Thoughts on Indigenous Spirituality June 2019

Recently I took a class at the University of Maine on Gender and Religion, which helped me to better understand why women are so angry about the past. I learned that the women born into the “religions of the books (the Bible, the Q’uran, the Torah) have clearly suffered more over the years as a consequence of religion than have the indigenous women of North America.  This was certainly the case in China and India, as well.  Pre-Christian North American indigenous society was more flexible in gender relations than these other cultures.  Women had more choices.  There was not necessarily only one right way to do things. 

Contemporary aboriginal women are remembering the power and knowledge of their maternal ancestors.  For example, the words of a song, “Okisikôwak,” written and performed by the indigenous women’s music trio, Asani, enunciates these memories:

Those very same hands stroke the face of a child

Warrior within, not meek or mild

Every step that she takes is clearing the way

Inspiring a change, for generations today.

Women were seen as warriors, every bit as much as men.  During the worst periods of government oppression of aboriginal people, Shalin Jobin tells how the women kept their knowledge and power alive through the stories they carried and passed to future generations (see Chapter 2, written about her Cree ancestors in Kermoal, N., Altamirano-Jiménez, I., & Altamirano-Jimenez, I. (2016). Living on the land: Indigenous women's understanding of place. Edmonton, CA: Athabasca University Press).  Jobin writes how the residential school system aimed to create a “double consciousness” in which the indigenous person could not help but look at himself or herself through the eyes of the colonizers and that her ancestors resisted this double consciousness through their commitment to the stories.

Raymond Bucko's book, The Lakota Sweat Lodge was his Ph.D. dissertation at the University of Nebraska, where he currently (unless he has recently moved) teaches (Lincoln, NE: University of Nebraska Press, 2004).  Bucko’s book also speaks to the flexibility and lack of a hierarchy of North American indigenous spirituality. Each family does things differently and it’s always correct for those who do it that way in the place where it’s done.  However, were he to write this book today, he would need a new title.  Elders tell us that we should not refer to this ceremony as a “sweat lodge.”  The word in Lakota is inipikaga, which is best translated as “revitalization ceremony.”  We hear that the Jesuits called this ceremony a “sweat lodge” because they saw sweat.  For the Lakota, this was not sweat, but was toxins exiting the body in its process of revitalization. In Bucko’s book, he discovered that no right way to do a sweat lodge exists.  He discovered that no central authority existed to say what should be done and that each family does things a little differently, though some basic similarities are present.  He similarly writes that no central authority exists for deciding what Native American spirituality is.  Felix Cohen is correct, I believe, in saying that Native Americans in the United States are at the bottom of the pecking order.  What happens to Native Americans will happen to other minorities eventually.  Bucko makes the point that this insanity of the governmental imposition of Christianity began at least as early as the time of Thomas Jefferson's presidency.  It actually began much earlier.  An infamous community in Massachusetts began to hang Indians who weren't Christians around 1640.

Bucko made another point that hit home -- that the contemporary pan-Indian identity arose as a shared opposition to the European invasion.  The shared reality of the oppression eventually led to a shared response, though not until the 20th century.  In the 19th century, tribes were still working against each other with one tribe serving as scouts or helpers to the U.S. Army in attacking their traditional enemies.

Before the Blood Quantum Act of 1904, no concept of being half-Indian existed.  One was either a member of the Nation or not.  During the time of the forced march of the Cherokee to Oklahoma (The Trail of Tears and Death), the head chief of the Cherokee, John Ross, would have been only 1/8 Cherokee by today's standards.  By the standards of that time, he was 100% Cherokee.  In 1904, the U.S. Congress invented Native Americans as a separate breed in the same way that horses or dogs are considered as half this or half that.  The goal of the blood quantum system was to eventually eliminate the Bureau of Indian Affairs.  Here's how it works.  If a Lakota person marries a Cree person, then their children are only half Lakota.  They are also half Cree, but that doesn't make them 100% Indian.  It leaves them half-Indian.  Then if the child marries a Crow person, their children are only 25% Lakota.  One more marriage to a non-Lakota and this person is removed from the BIA roles, even though they have only married other Native Americans.  It actually doesn't matter if they marry a non-Indian; anyone outside the tribe counts toward diluting the percent Indian.  What is amazing is that the numbers of Native Americans are growing anyway.  This is because of young women having multiple children.  Bucko quotes Marshall Sahlin as describing the extended kinship Native American family, which is inclusive of everyone.  That seemed entirely accurate to me, though he left out the dogs. 

O'Brien calls attention to the tremendous abuses of the Franciscans, which virtually destroyed the tribes of California.  Schooled by the Spanish Inquisition, the methods of the Franciscans were brutal.  The Jesuits were more subtle, but ultimately equally destructive, for they engaged in epistemological genocide, the destruction of people's ways of seeing the world. The New England Protestants created towns for indigenous people to shed all of their culture and religion and completely embrace the ways of the colonizers.

However, indigenous North Americans had difficulty relating to the religious ideas of Europeans.  The idea of a collection of rules that determined one's afterlife seemed absurd. In all the traditions I know, everyone goes to the spirit world and no punishment is inflicted there.  Whatever evil one accumulates in this life is left behind.  We are all so much better in the Spirit World.  The conflicts and disharmonies of this world are left behind.  The emphasis on eternal punishment would not fit within the Native American world view.  I can remember my grandmother telling me, if there were a hell, it would be here on earth.  The Creator wouldn't make such a thing, she said.  The idea of a limited number of spirits seemed strange as well.  Everything has a spirit.  The Visibles have spirits and the Invisibles are spirits.  The idea of limiting eligibility to Father, Son, and Holy Ghost seemed bizarre.  Also, the idea that one needed a priestly intercessor to speak to the spirits for one would have seemed equally bizarre.  However, many people converted out of necessity and continued their indigenous spirituality while tolerating the religion of the colonizers.  Others were so hopeless and distraught that they accepted the beliefs of the conquerors entirely.

The Indian Civilization Fund Act of 1819 provided money for Christian clergy to proselytize indigenous people and to create boarding schools to teach Native children English, the Christian faith, and European methods of farming. Here was the government violating its own principals of keeping church and state separate.  O'Brien describes Major John Chivington of the U.S. Army, who orchestrated the Sand Hill Massacre, in which he killed almost 400 Cheyenne, mostly women, and children, and then mutilated their sexual organs and scalped them to display to cheering crowds in Denver.  He was chided by the Army but not punished.  The Chief of the Cheyenne was in favor of peace and was flying an American flag at the time he was killed.

The Cherokee had tried to emulate the Europeans in every way but giving up their sovereignty, even to the point of changing their gender relationships and becoming patriarchal, though this strategy did not succeed in preventing the forced relocation to Oklahoma. 

The Fort Laramie Treaty of 1868 established a large reservation for the Lakota, which was progressively whittled down, especially with the discovery of gold in the Black Hills.  Gold was the worst-case scenario for indigenous people in North America.  Once discovered, the rest is downhill.

In the indigenous cultures of North America with which I am familiar, Creator is genderless.  Gender only enters later in the process of elaboration of creation.  Some versions of the Maine creation stories have a male creator, but these have clearly been shown to be revisionist stories influenced by Christianity.  Some people think that the Lakota have a male creator, because of the use of the word tunkashila, which means grandfather.  However, elders have explained to us that the elders of the time of first contacts were trying to explain their concepts to the Europeans and actually said, "your creator loves you as a grandfather would love his grandchildren," which is a powerful concept in Lakota kinship systems.  They didn't mean to say that the creator was a grandfather.  They abandoned this attempt at an explanation when the Europeans misinterpreted them.  Now the word Dakuskanskan is used, which is the proper term.  Literally, it means that (plural) which is the whitest.  The best interpretation of this is the spirit which is higher than the highest of the sky spirits. Similar, some people misstate rocks as grandfathers.  We hear people talking about bringing the grandfathers into the inipi ceremony (the hot stones).  They are not actually grandfathers, either, for the proper word is inyan, which means stone.  Stones are considered to be masculine and are the oldest inhabitants of our world, which is why perhaps the ancients thought to explain to the Europeans that they were like grandfathers. The Europeans didn’t understand that the Lakota were using metaphors, perhaps because they couldn’t step away from their assumption that indigenous people were primitive and stupid.

While rocks are male, the earth is considered feminine.  However, in Lakota, Dakuskanskan, has a male messenger Tate, or the wind, and a female messenger, Wohpe, or the White Buffalo Calf Woman.  In a famous story about the creation of the four directions and time itself, Wohpe is sent to the earth to tell Tate that it is time to create the four directions because people are coming, and they will need time and direction.  

There is a famous women's song associated contemporarily with Sissy Goodheart of Yates, North Dakota, that tells how women are sacred for they give birth to the Nation through their hearts, minds, bodies, and souls.  The song says that they are the heart of the Nation and are asked, therefore, to bring their highest selves to their task of being the heart and soul of the people. 

Paula Gunn has written about the respect which women received and the sacredness of menstruation and of the power of menstrual blood.  In the Lakota language, one word is used to refer to things of power and mystery, which is wakan.  This word can be translated as holy, sacred, or mysterious.  There really isn't a word that corresponds to the usage of the English word "taboo."  The word wogluze refers to something sacred or forbidden, a spiritual taboo or ceremonial restriction (as a certain animal or animal part that cannot be eaten because of a vision one has received or things that are forbidden to do during a pipe ceremony).  The other word is wahtani, which means to fail to perform a vow or to violate a tribal law.  However, in my experience wogluze is never absolute, but always subject to exceptions and alterations.

Problems are rampant in European translations of indigenous languages as in North Dakota, where a word that meant "lake of the spirits," was translated as "Devil's Lake," which is the current name of that town and that lake.  The general understanding is that one doesn't mess with things or beings that are wakan, unless one has a full understanding of how to use that medicine or power.  The word for power and the word for medicine are the same also.  I know women elders who have the power to work with menstrual blood and women with menstrual disorders, and I know male elders who stand in awe of that power.

Day 10 of the Australian Journey

Today was day of reflection and the day that we travel to Sydney for that part of our cross-cultural exchange.   Before the flight, we spent the morning caucusing and planning for the next year.   We learned that funding exists for next year and that a camp will happen, which pleased and excited us.   My highpoint from camp was Lily, the woman healer/elder/leader from Millumgimby in the Northern Territories, crying during the men's choir concert.   On the last evening of every camp, the men's choir comes over by boat to eat dinner with us and sing to us.   The choir is led by a Maori man, James, who I described in my blog last year.   Briefly, James is a Maori nuclear physicist who has worked for years for the Australian defense industry and has run Maori-style sweat lodges in Australian prisons for Maori inmates ( and anyone else who wanted to come).   The choir is composed of, as they say, "black fellows and white fellows."   After dinner the choir serenaded us with Maori songs, a song from the Solomon Islands, from where one of its members hailed, aboriginal songs, and English language favorites (West Virginia, Oh Shenandoah, and the like).   Lily cried because she had never believed in her life time that white men would sing to her.   I thought this moment got to the heart of what we are trying to accomplish with cultural exchange -- for all the Voices to speak and be heard with equal volume and respect; to equalize the privileged voices and the dispossessed voices.   Lily's tears were evidence to me that we were accomplishing our mission.

I wrote last year about the "black-white" distinction in Australia.   It rings strange to my eyes.   When I look at aboriginal people here, I do not see black people.   I see Australian aboriginal people.   So when they call themselves black fellows and talk about the white fellows, it's strangely disconcerting to me.   It reminds of how people talked in the American South during my childhood which was deeply disturbing at the time.   I confess to thinking of "black" people as people who identify with ancestors who came from Africa to North America against their will.   Of course, they don't all look black either.   In fact, an actually black person is very hard to find.   Most people are varying shades of brown depending upon how much melanin they have in their skin.   The colder the climate, the less melanin you need.   The more sun, the more you need.   The downside to having lots of melanin is that it slows the absorption of some of the vitamin D in climates with little sun.   A theory exists that African-Americans have more depression than white Americans (controlling for poverty, etc.) because of a relative lack of vitamin D.   I know when I measure vitamin D in Vermont, it's always low.   I stopped measuring it and just give everyone vitamin D, because that's more cost effective, since it can't hurt you anyway and it's cheap.   Maybe if I practiced in Arizona, I'd rethink that position.   But, anyway, it's confusing to see people calling themselves black fellows, but I've come to understand it's a result of the colonizing position that the British took as they invaded the Australian continent and forcibly imposed their will upon the people who lived here.   I suspect it justified their actions because, in the 19^th century, "black" fellows were seen as inferior to "white" fellows -- primitive, just one step above the animals.   Of course, "red" fellows in the United States (why red, I do not know) were even seen as below "black" fellows.   All this was justified with a variety of pseudoscience, including phrenology, the study of the shape of skulls and what that revealed about intelligence.   Charles Darwin, to his credit, argued vigorously that skin color was a minor gene that had very little relation to anything else and almost no correlation with anything except the strength of the sun where one's ancestors evolved.

Part of the success of our project is echoed in the increasing number of requests we are receiving to come to other communities and to assist other communities in creating "culture camps".   Apparently this idea of spending one week together exchanging culture and participating in each other's ceremonies is novel.   In Canada, culture camps to celebrate one's own culture and heritage are common.   In North America, now, many people spend over one week together to celebrate the sun dance.   But apparently spending time together to exchange culture is new.   We have seen that the process results in increased awareness of the value of one's own culture and culture carriers (elders, leaders, etc.).   There appears to be a beneficial effect of watching someone from another culture share his or her practices and participating in them.   The process brings us closer to together.   In celebrating diversity, we find unity.   We have seen that culture camp has inspired some of the "white fellows" to look for their own ancestors and practices, whatever those are.  

We also heard that being able to tell one's stories -- personal and cultural -- to others and to feel heard by them was also important.   For aboriginal people to tell their personal and cultural stories to "white folks" and for the "white folks" to listen was powerful.   Whenever trauma occurs, all the stories must be told and culture camp provides an opportunity for this to happen.   The energy of the story is what happens between storyteller and listener when the story is told.   This energy produces healing.   The obstacles in the story are the gifts of the story.   In the myths and legends of a people, our personal stories can emerge without the complication of interpretation which suppresses the story and the healing.   We heard that non-indigenous cultures always want the newest, shiniest, most dramatic stories, while indigenous cultures like the old stories, the ones that have been told over and over.

A woman in our group told about working in Croatia soon after the war.   She was hired to help women tell stories to their children, but the women had lost all the stories of their culture and only had Disney stories.   She was puzzled about what to do.   She went to a house one freezing morning when it snowed, and sat with the young mother around her kitchen table, who said, "It's bad for us, but not as bad as it is for the lions."   This family had little food and was virtually malnourished but they were most concerned for the lions in the zoo who were suffering more than they.   Our friend told about walking through the snow and entering the zoo in the middle of winter and how heart-wrenching it was to see the desperately thin, starving animals.   She came upon the fence around the lions and thought that once upon a time, this must have been nice, in a Communist sort of way.   She switched her task to working with the local women to create a new story about saving the lions and finding a way to get them out of the zoo and to a place where they could thrive.

Then we flew to Sydney and were met by Pauline, who will be our hostess for the next three days.   We drove through incredibly thick rush hour traffic to her home in Manly and had a marvelous meal of cioppino, prepared by her husband who had lived in San Francisco.

Day 9 of the Australian Journey

I awoke to run only to be greeted by the sound of a driving rain.   Though I don't relish the thought of loading the boats while getting drenched, the sound of the rain on the roof is strangely comforting.   The temperature is chilly.   We were warned that summer is very hot in southeastern Australia, even up to 40 degrees.   I am sitting on the veranda under the sheltered portion wearing a shirt, a sweat shirt, and a jacket.   I almost didn't bring the jacket.

Today is our last day at Boole Poole.   We travel again today to the cultural center for further interactions with the community and the elders.   We had an extra day at Boole Poole last year and that allowed us to do "doctoring" for some of the elders who came over on the boat.   I wrote about that in last year's blogs which are still available at www.futurehealth.org.     By doctoring, I mean the aboriginal North American version of energy medicine/osteopathy.   I suspect that every culture had its own form of energy medicine and hands-own manipulative medicine, though some do not carry these practices in their current repertoire.

                Eventually enough people awoke that we could have a discussion on the veranda around breakfast while the rain continued to steadily fall.   Our breakfast question was how to bring spirituality into human services.   That led us to consider pathology as an organizer.   In medicine and psychology, what's wrong with you, the diagnostic category, has become the pivot point around which everything is organized.   The assumption is that diagnosis tells you everything you need to know to assist someone.   Then relationship comes not to matter because once the diagnosis is made, anyone can apply the treatment.   Spirituality becomes unimportant.   It is like the steam generated by a locomotive -- pretty to much but not necessary for the operation of the engine.   It is a byproduct that can be ignored.   How do we change that?

                Our conclusion was that we have to listen to the many stories surrounding the person and to grant validity to all those stories.   Everyone has a story about how and why they got sick.   Often their stories have fused with the stories of the dominant paradigm, such as "I'm sick because I got bad genes and there's nothing I can do about it."   Everyone also has a story about how healing is supposed to happen.   We have stories that guide us to what to expect when we consult someone who is supposed to help us.   My story in seeking a traditional healer is very different from my story in consulting an orthopedic surgeon.   I have different expectations for what they will do to me and for me.   But, what if I had an expectation that each of them should see the Divine in me and acknowledge it before proceeding with what they do?   That seems logical for the traditional healer, but why can't I also expect that from the orthopedic surgeon?   Thus, the human services toward which we are striving includes a willingness to meet people where they are and to experience their experience.   As a practitioner in a human service, I need to be willing to "be in the story" that's brought to me.   I need to "be in the details".   I cannot maintain the same level of clinical distance characteristic of the biomedical paradigm.   I actually have to be empathic.   I actually have to care even if I can't do more than that.   Caring and listening are powerful interventions even if nothing else can be done.

                This led us to discuss the indoctrination that new professionals receive. Their training and socialization makes them less able to interact with aboriginal people.   Some people enjoy formality and distance.   Most aboriginal patients do not -- at least not in the same way.   I know I want to feel heard.   I want to believe that someone cares enough about me to hear all the stories that I feel I need to tell.   Perhaps he or she will care enough to elicit some stories from me that I didn't know I had.   I need to enter into the stories of my clients enough to share some lived space ("Lebenswelt") with them.   That is considered unprofessional in some circles.   I am not saying I need to share my ongoing problems with them, though I do use stories about problems I have solved as teaching tales with clients.   I think we distance ourselves from clients related to our fear of ambiguity, mystery, and helplessness.   The biomedical model purports to give us a certainty that it doesn't deliver.   However, if we scrunch our eyes tightly shut, we can pretend that all is as it says it is and that we have certainty.   Sometimes we are helpless to do anything and we don't like that either.   We are afraid to not know the answer.   If I can maintain enough distance, I won't be affected by the vicissitudes of my clients' lives, including when they die.   In the biomedical model, I can't afford to care too much.   I can't afford to love my patients.

                Doctors and patients often come from radically different cultures.   Implicit within this is a difference in class and wealth.   Managed care in the United States has removed much of the wealth possibility from doctors, but the image remains.   In other countries, doctors never had the wealth potential that they had in the capitalist countries.   When we come from different cultures, we may have such stereotyped stories about each other that we are incapable of listening or interacting.   We interact as if both of us were wearing a mask.   Maybe we are!

                We agreed that our shared task, and what culture camp accomplishes, is to build bridges with others who are trying to see the world and human services differently.   Our current systems do not encourage emotions for and with the clients.   We want to change that and to experience the human condition with them and from them.   When we do that, we bring spirituality into our practice because that is one aspect of being human -- to reach out to what is greater than us, to contemplate larger powers, to appreciate our small stature in the universe and to be awed by the vastness of all we can perceive.

                Culture camp is giving us a shared language for how to move in this direction.   It is validating our experience of wanting to hear each other's' stories.   By observing each other working in our own context, we learn to more deeply appreciate the human stories and to see the richness of our own.   Seeing others' cultures helps us to find our own hidden assumptions, the beliefs and stories generating those beliefs that we don't know we have. We have trouble seeing the stories which surrounded us when we were born as stories.   We think of them as ineluctable facts.   Seeing others who don't share those most basic stories helps us to recognize our own.

                One of the aboriginal elders told us that those who have lost sight of the world as animated and magical need to practice seeing the artifacts and sacred objects as really alive.   They need to learn to see the energy around the object instead of the object itself.   Compassion is the ears getting bigger and bigger, she said.   "Call upon your ancestors," she said, "and hear everything without judging."   We talked about the difference between judgment and discernment.   I can discern that I don't want to be involved in a particular process or don't want it for myself, without being critical of those who are involved in that process.   We heard about the young men from Idaho who come to the Northern Territories to convert the locals to the Church of Latter Day Saints.   They are on a mission.   They look so out of place in the tropics wearing white shirts and ties.   They must always be home at 10pm.   "I don't want their religion or to do what they're doing," one man said, "but I don't judge them for doing it.   Being in this strange new place must be quite exciting for a sheltered young person from the rural United States."  

                I brought up my favorite Lakota concept of the nagi, which I have already discussed in these blogs.   Unique about this concept is the sense of person as swarm and the notion of swaminess, which is a mathematical/engineering concept now of how swarms behave.    We are swarms of conscious stories and tellers of those stories rather than concrete objects.    Where all the bees gather, there is a queen.   The queen represents the collection of concatenated stories that we privilege as better somehow than the rest.   My example of swarm behavior comes from deer nibbling on the leaves of acacia trees.   The acacia trees then secrete toxins to stop the deer from nibbling which every acacia tree in the neighborhood does simultaneously.

                A woman present brought our attention to how are bodies speak their story for us.   Laura told a story about a time when she felt traumatized.   She was also suffering from pain from her left shoulder down to her left hip.   She used phrases like, "I'm all twisted up about this."   "I overreached."   "I stretched myself too far." "I feel down."   "I bent over backwards."   We were able to point out to her how her language matched her body sensations.   The situations of her life were reflected or were parallel in her body.

                The discussions continued throughout the day with the eventual result of planning for next year's conference.   The rain continued so we made our soaking way to the boat with all of the sweat lodge blankets, some of which got quite wet.   We made a bumpy trip to the mainland and loaded the car for the drive back to Melbourne.

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.