but now it's time to go to sleep.   More tomorrow".

Day 6 of the Australian Journey 2012

Today we arrived at Boole Poole, the ancestral land and burial grounds owned by the aboriginal cooperative for the formal start of Culture Camp 2012.   Several of us were wearing Culture Camp 2011 T-shirts in bold red, black, and yellow, the colors of the Australian aboriginal flag.   Boole Poole is only accessible by boat which was a rough ride in a rainy sea.   Flocks of pelicans sailed overhead, experts at riding the currents of wind.   Black swans floated gracefully on the swells, while young cormorants appeared to be walking on water as they got out of the way of the boat, flapping their wings faster than imaginable.   The rain had begun as we unloaded the boat at the pier.   By the time we had pulled the trolley with our things to the house, it was a downpour.

The food at Boole Poole is continuous and one meal runs into the next.   Looking for an alternative to eating, I decided to interview Miriam, the newest physician to work for the Aboriginal Cooperative and their first and only full-time physicians.   My colleague, Rocky, had already spent time with her on his last journey to Australia when he consulted to the physicians who worked for the Cooperative.    The rain drummed on the roof as we talked in the living room of the house while most everyone else watched films of aboriginal dancing from the community at Mullingimby, the home of Shadow and Lily.

"How long have you been at the Coop now?" I asked.

"Since last August, 2011.   Now, it's six months."   Miriam answered.    She had trained in Brazil and had practiced for some time with aboriginal people there.   In Brazil she had a catchment area of 4000 people.   She worked for the public medical care system.   In her clinic, she had four health workers, one nurse, and her.   I wondered how it was to have that many families under your care.   She said it was a matter of doing the match.   In any given month, one expects 4% acute care visits.   She used the morbidity tables for the percentages of chronic diseases in her practice to calculate how much time to allocate for chronic disease care.   Time was very scientifically managed.   Next I asked her what was her biggest challenge in coming to the Coop in her first week.

"My first week was one of introductions and cultural awareness.   I was taken to the different sites I needed to know about; taken to meet the people with whom I would be working and whom I would be calling. They (the coop) introduced me to elders.   That first week was also an introduction for the community to me.   It was a pleasure.   They believed it was fundamental for me to understand the geographical space in which the patients lived.   They were open to all my questions.   They introduced me to all the places that were important to know.   The two aboriginal health workers did that -- Shane and Judi Ann.   Judi worked with the midwife and could bring her all the issues with pregnancies in young people and what they need, their expectations.   That was my first week." I was impressed with how culturally sensitive the Coop was to Miriam.   I hoped we had contributed something to that awareness. Then I asked Miriam about her second week.

"During my second week I was in the unit of my mentor, Dr. Jane Greason.   She was able to introduce me to the program and what they had been doing in the community.   She has been there more than 12 years."   Then I asked her what other doctors work for the Coop.

"Dr. Greason is my supervisor.   There is Dr. Gene Wofurt who was raised in Bairnsdale, then Dr. Schoefeld, and Dr. Black.   We have two offices at the health center.   Usually only one session or two sessions occur at the same time."   I learned that the other doctors had contracts with the Coop and did their own billings.   Miriam was on a salary.

"My challenge is, not by the production, but to help people get well.   I am not billing medicare like the other doctors who have to see patients one after the other, 1, 2, 3, 4.   I have A, B, and C consultations.   An A consultation is scheduled for 10 to 15 minutes.   B is 40 minutes and C is one hour.   Because we have the other doctors, if I have another doctor at the unit, the other doctor does their patients and I do the health assessments with the aboriginal health worker and do the gp planning."   I hadn't heard the term "gp planning" so I asked what that was.   Assessments are always category C consultations.

"After the assessment, you have at least some idea of the risk factors, medications, and social information.   That supports the gp planning.   We identify the patients with the chronic disease and the special needs.   After that, you have to work in a way that you agree with the patients and negotiate with them what can be done and how.   We set some goals between us.   I have to write this down.   That is the product we call GP planning.   The Coop is a very special situation because they have more than just general practice.   They have the family service, the alcohol and drugs follow-up, the midwifery service, and many more community outreach services.   With these special services, it's easier for us to go further than a simple gp plan in mainstream medicine.   There they have hard work because they don't have the facilities to refer as I have here.

"When I arrived in the heatlh center, I realized some of the aboriginal health workers were not having time with the doctors.   Every doctor had a small time with the patient.   I started doing the health assessments with the aboriginal health worker and the patient together.   I also did the gp planning with the patient and the aboriginal health worker together.   This seemed like a natural way to do this. It would be a longer appointment if we did it together, but we would get so much more done.   It is the job of the aboriginal health worker to visit the patient in the community and to make sure the plan that we have negotiating is being implemented.   If I cannot finish the gp planning with the patient, I will finish it with the aboriginal health worker.   Sometimes that's necessary because I didn't have all the necessary background.

"We have a clinic coordinator who is a nurse practitioner and we have Leslie who is a nurse practitioner who is more responsible for immunizations and wound management.   She's a more unit centered nurse.   Another nurse does diabetic education.   We have another midwife who works with Liz Boyer, who is one of the doctors responsible for antenatal care and deliveries at the hospital.   The midwife is a nurse, too.

"After gp planning, I keep in contact with the aboriginal health worker to be sure every action that we have planned is happening.   In that stage I had some concerns because the aboriginal health workers belong to the families.   If I have a male patient, they have male business and they will be ok with these patients, but if they belong to other families, maybe they will not be ok.   We lost one aboriginal health worker because she couldn't do the male business.   Judi worked with the midwife and had good support in the women's business.   It's very hard because you know they belong to their families and sometimes they don't want to get involved in other families' business.   I have to be very careful, because I don't know where I am walking.   Some of them are close to these patients.   I have to be very respectful.   Once I went to aboriginal health worker and said what I wanted to do with this patient and he said, doctor, I prefer not to work with this patient, because she is my wife.   He could help her as a husband but not as a health worker.

"Patient confidentiality is minimal.   Everybody is a relative.   You have to be very careful what you have as a goal.   What we have to do is ask the patient.   I have the opportunity to talk with the patient myself before we discuss things with the aboriginal health worker.   I explain what is a good aboriginal health worker and they agree with me.   Then I ask them if they are ok with who will be assigned to them.   Some of them don't accept the aboriginal health worker."   I asked Miriam about the challenges to health in the community.

"People in the community want to be heard.   They have a hard time with drug addiction, alcohol, domestic violence, but when you open the door, they go through it.   If you listen to them, they will tell you things which will give them some relief.   I remember one patient who was very upset.   In their community, it's not normal practice to have an elder in a retirement home.   She was very upset with that.   She came for high blood pressure.   She was very upset.   She was fighting with the family because one of the sisters got the guardianship of their mother.   The sister wanted their mom in this specific retirement home.   I started to treat her blood pressure but I knew the stressful situation was    part of what was raising her blood pressure. Part of my job was to be a problem solver strategist.   To help her make small changes to cope with the situation was what I needed to do.   She is still working through her issues but she is changing.   She asked me to support her with her alcohol issue because that was why her mother was in the retirement home.   She was not able to take care of her mother because of her drinking.   She was then able to go to alcohol treatment.   She could choose an alcohol counselor. " I have this problem and how can I solve with the resources we have here.'   Now her mom is in the retirement home and she is struggling to cope with alcohol problems and she accepted the situation as transitory because she wants to recover so she can take care of her mother.   She is in the middle of her process now.   She has access to the consultations.   Every time she needs to contact me, I have an agenda for her to come every week as a crisis like, trying to support her in this journey.  

"Second I have a list of resources we can present to the patient.   Patients can choose what they want.   If it's housing, I have people who can help with that. One of her [the above patient] issues was that she didn't have a house.   She got connected to the aboriginal legal services and I could do a letter supporting her for housing.   It was important for her for the crazy stress.  

"The aboriginal health worker is very important, because they know how to work the system.   If the patient doesn't allow me to contact the aboriginal health worker, I have the list of the resources and I ask the patient how to help them.   Sometimes they say it's impossible.   They give me the limitations.

Day 5 of the Australian Journey 2012

Today is our second day in Warburton with Auntie Jennie and the Karith House of Prayer.   Every morning on the Australian Tour, I get up before the sun and run.   Yesterday I ran along the Upper Yarra River to Martyr Hill (a 27% grade) where I painstakingly ascended to the top, then entered the Donna Buang Trail, a 70 kilometer hike, of which I sampled just the first bit. The songs of the birds spectacularly surrounded me, resembling what I would expect from a rain forest, though in my naivete, I expected monkeys to be part of the auditory scenery.   I had the privilege to see a beautiful red fox, which surprised me since I didn't think foxes lived in Australia.   Later when I asked about the fox, I learned that they had been brought to Australia by the British rulers for their classic fox hunt.   The foxes quickly overran the local wildlife since they had no natural predators and became pests.   (Just like the English, someone at the breakfast table quipped.)   I pointed out that it wasn't actually the fault of the foxes, since they weren't the ones to buy the tickets to Australia and probably didn't enjoy the journey either.   You can get $10 for killing a fox and presenting its pelt.   It's equally not the personal fault of those who have English ancestry for bringing the foxes since they weren't alive when the fox idea was conceived and executed.   I don't think we have to hold guilt for the deeds of our ancestors.   There's enough in the world to make everyone dysfunctional without needing more.   I agree with don Miguel Ruiz and Olivier Clerc that we need to forgive and be forgiven more than we need to blame and be blamed.

This part of Australia superficially resembles Vermont, where I live.   The mountains are a bit higher in Vermont, but that's where the resemblance ends.   There's no rocks here.   The forest floor is thickly filled with ferns and exotic looking plants that resemble large pineapple plants without   the fruit.   The major tree is the eucalyptus or gum.   As one ascends to the higher altitudes, pines appear, but not like any Vermont pine.   Last year we were running when it was still dark and saw a wombat.   I only saw scat this year.   Surprisingly given daylight savings time, the sun rises late in Southeastern Australia.

This morning I took a different route.   I ran up a new road on the same steep hill to get to the O'Shaunessy Aqueduct Trail.   I ran along an old aqueduct for a ways before turning up the hill on the Mt. Victoria Trail.   I wondered how one keeps the water out of the aqueduct even as streams tumbled down the hill beneath it.   Nature was breaking up the concrete and taking back the land.   A short ways up the last trail, I had to turn around and ran back to Karith.   I can vouch that it's quicker to run downhill than uphill but it's harder on the thighs.

Warburton is a small town, barely one row of buildings on either side of the road.   The architecture is one I have only encountered in Australia, a kind of combination between English country homes and Indonesian style.   The closest I have seen elsewhere is the French Quarter in New Orleans.   The Upper Yarra River runs behind one of those rows, flowing all the way to Melbourne and into the ocean there.   I met a woman named Maya who wrote a marvelous book on her hiking journey along the Upper Yarra River from its source to the sea.   I asked her if she was going to honor any other rivers, but she said, "No, this is my homeland.   That is my River.   I wouldn't have authority or permission to write about anyone else's river.   She was obviously aboriginal in her thinking about land and territory.

When we arrived at the Village Hall where we were doing the workshop, the door was locked.   We milled around in front of the movie posters including George Clooney's latest film for the Town Hall doubled as the Village Cinema.   Since "the show must go on", we had to improvise.   Our hosts were frantically trying to track down one of the City employees to open the building.   I suggested we go sit beside the river and at least get started.   We meandered down our side of the river to the Brisbane Bridge and crossed over to the other side where I had spotted a nice grassy area suitable for our group.   Rocky and I proceeded to do the opening song to honor the Four Directions after we had acknowledged the land, the aboriginal people who were attached to this land along with their ancestors, and the spirits who walked upon the land.   Then we did a spirit calling song to make sure that proper notice had been given to the spirits that we were planning to do a ceremony.   Auntie Jennie then spoke some about the importance of men coming into the medicine.   In her family as in mine, there were at least two, if not three, generations which were entirely lacking in men.   All the men were dead or in jail or lost.   My grandfather was the only exception as was Aunt Jennie's.   She continued to talk about the men in her family and her ancestors which inspired me to propose that we do a tobacco ceremony in which we smoke for the spirits and anyone who receives a message from them stands up and delivers it.   This turned out to be a powerful ceremony.   I offered the tobacco and a number of people stood and spoke in Quaker meeting fashion.   In my mind's eye I saw my ancestors crossing the great divide (the Pacific Ocean) and embracing Auntie Jennie's ancestors and all sitting down in a circle and smoking together to signify unity and peacefulness.   One said that war actually hadn't been on the planet all that long and could still be eradicated.   I saw ancestors standing behind each person present.   Several others spoke of similar sightings.   We passed tobacco around the circle for everyone to smoke just as I had seen.   Then one of our hosts appeared and announced that the employee who was supposed to open the hall had finally arrived and we could return.   Many of us did not want to leave the river and its soothing sounds as it moved past the first rocks I had seen in this countryside.

After we settled back into the building, Rocky spoke about the untold and silent stories that become physical illnesses.   These stories need to be elicited.   The organs and the tissues who manifest the diseases need to be engaged in conversation to tell their stories.   The lessons we were learning were not just pertinent to mental health.   He gave an example of working with a woman who was having severe right hip pain.   He used acupuncture and some osteopathy while he encouraged her to let her hip tell its story.   As a surprising but highly relevant story emerged, the pain moved to the left hip, then the left knee, and then left her body.   It had been stuck in her hip.   I suggested Brian Broom's marvelous book, Meaning-full Illness.   Auntie Jennie confirmed that this view was also consistent with what aboriginal people believe and how they heal in her area of Australia.

After lunch we wanted people to experience how ceremony builds community, so we chose a ceremony that I created based upon my readings from ethnographies written before 1900 of a "Welcome to Camp" ceremony.   It hasn't been done since 1880, as far as I can determine.   I can imagine someone getting ready to bristle, so I'll quickly say that I believe it's acceptable to create ceremony for specific purposes as the need arises.   It's not a Native American ceremony because it's not currently done and there's no model to follow or elder to teach it.   It may have some Native American flavor (we can't help infusing our spirituality into the ceremonies we create), but it's really an ecumenical attempt at experiencing some degree of transcendence toward the spiritual, which is exactly what I would call it.   Or, since I'm also a member of the Unitarian-Universalist Church, perhaps I should call it a "U-U greeting ceremony".

   The inspiration for this ceremony comes from Plains peoples of North America, before they were penned into reservations.   In those days, camps frequently moved.   During certain times of the year camps would join each other for celebrations and larger rituals.   A ceremony was done to oversee this process.   In one that I read, seven tipis were set in each of the seven directions so that the person walked a spiral toward the center.   This was done outside and to the East of the main camp.   Those people wanting admission to camp participated in the ceremony along with those who controlled the admissions process.   The supplicant who wished to enter the camp started in the West and passed to each of the directions.   In the original ceremony, the intent was that each person proved that he possessed the virtue of that direction.   In my readings, only men participated, but that may have been a side effect of the gender-nearsightedness of many of the ethnographers writing before 1880 who were often sexist and might not have noticed women even if they outnumbered men.   At each direction, the applicant to the camp tells a story about a deed that exemplifies the virtues of that direction.   In my ceremony, I used courage for the west, strength and endurance for the north, receiving and following a vision for the east, compassion for the south, protecting someone for the sky, and nurturing someone for the earth.   Then he is welcomed in the center and led into camp.   I'm going to guess no one was ever turned away because the incoming group were known and had been previously vetted.   This was just a formal way to say hello.

I use my ceremony with Native American people though, as I said, it is not a traditional Native American ceremony.   I use it especially with people who have drug and alcohol problems because they are not used to saying anything positive about themselves.   The beauty of this ceremony is that it emphasizes one's good traits and deeds.   So many people are quick to tell stories about their faults and misdeeds, but isn't it much harder to tell stories about what we have done well, or times when we have been courageous, or strong, or compassionate, or protected someone or something else?   This ceremony forces people to reflect upon what is good about them and to share it with another person who only listens, standing in the position that symbolically represents one of the Directions.   Participants feel how it changes them to tell good stories instead of bad stories and they feel the camaraderie that comes from being heard without commentary or personal response and being accepted.   Those who have completed the process are led to a nearby part of the room where they can sing, dance, or help each other in some way.   We keep a continual steam of singing and dancing going, because, as a Sari elder told us in Mexico, you can never sing or dance enough for the spirits.   When we did ceremony with her, she would exhort us with "mas bailando; mas cantando".

We did this ceremony with the group and Auntie Jennie agreed that it did succeed in giving them some flavor of the transcendence and sense of group membership that participation in tradition ceremony in community provides.   People also spoke about how difficult it was at first to be positive about oneself and how embarrassed they were.   Isn't it interesting that we are more embarrassed to tell positive stories about ourselves than negative ones?!   They also spoke about how transformative it felt to actually get out the positive story and for it to be accepted. They described the joy of completing the process and being welcomed to the community.   For some that community will continue, since talking circles are held weekly for those who live in the area and efforts are being made to find constructive ways for people to spend time with each other.

Later that evening after the workshop, we talked with our hosts about the problem in aboriginal communities for some people that family gathering was centered around drinking or doing drugs. The physician in our party who worked in the aboriginal community reported that she wasn't permitted by some families to make home visits on Thursday, Friday, or Saturday because of the partying that they didn't want her to see.     In relation to this we talked about the power of ceremony, even the ceremony of drinking together, for it is, after all, a kind of eucharist or communion.   It's no accident that alcohol is called "spirits".   We talked about the necessity of engaging the elders to put healthier ceremonies back into place in communities in such a way that people can notice and can attend.

In Warburton, we finished the day by offering traditional pipe ceremonies for those present.   We left to return to Melbourne to prepare to travel into the East Gippsland countryside early the next morning for Culture Camp 2012.

Day 4 of the Australian Journey 2012: Musings with Auntie Jennie

Today we are in Warburton where we encounter Auntie Jennie, an aboriginal elder from Queensland.   I wrote about Auntie Jennie last year.   She is doing her medicine for her community and much the same way as aboriginal elders in North America.   Our revelation from last year was that we are more similar than different and that continues to be true.   We stayed at Karith, a Catholic retreat center for people of all faiths.   Karith means a place for prayer, and this is what it is, managed by Sister Catherine and Brother Ken.  

We began our workshop/worship in Warburton by singing and calling in the spirits of the land and its original people.   Then we did an introduction process in which each person says what they are called, where they come from, and introduces one of their ancestors to the other person in one quick sentence or so.    I learned that sentences are not quick in Australia and people have much to say and tell.   Introductions took over two hours.   People were starved for the opportunity to tell their stories and to be heard.   After lunch we continued with the theme of hearing the silenced voices, one that is apropos to Australia in which aboriginal people were silenced to ourselves in which we silence the voices within that we don't like or don't appreciate.   In the post-lunch exercise, much as what we did in the Hearing Voices conference, the goal was to meet one or more of our voices that we have silenced and to remove the gag and allow them to talk and be heard.   This turned out to be powerful, too.   So many of our voices have been silenced by the dominant culture, which is one of greed and individuality.   The voices of sustainability and cooperation have been drowned out by the sounds of greed and what Thomas King, the Canadian aboriginal writer, has called the "Ferenghi laws of acquisition (see his collection of stories called A Short History of Indians in Canada".   The Ferenghi are from Star Trek and primarily represent the "all for me, and none for you" point of view.   Allowing the silenced voices to speak is a powerful process.

I went on to talk about the ways in which the mind is a model of the larger social world.   Just as we have marginalized indigenous people in the broader social world, we have marginalized the indigenous voices within us in the social world of our minds.   We need to allow them to be heard.   Here comes dialogical self theory again, which was the topic of my keynote address at the Hearing Voices conference.   Dialogical self theory sees the mind as a collection of voices all of which are speaking at once trying to be heard.   Therapy consists of imposing a kind of order of politeness and respect in which all the voices can be heard and can dialogue with each other.   Richter (author of integraring Existentialism and Narrative Therapy) has written about the many me's within us.   Each "me" manages one of my relationships and carries voices, experiences, and stories for negotiating that relationship.   Some "me's" are more appropriate for some contexts than others.   Social skill consists of knowing which me's to bring out for any given encounter.  

Relevant to this is Marius Romme, Professor of Social Psychiatry at the University of Limburg in Maastricht, The Netherlands, who is credited as being one of the European founders of the Hearing Voices movement, though in my talks, I was quick to add that what Romme proposed has been practiced and believed by aboriginal elders for centuries, perhaps even 43,000 years.   Romme was practicing psychiatry in The Netherlands when one of his patients, Patsy Haagan, said "You believe in a God no one can see, so why don't you believe in the voices which I at least can definitely hear and which are real to me."    Romme thought about her proposition and found that he could agree with it.   Why not?    He accepted the ontological reality of Patsy's voices (just as indigenous elders do). He invited other voice hearers to talk together about their experiences but found that although they could talk they didn't really help each other.    So, he and Patsy appeared on Dutch TV and invited others who heard voices to call into the program.   Four hundred, fifty viewers who heard voices phoned.   Of these, 150 people said they coped without the assistance of psychiatry; indeed some said they were happy to hear voices.   Romme asked, "Could perhaps the techniques used by those who coped well with the voices be used by those who didn't?"   A conference was organized to encourage broader discussion, similar to the conference we had in Melbourne.   From this Healing Voices groups formed around the world.   Ron Coleman, who spoke at the Conference, founded the first one in England 25 years ago.

My proposition was that narrative medicine has much to offer the Hearing Voices movement just as does dialogical self theory and therapy.   Rita Charon, MD, PhD, one of the leaders in the world narrative medicine movement wrote that narrative medicine is "Medicine practiced with narrative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights of others." (Charon R. Welcome and introduction. Presented at: Narrative Medicine: a colloquium; May 2, 2003; Columbia University, New York, NY). As doctors/, we act on the narratives presented to us daily by patients, their families, and other health care team members.   This is what Romme did.   He accepted the story brought to him by Patsy Haagan and worked within that story.   The late Canadian family physician, Miriam Divinsky wrote that, "[Stories] help us see other ways of doing things that might free us from self-reproach or shame". Hearing and telling stories is comforting and bonds people together."   This is what people had found at the Hearing Voices conference and what we found at the Warburton workshop.   Coming together in circle to tell and hear our stories with each other creates relief and builds community.   Within the Lakota concept of nagi, once we hear another's stories they are forever a part of us.

In Warburton, I spoke about the nagi, which is the swarm surrounding us of all the stories that have ever been told about us, by us, and by those who have influenced us coupled with a part of the spirit of the teller of that story.   Nagi is what forms and shapes us and makes us who and what we are.   It is our legacy.   Once we tell or hear a story that story becomes forever a part of the listeners nagi.   Miriam Divinsky further wrote that "Stories offer insight, understanding, and new perspectives".They educate us and they feed our imaginations." (Divinsky M. Stories for life. Introduction to narrative medicine. Can Fam Physician 2007;53:203-5 (Eng), 209-11 (Fr))      Through story

(1) we structure and interpret our life experiences;

(2) we create a coherent life story;

(3) we construct, display and reinforce our sense of self;

(4) and we manage this self in relation to others in our social worlds.

As I said in Melbourne, story is the default mode of our brains.   It is our best way to store and manage information.   The narrative structure is ubiquitous in human experience and emerges, according to the Scottish developmental psychologist, Colwyn Trevarthan, even in the early exchanges between mother and infant.   In these interactions, infants engage in stories without words or with words supplied by their mothers.   We have the task of creating a coherent life story, often with the help of our family and friends.   Through the use of narrative structures, we invent an "I" to integrate our many me's.   In fact, we know at least one part of the brain located in the mesial pre-frontal cortex which eliminates our ability to tell a coherent "I" story if it is rendered dysfunction by stroke or other damage.   We use story to run countless simulations about what might happen if we behaved in particular ways in future encounters with others.   I gave an example of this in which I asked everyone to remember a time in which he or she had an argument with their spouse or partner and had to leave home for work or another errand before the argument was resolved.   "All the way home," I said, "you are running various "what if"." scenarios in your mind, rehearsing the discussion that will take place when you arrive home.   Depending upon the outcomes of these various simulations, you decide whether to stop for Chinese take-out, flowers, chocolates, or perhaps a drink at the pub."   Everyone could relate to this.

                Then I defined a narrative unit (following the work of Labov) as one containing at least 2 Complicating Action clauses where the verbs are in the past or historic present tense, and where we can infer an order to the clauses.   There are also one or more Orientation clauses setting out who was involved in the events, when and where the events took place, and giving other necessary background information.   I used an example of a short narrative from one of our clients who comes to our complicated minds group.   Mandy said,   "Then there was the time when I killed my boyfriend, except that he didn't die, and there he was at my back, trying to strangle me again."   This actually has three Action clauses.   True to the requirement for an Orientation clause (which can be implicit in the conversation), Mandy added, "That was when we lived in Georgia and I was dealing coke and he was really jealous, but then we broke up and now we're best friends. I know all his girlfriends and all his kids."   I asked everyone if they could feel Mandy's charm as a person from the story and everyone could.   This occurs because we recognize the other aspect of a narrative -- the affective strand of meaning where narrators reveal their feelings about the events they are accounting.   This justifies the telling and shows the kind of person the speaker claims to be: "narrative is a presentation of the self, and the evaluative component in particular establishes the kind of self that is presented".   This illustrates the narrative competence of the speaker in putting together a multi-voice, multi-faceted story in accessible language.   

Next I moved onto illnesses, discussing how narrative competence allows us to Use the different perspectives of storytelling to create a complete picture of the illness and its meaning to the patient.

The narrative of an illness needs to not only give the patient a voice, but also to re-present the dialogue between patient and caregivers, inclusive of the voice of the caregiver or health professional.   I gave the example of the story of the first encounter with the illness being named.   Mandy said, Linda: We fought for 6 hours that day because I fought back.   At one point I was slamming his head into my knee.   I went to the hospital and that's when I found out I was pregnant. That"s when they diagnosed me."   To her credit, Mandy had received every psychiatric diagnosis available from someone.   This is how she came to have a "complicated mind".    Mandy also told habitual stories that illustrate usual activities.   For example, she said, " I get so angry, I mean he would wake me up for no reason, and he knows I can never get to sleep and so I have a 3 hour panic attack because he needs $5, right now, so I would lock him in the basement.   I would just get so sad. I would take all my pills, whatever I had around. I'd still do it but my son put me right, he said he didn't want to be without me. They would call me from the other side, my best friend, my son's father. And he was really good looking."   Mandy was talking about her usual activity of taking all the pills at hand when she was upset.   She was however, entertaining a counter story during her time she had been in the Complicated Minds group -- that her son loved her and would miss her and needed her to stop overdosing on pills.   People also have "reported speech" narratives in which they describe important conversations with others.   Mandy said, "The doctors don't want to hear what I tell them.   They get really nervous when I come in the office. I made one of them brownies but it doesn't help."   Mandy's experiences with physicians were generally negative.   She made them uncomfortable and recognized it.   These stories are important.   During our interactions with health professions decisions are made about the management of the illness and the health practitioners story about the illness is transmitted to the patient. Interactions between patients and health care professionals thus play a major role in the social construction of illness narratives.   We rely upon physicians to tell us what we have and why we have it.   This generates "because narratives" in which we explain ourselves, often in reference and comparison to others, which are called narratives of comparison with others.

                We completed the workshop in Warburton with examples and exercises of people telling each other stories and listening for the smaller narrative units comprising the story, thereby recognizing points of potential intervention.   Then we went across the street to the Polish Jester for a wonderful Polish meal of pickled vegetables, smoked herring, and stuffed cabbage.   I fell asleep immediately upon returning to Karith.

Day 3 of the Australian Journey 2012: Hearing Voices in Melbourne

 
 
 
 
 

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Day 3 is the final day of the Hearing Voices Conference.   I'm going to finish telling about my keynote address and also the workshop that I did and other connections that were made.   One of the most remarkable events occurred at the panel on the last hour of the day when Ron Coleman announced that a young woman who was being tortured by her voices had nowhere to go to get help and no money.   He told the audience that she could come to his farm in Scotland and stay for free as long as she wanted if the assembled people would all contribute money toward her ticket.   He announced that he was going to put a jar by the door and everyone could contribute what they could.   I learned later that the money had been raised and she would be on her way to Scotland in three weeks!   That was amazing.   I was so impressed that Ron Coleman had a farm where people could go to work on their voices for free.   I wish I had such an environment and the funds to make it work.   We've (Coyote Institute) been casting about for funding to create a safe house in Brattleboro, Vermont, for people who are going through a psychotic experience, but so far, we've raised very little money.   Apparently, we don't move in the circles of people who have extra cash to donate.   We'd like to change that, of course.

Today there were a number of concurrent talks by aboriginal elders about their culture and how they managed voices and people who hear voices.   As I said in yesterday's   blog, it was so inspiring to have aboriginal people fully integrated into the conference and presenting their successful strategies for voice management.

I tried to make my workshop completely experiential since I had given enough theory in my keynote address.   I started with a guided imagery process in which people travel through a portal to the dimension in which their voice resides and in which it has a physical form.   I mentioned that all voices must be attached to physical images.   No disembodied voices allowed for they are frightening.   If a voice has a physical form, we can modify that form to make it look ridiculous if it's being too scary.   In one of the Harry Potter movies, students in "Defense against the Dark Arts" learned to turn their worst fears into ridiculous looking versions as the fear came out of a cupboard.   The spell word was "Ridiculopathy", or something like that.   In the exercise, people were asked to enter into the world where their voice lived in a body and find it.   A number of strategies were proposed for how to do that.   My favorite is to follow a path through the woods, around a pond, up a ridge, and to see it standing in the middle of a meadow, though there are many more.   Then the person asks for the voice to tell its story.   Many voices are boringly repetitive.   They just keep saying over and over, "You should kill yourself because you're not even worth the air that you breathe," or something similar and equally inane.   However, rarely do we get the story from the voice about how it came to be in the person's mind in the first place.   We want to know where it came from, where it was born, who were its parents, and all the interesting details of its life.   We want to know how it came to the conclusion that led to what it's been saying.   We want to know what other beings agree with it.   Who are its friends?   What coalitions has it formed?   We actually want to start a relationship with the voice in which dialogue occurs and change can happen.   If the voice is stubborn and refuses to change or even to converse, we have to find other voices to stand up to it.   We have to start finding stronger voices to drown out the mean ones.

Following this exercise, each person told their experience to another person so that sharing could take place to an audience.   In our work with voices, we are striving for increased narrative competence -- better story telling skills.   It's important to have an experience and then to be able to come back and tell a coherent, congruent, understandable story about that experience.   Next I asked each pair to let one of its members become the voice so that a dialogue could take place.   Like most exercises taken from improvisational theatre techniques, I tell people to just trust their gut impulse and say whatever they are driven to say.   Don't worry that you aren't sure what the voice would say.   Just say whatever   you're moved to say.   The conversation lasted 10 minutes or so and then we switched.   Finally, one person volunteered for the last exercise.   She had three voices and picked three other people from the audience to play her voices and one to play her.   She took them outside the room and briefed them on what her voices were.   Then we started the "skit".   This woman's voices had been gone for 10 years.   They were trying to return and were demanding her to let them in again.   She was refusing.   They promised to show her a good time.   They promised to tell her to get naked in front of lots of people.   She continued to refuse to let them back into her head.   The actors and actresses did an excellent job of portraying the struggle she had been experiencing.   Finally we discussed what had been happening in the workshop and ground it into aboriginal thought about extraordinary realities and our capacity to negotiate them.   I mentioned the problem with some young people of our day trying to journey in other dimensions without guides.   That's why we have elders, I said.   Elders and teachers are there to help us navigate extraordinary spaces and to give us the stories to understand what's going on so that we don't get too far away from the ordinary world and not know how to get back. More later.

Culture as Medicine Day2 for 2012: Hearing Voices

Today I gave the keynote address at the International Healing Voices Conference in Melbourne.   The conference was organized by Voices Vic (for Victoria, the state in which Melbourne lies).   Speakers came from around the world -- Ron Coleman (who started the Hearing Voices Network in the U.K.); a woman from Auckland, New Zealand; Eleanor, a young woman/psychologist/voice hearer from Australia, and more.   Unlike most mental health conference, where the attendees are mostly practitioners of various kinds, this conference was mostly "patients".   And was it different!   The energy was so upbeat!   The conference was all about hope and recovery.   People told inspiring story after story of being severely mentally ill and recovering to the point of becoming a practicing psychologist, for example.   I'll start with Eleanor's story.

By all appearances Eleanor was an aspiring young psychologist.   She could have help her own at any professional meeting.   She was attractive, articulate, well-dressed, well-spoken -- the kind of graduate any psychology program would be proud to proclaim.   However, once upon a time, she had been a patient in the mental health system.   She heard voices that tortured her.   Once she tried to drill a hole in her head to let the voice out.   She wasn't trying to harm herself.   She just really believed that the voice would leave if it had an exit pathway.   Her longest hospitalization had been for 5 months and she had more of them than she could count or remember.   She had connected with the Hearing Voices Movement and had learned how to manage her voices.   Slowly but surely the positive voices gained sway over the negative voices.   Eventually her mind became more peaceful and she was able to return to her University studies.   She could concentrate and learn again and went on to complete a doctorate in clinical psychology and to become a licensed psychologist.

As so many people have told me, Eleanor reported that the medications only made her worse.   The drugs didn't touch the voices.   They just made her completely unable to think.   Being unable to think prevented her from doing the cognitive therapy she needed to do to learn how to manage the voices.   Being unable to think left her in complete misery.   Eleanor told us that she wasn't against medication or anything that helped people.   She would have been happy to take a drug that worked.   However, she said, "I'm against forcing people to take drugs that don't work and make them worse and prevent them from working through the problem."   For that she received a standing ovation from the audience.   I was impressed.   This was not an anti-psychiatry group.   This was a group of pro-active consumers demanding realism of outcome.   They were angry with a mental health system which pretended to help when it didn't and actually made them worse.

However, I have gone ahead of myself.   The conference began with a welcome from its organizer, a woman named Indigo, who also heard voices.   Then the "Welcome to Country" was given by an aboriginal man from the people who originally inhabited the area that is now known as Melbourne.   He played an amazing concert on a digeridoo that he had made.   Then, to my surprise, a North American aboriginal man came out to dance.   He was Ojibway from Minnesota.   The music started and to my surprise it was a Lakota song.   He didn't dance.   He waited and waited.   Then he looked at Indigo puzzled.   "You put on the wrong song," he said.   He went to the podium and clicked the correct song on the computer.   Ojibway words filled the room instead of the Lakota.   I had known that song and was singing along.   However, I knew Ojibway wouldn't dance necessarily to Lakota.   That's been a rivalry for hundreds of years.   In 1420, the Lakota attempted to defeat the Ojibway in the area around Thunder Bay, Ontario.   The Lakota suffered a miserable defeat.   I'm reminded of that every time I visit Thunder Bay.

Next came the official welcome and address from the Chair of the Agency funding Voices Vic, which was delivered by a man named Quinn from Prahan Mission.   To my surprise, our host, Tony Gee, had worked with Quinn in the past at other agencies.   Tony is the Chair of Life Is ". Foundation, which is one of the collaborators in our Australian Cross Cultural Exchange.   Life Is" has a mission of preventing suicide and assisting those left behind by a suicide to heal.   Then came my talk.   I'm going to share what I had to say, but first more observations from the conference.

The strong indigenous presence also contributed to making this a different kind of conference than others I have attended.   We heard often that aboriginal healers were not afraid of voices.   Hearing voices is normal and honored in the aboriginal community.   One hears the voices of the ancestors, the voices of spirits, the voices of the animals and of nature.   To be a voice hearer is a privilege and an honor.   Aboriginal elders were present from diverse parts of Australia to share how they assisted people who heard frightening and terrifying voices.

All this converged on the subject of my talk -- that hearing voices is an ordinary human experience that we all have.   What's different is the spin we put on the voices and the voices to which we give our attention.   I showed brain imaging slides for "hearing voices", "people with the diagnosis of schizophrenia who were not at the moment hearing voices, and so called "normal controls".   I joked with the audience about not knowing where they could have found a room full of normal people, since they were so rare.   The imaging studies suggested that the only difference was in the frontal lobes.   The frontal lobes are what we use to make up stories about our voices.   One story is that these are just our own thoughts.   Then we call those people with intrusive and disturbing thoughts "OCD".   We spare them the psychosis diagnosis because they know the thoughts are their own despite their disturbing and even terrifying nature.   In other stories, the Voices are Ascended Masters trying to take over one's mind for the purpose of eternal punishment.   In the indigenous story, some of these voices are the whispters of the ancestors, some of them come from the spirits, and one's job is to listen carefully to all the voices and practice discernment.   An elder told us never do anything a voice tells you to do if it will hurt you or someone else.   Good spirits wouldn't tell you to hurt anyone or hurt yourself.   They're funny and they make you feel good.   My suggestion is that hearing voices isn't abnormal and isn't even worthy of treatment or diagnosis.   Instead, people suffer due to the stories they create or absorb about what the voices mean and who they are and also for being fixated on negative voices that criticize, castigate, berate, wheedle, and excoriate their listener. I suggested that this tendency to focus on the negative voices is related to painful life experiences which was in keeping with Eleanor's talk (came after mine) in which she reported that people who experience trauma are 46 times more likely to receive a psychotic diagnosis than those who don't.   Eleanor's trauma was being raped and molested repetitively in a day care center run by pedophiles.   She told us her home life otherwise was atraumatic and that her parents had been loving and warm, but she had had no way to express her traumatic experiences since they occurred when she was so young and they just kept building inside of her like a pressure cooker ready to explode which she finally did during her second year at college.

I suggested that the work with voices was to make sure all voices are heard and none are necessarily more privileged than others even when those inner voices match the broader messages of the dominant culture.   I introduced Bakhtin, Hermans, and dialogical self theory to the group.   The Russian, Mikhail Bakhtin, is easily one of my favorite philosophers.   In one often quoted passage, he described the mind as a room filled with a cacophony of polyphonous voices, each arguing with the other, each trying to achieve ascendency, some forming shifting coalitions to win out over others (sounds like the U.S. Congress to me!).   He thought Doestoevsky had done the best job describing the mind in this manner, especially in Crime and Punishment, in the way in which Raskolnikov's mind is presented.

Hermans and his colleagues have taken this further into a mature psychological theory which matches the concepts of social constructionism and critical constructivism.   The mind consists of many "me's".   Each "me" emerges to manage a particular relationship and collection of stories related to that relationship.     More about this tomorrow!

Culture as Medicine in Australia Day 1

Day 1: Australia 2012

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I arrived yesterday in Australia.   Today is Day 1 of the Australian Journey.   We begin by my presenting at Life Is" Foundation, Native American Culture and spirituality.   My job was to share some aspects of Native North American culture and spirituality with people in Melbourne.   This is part of our fundraising mechanism for the work we are planning to do in East Gippsland.   I am not going to say much about my presentation, because I have written about Native American Culture and spirituality at length.   Rather, I'd like to talk about what emerged from the dialogue at the presentation.

I learned a bit about the politics of "Welcome to Country".   In Australia, it is common to open events with a "Welcome to Country" address.   In this procedure, an aboriginal person who comes from a group native to the land upon which one stands comes and welcomes delegates or attendees or members of an event to the land as one of the original people who inhibited that land.   Typically the person chosen to offer the "Welcome to Country" tells of his or her ancestors who lived on that land and sings a song or two, speaking in the language of the land and then translating into English.   Typically that person is paid to come and provide the "Welcome to Country".   However, it's easy to imagine the political intrigues associated with this practice.   Though an aboriginal person welcomes outsiders to his or her country, typically he or she owns none of the country.   The symbolism of a disenfranchised person being paid to welcome outsiders to a country he or she no longer owns is not lost on we outsiders.   It smells of co-opting.

We couldn't find a local to welcome me to country in Melbourne, so we chose not to use someone from a neighboring territory but rather to acknowledge the original holders of the land and to note that none of them were available to welcome me to country.   Therefore, we acknowledged the original people of the land and their ancestors and wished that they could be present with us.   Of course, two people from a neighboring aboriginal group were critical of the lack of "Welcome to Country" by an aboriginal person.   We should have contracted with them.   That didn't make sense to me, since they weren't from the land where we were speaking.   Thus, politics emerge.

"Welcome to Country" aside, we heard important information.  

Aboriginal people were first counted as citizens in the 1971 Census. Since then, censuses have shown a significant increase in people identifying as Aboriginal and/ or Torres Strait Islander peoples:

• Between the 1991 and 1996 Census there was a 33% increase recorded in the numbers of Indigenous peoples.
• Between the 1996 and 2001 Census there was a 16% increase.
• Between the 2001 and 2006 Census there was an 11% increase. ^[6]

Despite the increases in the numbers of people identifying as Indigenous in censuses, however, there are still believed to be significant undercounts occurring. In the 2006 Census, Indigenous status is unknown for 1,133,466 people, comprising 5.7% of the total number of people surveyed. ^[9]

2.1 Size and characteristics of the Indigenous population

In the 2006 Census, 455,028 people identified themselves as being of Aboriginal and/ or Torres Strait Islander origin, comprising 2.3% of the total population. ^[11]

There were approximately 409,729 people of Aboriginal origin (90% of the total) and 29,239 of Torres Strait Islander origin (6%). A further 19,552 people (4%) identified as of both Aboriginal and Torres Strait Islander origin. ^[12]

Where Indigenous peoples live

Table 1 below details the percentage of the total number of Indigenous peoples that lives in each State and Territory, and the proportion of each State and Territory's population that is Indigenous.

Table 1: Location of Indigenous peoples - by State and Territory (2006) ^[22]

Percentage of the total Indigenous population living in a State or Territory
Percentage of the State or Territory's total population that is Indigenous

New South Wales

28.7
2.2

Victoria

6.0
0.6

Queensland

28.3
3.6

South Australia

5.0
1.7

West Australia

15.1
3.8

Tasmania

3.3
3.4

Northern Territory 

12.9
31.6

ACT

0.8
1.2

Language and culture

Indigenous cultures today reflect both traditional elements and the influence of non-Indigenous cultures. The 2006 Census reported:

• 86% of Indigenous respondents reported speaking only English at home, which is about the same as the non-Indigenous population (83%);
• 12% of Indigenous respondents reported speaking an Indigenous language at home; with three quarters of those recording they were also fluent in English;
• Many Indigenous peoples are bilingual; however, the pattern varies with geographical location with 56% of respondents living in remote areas reported speaking an Indigenous language, compared with one per cent in urban centres;
• Older Indigenous peoples (over 45 years) are more likely to speak an Indigenous language than younger Indigenous peoples. (Of those Indigenous peoples aged 45 years and over, 13% speak an Indigenous language, compared with 10% of 0-14 year olds);
• Indigenous languages are more likely to be spoken in the centre and north of Australia than in the south. ^[30]

Health

Self reported health status

In the NATSIHS 2004--05:

• 43% of Indigenous respondents aged 15 years and over reported their health as very good or excellent;
• 35% reported their health as being good; and
• 22% reported their health as fair or poor.

After adjusting for differences in the age structures of the Indigenous and non-Indigenous populations, Indigenous Australians were twice as likely as non-Indigenous Australians to report their health as fair or poor in 2004--05.

Indigenous Australians aged 15 years and over in non-remote areas were more likely than those in remote areas to report fair or poor health (23% compared with 19%). ^[33]

  Life expectation and mortality

Under the life expectation estimation formula adopted by the ABS in 2003, ^[34] Indigenous males' life expectation was estimated to be 59.4 years over 1996-2001, while female life expectation was estimated to be 64.8 years: a life expectation inequality gap when compared to the general Australian population of approximately 17 years for the same five year period. The ABS has not released a life expectation estimate for Indigenous peoples for the years 2002 on. ^[35]

The gap in life expectation between Indigenous and non-Indigenous Australians exists in part because of the dramatic increase in life expectation enjoyed by the non-Indigenous population over the past century. Over the period 1890 -- 1997, for example, it has been estimated that, for the non-Indigenous population, women's life expectancy increased around 26 years; while for males, 28 years. In contrast, while figures are not available, much smaller gains appear to have occurred in the Indigenous population contributing to the development of a 17 year life expectation gap. ^[37]

Text Box 1: International comparisons in Indigenous peoples' life expectancy 

Approximately 30 years ago, life expectation for Indigenous peoples in Canada, New Zealand and the United States of America was, like Indigenous peoples in Australia today, significantly lower than that of the respective non-Indigenous populations of those countries.

However, significant gains in life expectation by Native Americans and Canadians and the Maori have been made in recent decades. Today, Australia has fallen significantly behind in improving the life expectation of its Indigenous peoples. Although comparisons should be made with caution (because of the way different countries calculate life expectation) data from the late 1990s suggests Indigenous males in Australia live between 8.8 and 13.5 years less than Indigenous males in Canada, New Zealand and the USA; and Indigenous females in Australia live between 10.9 and 12.6 years less than Indigenous females in these countries. ^[41]

(a) Mortality

For the period 2001--05, among the residents of Queensland, Western Australia, South Australia and the Northern Territory (jurisdictions where the data is deemed reliable), deaths recorded as being of an Indigenous person accounted for 3.2% of all deaths, higher than their presence as a percentage of the total population (as noted, estimated at 2.5%). ^[42]

In Queensland, Western Australia, South Australia and the Northern Territory combined, approximately 75% of Indigenous males and 65% of Indigenous females died before the age of 65 years. In contrast, in the non-Indigenous population 26% of males and 16% of females died aged less than 65 years. ^[43]

For the period 2001--05, Indigenous infant deaths represented 6.4% of total Indigenous male deaths and 5.7% of total Indigenous female deaths compared with 0.9% and 0.8% of the total for non-Indigenous male and female infant deaths. ^[44]

(b) Years of life lost

Years of Life Lost (YLL) is an indicator of premature mortality.

A 2003 study on the burden of disease and injury among Indigenous peoples found there were an estimated 51,475 YLL due to disease and injury for the Indigenous population, or approximately 4% of the total YLL for disease and injury for the total Australian population. ^[45] This is significantly higher than their presence as a percentage of the total population.

Cardiovascular disease was the leading cause of years of life lost accounted for around one-quarter of total YLL among Indigenous peoples; followed by cancer (14% of YLL); unintentional injuries (11%), intentional injuries (9%) and diabetes (7%). ^[46]

5.3 Infant and child health

(a) Low birth weight infants

Indigenous infant and child health is significantly poorer than that of non-Indigenous infants and children. A 'low birth weight baby' weighs less than 2,500 grams at birth ^[47] indicating, among other things, foetal malnutrition. There is a growing body of evidence that suggests a malnourished foetus will program its body in a way that will incline it to chronic diseases later in life. ^[48]

Approximately twice as many low birth weight infants were born to Indigenous women compared to those born to non-Indigenous women over 2001 and 2004. ^[49] The ABS reported in 2005 that since 1991 there appears to be no change in both the rates of low birth-weight infants being born to Indigenous women and the mean birth weights of those infants. ^[50]

(b) Infant mortality

After significant reductions to the Indigenous infant mortality rate in the 1970s and 1980s, there was a levelling out of the rate in the mid 1990s. The decline is believed to have halted because of the generally poorer health of Indigenous mothers; their exposure to risk factors; and the poor state of health infrastructure in which infants were raised. ^[51] http://www.blogger.com/blogger.g?blogID=1856550366954823610#editor

The infant mortality rate is expressed as the number of deaths in the first year per 1,000 births in a population. The ABS concluded in 2001 that no reliable Indigenous infant mortality rate national trend (either for better or worse) was identifiable, largely because of the poor quality of data. ^[52] In jurisdictions where the data is deemed reliable, for the period 2001 to 2005, approximately two to three times the number of Indigenous infants died before their first birthday, as non-Indigenous infants. ^[53]

5.4 Chronic diseases

Chronic diseases, and in particular cardiovascular disease, are the biggest single killers of Indigenous peoples and an area where the Indigenous and non-Indigenous health equality gap is most apparent.
The rates of death from the five main groups of chronic diseases compared to the non-Indigenous population over 2001-05 is set out in Table 2 as a Standardised Mortality Rate (SMR). The SMR is calculated by dividing recorded Indigenous deaths by expected Indigenous deaths (with the latter based on the age, sex and cause specific rates for non-Indigenous Australians). ^[54]

Table 2: Indigenous Deaths, main causes, 2001-05 - Standardised Mortality Rate. ^[55]

Cause of Death
Males SMR
Females SMR

Diseases of the circulatory system

3.2

2.7

Neoplasms (including cancer)

1.5

1.6

Endocrine, nutritional and metabolic diseases

7.5

10.1 

Diabetes

10.8

14.5

Diseases of the respiratory system

4.3

3.6

Diseases of the digestive system

5.8

5.1

Communicable diseases

Communicable diseases in Indigenous peoples reported as multiples of the rates in the non-Indigenous population (2004-05) ^[57]

Communicable disease
Detected in Indigenous peoples at...

Hepatitis A

11.7 times the rate detected in the non-Indigenous population

Hepatitis B 

5.4 times the rate detected in the non-Indigenous population

Meningococcal infection

7.8 times the rate in the non-Indigenous population

Salmonellosis

4.3 times the rate in the non-Indigenous population

Chlamydia Infection

7.9 times the rate detected in the non-Indigenous population

Tuberculosis

1.6 times the rate in the non-Indigenous population

Social and emotional well being

The NATSIHS 2004-5 was the first Indigenous-specific survey by the Australian Bureau of Statistics that aimed to measure the emotional and social health of Indigenous adults. In this, more than half the adult Indigenous population reported being happy (71%), calm and peaceful (56%), and/ or full of life (55%) all or most of the time. Just under half (47%) said they had a lot of energy all or most of the time. ^[60] And Indigenous peoples in remote areas were more likely to report having had these positive feelings all or most of the time, than were Indigenous peoples living in non-remote areas. Conversely, about 15% of the total number of adults who were asked felt these things only a little of the time, or none of the time. Results again were better for Indigenous peoples in remote areas. ^[61]
The NATSIHS 2004-5 also included five questions designed to highlight psychological distress. Responses showed that almost one in ten Indigenous adults reported feeling nervous all or most of the time. When asked how often they felt without hope, 7% said that they had this feeling all or most of the time. Similarly, 7% said that they felt so sad that nothing could cheer them up, all or most of the time. A higher proportion of the Indigenous population reported feeling restless (12%) and/ or that everything was an effort all or most of the time (17%). ^[62]

The Western Australian Aboriginal Child Health Survey collected data on approximately 5,000 Indigenous children over 2000-01. It reported that one in four Aboriginal children were at high risk of developing serious emotional or behavioural difficulties. This compares to about 1 in 6 or 7 of non-Aboriginal children. ^[63]

Mental health

Data on hospitalisations for mental and behavioural disorders provide a measure of the use of hospital services by those with problems related to mental health. In 2005--06 there were more hospitalisations of Indigenous males and females than expected based on the rates for other Australians for most types of mental and behavioural disorders. ^[64] In particular, hospitalisations for 'mental and behavioural disorders due to psychoactive substance use' were almost five times higher for Indigenous males and around three times higher for Indigenous females. ^[65]

Hospitalisation rates for intentional self-harm may also be indicative of mental illness and distress. In 2005--06, Indigenous Australians were three times more likely to be hospitalised for intentional self-harm than other Australians. ^[66]

Disability 

In the 2006 Census of Population and Housing, a total of 19,600 Indigenous peoples (approximately 4% of the total Indigenous population) were recorded as requiring assistance with core function activities (self-care, mobility and/ or communication) on a consistent basis. The level of assistance required by the Indigenous population was twice as high as that required by the overall Australian population. ^[79]

Income

In the 2006 Census, the mean equivalised gross household income for Indigenous persons was $460 per week, which amounted to 62% of the rate for non-Indigenous Australians ($740 per week). ^[82] ^top

Employment

Participation in the labour force

The labour force participation rate for the non-Indigenous population was 63% in 2001 compared with 65% in 2006. When adjusted to include only people aged 15-64 years, the disparity in labour force participation widens further. In 2001 there were 54% of Indigenous peoples in this age group in the labour force compared with 73% of the non-Indigenous population. In 2006, 57% of the Indigenous population in this age group was participating in the labour force compared with 76% of the non-Indigenous population. ^[87]
Labour force participation rates for Indigenous peoples declines with remoteness, with a 57% participation rate in major cities compared with 46% in very remote areas. ^[88]

Nationally, 46% of all Indigenous peoples aged 15-64 years were not in the labour force in 2001. This figure dropped to 43% in 2006. (This indicates that they were not actively engaged in the labour market, for reasons including carer responsibilities, illness, disability or lack of market opportunities.) In 2002, 27% of the non-Indigenous population in the same age group were not participating in the labour force, while in 2006 this figure dropped to 24%. ^[89]

Education

Educational attainment among Indigenous peoples continues to improve. Between 2001 and 2006, the proportion of Indigenous peoples aged 15 years and over who had completed Year 12 increased from 20% to 23%. There was also an increase in the proportion of people who had completed a non-school qualification (20% to 26%).

^top

9. Housing and homelessness

Between 2001 and 2006 the proportion of Indigenous home owner households increased from 31% to 34%. The proportions of Indigenous households renting from Indigenous or mainstream community housing organisations and those renting from private or other providers, fell by around two percentage points between 2001 and 2006, while the proportion of Indigenous households renting from state housing authorities remained relatively unchanged over this period. ^[102]

In comparison, 69% of the estimated 7 million other Australian households were home owners (with or without a mortgage) 26% were renting and 2% had other tenure types. ^[103]

Generally speaking, in remote areas, Indigenous peoples are less likely to own their home than in urban centres.

Indigenous People and the Criminal justice systems

The Royal Commission into Aboriginal Deaths in Custody (RCIADIC) reported in 1991. At that time, Aboriginal people made up 14% of the total prison population and were up to 15 times more likely to be in prison than non-Aboriginal people. The Report made a large number of recommendations to address this issue. ^[122] 

Despite this, the number of Indigenous prisoners has increased significantly over the 17-years since the RDIADC. Indigenous prisoners represented 24% of the total prisoner population (6139 males and 567 females) ^[123] as of the 30^th June 2008, a proportion unchanged from the previous year. ^[124] The ABS notes that caution must be taken in interpreting the increases in the percentage of Indigenous peoples in the prison population, the increase may be due to alterations in the method of data collection and/ or the willingness of Indigenous prisoners to participate and identify themselves as Indigenous. ^[125]

Incarceration rates for women generally have increased more rapidly than for men and the increase in imprisonment of Indigenous women has been much greater over the period compared with non-Indigenous women. ^[130] The Indigenous female imprisonment rate has increased by 34 % between 2002 and 2006 while the imprisonment rate for Indigenous men has increased by 22%. ^[131]

Indigenous women are also 23 times more likely to be imprisoned than non-Indigenous women while Indigenous men are 16 times more likely to be imprisoned than non-Indigenous men. ^[132]

Child protection

Both the 1994 and 2002 surveys report that 8% of Indigenous respondents aged 15 years or over at the time of the surveys, had been taken away from their natural family. ^[143] The incidence of removal increased slightly with age, (perhaps reflecting greater numbers of removals in the past):

• 10% of Indigenous respondents aged 25 years or over reported that they had been taken away from their natural family.
• 10% was recorded for the closest equivalent age cohort group (35 years or over) in the NATSISS 2002.

In the NATSISS 2002, 38% of respondents reported that they had either been removed themselves and/ or had relatives who, as a child, had been removed from their natural family. The most frequently reported relatives removed were grandparents (15%), aunts or uncles (11%), and parents (9%). ^[144]
The intergenerational impacts of past child removal practices are reflected in the higher numbers of substantiation orders, child protection orders and child removal orders being made in the present day in relation to Indigenous children.

The intergenerational impacts of past child removal practices ^[145]

Among all of the Aboriginal children and young people living in Western Australia, 35.3 per cent were found to be living in households where a carer or a carer's parent (e.g. grandparent) was reported to have been forcibly separated from their natural family.

It was found that carers who had been forcibly separated from their natural families (compared with carers of Aboriginal children who had not been forcibly separated) were:

• 1.95 times more likely to have been arrested or charged with an offence
• 1.61 times more likely to report the overuse of alcohol caused problems in the household
• 2.10 times more likely to report that betting or gambling caused problems in the household
• Less than half as likely to have social support in the form of someone they can "yarn' to about problems
• 1.50 times more likely to have had contact with Mental Health Services in Western Australia.

Further, Aboriginal children whose primary carer had been forcibly separated from their natural family were found to be 2.34 times more likely to be at high risk of clinically significant emotional or behavioral difficulties than children whose carers were not forcibly separated.

Bibliography

---

^[1] Australian Bureau of Statistics, National Aboriginal and Torres Strait Islander Social Survey 2002, ABS cat no 4714.0 (2004).
^[2] Australian Bureau of Statistics, National Aboriginal and Torres Strait Islander Health Survey 2004-05, ABS cat no 4715.0 (2005).
^[3] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008).
^[4] Australian Bureau of Statistics, Population Distribution, Aboriginal and Torres Strait Islander Australians 2001, ABS cat no 4705.0 (2002) p 7-15.
^[5] For further information, see also Australian Human Rights Commission, Face the Facts (2008). At: http://www.humanrights.gov.au/racial_discrimination/face_facts/index.html (viewed 22 January 2009).
^[6] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 12.
^[7] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 12; Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2001, ABS cat no 4713.0 (2001) p 12.
^[8] Australian Bureau of Statistics and Australian Institute of Health and Welfare, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2003, ABS cat no 4704.0 (2003) p 245.
^[9] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 10.
^[10] Australian Bureau of Statistics Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 15.
^[11] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 12.
^[12] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 19, table 2.2.
^[13] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 9.
^[14] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 79.
^[15] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 79.
^[16] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 80.
^[17] Australian Bureau of Statistics and Australian Institute of Health and Welfare, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2005, ABS cat no 4704.0 (2005) p 74.
^[18] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 14-15.
^[19] Australian Bureau of Statistics, Yearbook 2008, ABS cat no 1301.0 (2008) p 198.
^[20] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 15,(unnumbered graph).
^[21] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 14.

^[22] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 16.
^[23] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 12.
^[24] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 13.
^[25] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 27.
^[26] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 27.
^[27] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 28.
^[28] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 27.
^[29] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 27.
^[30] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 35-37.
^[31] Australian Bureau of Statistics, National Aboriginal and Torres Strait Islander Survey 1994 -- Detailed Findings, ABS cat no 4190.0 (1995) p 4.
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^[33] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 9.
^[34] There are long-standing issues pertaining to the identification of an Aboriginal and/or Torres Strait Islander person as the deceased on death certificates that prevent definitive statements being made about Indigenous peoples' life expectation, hence the reliance on life expectation estimation formulas to arrive at figures. In 2006, it was estimated that only 55% of the deaths of Indigenous peoples were correctly identified. Australian Bureau of Statistics, Deaths 2006, ABS cat no 3320.0 (2006) p 69, Table 9.1.
^[35] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 154.
^[36] United Nations Development Program, Human Development Report 2005 (2005) p 220, Table 1.
^[37] F Baum, The New Public Health (2002) p 198.
^[38] Australian Bureau of Statistics, Deaths 2006, ABS cat no 3320.0 (2006) p 9.
^[39] Australian Bureau of Statistics, Australian Social Trends 2002, ABS cat. no. 4102.0 (2002) p 83-85.
^[40] Australian Bureau of Statistics, Deaths 2006, ABS cat no 3320.0 (2006) p 8.
^[41] I Ring and D Firman, "Reducing Indigenous mortality in Australia: lessons from other countries', Medical Journal of Australia (1998) 169, p 528-533.
^[42] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 156-7.
^[43] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 156-7.
^[44] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 156-7.
^[45] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 159.
^[46] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 159.
^[47] Australian Bureau of Statistics and Australian Institute of Health and Welfare, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2005 (2005) p 79.
^[48] National Health and Medical Research Council, Nutrition in Aboriginal and Torres Strait Islander Peoples, an information paper (2000) p 21.
^[49] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 83.
^[50] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 84, Graph 6.6.
^[51] N Thomson, "Responding to our "Spectacular Failure"', in N Thompson, The Health of Indigenous Australians, (2005) p 490.
^[52] Australian Bureau of Statistics, Deaths 2001, ABS cat. no.3320.0 (2002) p 23.
^[53] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 94.

^[54] Standardised mortality rate is observed as Indigenous deaths divided by expected Indigenous deaths, based on the age, sex and cause specific rates for non-Indigenous Australians: Australian Institute of Health and Welfare, Australia's Health 2008, ABS cat no 8903.0 (2008) p 76.

^[55] Australian Institute of Health and Welfare, Australia's Health 2008, ABS cat no 8903.0 (2008) Table 3.4.
^[56] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 130.
^[57] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 121, Table 7.34.
^[58] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 133.
^[59] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 134.
^[60] Australian Bureau of Statistics, National Aboriginal and Torres Strait Islander Health Survey 2004-05, ABS cat no 4715.0 (2005) p 3.
^[61] Australian Bureau of Statistics, National Aboriginal and Torres Strait Islander Health Survey 2004-05, ABS cat no 4715.0 (2005) p 3.
^[62] Australian Bureau of Statistics, National Aboriginal and Torres Strait Islander Health Survey 2004-05, ABS cat no 4715.0 (2005) p 3.
^[63] S Zubrick, S Silburn, D Lawrence and others, The Western Australian Aboriginal Child Health Survey: The Social and Emotional Wellbeing of Aboriginal Children and Young People, Curtin University of Technology and Telethon Institute for Child Health Research (2005) p 30.
^[64] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 111.
^[65] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 111.
^[66] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 111.
^[67] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 139.
^[68] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 139.
^[69] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 139-140.
^[70] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 144.
^[71] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 144.
^[72] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 144.
^[73] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 145.
^[74] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 140.
^[75] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 141.
^[76] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 141.
^[77] Department of Families, Housing, Community Services and Indigenous Affairs, Review of the First Phase of the Petrol Sniffing Strategy (2008). At http://www.facsia.gov.au/indigenous/petrol_sniffing_strategy_review/p02.htm (viewed 19 January 2009).
^[78] Department of Families, Housing, Community Services and Indigenous Affairs; Department of Health and Ageing; and others, Submission to the Senate Inquiry into Petrol Sniffing and Substance Abuse in Central Australia, 22 August 2008, p 8. At http://www.aph.gov.au/SENATE/COMMITTEE/clac_ctte/petrol_sniffing_substance_abuse08/submissions/sub14.pdf (viewed 19 January 2009).
^[79] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 55.
^[80] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 55.
^[81] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 81.
^[82] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 103.
^[83] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 103.
^[84] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 104.
^[85] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 107.
^[86] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2001, ABS cat no 4713.0 (2001) p 65; Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 80.
^[87] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 80.
^[88] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 66.
^[89] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 81.
^[90] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2006, ABS cat no 4713.0 (2008) p 83 and 104.
^[91] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 16-17.
^[92] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 16-17.
^[93] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 16-17.
^[94] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 16-17.
^[95] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 16-17.
^[96] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 20.
^[97] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 22.
^[98] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 24.
^[99] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 24.
^[100] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 25.
^[101] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 29-30.
^[102] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 30.
^[103] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 30.
^[104] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 30.
^[105] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 30.
^[106] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 37.
^[107] The Canadian model is sensitive to both household size and composition and uses the following criteria to assess bedroom requirements:

• there should be no more than two people per bedroom;
• a household of one unattached individual may reasonably occupy a bed-sit;
• couples and parents should have a separate bedroom;
• children less than five years of age, of different sexes, may reasonably share a bedroom;
• children five years of age or over, of the opposite sex, should not share a bedroom;
• children less than 18 years of age and of the same sex may reasonably share a bedroom; and
• single household members aged 18 years or over should have a separate bedroom.

Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 40.
^[108] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 40-41.
^[109] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 41.
^[110] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 41.
^[111] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 41.
^[112] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 42.
^[113] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 43.
^[114] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 43.
^[115] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 42.
^[116] Australian Bureau of Statistics, Housing and Infrastructure in Aboriginal and Torres Strait Islander Communities 2006 (Reissue), ABS cat no 4710.0, (2007) p 87.
^[117] Australian Bureau of Statistics, Housing and Infrastructure in Aboriginal and Torres Strait Islander Communities 2006 (Reissue), ABS cat no 4710.0, (2007) p 56, Table 4.9.
^[118] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 43.
^[119] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 43.
^[120] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 43.
^[121] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 42.
^[122] Royal Commission into Aboriginal Deaths in Custody, National Report (1991) volume 1, para. 9.3.1. At: www.austlii.edu.au/au/other/IndgLRes/rciadic (viewed 19 January 2009).
^[123] Australian Bureau of Statistics, Prisoners in Australia 2008, ABS cat no 4517.0 (2008) p 22, table 8.
^[124] Australian Bureau of Statistics, Prisoners in Australia 2008, ABS cat no 4517.0 (2008) p 6.
^[125] Australian Bureau of Statistics, Prisoners in Australia 2008, ABS cat no 4517.0 (2008) p 6.
^[126] Australian Bureau of Statistics, Prisoners in Australia 2008, ABS cat no 4517.0 (2008) p 6.
^[127] Australian Bureau of Statistics, Prisoners in Australia 2008, ABS cat no 4517.0 (2008) p 6.
^[128] D Weatherburn, B Lind, B Hua and J Hua, "Contact with the New South Wales court and prison system: the influence of age, Indigenous status and gender' (2003) Crime and Justice Bulletin 78(1) p 4-5. At click here='_blank' (viewed 19 January 2009).
^[129] Australian Bureau of Statistics, Prisoners in Australia 2008, ABS cat no 4517.0 (2008) p 8.
^[130] M Cameron, "Women Prisoners and Correctional Programs', AIC Trends and Issues in Crime and Criminal Justice, no 194, Australian Institute of Criminology (2001) p 1.
^[131] Steering Committee for the Review of Government Service Provision, Overcoming Indigenous Disadvantage: Key Indicators 2007, Productivity Commission (2007) p 128.
^[132] Steering Committee for the Review of Government Service Provision, Overcoming Indigenous Disadvantage: Key Indicators 2007, Productivity Commission (2007) p 129.
^[133] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 228.
^[134] M Lynch, J Buckman, and L Krenske, AIC Trends and Issues in Crime and Criminal Justice, Australian Institute of Criminology and Queensland Crime and Misconduct Commission, Issues paper 265 (2003).
^[135] M Lynch, J Buckman, and L Krenske, AIC Trends and Issues in Crime and Criminal Justice, Australian Institute of Criminology and Queensland Crime and Misconduct Commission, Issues paper 265 (2003) p 2.
^[136] Australian Medical Association, Undue Punishment? Aboriginal People and Torres Strait Islanders in Prison: An Unacceptable Reality, Australian Medical Association Report Card Series (2006). At https://fed.ama.com.au/cms/web.nsf/doc/WEEN-6PU9BH/$file/Indigenous_Report_Card_2006.pdf (viewed 19 January 2009).
^[137] T Butler, L Boonwaat and S Hailstone, National Prison Entrants Bloodborne Virus Survey Report 2004, Centre for Health Research in Criminal Justice and National Centre for HIV Epidemiology and Clinical Research (2005), p 5. At http://www.justicehealth.nsw.gov.au/publications/bbv_survey.pdf (viewed 19 January 2009).
^[138] T Butler, L Boonwaat and S Hailstone, National Prison Entrants Bloodborne Virus Survey Report 2004, Centre for Health Research in Criminal Justice and National Centre for HIV Epidemiology and Clinical Research (2005), p 5. At http://www.justicehealth.nsw.gov.au/publications/bbv_survey.pdf (viewed 19 January 2009).
^[139] A Kariminia, T Butler, S Corben, M Levy, L Grant, J Kaldor and M Law, "Extreme cause-specific mortality in a cohort of adult prisoners- 1988-2002: a data linkage study' (2007) 36(2) International Journal of Epidemilogy 310, p 314.
^[140] A Kariminia, T Butler, S Corben, M Levy, L Grant, J Kaldor and M Law, "Extreme cause-specific mortality in a cohort of adult prisoners- 1988-2002: a data linkage study' (2007) 36(2) International Journal of Epidemilogy 310, p 310.
^[141] M Lynch, J Buckman, and L Krenske, AIC Trends and Issues in Crime and Criminal Justice, Australian Institute of Criminology and Queensland Crime and Misconduct Commission, Issues paper 265 (2003) p ix .
^[142] J Joudo and J Curnow, Deaths in Custody in Australia: National deaths in Custody program annual report 2006, Australian Institute of Criminology, Technical and Background paper no. 85 (2006) p xiii.
^[143] Australian Bureau of Statistics, National Aboriginal and Torres Strait Islander Health Survey 2004-05, ABS cat no 4715.0 (2005) p 2.
^[144] Australian Bureau of Statistics, National Aboriginal and Torres Strait Islander Health Survey 2004-05, ABS cat no 4715.0 (2005) p 5-6.
^[145] Kulunga Research Network and the Telethon Institute for Child Health Research, Submission to the Senate Committee Inquiry into the Stolen Generation Compensation Bill 2008, April 9, 2008. At www.aph.gov.au/SENATE/committee/legcon_ctte/stolen_generation_compenation/submissions/sub42.pdf (viewed 19 January 2009).
^[146] For a detailed explanation of care and protection classifications and statistics see: Australian Institute of Health and Welfare, Child Protection 2001-02 (2003) ch 1.
^[147] The ABS cautions that data for Tasmania, however, should be interpreted with caution due to the low incidence of child protection workers recording Indigenous status at the time of the substantiation: Australian Bureau of Statistics, Population Distribution, Aboriginal and Torres Strait Islander Australians 2001, ABS cat no 4705.0 (2002) p 222. 

^[148] Australian Bureau of Statistics, Population Distribution, Aboriginal and Torres Strait Islander Australians 2001, ABS cat no 4705.0 (2002) p 223, Table 11.2.
^[149] The ABS cautions that SA data should be interpreted with caution due to the high proportion of investigations not finalised by 31 August 2006 (the cut-off date for the processing of investigations for inclusion in the data for that year).
^[150] Australian Bureau of Statistics, Population Distribution, Aboriginal and Torres Strait Islander Australians 2001, ABS cat no 4705.0 (2002) p 223, Table 11.3.
^[151] P Anderson and R Wild, Ampe Akelyernemane Meke Mekarle - Little Children are Sacred, Report of the Northern Territory Board of Inquiry into the Protection of Aboriginal Children from Sexual Abuse (2007).
^[152] P Anderson and R Wild, Ampe Akelyernemane Meke Mekarle - Little Children are Sacred, Report of the Northern Territory Board of Inquiry into the Protection of Aboriginal Children from Sexual Abuse (2007), p 6. ^[153] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 225, Table 11.4. ^[154] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 225, Table 11.4.
^[155] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS cat no 4704.0 (2008) p 225.
^[156] Access Economics for Reconciliation Australia, An overview of the economic impact of Indigenous disadvantage, (2008) p 5-6 (extracts). At click here (viewed 19 January 2008).