Fly-in, fly-out heath care fails remote Aboriginal communities

I’ve written in the early days of my blog about the effect of fly in – fly out miners on rural and remote communities.

This article by Stephen Duckett, La Trobe University looks at the effect of fly in fly out health services.

This is a story about two small Aboriginal communities in the Gulf region of North Queensland: Mornington Island and Doomadgee. They share two key characteristics with many other remote communities: very poor health status on every dimension and fragile permanent staffing of their health services. But they also share an increasingly common third characteristic: an abundance of fly-in, fly-out siloed health services.

I recently visited Mornington Island to learn more about primary health-care delivery in the region. Getting off the plane with me was a renal nurse practitioner, a sexual health nurse, an alcohol and drug worker and a mental health worker, all arriving for their regular visits and clinics. The Royal Flying Doctor Service wasn’t in town for its clinics that day, and, of course, specialist doctors normally come by charter. The same sort of pattern applies in Doomadgee.

I spent about an hour in Mornington talking to an elder, whose main message to me was not about the key health problems in her community but that the community had established mechanisms for consultation that were being ignored.

Aunty Pearl (not her real name) made a heartfelt plea for the community to be consulted before new services were helicoptered in, and for community leaders to be apprised of new clinics being established, so that if they were local priorities, the leaders could work with the whole community to build awareness of the new clinics and hence increase their effectiveness.

In Doomadgee, a whole new service is being established by a new-to-the-town non-government agency. Local health services know it will provide health services for kids but have no idea about the specifics, whether it will duplicate what they are doing already, or how it will integrate with existing services and existing staff.

I asked staff to estimate what sort of contribution the existing fly-in fly-out services were making: were they mostly bringing skills or just time to do things the overworked locals didn’t have time to do? The answer in this non-scientific survey was about 90% skill, 10% time.

The follow-up, then, was whether, with purposive effort (which isn’t seriously occurring now), that ratio could change, by how much and by when? The response was it could shift to 50/50 over an 18-month period.

So here’s the rub. We are all full of good intentions, we want to do something about the Aboriginal health tragedy, and do it now.

But what we are doing is not creating a sustainable service. Staffing by locums, agency and fly-in fly-out staff is expensive. They generally don’t provide continuity of care. And we get the dismal trifecta because they disempower the locals and don’t build a sustainable, local workforce.

The international development literature is full of papers on the distorting effects of siloed funding: specialist disease-specific funding agencies establishing narrowly-defined, specific programs available to developing countries with no one willing to fund the broad primary health-care infrastructure which is necessary for a sustainable and effective health system.

We are doing the same in Australia with special funding programs by state, Commonwealth and non-government agencies. Which brings me back to Aunty Pearl. What we need is good local priority setting: working with the community to determine the local health-care needs.

But let’s not be naive: local planning is hard. Humans and local communities suffer from bounded rationality: we don’t know what we don’t know. So local planning needs to be supported and informed by planning in the larger region or district.

We also need ongoing effective mechanisms to ensure local collaboration among service providers, which do something about long-term workforce sustainability. The 50/50 skill-to-time ratio or even the 90/10 one begs the question of whether the benefits of higher order skills being provided to these communities are greater than the coordination costs created.

For communities where chronic disease is so prevalent, the place to start is clearly to ensure a good primary care foundation. Wagner’s chronic care model now forms the base of chronic disease management and promotes the idea of “productive interaction” between an “informed, activated patient” and a “prepared, proactive practice team”. Both sides of this interaction require support to be effective.

In Wagner’s model, support comes both from the community (in terms of resources, policies, and self-management support) and from the health system, involving improvements to the organisation of health care, delivery system design, decision support, and clinical information systems.

This does not appear to be happening in either Doomadgee or on Mornington Island, or at least, is happening only in fits and starts.

The fly-in, fly-out model of siloed care I saw is certainly responding to the immediate needs of those communities. But it may be doing so in a way that inhibits a long-term improvement in the health of these communities.

Stephen Duckett was Thinker in Residence at Mt Isa Centre for Rural and Remote Health

The Conversation

This article was originally published at The Conversation.
Read the original article.

Violence, Crime and Fly In Fly Out Workers

Fly-in Fly out workers to sites in Western Australia and Queensland are ruining country towns close by their camps and are increasing the crime rate according to reports on (here and here.

The study by Queensland University of Technology’s Professor Kerry Carrington was published in the British Journal of Criminology. Here’s the abstract:

Over the last two decades, two new trajectories have taken hold in criminology—the study of masculinity and crime, after a century of neglect, and the geography of crime. This article brings both those fields together to analyse the impact of globalization in the resources sector on frontier cultures of violence.

This paper approaches this issue through a case study of frontier masculinities and violence in communities at the forefront of generating resource extraction for global economies.

This paper argues that the high rates of violence among men living in work camps in these socio-spatial contexts cannot simply be understood as individualized expressions of psycho-pathological deficit or social disorganization. Explanations for these patterns of violence must also consider a number of key subterranean convergences between globalizing processes and the social dynamics of male-on-male violence in such settings.

mining truck 1.

Only two remote mining towns in western Australia were visited (unsure of how many in Queensland) but the results of the study seem to reflect (actually seem worse than) previous posts I have written on this topic (Remote Mining – check links in article).

If the abstract is a bit dry here are some quotes from Professor Kerry Carrington:

These (communities) are in a David and Goliath struggle, these are little people in a community that have very little voice, that are watching these massive, powerful, big mining companies build these work camps on their door steps

In one Western Australian mining community, which was surrounded by work camps housing about 8000 mostly male workers, the rate of violence was 2.3 times the state average.

The workers then get bussed to these pubs that are surrounded by wire mesh, they drink hard and get plastered, get into fights, sleep it off and go again.

One quote in the articles reflect my own views.

Queensland is regulating these social impacts somewhat by forcing mines to plan for them but WA does not have the same policy

The big problem we had in the WA mining industry was that (mining executives) refused to talk to us and didn’t see it as their problem. That’s because they sub-contract out their workforce.

Until mining companies are forced to improve local communities near their mines and to spend the time to train up and mentor the local population (in many cases poor with significant indigenous residents) to improve the community and reduce the fly in fly out workforce these problems will only get worse.

Remote Mining and Indigenous Housing

In 2003 a Western Australian commissioned panel looked at the long working hours in the mining industry. A lot of the focus was on the Fly In Fly Out (FIFO) workforce suggesting they suffered from higher levels of drug abuse, depression and family breakdowns. It didn’t seem to stop the increasing numbers of FIFO workers.

I have written before (and here) on what I see as the destructive impacts on local communities by mining companies not putting into these local communities.

MATTHEW CARNEY: Rather than growing communities, centres like Port Hedland were being gutted and the divide between the haves and the have-nots was as wide as an open cut.

However the mining companies continued to produce reports that purportedly showed that FIFO workers benefited communities. With the economic turn-down mining companies seem to be moving opposite ways. A contractor at the Argyle diamond mine will give preference to local workers over FIFO workers as they start laying off staff. Unfortunately the larger mining companies who are the major employers seem to have other ideas.

Port Hedland still wants a rethink on the use of FIFO workers

The Member for the Pilbara, Tom Stephens, has criticised the mining company over its plans to increase its work force by 20 per cent over the next three years without building new houses in Port Hedland and Newman.

ABC TV recently reported on a Western Australia study that showed the health and social effects supposedly suffered by a FIFO workforce (talked about in the opening paragraph) was not correct and there was no more hardship than local workers. This led to one company to say they would increase the FIFO workforce (supposedly to the detriment of local workers, community infrastructure etc as cost is always the driving factor).

When mines are opened on land owned by indigenous people under Native Title, Native Title Agreements are entered into with the land holders. Sometimes this leads to increased local indigenous employment. However some companies quote the indigenous employment at various mine sites with out disclosing many of them are FIFO workers.

Most importantly, research from Griffith University has shown that these agreements between mining companies and native land owners has NOT led to any benefits for the local people.

results show the Tribunal, which administers the Native Title Act (NTA), seriously disadvantages Indigenous groups when negotiating with mining companies. ……..

“In all 17 cases taken to the Tribunal in the last decade, the Tribunal has granted the mining leases and been unwilling to impose conditions that might prove onerous for the miner…..

“Research shows the Tribunal demands more stringent standards of proof from Indigenous groups than from companies, and tends to accept particular types of evidence when this favours companies but reject the same sort of evidence when it favours Indigenous groups.”

Native Title should provide Indigenous people with the opportunity to benefit from Australia’s resources boom, to reduce their dependence on welfare and increase their presence in the ‘real economy

The Australian Institute of Health and Welfare in an article titled Housing and Infrastructure states:

Housing has been identified as a major factor affecting the health of Aboriginal and Torres Strait Islander people. Adequate housing provides protection from the elements, minimises the risk of disease and injury, and contributes to the physical, mental and social wellbeing of the occupants. Inadequate or poorly maintained housing and the absence of essential infrastructure, such as a supply of safe drinking water and effective sewerage systems, can pose serious health risks.

One hundred and fifty five million dollars is about to be spent in the Northern Territory on indigenous housing as part of a five year, $672 million dollar program. (A list of the involved communities is here). I find it difficult to understand comments made by intelligent men such as those by Gary Johns of The Bennelong Society, who has stated:

“housing should not be provided to remote Aboriginal communities where there are no jobs and people are unable to pay rent or service a mortgage”

and that they should move to where there are jobs.

I have commented here(and over here!) on the health benefits of indigenous people living in small communities on country.

The earlier part of my post talked about the major companies flying in and out workers rather than increasing local infrastructure and employing locally. So where do we build these indigenous houses so they are closer to work? Do we have them move to towns first and live in overcrowded conditions if in a house at all or do we build a house first and try and reduce overcrowding and the diseases that I am sure the members of the Bennelong Society have never suffered from.

Why don’t we look at ensuring the agreements signed between mining companies and native title holders provide real benefits, including jobs, are delivered to the local indigenous population.

Perhaps in their effort to find 50 000 jobs for indigenous Australians rather than fly people from Queensland to Western Australia they could fly remote indigenous Australians from their larger communities to the nearest mine site, provide proper training, assist with schooling and negotiate to improve indigenous communities.

I am sure we as a country and the members of The Bennelong Society if they could bury their ideology for a while) can come up with innovative and workable proposals that benefits as well as respects indigenous Australians and their culture.

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When Remote Australia and Mining Australia Meet continued.

A couple of days ago I wrote about When Remote Australia and Mining Australia Meet.

Four Corners, an Australian ABC current affairs show ran a program looking at the mining and gas/oil companies and their impact on remote Australia. A reading of the transcript states:

Tonight on “Four Corners” – the virgin coast, gas giants out to plunder the deep and the Indigenous deal-maker looking to make the development pay off like never before.

VOX POP: Rents will go up higher, we’ll have more fly-in-fly-out people that are very disconnected from the community come here to spend money on alcohol, on drugs. I think a lot of those problems will get worse.

PPP: A month ago Four Corners reported on boom times in the Pilbara – the West Australian money pit driving the national economy. On the ground, there was more pain than prosperity.

RAY SKENDER, SKENDER CONTRACTING (Excerpt from “The Money Pit”, “Four Corners” – August, 2008): Everyone comes up here hoping to make a big dollar, then they find out they can’t get accommodation. The infrastructure up here’s just ridiculous.

MATTHEW CARNEY: Rather than growing communities, centres like Port Hedland were being gutted and the divide between the haves and the have-nots was as wide as an open cut.

(Excerpt continued):

LINDA DOOGIEBEE, BUNARA MAYA HOSTEL: Now, mining boom-town has come, it just blew everything out, blew our people away from each other.

REAL ESTATE AGENT: Port Hedland, we’ve got a three-bedroom, one-bathroom, for $1400 and a five-bedroom, two bathroom for $1500 a week.

The program can be seen in full here

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