Day 12 of the Australian Journey 2012

Today I was more accepting of my lack of status as a pedestrian while I took my morning run.   To show the difference in perception, I mentioned to my Australian hosts that the law of the sea gives the right of way to the slowest vessel.   They were aghast.   How could that be possible?!?   The right of way should go to the fastest vessel, and that's how they drive on land also.

Today we did another inipi ceremony (a.k.a., sweat lodge) for our Mission Australia hosts.   Two locals joined us who had spent substantial time on the Pine Ridge Agency in South Dakota and knew many songs.   They tended fire for us and carried stones, and the lodge sat on land they leased to be able to run regular ceremonies.   We really appreciated their help and to know about the Lakota-Sydney connection in which Lakota elders regularly came to teach in Sydney and Sydney-ites went to visit the elders in South Dakota.

Another thought came to me today -- culture exchange is different from cultural tourism.   In cultural exchange, each culture has something to offer the other.   In our coming here to do culture exchange, we gave as much as we received.   The local aboriginal people enjoyed participating in our culture as much as we enjoyed participating in theirs.   To my surprise, now, I know more about local aboriginal practices that many Australian I meet.   Like people in the States, they look for the exotic (our current spirituality du jour is Peruvian and ayahuasca) and ignore the richness of practice happening all around them.

The remainder of the day focused on Mission Australia with a fitting ending of listening to our host, Phil, play a mean lead guitar at open mike night at a local restaurant/bar in Manly.   The humor began when we heard it referred to as a Manly gig. Therefore what I want to discuss next is what I learned about the excellent work that they do.

First we heard about the Catalyst-Clemente program, which offers a model of how university education can become accessible to disadvantaged people.   It uses higher education in the humanities, delivered in a community setting, to engage with people who are disadvantaged and would not otherwise receive this education.   It involves a partnership between a university, community organizations, and a range of external supporters.   The subjects taught are fully accredited by the university and are in areas such as history, literature, ethics, and art.   The basic requirements for participants are a willingness to learn, a willingness to commit to a 12 week program, a literacy level that is sufficient to read a newspaper, and some stability in their lives.

To my surprise the origins of this program lie in the USA where New York journalist and social commentator, Earl Shorris, began the Clemente program in 1997.   Its philosophy is that tertiary-level education in the humanities can assist socially disadvantaged/marginalized people to think about and reflect upon the world in which they live.   In turn, this intellectual engagement can promote a broader re-engagement with society, activity with other people at every level, and assist them to exit from the cycle of poverty.   (See Earl Shorris, Riches for the Poor: the Clemente Course in the Humanities,published in 2000 by W.W. Norton and Co. in New York City).   "Students learn to view themselves in terms of their intellectual and personal capacities, to see themselves not as victims, but as agents.   Mission Australia is running this program in conjunction with Australia Catholic University.   I thought, this is something my institution, Union Institute & University, could consider doing in partnership with other community agencies.

This program is being researched around the world.   Mission Australia conducted a pilot student into the impact of the program on re-engaging homeless people in inner city Sydney.   Results were positive, showing increased student self-esteem and autonomy (Yashin-Shaw, I., Howard, P., & Butcher, J. (2005).   Educating disaffected adult learners: Re-engaging the homeless through tertiary level humanities studies in Vocational Learning: Transitions, interrelationships, partners, and sustainable futures. Proceedings of the 13^thAnnual International Conference on Post-Compulsory Education and Training, Brisbane, Australian Academic Press).   Following this pilot study, Mission Australia, the St. Vincent de Paul Society, and the Australian Catholic University (ACU National) carried out a second phase of research into the benefits of this program.   They ran three Catalyst-Clemente courses (as they named them) simultaneously in Sydney and in Brisbane.   An art history course was taught at Mission Australia Centre including a visit to the New South Wales Art Gallery and a couple walking tours of the city.   A practical art class was taught in Brisbane including an exhibition with other ACU National students of the artwork created during the course.   A literature and drama course was taught at Vincentian Villege in Sydney, including students performing a play and attending a production of Shakespear's The Tempest at the Sydney Opera House with other ACU National students.   Over half of the students successfully completed the courses, which was extraordinary given their disadvantaged backgrounds.   The students' descriptions of how the course changed their lives are moving and can be found on the Mission Australia website athttp://www.missionaustralia.com.au and in their publication, Enhancing participation: New possibilities for disadvantaged Australians.   The work was especially interesting to us in relation to a small pilot project we did of teaching homeless people with HIV/AIDS (and mental health issues and substance use problems) in New York City how to give Reiki energy healing treatments to one another.   The effect was one of empowerment and building a sense of agency -- pride that they had something to offer other people.   Even staff members at the facility where we encountered them would ask some of them for a Reiki session.   We published this study in the Permanente Journal in 2011.   Encountering this program at Mission Australia has given me more ideas for how to empower our population in Vermont, some of whom are homeless, and many of whom suffer chronically from any number of problems.   (I've noticed that people who have psychological suffering invariably have "physical" suffering.   The division of psychology and body is artificial and for academic purposes but perhaps compromises care.   Almost all of our patients with what we call "complicated minds", because they like the term and don't feel it is pejorative, also have chronic back pain, chronic neck pain, neuropathic pain.   Some have diabetes.   Many have asthma.   Some have chronic obstructive pulmonary disease.   Almost all have difficulty sleeping, and many have arthritis, hypertension, heart disease, and more.   The list is endless.   Because we do both medicine and psychiatry, we are addressing the whole person and that's a lot to handle.   I thought how wonderful it would be if our population had a Catalyst-Clemente Program.   Currently they can't access the courses offered through Community College of Vermont because the tuition is beyond their means (about $500 per three credit course).   Also, paralleling the findings of Mission Australia, going to CCV is not necessarily friendly for them.   They're not familiar or comfortable with a school environment.   Classes are often larger than 8 to 15 people.   They don't necessarily have a case manager who can support their non-educational needs to whom learning partners and the course instructors can turn for support.   They don't have IT support or access to computers or knowledge about how to use computers.   Mission Australia provided all this in an integrated, delivery environment in which the students felt comfortable.   This is what I do not see us doing in Vermont, at least, not yet.

The other project about which we heard much was "The Michael Project", conducted by Mission Australia in collaboration with Murdoch University.   "The Michael Project combines homeless and accommodation services, assertive case management, and eleven specialist allied health and support services."   I is a three year, private donor funded project, working with homeless men in the Sydney area.   It provides homeless/accommodation services, ranging from mobile, street-based outreach, through to emergency, short-term, and medium-term accommodation.   Case management involved frequent contact and integrated support.   The specialists involved included dentist, podiatrist, psychologist, drug and alcohol counselor, recreation therapist, barber, occupational therapist, reading and math teacher, computer consultant, and two street-based aboriginal health outreach workers.    The Michael Project reduced the percent of "rough sleepers" (no shelter) from 27.4% to 3.3%.   The percent of people accommodated rose from 27.8% to 93.9%.   The percent in temporary shelter (caravan, boarding house, etc.) felt from 20.7% to 0.8%.   The percent in hospital or prison fell from 15.2% to 0.8%.   This had to be cost-effective!   They are well on their way to publishing their Wave 2 results, which I hope to receive soon.

As part of the Michael Project, homeless people were surveyed to learn more about their situation and how they came to be that way.   The researchers found that sleeping rough is common with the mean length ranging from 1.5 years to 4 years.   The prevalence of mental health conditions and substance use was at least 20 times higher than those of the overall Australian male population.   To their surprise, half of the people had held a full-time job in the last 2 years.   Of course, poverty was overwhelming.   A majority had children, but lacked supportive family members and friends, which contributed to their social isolation, as did their lack of paid work, money, access to transportation, and poor health.   Quality of life was low compared to overall Australians, particularly in terms of social relationships and living environment.   High levels of health service use and contact with the criminal justice system were found.   Ninety-five percent of the participants had experienced one or more traumatic events, which is not surprising considering that people who are diagnosed with psychosis are about 50 times more likely to have experienced traumatic events than the general population (see my blog about the Hearing Voices conference on Day 3 and 4).   I'll also be very interested to read about the cost-effectiveness study that is being conducted.

That completed our day.   Tomorrow we will interact with Child and Youth Initiative (CYI workers) about how increasing narrative competence can improve their work with youth.   Particularly, I believe almost every adolescent male in today's culture is looking for some type of heroic role to perform.   Everyone wants to be heroic and to be seen as a hero.   But, how?   Sometimes anti-heroes are easier to perform than socially acceptable heroes.   And, sometimes, adolescents notion of hero does not match that of adults.   More about that tomorrow.

Day 11 of the Australian Journey 2012

Today we interacted with Mission Australia in Sydney, but first, I awoke early and went running down Manly Rd. through 3 km of forest.   A sign read, "Wildlife", but I only saw road kill -- a possum, a snake, and a rat.   Australian drivers (Melbourne, Sydney, and Gippsland is my sample space) never slow down, not for pedestrians, not for other cars, not for bicycles, not for wildlife.   I discovered that Sydney bicyclists at 6 am on a Saturday morning were just as ruthless.   Well decked with racing togs, they aimed straight at me and gave no ground along the shoulder of the road.   I had to step aside into the bush or they would have mowed me down.   Imagine two headlights coming straight at you on the shoulder of the road.   What's that care doing, driving on the shoulder?   Is it some crazy man trying to kill me?   No, as it gets closer, I realize it's two bicycles riding parallel with no intention of sharing the shoulder of the road with me despite catching me in their high beam headlights.   Luckily, unlike the wildlife, I survived Manly Road, though perhaps more ignobly than manly, and returned to the house where we were staying in time to shower and pile into the Subaru SUV to make the journey into downtown.

Mission Australia was amazing!   I can't begin to say enough about their services and commitment to the homeless and the poor!   They provide programming and shelter for homeless adolescents and adults.   People come for an initial period of 3 months.   Some then transition to other spaces and others continue to stay.   Detox used to take place in the basement, but it has moved to another building.   Adolescents and actually anyone who lives in the vicinity can take advantage of the many programs offered.   They can access a center to help them find employment.   They can get dental and medical care free.   They can use the computers and the internet.   They can take yoga.   They can access a number of offerings about the practicalities of life including managing a bank account, playing chess, taking martial arts, writing a resume, and more.   They can take college courses through Australia Catholic University's Catalyst Program.   On the bulletin board were notices for Intro to Sociology, Intro to Art, Drawing 1, Graphics Art, and more.   We entered the building through the art studio which was massive and full of amazing work.   I learned that people entered the building as prostitutes and emerged as artists!   Their work lined the walls and was deeply moving, highly artistic, and sometimes disturbing.   From the art studio, we entered a recording studio where clients could take a course that culminated in their making a CD of their own music.   A number of CD's were available for us to take.   They were amazingly good!   This studio was a project of our hostess's husband, Phil, who is both a musician and a psychologist.   He serenaded us the previous evening with his Fender Stratocaster guitar, apparently the same model favored by the legendary blues musician, B.B. King.   The amount of program offerings and courses was overwhelming.   I have never seen such a comprehensive, integrated program in North America.

Mission Australia serves many aboriginal people in a culturally sensitive manner.   Another of our hostesses, Sally de Beche, now affiliated with Life Is"Foundation in Melbourne, used to work with Mission Australia in Sydney.   As part of her work she made a DVD documentary, Unsung Heroes, the stories of aboriginal elders in Dubbo, New South Wales, sharing their stories with young indigenous people.   The DVD focuses on lost traditions, cultures, and experiences for young people.   One of the elders didn't live in a house until he was 10 years old and didn't have electricity.   He was concerned about bringing his friends home because he lived in a tent.   One of the young aboriginal people commented that he didn't even know how to go camping.   It's about sharing verbal stories which the elders were forbidden to pass to the young people.   Hence, a lot of young people are just learning these stories which are not written down.   These stories explain for young people their feelings of being lost or disconnected from culture.   This reconnects them with the source of their traditions.   Sally told us how impressed she was with the resilience of these people.

We began our workshop at Mission Australia with a talking circle in which we heard people's wishes and concerns and what they wanted to learn from us.   Their focus was to learn new ways for dealing with psychological suffering.   Sally talked about using mindfulness and inner child work.   She mentioned a grief and spirituality group that she and Tony Gee conducted at Life Is"Foundation.   Everyone in that group had lost a child, either to suicide, accident, or disease.   Using a talking circle format, people told their stories to each other.   Paradoxically, this became an uplifting experience in which they connected with the link to "expansive reality".    Another participant wanted to learn about the use of ceremony with clients.   A third wanted to explore how to release ancestral pain.   I gave a short lecture about the post-modern, narrative paradigm, which is remarkably similar to indigenous thought.   I also let people know, as I have done everywhere we have gone during these two weeks, about the Narrative Medicine and Psychology Program we are starting at Union Institute & University in the USA where I teach.   I talked about how radical it is to see everything as a story, to move past the idea that some explanations (stories) are more privileged than others or that there is a "truth" out there waiting to be discovered.   In this paradigm, I said, we realize that we are forever uncertain about the nature of things.   We invent the best stories we can and revise them as we go.   In essence, this is Karl Popper's philosophy of science.   We make up stories to explain the actions of the world around us.   Some of this stories work better than others.

I talked about the Kaua'I Longitudinal Study from Hawai'i, started in 1950, in which young children, living in the most abject circumstances were followed to assess what would happen to them.   The study continues today, over 60 years later.   In the 1950's, the prediction was that everyone would be scarred for life and would have a terrible outcome.   Actually, this happened only to one-third of the children.   Another third had perfectly normal lives, and the final third excelled far beyond anyone's expectations and beyond the middle class children of the area.   Mentoring made a huge difference, sometimes even only briefly.   My point was that trauma is not always indelible or irreversible.   Today, trauma is our new devil.   "Trauma made me do it," is the contemporary story.   My point was that all truth claims are suspect and subject to refutation.   What matters is that I enter into the story of the client.   My story actually isn't very important and pales in comparison to the story of the client.   When I listen carefully to the client's story and enter into it, I can move it along toward healing, toward reduction of suffering.

I also talked about how Native North American culture is very present-centered.   The Lakota language does not have past or future tenses.   The indication that something is past or future is accomplished by a particle at the end of the sentence, almost as an afterthought.   Most of our pain happens when we live in the past or the future.   Focusing on the present reduces our pain dramatically for the present moment is usually pretty comfortable.   Unfortunately, the default nature of our brain is make stories.   That's good and bad.   We use our large brains to generate simulations of what people might do in various social situations given various behaviors we could perform.   That's really useful for being social animals but we can get carried away.   We can make story so much in the past or the future that we drive ourselves crazy.   Making story uses the least amount of glucose of any activity we do.   To meditate requires much more glucose.   Meditation is an effort.   We have to work to stop spinning yarns.   Though the effort is worthwhile.   When we stop making story and quiet our minds, we realize life is good in this moment.

I also talked about the similarity of Morita thought to Native American culture.   Morita viewed emotions as weather.   If you don't like what you are feeling, he wrote, wait five minutes.   Definitely, he said, if you are angry at someone and want to take revenge, wait three days.   You will feel differently.  

I spoke about the Lakota language having no word for "I".   There are me's, but no I's.   The implication is that we are defined by the group rather than ourselves.   As I have said before in these blogs, Lakota has no self.   Being is composed of the nagi (all the stories that shape us and the tellers of those stories), the s'icun (our presence or what we feel when a person leaves the room or when we enter the home of someone who is not there), the "breath of life" which makes the air go in and out and the blood go round and round, and finally, the spark of the Divine which lives within us.   "I" is a story we construct to fit the social situation in which we find ourselves.   We select from our many "me's" to create an "I" which changes as the social situation changes or as we evaluate the created "I" to see if it got what we wanted.   Hermans and Baumberg call this positioning.

I talked about North American aboriginal thought seeing illness as more of a teacher and biomedicine seeing it more as an enemy.     We continued our discussions and then a woman volunteered to be interviewed.   I wanted to demonstrate a narrative interview and the process by which we arrive at a shared story or metaphor for the illness. This woman whom we will call Ursula had migratory pain which rotated between her lower legs, elbows, neck, shoulders, back, and hands.   I asked for her explanatory story.    She said the doctors said that she had an autoimmune process had created her pain.   Her other story was that she was carrying the pain of her ancestors.   Medically she had been diagnosed with celiac disease, sarcoidosis, and Sjogren's syndrome.   She said her pain had been present for as long as she could remember.   As a small child she spent time in the hospital frequently for injuries.   She dislocated joints, cut herself, sprained herself, and on and on.   Between incidents she felt ok.   I inquired about her carrying the pain of her ancestors.   How did she arrive at that idea?   She said, from reading, feeling that it fit, and knowing what she knew.   "I carry their stuff.   Not with my permission except I must have agreed on some level."

"What is this stuff?" I asked.

"Negativity, dysfunction, emotional pain, physical pain."   She said that she was carrying something that" I can feel but cannot see.   It's a heaviness in body, a weight, a darkness, a blackness."   I remarked that this stuff was hard to see.   That you couldn't pet it, touch it, or see it.   It didn't walk across the lawn.   You couldn't eat it and it couldn't eat you.   (This was one elder's definition of "real" for me.)

Ursula went on to tell about her childhood physical abuse from her mother and sexual abuse from other family members.   Those experiences led her to feel unloved, disrespected, and not allowed to live a life free from danger.   At age 17, she left home.   From then on, she lived in a manner in which she felt loved, respected, and free from danger.   She said she was confused because she'd tried forgiveness and that hadn't worked.   She believed this was because she had more healing to do.   I asked her if she had talked to her pain or her joints.   She had, she said, but they were strangely silent.     I poked at her story in various ways, trying to understand her assumptions. I'd have to watch the video or read the transcript to understand how we got there, but we arrived at a shared metaphor of Ursula and this stuff as a painting with her standing in the middle of a dark and gloomy, bleak landscape without any color, and full of shame and pain.   The music playing was from Sibelius -- ponderous and solemn.   The painting was kept in a back room, away from the exhibition space of the museum.   Its only audience consisted of her husband and her two best women friends.   Nobody else was allowed to see it. "I have other paintings," she said.

"What are they?"

"I have a beautiful painting of me at the seashore in a tropical environment with deep blue water and light blue sky.   I have another painting of me in a forest surrounded by animals and my dogs.   These are my happy paintings.   We talked about the concept of the desirability of being pitiable, as in worthy of others' pity.   I told Ursula that back home on the Rez instead of hiding the gloomy painting out of side, a person might put it up on a billboard outside for everyone to see because of the desirability of being worthy of pity.   Aboriginal participants agreed that this fit Australian local culture, too.  

"You see," I said, "in dominant white culture you learn to hide your misery and shame and pain, but in other cultures, you bring it out for everyone to see as your legacy, your badges of courage, your medals of honor.   You can be proud of how you have suffered because on some level, you do it for the community.

Then we had our lunch break.

After lunch my task was to demonstrate to the participants how I would create a ceremony for Ursula in an office space in which I couldn't burn sage or tobacco or any of my other tricks.   All I could do was sing and talk.   Rocky assisted me.   Her ancestors (insert "My intuition if you don't believe in spirits) told me that they had a hard life and lived in great hardship.   Then we sang an invocation song, invited her ancestors to join us, sang an honoring song for them, and then invited Ursula to tell positive stories about them.   This proved to be very difficult.   "How do you expect them to come if you only tell negative stories?" I asked.   This was a new concept to Ursula.   She struggled and slowly found positive stories to tell about her mother, grandmother, grandfather, brother, uncle, and great-grandfather.   Once we had some positive stories, I could ask them to speak through anyone present in the room.

What emerged was a presentation by Ursula's grandfather that her grandmother and mother had done the best they could.   They had hard lives.   They were banana and dairy farmers and life was difficult.   We suggested that she needed to find more positive things to say about them.   Probably, now that they were dead, they had moved forward and perhaps they resented being presented so consistently so negatively.   Maybe she needed to tell positive stories about them.   I told her about being taught only to speak positively of the dead because they could get mad at negative comments.   We announced to her ancestors that the storage shed in which they were keeping their "stuff" was closing and they would have to come get it or it would be sold in auction.    I suggested more humor and more respect for her ancestors.   Ursula felt much better, lighter, and less dark.   What had happened is that we had moved her relationship in the past into a relationship with her ancestors in the present, which could be a very positive move toward health.

We closed with "doctoring", which is energy medicine North American aboriginal style.   Following was a discussion of the sweat lodge ceremony we would be doing the next day.   That brought us to the end of the day and we left for another marvelous dinner at Pauline's house.   Traffic was becoming intense because Sydney was having mardi gras.   We pointed out that it couldn't be mardi gras because it wasn't Tuesday.   It has to be samedi gras.  The Australians weren't amused.   This was the biggest gay parade of Sydney.   How different from what we knew from New Orleans!   Not very Catholic at all!   Traditions change across the ocean.   Who knew!   Tomorrow we will do a sweat lodge ceremony for those who want to come.

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 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.