Breaking Cultural Barriers

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Using Indigenous Australian drama to break culturalbarriers in healthcare relationshipsK Matharu

Correspondence to:Mr K Matharu, University ofCalifornia, Davis School ofMedicine, 610 N Street,Sacramento, California 95814,USA; [email protected]

Accepted 22 October 2008

ABSTRACTSince colonisation, the marginalisation of IndigenousAustralians has adversely affected their language, cultureand health. Mainstream society has failed to addresssocial differences and establish culturally-appropriatehealth programmes for these groups. This paper extractsimportant humanistic themes within the context of healthfrom four Indigenous Australian plays written during aperiod of social unrest in response to past oppression: (1)The dreamers, by Jack David; (2)Murras, by Eva Johnson;(3) Coordah, by Richard Walley; and (4)The keepers, byBob Maza. These plays will be analysed to (a) illuminatehuman suffering from an indigenous perspective, basedupon social and cultural planes of analysis; (b) understandthe socio-cultural basis of poor health; and (c) instructhealthcare professionals that health is a social constructthat can be interpreted as the product of select plays thatare not solely based upon an illness narrative.

In February this year, the Prime Minister of Australia delivered a long awaited apology to Aboriginal and Torres Strait Islanders and begana process of reconciliation and healing. Australiaranks high in the world in terms of healthcare, yetIndigenous Australians exhibit a mean life expec-tancy that is more than 20 years less than non-

Indigenous Australians. This fact is particularly startling compared to other indigenous groups,such as the Maori in New Zealand and Native Americans in the United States, with life expec-tancies that are not as decreased as in Australia. 1

Aboriginal and Torres Strait Islander peoples sufferfrom lifestyle-dependent illnesses such as rheu-matic fever, trachoma and skin infections, whichare more prevalent in underdeveloped nations. Thecontrast between medical services to Indigenous Australians and non-Indigenous Australians is dueto a multitude of complex factors includinggeographic location, access to hospitals, along withsocial and cultural ideologies. This is evidenced by the fact that many diseases, such as cancer, affectboth Indigenous and non-Indigenous Australians,but result in higher mortality rates in the former. 2

Difference in quality of treatment results from thelack of culturally appropriate programmes toaddress the incongruence of Indigenous- andnon Indigenous-based health programmes.Aboriginalised programmes and community-controlled health centres represent, to many individuals, another form of control from adominant authority that precludes indigenousauthorisation. 3 Due to lack of public health andethnographic data differentiating between

Aboriginal and Torres Strait Islanders, this paperwill focus on the health of Indigenous Australians

collectively, with the understanding that thecultures of these groups are vast and intrinsically unique. This, however, should not detract from theimplicit understanding that various groups experi-ence different health concerns, values, standards of living, economies and education attainment levels.

Indigenous Australians comprise 2.5% of the Australian population, with over-representation inremote areas of the country. Torres Strait Islandersmake up 0.3% of the total Australian population. Approximately 31% of Indigenous populations livein defined major cities, versus 67% of non-Indigenous Australians. 4 Of Indigenous Australians who live in remote areas, 28% citedistance from a medical facility as an impedimentto healthcare versus 7% in non-remote areas; thisstatistic remains fairly constant when looking atthe availability of a particular service (28% of Indigenous Australians in remote areas versus 3%in non-remote areas). The problem of access isexacerbated in isolated communities, where 50% of families do not own motor vehicles compared to20% in non-remote areas. 5 Those in remote areasmay be more than 1000 km away from the nearesthospital. Fortunately, there are several prominentexamples of clinical organisations that wereoriginally established and run by Indigenous

Australians to meet the needs for those seekingcare that was available and culturally sensitive.The involvement of Indigenous Australians in

administering health services did not occur untilthe 1970s. The Central Australian AboriginalCongress, established in 1973, has been critical toproviding healthcare to Indigenous Australianswithin Alice Springs and various outstations.Services provided by the multiple branches includeprimary care, womens and mens health, adoles-cent care and extensive psychological counselling.The Congress at Alice Springs also includes publichealth advocacy as another tool for improving thehealth of Indigenous Australians. A similar pro-gramme was created in the Northern Territory capital city of Darwin, named Binna Billa. 6 Furthersupport for individuals living in extremely remotelocations without adequate access to major hospi-tal centres is provided by the Royal Flying DoctorService. Established in 1928, the service provides forthe immediate healthcare of seriously ill patients inaddition to long-term care through immunisationsand routine health checks. In Sydney, the Aboriginal Medical Service was established in1971 to address the health concerns of Indigenous Australians in a socially- and culturally-appropriatemanner. 7

Unfortunately, despite the establishment of medical centres and increased monetary support

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to Indigenous Australians, individuals and communities remainfinancially under-resourced (Pink 2008, p188). 5 Contributing tothe poor health status of Indigenous Australians is the lack of medical practitioners within communities, especially in iso-lated parts of the country. The medical workforce crisisbecomes apparent in remote communities, where physicianstrained overseas are recruited for jobs. The dearth of healthcareis also felt in urban centres, where medical practitioners are

continually shifting to communities where private billing yields higher incomes.8 As a result, there are not enoughphysicians trained or willing to handle indigenous healthconcerns that may be specific to a certain group within an area.This phenomenon can be especially well hidden in urbancentres, where poor health may solely be attributed to racismwhen there are not enough physicians to address the healthneeds of one specific ethnic group. Despite the establishment of academic hospitals in major cities, there remains a stigma dueto past negative experiences.

From a strictly ethno-medical perspective, distance frommedical facilities and the number of available physicians doesnot sufficiently explain the shorter life span, higher prevalenceof disease and dissatisfaction with the healthcare system withinthe Indigenous population. 9 The Indigenous social experience isplagued by factors contributing to poor health such as loweremployment expectations, reliance on welfare, poor housingand inadequate access to education and health services. Calledthe most socio-economically disadvantaged subsection of Australian society, Indigenous Australians often fall intovicious cycles of despair due to injustices that have been partof government policies. 10 The Henderson Poverty line, describ-ing the poverty levels of the Australian population, includedstrategies for social inclusion and closing socio-economic gaps.Education and literacy levels are strong indicators of poverty and health. Half of non-Indigenous Australians complete Year12 compared to just 22% of Indigenous Australians. In remote

areas only 15% of Indigenous Australians achieve non-schoolqualifications compared with 34% of those who live closer to anurban centre (Pink 2008, p249). 5 Such striking differences stir upimages of a devastated minority within a highly educated andhealthy first-world nation.

Many within the public health sector propose a broaddefinition of good health, in which health itself begins withrecognition of the need for favourable social conditions. 11 Thehealth of those within a community is not determinedexclusively by the summation of ethno-medical factors, but isconditioned by a distinct set of social and cultural issues. 12

Indigenous Australians consider health to represent the totality of their communitys wellbeing, with many factors beinginterdependent. 13 Those who treat illnesses within the commu-nity do so in a manner that is based more upon social orsacred mechanisms. European-based medical treatment thatwas seen as punitive often clashed with traditional methodsof healing. (Hunter 1993, p54) 7 Paternalistic behaviour on thepart of the medical profession as well as the Australiangovernment resulted in sanctioned policies such as forcedsterilisation and removal of children from indigenous commu-nities. 7 14 Indigenous patients remain fully engaged with theirclinician, interacting at an interpersonal level that transcendsthe traditional patient-physician relationship. Injected intothis complex relationship is the idea that kinship relations arebased upon jural aspects as much as moral and religiousones. 15 Due to the underlying relevance of culture in clinical

interactions, theatre emerges as a strong candidate to addressthe range of complex issues surrounding poor minority health

and express a perspective that is based upon evaluating humanrelationships.

DRAMA: AN INFORMAL MEDICAL SCRIPT FOR THEDISENFRANCHISEDThis paper addresses the need for a better understanding of indigenous-specific health concerns from an analysis of dramaticworks written in a highly political era. They provide anopportunity for physicians, nurses and other healthcare workersto supplement their ethno-medical education with social andcultural tools of analysis. Within an Aboriginal context, actingrepresents an integral part of educating others on importantcultural traditions and rituals. Mimicry, or mimesis, is central tocultural production that may be humorous and extends beyondthe act of replication. Imitation within Aboriginal communitiesis by no means a static factor that copies, but rather extends thelearning process. Pitted against theatrical production, ritualisticperformances are contingent upon cultural laws that areindependent of hegemonic forces. 16 Dramatic works can thustranslate the health concerns of Indigenous Australians whileinterpreting those concerns clearlywith courage, humour,

pathos and anger.Drama can reach a wide audience and often covers neglectedissues of immediate relevance to minority groups, such ascultural evidence for poor health and the importance of stronginterpersonal relationships. In a study of Aboriginal Australiandrama, Shoemaker notes that more than ever, Aborigines fromall parts of the country [were] mounting a unified response tomajor events that were a constant controlling force over thecommunity. 17 This originates to settlement and the historiccontrol of anthropologists over Indigenous Australian commu-nities. In the case of Ted Sterhlow, controversy arose because of his deep-rooted incorporation within the Aboriginal commu-nity, in which he received sacred objects from traditional landowners rather than to other members of the community. 18

Following the 1960s, an era preceding the establishment of Indigenous health centres, an international trend emerged inwhich many audiences became increasingly receptive topolitically-charged theatre, including positive responses tonon-Western theatre companies [that] chose active oppositionto their national regimes and helped oppressed countrymentoward better lives and political liberation. 19 This timeframewas especially important for Indigenous Australians because theburgeoning of theatrical productions coincided with importantpolitical struggles. The Aboriginal Land Rights (NorthernTerritory) Act of 1976 was created for the re-appropriation of land to Indigenous Australians. 20 Explanation of culture andperformance can be synergistic as evidenced by land claim

meetings in which community members transmit pertinentinformation to the commissioners via song and dance. 21

Dramatisation in Aboriginal communities is limited and oftennot the discourse of choice due to strict traditional laws andobligations that restrict the viewing of rituals meant for certaintribes and tribal members. Additionally, placing a ritualisticsong or dance on paper renders it static, when in reality it is asfluid as human nature. 22 23

Understanding the health problems of Indigenous Australiansrequires an understanding of politics and connections to people,place and ones body through a medical lens facilitates anunderstanding of the health problems of Indigenous Australians. Many of these problems are sensationalised in themedia. 24 Characters that are faithfully presented in a dramatic

piece override such negative associations and elicit a directemotional response. A scripted, fictional character may be

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presented sympathetically in context, whereas this same personmight have been unfairly judged in real life without contextua-lisation. There appears to be a special kind of cultural andliterary interaction in drama that is harder to achieve in othergenres like novels and poems.

The plays discussed here provide a way of producing changesin attitudes toward marginalised groups. These dramatic worksare the products of a watershed moment in Indigenous

Australian history, when political matters as they related toland rights claims became increasingly important for culturalsafety. During this period, issues of identity and sovereignty became more prominent with the right to vote and participatein government affairs after a long period of suppression. Thegoal of this paper is to discuss how physical displacement, poornutritional status and housing conditions, cultural humiliationand racism relate to health and to apply that understanding togeneral medical education. The four plays (summaries providedin box 1) show how poor health in indigenous communities isconditioned by cultural and political circumstances.

PHYSICAL DISPLACEMENT AND CULTURAL DISPOSSESSION

Forced relocation is an important issue affecting Indigenous Australians mental, physical and spiritual health. This waslargely the result of obtaining land for profit, as well as theinherent power of controlling social structures that were basedon already established land demarcations. 25 Major texts writteneven by non-Indigenous authors highlights the interweaving of the human spirit with the soil. 26 Theatrical performancesexamining emotional and physical movement should not betaken as solely text-centreed or text-centric (Zarrilli 2006,p320).19 Here, drama becomes a fluid, social dialogue thattranscends its actual text in portraying the ramifications of being removed and moved.

In Daviss The dreamers, Worru is the eldest living member of the Wallitch family in Southwestern Australia. Alone, he beginsthe play:

I walked down the trackto where the camp place used to be

and voices, laughing, singingcame surging back to me.It was situated on the Swannot far from the old homestead.Thats gone too. 27

Worrus words are a poetic tribute to the land from which hecame. Now, taken from his place of origin, he is left withmemories of happier times that make him realise that the worldhe was used to will never be again. Stage directions preceding Worrus entrance describe a tribal family, walking along anescarpment, carrying weapons, bags and fire sticks. The familysdeparture from the stage prior to Worrus speaking signals thedisappearance of traditional domestic life. Dolly, the strongmatriarch of the family, reminisces with Worru about the timesat their camp. The last time she [saw] a corroboree was atthat camp. Worru responds: kia, kia, the yongarah dance, thewaitj dance they all finish now, all gone. 27

We are confronted with the real possibility that importanttraditional dances have been lost. The audience is left to inferthat this particular family was forcibly evicted from their landand that they continue to mourn this loss. Dollys casual

statement about not seeing a traditional dance demonstratesthat physical dislocation results in ones inability to immerse inones culture of origin. This can lead to subsequent emotionaldistress, because of the missing cultural link in ones life.

The keepersalso touches upon physical removal and culturallosses. Set in the mid-19 th century, it is a period of inevitableconfrontation. Mirnat, an Indigenous woman, and Elizabeth, aScot, are brought together when Elizabeth and her missionary husband settle in the area. Koonowar, Mirnats husband, iskilled over suspicions that he robbed and killed a European man. After this incident, Elizabeth and her husband flee, because of their close relationship with Koonowar. They take Mirnat withthem to prevent retaliation. Many years later, when Mirnatspeaks better English, she interacts with Elizabeth, who hasnow become one of her close friends:

Mirnat: Seems like it was yesterday. Yknow, I felt really badwhen I left my country.Elizabeth: Mirnat, I never realised you felt that way. I mean youseemed so happy and pleased to be coming with us Imean it was you who kept everyones spirits up with yourstories You were always laughing.Mirnat: Listen, Elizabeth I dont think youll ever be able tounderstand the blackfella. Youll never know what its like to seesomething precious as what our land is to us the Boandik to me. Oh, yes, my friend, I was laughing but thats so my people couldnt see I was bleeding inside. I had to be strong togive them hope Its no matter we lost our home our name everything We had to keep going We had to. 28

This interaction between two women who are so close and yet so different highlights the immense emotional pain thatMirnat must feel for leaving her community. Elizabeth, even asa close confidante, fails to understand the psychological effectsthat the move had on Mirnat.

In Murras, the family lives between their original community and the city. The phrase given to such individuals is fringe dwellers, because their physical location is uncertain and they often live in poverty-induced squalor. 29 The play begins with atelevision announcer reporting on the news:

Commonwealth and state ministers stated that: The policy of assimilationseeksthat persons of Aboriginal descent will choose toattain a similar manner and standard of living to that of other Australians and live as members of a single Australian community,

Box 1 Summary of the four plays discussed in this paper

c The dreamers (1980) by Jack Davis. In the juxtaposition ofIndigenous with white Australian culture, the death of Worru,a family elder, serves as a harbinger for the disappearance ofIndigenous language, tradition and culture.

c Murras (1988) by Eva Johnson. The physical and

psychological effects of moving from the place of ones originto an urban location are manifest in the loss of ones ability toexpress oneself in a culturally-significant manner, poorhousing conditions and sanitation, and eugenics.

c Coordah (1987) by Richard Walley. A group of Indigenous menregain a sense of pride in their culture by preparing a culturaldance for a televised appearance. In doing so, these menrelinquish health concerns like alcohol, which is shown to bedestructive to ones physical and cultural health in other playsdiscussed.

c The keepers (1988) by Bob Maza. This is the tale of anIndigenous and white Australian couple dating back tosettlement, in which the wives grow emotionally close despitevast cultural differences that undermine the understanding of

indigenous culture.

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and we believe that if Aboriginal Australians can be helpedand encouraged to help themselves, then they will be readily attracted to and welcomed to the assimilation we aim for.Therefore, new housing will be allocated for them in differenttowns and cities. 30

Such paternalistic attitudes and decisions fuel resentment anduncertainty in the family. Ruby, the matriarch, adamantly states, I cant leave my country. What Im gonna do ? 30 Thegrandmother echoes Rubys fears, stating that she has seen toomany things changing. Too many people dyin from wrongways. Moving about too much, disturbin the land. Sheominously states that soon we all gone. 30 The audienceimmediately senses the contrast between the bureaucratic toneof the announcer and the demotic tone of the family members.From the beginning, this difference between the composedsentences of the television announcer and the informal units inwhich the characters speak is obvious. The assistance thegovernment provides to Indigenous families literally becomeslost in translation.

The link between forced relocation, poor health and evendeath emerges from the governments paternalism and mis-

understanding. The grandmother states that the governmentwants to move [them] around like cattle. 30 The imagery herereflects the historically low opinion the government often hashad toward indigenous peoples. Interacting with a liaison officernamed Russel, Ruby finds out that he is Indigenous, but he doesnot know where he came from. He was taken away from hisfamily at a very young age and placed in the care of a white Australian family. Ironically, Ruby learns this fact about him ashe tells her that her family must move to the city, where life,according to the government, will be better for them.

DEMISE OF INDIGENOUS HEALTH RESULTING FROM POORNUTRITION AND HOUSING

The plays link poor indigenous health to inferior livingconditions and malnutrition. Many Indigenous Australianfamilies are forced to live in small and overcrowded housingwith up to 26 individuals living in one unit. 31 Such factors areconducive to the spread of infectious diseases such as rheumaticfever and skin infections, along with the exacerbation of risky drinking behaviour. Some of the increased incidence of diseasein Indigenous Australians also can be attributed to the poorsanitation that accompanies destitution and squalor. 32 Over50% of Indigenous Australian households are supported in partby government assistance such as Commonwealth Rent Assistance and the State Owned and Managed IndigenousHousing (Pink 2008, p38). 5 Furthermore, 15% of Aboriginalchildren lived in households that were deemed overcrowded(Pink 2008, p40).5

From a health-management perspective, the solution toinfections in such a setting is not antibiotics. However, it isnot always possible to prevent overcrowding, given that many Indigenous Australian families invite relatives into theirhomes. 33 Problems arise because indigenous ideas about howextended families should be housed together clash with white Australian ideas of single-family housing based on the nuclear,not extended, family. Culturally-appropriate housing optionsthat address indigenous notions of selfhood can include severalbathrooms and bedrooms could anticipate those times whenthere will be many individuals staying in one housing unit.Healthcare workers wish to obliterate the diseases fostered by

crowded conditions, but they fail to grasp why indigenouspeoples live in what look to white Australians as crowded

conditions. Drama offers a way of instructing healthcareworkers on this phenomenon within indigenous communities,so they can better understand family life.

In Murras, the Aboriginal Liaison Officer, Russel, is judg-mental of the familys living conditions. He initially exclaimsMy God, look at this place. I mean, how long you been livinglike this? I mean here ? 30 The interaction between Ruby andRussel, in which Ruby persists in finding out where Russel isfrom, reveals just how much Russel has distanced himself fromhis roots. His shock at the living conditions disturbingly relatesto the physical and emotional ramifications of filth.

Rather than recognise Rubys anxieties over leaving, Russelmatter-of-factly states that the move is for her (and herfamilys) own good and thus establishes an us/themconfrontation. Russel has included himself within the uscategory, which includes proper living and hygiene. In disgust,he states that their house is a breeding ground for rats anddiseases,30 but does not acknowledge that the governmenthousing to which the family would move likely will be nobetter. This adds further insult to injury.

Overcrowding arises in Coordah. Note the setting for one

particular scene: TREB and ELLYS place, next morning. TREB isup; NUMMY sleeps at the table, TANK on the lounge chair, GAZ onthe floor.34 Preparing for a cultural show in which the men willdance for a television station in the nearby capital city of Perth,several are staying at the house to practice, socialise andstrengthen the already strong bonds between them. However,there are not enough beds, so the characters sleep on tables andin chairs.

DESTRUCTION OF CULTURAL ROOTS SECONDARY TO PHYSICALRELOCATIONOne harmful result of moving to an unknown place isunemployment. When the men cannot work, they are more

prone to drink and gamble. Drinking destroys traditions simply because individuals cannot perform important rituals or reciteancient songs. In The dreamers, the majority of the men areeither drinking or gambling while Dolly is out buying groceries,bringing Worru back from the hospital, and preparing meals.This illustrates how indigenous men can be more vulnerablethan women, whose social roles are more likely to be preservedin a new location. More generally, studies have shown that menare more susceptible to destructive behaviours resulting fromalcoholism. 35 Alcohol consumption was only moderately increased, 20.4% versus 19.1%, when comparing Indigenous Australians that were unemployed versus employed. Additionally, risky alcohol intake displayed an inverse relation-ship with educational attainment, with 12.2% of thosecompleting Year 12 compared with 17.2% completing Year 9or below (Pink 2008, p138). 5 However, it is important to notethat these statistics are inextricably linked, as levels of education may correspond to employment status.

Worru exerts full authority over his cultural domain when heis sober. When drunk, he is unable to recount and enactimportant traditional practices and stories. What is mostdisconcerting to the audience is that this elder who possessessuch a vast fund of knowledge is losing it before he can pass iton to the next generation. In one scene, [WORRU rises andbegins a drunken stumbling version of a half-remembered tribaldance until his feet tangle and he falls heavily.] 27 Ratherthan teaching others, he simply becomes someone to laugh at.

Later, Worrus dirge dramatises the cultural groundings of alcoholism in indigenous communities:

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We are tired of the benches,Our beds in the park; We welcome the sundownThat heralds the dark. White lady methylateKeep us warm and from crying,Hold back the hate And hasten the dying. 27

In Murras, the direct effect of alcohol abuse is seen when oneof the characters passes away before the first characters interact. Wilba sadly questions her mother: What he have to die for,Mum ? What did my father have to die, what he drink that[Whitefella] drink for, make him sick, make him die ? 30 Whentrying to put together an annual cultural show to exhibit atraditional male dance, Treb angrily states: None of youbastards can dance: youse cant stay sober long enough tolearn.33 However, once the men do stay sober, they do learn thedance, truly amazing the rest of the family because sobriety is sounusual in the house. Tara states:

They were all sober. Uncle Blue couldnt get over it. He hid hisbottles when he seen Nummy coming, but he left six cans in the

fridge. Nummy opened the fridge door, pushed the beer aside andhad a drink of milk.33

From a cultural perspective, alcohol is the [W]hite mansdrink, and not part of original Indigenous culture. The samecan be said of certain Whitefella foods. 36 The integration of white flour and alcohol into the Indigenous culture can beviewed as a form of domination by European colonists,destroying indigenous notions of economy, selfhood andhealth. 3739

RACISM AND INDIGENOUS AUSTRALIAN HEALTHIn hegemonic societies, it is not unusual for a minority portionof the population to feel uncomfortable with particular aspectsof the society, including healthcare. 40 Worru, in The dreamers, isthe individual whose health remains poor throughout the story,until his death. He hates hospitals, but is forced to check intoone by family members. Upon his return, he states: Needles,needles. [ Pointing to his arms] In ere, in ere [ pointing to his side]an in there; [ pointing to his posterior] an in there. I feel like abloody nyngarn.27 Worru does not understand his illness or thetreatment for it, so he resists going to the hospital and takinghis required medications. He only accepts medication fromcertain members of his family. In fact, the audience later learnsthat Worru only wishes to see [a] Nyoongahdoctor.27 Worruwants to see an Indigenous doctor because he does not want tobe treated by someone whose ancestors may have treated his

kin poorly.In Murras, one of the most horrifying scenes is an exchange

between Ruby and Jayda:

JAYDA: It was a routine check-up. The doctor called me in oneday. He had some special papers there, he said they were from thegovernment, said that I was part of a programme or something,long time ago. Had to do with those injections that Sister used togive me and Jessie.RUBY: Injections ? You didnt tell me about any injections.JAYDA: Mum, she said it was alright. I thought you knew, shesaid she explained it to you. She told me it was to stop diseases.RUBY: She lied. Injections to stop disease, injections to stopbabies. They lied to us, who they think they are ? Boss over you,boss over meyour mother ?

JAYDA: Mum, it was an experiment. We cant do anythingabout it now. Mum, Im alright, its alright. 30

The realisation that the family is powerless to act comes tolight when Jayda discovers that she cannot have a child. What isespecially disturbing is that such standard procedures wereimplemented without the knowledge of Jaydas mother. Themain purpose of sterilisation was to prevent the propagation of the Indigenous race. When Jayda asks a social worker for advice,the social worker advises that nothing can be done because of secret records and official lies of health workers.

HOW TO IDENTIFY APPROPRIATE INDIGENOUS PLAYSDrama can quite easily frame important arguments. However,there are many factors involved in presenting literary works to amainly non-Indigenous audience, beginning with the very definition of Aboriginality. There remains the problem andpractice of classifying Aboriginality has been something givento and expected of Aboriginal people and that it is a definitionthat Aboriginals have had to accept and run with in everyday life.41

What makes the presentation of these scenes so powerful isnot only that they are racial, and are inherently so because of the playwright, plot and underlying political agenda, but alsothat they can be interpreted in a broader social sense.Indigenous literature is not restricted to an indigenous audience(Heiss 2003, p25).41 The question of legitimacy for whether apiece is actually indigenous in nature often arises because of peoples preconceived notions that may be racialised.Commercial marketability is a major issue that often plaguesmany non-mainstream works because the audience determineswhether a play is published, or whether it is performed in acertain arena for an audience (Heiss 2003, p58). 41 Further issuesarise over whether the material contained within the plays areverifiable. The complex nature of the playwright and thecultural facets he/she aims to encapsulate preclude an unam-biguous statement on the authenticity of observations. Writerswho are not Aboriginal, such as Mary Durack and Judith Wright, but contribute tremendously to the body of Indigenousliterature, are widely acknowledged for increasing awarenessbefore the prolific onset of Indigenous authors. Duracks workspresented facets of Outback Culture that vividly portray lands in the Northern Territory where black and white peopleinteract with each other and establish their unique connectionsto the harsh land. 42 Wright, a prolific author and politicalactivist on behalf of the Indigenous Australians and environ-mental conservationism, notes the confounding implications of demarcating a literature subset that is not only a response todominant culture, but very much a part of it despite using theEnglish language as an alien imposition.43 To that extent,there remains a difficulty in delineating an exact definition of

Aboriginality that satisfies both Indigenous and non-Indigenous Australians. For the purpose of medical education,physicians can use the plays discussed with the understandingthat they are the social and political products of a well-definedperiod of Indigenous Australian literature.

SOCIO-CULTURAL BASIS FOR UNDERSTANDING INDIGENOUSAUSTRALIAN HEALTH AND APPLYING THAT TO MEDICALEDUCATION PROGRAMMES Although many dilemmas, situations and aspirations arepresented in these plays, some of them are specific toIndigenous Australians. Other situations can be experiencedby anyone (eg, an ill grandfather). The play is an effective mode

of discourse that lets the audience not only delve into the mindof the artist who constructed the drama, but also into social

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concerns within the actual dramatic action. Drama is one of themost commonly talked about forms of literary discourse, morefluid than a novel, because of the freedom with which one caninterpret the genre through performance.

Plays written by Indigenous Australians deal with some of the most far-reaching aspects of indigenous culture in con-temporary society and provide considerable insight. As aspecialised form of artistic representation, many of these plays

have been accepted by a wider audience. The goals of theseplays have been two-fold, namely to act as a catharsis inpresenting their side of colonisation and its ramifications, and togain wider acknowledgement of the truth that Indigenous Australians do, indeed, have a unique culture and set of socialbeliefs. The stories and oral histories that these plays presentthrough their characters provide an intimate communication toothers about the Indigenous community. Plays can changepeoples perspectives regarding minority health and the provi-sion of mainstream healthcare services.

University-based Aboriginal Health Worker programmescomprise an important route for Indigenous Australians toenter the professional fields of medicine, public health, nursing,dentistry and pharmacy. 44 Incorporating these plays into theirtraining programme is one way of providing a range of perspectives on indigenous health issues. For the presentationof dramatic stories, it is essential to have full authority andleadership given to Indigenous Australians in these exercises.Rather than a didactic system with a non-Indigenous instructor,there should be an Indigenous instructor for the presentation of cultural knowledge. The representation of Indigenous charac-ters and communities by non-Indigenous authors in particularnovels and works such as in Duracks Keep him my countryareoften controversial because they were not written by anIndigenous individual. 45

There are two ways to implement discussions on importantthemes and motifs presented within an analytical, social and

cultural sphere in these plays. One involves the incorporation of dramatic works in medical education. This has been usedsuccessfully in some instances with one-person shows to makecogent remarks about particular illnesses, such as HIV/AIDS. 46

Another method would be via performance at local art centres.These performances could be staged for healthcare profes-sionals, medical students and members of the general commu-nity and could incorporate opportunities for discussion andaction. The Project Steering Committee within the Committeeof Deans of Australian Medical Schools under Gregory Phillipshas established ways to better prepare Australian physicians toimprove indigenous health outcomes. Guiding principles of thecurriculum aim to instruct students on the vast diversity of indigenous cultures and gain an appreciation for their value forminority and mainstream healthcare. Suggested subject areasinclude population health, models of healthcare delivery andcommunication skills. Multi-disciplinary education constitutesan innovative avenue through which indigenous literature andanthropological works can be discussed. 47 Several Australianmedical schools, from James Cook University in Queensland tothe Australian National University in the Australian CapitolTerritory, have incorporated indigenous health as an importantpart of the clinical curricula. 48

Medical education should include the use of radio, television,film and theatre to broaden the cultural knowledge of futurephysicians. Each medium has unique characteristics. Indigenous Australian films have played an important part in providing an

indigenous perspective on key issues such as cultural safety andoppression, but have done so in ways that are entertaining to a

non-Indigenous Australian audience. One noteworthy exampleis the film Rabbit proof fence, released in 2002, which told thetrue story of Aboriginal Australian girls who ran away from theMoore River Native Settlement to return to their families. Anaccompanying study guide for the film offers one a chance todiscuss pertinent questions relating to the forced removal of indigenous children from their communities along with thepsychological, social and cultural ramifications of government-

sanctioned acts.49

One of the major benefits of experiencing a play is the ability to actively interact with the form as either an actor or a viewer. When viewing a scene from a play, there is an ability to addvarious subtleties and oblique ideas that can be discussedfurther by members of the audience. The incorporation of interpersonal connections through active discussion at aperformance may prove attractive to Indigenous and non-Indigenous Australian audiences alike. 50 Live plays can comple-ment Aboriginal-supported radio and television programming,with 8KIN and Imparja Television standing out as prominentexamples (Bell 2008, p314).50 There are other community radiostations that play songs, host guests and provide information of interest to the Indigenous and wider community in the states of New South Wales, Queensland and Western Australia. 51

The issue of language arises because many physicians cannotappropriately treat patients who speak different languages. A recent study by Cass et al has shown that miscommunicationand communication barriers due to an inability to conversethrough their language of origin have prevented Indigenous Australians from receiving adequate healthcare. 52 These barriersinclude lack of control by patients, differing modes of discourse,dominance of the biomedical model, lack of shared knowledgeand understanding, cultural distance and a lack of training incross-cultural communication. Illiteracy in the Indigenous Australian population is an impediment to receiving highquality care and is the result of poor social and economic

status. If more general practictioners were to learn the languageof the remote community they practiced in, there would be animprovement in communication with the patient. An idealcombination for effective treatment would be widely availableinterpreters to teach the physicians the language. However, itshould be noted that linguistic acumen alone will not overcomebarriers in treating an Indigenous patient. 53

Humour provides another outlet for breaking down culturalbarriers and allows for the improvement of health provisioning.The Humour Foundation disperses clown doctors to varioushospitals in Australia, aiming primarily to address the psycho-social needs of children, but also to adults in palliative care.Clown doctors work with health professionals to providedistractions for those who are extremely ill. 54 The high valueplaced on laughter and humour as they relate to interpersonalrelationships would prove an invaluable adjunct to indigenousdrama. Dramatic representation of the key issues may bridgethe gap in cultural understanding for both the Indigenouspatient and the physician.

A current project is underway at the University of California,Davis School of Medicine that aims to compile an audiovisuallibrary of patient stories from student-run clinics and medicalstudent re-enactments from theatrical works of culturalsignificance. The project, among the first in the USA, involvesparticipation from the Departments of Internal Medicine andEnglish Literature to combine methods of instructing theprofessional and mainstream community on the efficacy of

understanding the social and cultural manifestations of healthfrom performance, both real and acted. The underlying goals of

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the project align with those presented in this paper: to provide acultural snapshot of a particular ethnic group in order tohighlight social mechanisms of poor health. Plays are selected asthey have been in this paper, that is, to delineate a particularly unique period of time with a rich abundance of literary works.

CONCLUSIONOne of the main issues facing Indigenous Australians andhealthcare workers together is pervasive paternalism and victimblaming. 55 Plays and theatre as political works often arousestrong emotions and responses in readers and viewers. Dramacan communicate a sense of tragedy and elicit an empatheticresponse. The thematic constructs of drama, which is literatureboth read and, more importantly, performed, make drama aninformal, but truthful and accurate way to characterise. Therealso is an immediacy and aliveness to such enactments that ismore potent than just reading text. The text jumps off the pageand out onto the stage, to become a living, breathing entity thatthen bonds with the audience and presents health as a productof cultural conditioning.

This paper has dissected a group of plays written in the 1980sby Aboriginal authors, and can be seen as a presentation of cultural facets that explain several important issues of health. With improved understanding of the key issues of health andculture through one alternative method of explaining healthissues, more of these problems will be examined, and over time,more completely resolved.

Acknowledgements: This manuscript is dedicated to the memory of G Matharu, animmense source of courage and inspiration. I would like to thank J Gordon, Universityof Sydney, and W Harbert, Cornell University, and L Liddle, Australian NationalUniversity, for tremendous guidance and critical review of the manuscript.

Competing interests: None.

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doi: 10.1136/jmh.2008.0003642009 35: 47-53Med Humanities

K Matharu

cultural barriers in healthcare relationshipsUsing Indigenous Australian drama to break

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