In reply: It saddens us that Winsor’s experiences as a remote visiting specialist are so depressingly familiar, but his nihilism is even more disturbing. There has in fact been improvement in the health of the Indigenous population in remote communities; examples of this include the evidence provided by articles in the very same issue of the Journal, by Margolis and colleagues (falling rates of serious injury retrieval) and Ward and colleagues (declining syphilis rates).1,2 An understanding of the social determinants of health is essential to accepting that we can indeed work towards improving health, perhaps not through focusing on specialist medical services but rather in the broader primary health care context. Our students and patients deserve clinicians and mentors who might inspire and look for solutions, rather than retreat into despair. Progress in closing the gap will be far slower than many imagine, but it is not impossible, as we have already seen.
We totally refute that we used a “quasi-scientific methodology”. Our study is a simple retrospective audit with not a P value in sight,3 and it has no pretensions to be otherwise. It aims to present a clear story from a defined group, and to add to the many individual anecdotes, such as Winsor’s, that on their own do not gain the attention of employers, policymakers, or government. By building a body of evidence, surely we will be able to more effectively advocate for systemic changes. Collaborating with interested colleagues such as remote area nurses who have published more widely on their own adverse experiences4 is another key strategy in influencing change.
We agree wholeheartedly with Nielsen’s viewpoint that obligations to workplace health and safety legislation and to company policy and procedures should be paramount. However, this breaks down when individuals employed or contracted in various capacities are incompetent, ignorant, stupid or just have a sheer disregard for the rules. In addition, there appears to be a lack of scrutiny in remote areas where lower standards are somehow acceptable, and legal frameworks somewhat more fluid. The romanticisation of the bush and the culture of “making do” is partly responsible for the laissez-faire attitude to occupational health and safety. Perhaps our metropolitan colleagues could assist in challenging the status quo and the deeply entrenched beliefs, attitudes and systems that collude in silencing questioners and burnt-out staff.
- 1. Margolis SA, Ypinazar VA, Muller R, Clough A. Increasing alcohol restrictions and rates of serious injury in four remote Australian Indigenous communities. Med J Aust 2011; 194: 503-506. <MJA full text>
- 2. Ward JS, Guy RJ, Akre SP, et al. Epidemiology of syphilis in Australia: moving toward elimination of infectious syphilis from remote Aboriginal and Torres Strait Islander communities? Med J Aust 2011; 194: 525-529. <MJA full text>
- 3. Patel A, Underwood P, Nguyen HT, Vigants M. Safeguard or mollycoddle? An exploratory study describing potentially harmful incidents during medical student placements in Aboriginal communities in Central Australia. Med J Aust 2011; 194: 497-500. <MJA full text>
- 4. Cramer J. Sounding the alarm: remote area nurses and Aboriginals at risk. Perth: University of Western Australia Press, 2005.
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