The Challenges of Aboriginal Health in Australia: An interview with John Boffa

18 Jan 2012

9/01/2012 12:56:00 PM

Transcript of Interview with John Boffa conducted by Paul Komesaroff and Paul James Jan 2nd, 2012

Part I
QUESTION: What took you to work in such a difficult field, where you’d always feel yourself to be both an insider and an outsider?

JB: Well, I was working at the Alfred Hospital and not finding a great degree of satisfaction or depth of meaning in what I was doing –  there were many other people doing similar work and I didn’t feel I was getting the rewards I wanted to get from work. And part of that was that I had something to compare it with because while I was going through uni I used to work one night a week at a house in Gertrude Street Fitzroy called The Way, which was run by the Jesuits. I used to go at 11.00 at night and sleep the night. It was a house for skid row alcoholics. There’d be about twenty blokes staying there overnight and these were blokes who were all men, women weren’t allowed in that house, but they were very disadvantaged and in great need and the experience of working with those men made me appreciate how easy it is to make a big difference in the lives of people in great need. Small things can make a big difference. Like just being there when someone fitted and knowing what to do would make a big difference. Compared to in a big hospital, there were so many other people around doing similar things, if you did something or not didn’t really make a big difference. Someone else would do it.

So I wanted to experience working somewhere where my skills and what I could offer were able to make a difference and were very much more needed than where I was working, which is why I decided to take a year off from physician training. At that stage I thought I’d come back to it, but I had to get permission from the powers that be – Professor Stockigt and various others. It took a while before they said OK you can have a year off and we’ll guarantee your re-entry back in the training program. Cause I wouldn’t have gone if they hadn’t have said – at that stage I thought I wanted to be an infectious diseases physician

QUESTION: And you never came back?

JB: No I never came back. Because it’s competitive I wouldn’t have wanted to lose a place. So I took a year off and I planned to go to India and work in a Jesuit mission in India in a hospital in Bihar. I applied for a visa some six months before the year ended something like Jan 12th. And when it came time my visa hadn’t come through. It had been held up. At that time they were very reluctant to let overseas doctors into India, particularly ones that were working in missions. So then another Jesuit friend of mine told me about this health service in Tennant Creek where he knew the director, an Aboriginal woman called Chris George. And they hadn’t had any doctor for three weeks, the previous doctor having been sacked, I wasn’t sure why. So I said well I’ll go there for a while and wait for my visa to come through. So I went to Tennant Creek.

QUESTION: How long ago was that?

JB:  February 22 1988. And sure enough there were no doctors. And within a very short space of time one – I mean I’d hardly ever met Aboriginal people in Melbourne. I’d met one or two, hardly any. But I had no idea of the level of disadvantage. I mean it was just mind blowing. The town camps at that stage, a lot of it was tin sheds. And a lot of people living in tin sheds without running water. There were a couple of proper houses. The level of alcohol abuse, violence and overcrowding. And the illnesses people had in the early were just very simple things, a lot of them were infections treatable with penicillin.

Medical care was clearly making a big difference. It was immediately obvious that they needed a doctor. Plus I also I got excited by the whole community controlled health service environment. It was completely different.  Here I was working with a whole team of people. With leaders and managers who were very committed and had a very progressive world view which I hadn’t been exposed to so it was very exciting.

QUESTION: What was it that attracted you to working in that sector?

JB: It was more that I wanted to work in a disadvantaged community. As I said a Jesuit told me about the service in Tennant Creek. So I really only went to the Centre -I could have gone anywhere really – because they needed a doctor. It was an area of need and that’s the sort of experience I wanted to have.

QUESTION: Why did you want to work in a disadvantaged community?

JB: Because I wanted to experience what it was like to work full time in an area where people were in great need and were disadvantaged.

QUESTION: One of the things about someone with that motivation, which is fantastic, it can go towards the charity model, towards the helping out of, which in 1988 at the time we are talking about there were two things happening in the world. One was that charity was seen as a good thing but from an Aboriginal point of view was also part of the problem.  And secondly we’d gone through that stage of thinking we’ve now been settled as a country for this period of a hundred, two hundred years. So at that point Aboriginal politics was very complicated and therefore they would respond well to you as a doctor coming, but badly as a helper. How did you deal with it?

JB: A couple of things helped.  When I first went there I refused to accept any money, so I wouldn’t accept a salary and just said that living expenses was all I wanted. That I think was quite important in building a relationship with the director of the service. But also the director had a huge influence on me in broadening my political understanding and my understanding of the social determinants of health, which were very, very weak when I went there. I was very conservative and thought basically that people determined their own health chances by the choices they made, didn’t understand the structural determinants of health. So very early on I became involved in partnership with her and the Board of the organisation in beginning to work on the structural determinants of health.

The very first campaign I was ever involved in was getting the strip shows out of the public bars in Tennant Creek. Within the first few weeks I’d been exposed to these strip shows which were happening in the three big alcohol outlets. Thursday lunchtime, Thursday night, Friday lunchtime, Friday night, Saturday lunchtime, Saturday night and Sunday lunchtime they had strip shows in the public bars and every second week or so the women who came up would work as prostitutes. The town was just a magnet every weekend not just for the Aboriginal people but all the non-Aboriginal,  the miners, the meat workers, the people working on cattle stations, the tradesmen, all came to Tennant Creek for these strip shows.

I started as a GP, seeing Aboriginal women who’d been raped on the way home from the shows because they had, the shows involved  a large amount of audience participation. They had drop the top contests, so for a $50 buck grog voucher local women would get up and take their tops off and if they won they’d win $50 bucks of alcohol. The blokes would see that as, if women would do that they were up for it. But the bottom line, the final straw, came when a 15 year old boy who’d been at a show, on the way home raped his school teacher. So this is within the first few months of me being there we correlated this issue with violence, with rape, with alcohol use and began a campaign through the health service to get strip shows out of the public bars.

QUESTION: You’re in a complicated position where you’ve got to negotiate the politics of change against an establishment which is making a lot of money out of this, but also a situation where you’re crossing cultural boundaries, Aboriginal and white, where there’s a changing form of apartheid…how do you negotiate such a difficult set of circumstances?

JB: Well I wouldn’t be able to do it on my own. It was only because I was in an Aboriginal organisation where I was able to talk through the issues with the Director, with the Board, with other workers and get the support of the community through that process.

QUESTION: Was the director Aboriginal herself?

JB: Yes she was an Aboriginal woman from Queensland. So by talking through the issues and getting the support –  and in the end the level of support was that we had drivers for the organisation also worked as bouncers at one of the main hotels where this happened and they did affidavits which were incredibly important  because their affidavits were able to show that prostitution was happening, and the fellow organising the prostitution was the DJ. They exposed that, so we even had that level of support from…

QUESTION: What was the effect of abolishing the strip shows?

JB: The outcome in the end was a very big public campaign. It empowered the community, the community had a real sense after that that they could a change in the town through collective action. The outcome was that a voluntary code of ethics became law. There were these ten ethics which said you could have strip shows but the strippers had to focus on the dance routine, they weren’t allow to spend the majority of time stark naked, there was to be no audience participation…There was quite a good code of ethics which wasn’t being followed, that was made law and subject to a licensing agreement. Within the space of a few months all the strip shows stopped because everyone lost interest once they weren’t allowed to do all that stuff and it was just a routine strip show, attraction waned and one of the outlets went broke

QUESTION: So what did impact did that have on you, what did you learn or take away?

JB: I learnt a lot about the effectiveness of collective action for social change. And in the process of running that campaign I also learnt a lot because two of the town’s most prominent doctors publicly supported the strip shows. They came out in the midst of the campaign saying this is just harmless fun, this has nothing  to do with health, what’s this health service on about. They went to the shows and had themselves filmed, photographs taken at the shows…So I started to realise that people had very different views of health and this reductionist view that I had before I went to Tennant Creek was very common amongst the medical profession. There was only one doctor out of eight in the town that supported the campaign, all the rest were opposed to it. I learnt a lot about gender politics. Blokes were so angry they actually tied women up to stop them coming to public meetings. I had a bloke pull a gun on me when I went to a house to help his wife who was an Aboriginal woman being beaten up. I went in the house, as soon as I walked in the door he said ‘you’re the bloke that’s trying to get rid of the stop shows’ and pulled a gun on me. It wasn’t loaded, but I didn’t realise that at the time so that was fairly frightening. So I learned a lot about patriarchy, gender politics, processes of change, collective action. And that empowered me too, to realise you can change things.

Part II
QUESTION: Can you mention some other campaigns you’ve been involved in?

JB: That was the first one. That led to the ‘beat the grog’ working group which kept working on supply reduction. It was a much bigger…

QUESTION: Still in Tennant Creek?

JUB: Yes. That culminated in the Tennant Creek alcohol restrictions which got rid of all cheap alcohol. In those days it was only 4 and 5 litre casks, they didn’t have cheap bottle wine. So eventually those restrictions came in. It took years of lobbying though. It was much easier to get rid of the strip shows than it was to begin to restrict alcohol supplies.

QUESTION: What was the difference?

JB: The vested interests against the issue of restricting alcohol supplies were much bigger. They were prepared to let the strip shows go. And particularly one thing which happened which was pivotal was a documentary being filmed by Sophie Lee, “Sex in Australia”. She came to Tennant Creek and I took her to the show being filmed in the Tennant Creek Hotel. While we were there I said to her you wouldn’t believe who’s there at the bar, the Deputy Chief Minister of the Northern Territory, Barry Calder.

So they walked up to him on camera and said ‘Oh Barry, we’re doing a documentary. What do you think of the strip show?’ He said ‘What strip show?’  The camera moved to the strip show and back to him and they said ‘That strip show at the bar.’ And he said, ‘That, oh that’s just a bit of harmless fun.’ They said, ‘You think it’s just harmless fun? That’s interesting because we’ve just interviewed these people and found out about rapes’. He looked so bad. So that was just a bit of gratuitous publicity that forced them to change.

QUESTION:  So going back to the alcohol..?

JB: There was no pivotal event like that. It was a much tougher issue because people felt, whereas the harm from the strip shows was really obvious, the harm from the alcohol raised the issue of people’s right to choose and you shouldn’t restrict people’s access to alcohol. It was a much broader issue.

QUESTION: Were you involved in the petrol sniffing campaign?

JB: No, petrol sniffing didn’t happen in Tennant Creek and when I got to Alice it was an issue in the Anungu Pitjantjarra lands only initially. I was involved in getting Opel unleaded introduced..

QUESTION: How were you involved in that?

JB: When I first heard about the product I was the first person to come out publicly and got a lot of national publicity saying this could potentially be an incredibly important initiative. Because people and Aboriginal leaders were coming out saying it’s not going to work, it’s too simplistic, the problems of youth are much deeper than that, what a stupid idea. So I came out on the basis of my experience in alcohol availability and reducing it, saying if it’s true it’s unsniffable then this could be an incredibly important measure. Then advocated for it to be introduced when it was produced and was unsniffable and that was clear then congress advocated strongly and lobbied Tony Abbott extensively and went public on a lot of occasions saying it had to be introduced, it’s got to be subsidised. It cost $10 million in Central Australia. So we were part of that campaign.

But back to your original question about charity, I think it’s very true that there’s a risk of being seen to be just wanting to help and doing nothing about the structural determinants. But as long as you’re doing both, as long as you’re not just helping but you’re also seen to be helping to address the reasons why people are ill in the first place, then you’re protected from that accusation.

Also I was studying theology at the time and one of the most important things that I read was an essay by Paul Tillich on the ontology of love, power and justice and he argues that all three have to be in equilibrium. Love and power without justice is paternalism and love with power is sometimes necessary to overcome power without love…xxx. I particularly like the idea that love without justice is paternalism, so that if you’re loving people but not in any way interested in addressing the injustices they’re suffering from then you can become very paternalistic in the way you work and what you’re doing.  So you need to combine both. What’s exciting about primary health and community controlled health services is that you’ve got this structure in which you can absolutely do both, in which you are required to do both.

QUESTION: What are the most important things you’re doing now?

JB: Two things. One is promoting excellence in clinical care through quality improvement programs and quality improvement processes. Secondly, addressing the key structural determinants of ill health which I think now are early childhood and lack of education, alcohol abuse, overcrowding and those issues and income inequality. I think we are able to work around the health system itself, and that’s improved a lot. You can really see the impact that Aboriginal health services have had and non-Aboriginal health professional have been part of that.

Part III
QUESTION: What are the most important things to you?

JB:  Working in Aboriginal health we are at the coal face of inequality more generally and it allows you to appreciate much more clearly the contradictions and problems in Australian society, so that by working with some of the most disadvantaged people those contradictions become really apparent and really clear.

QUESTION: Can you tell us more, because that issue is a key one. We’re not going to Aboriginal culture and politics simply to provide support , we’re also seeing them as contributing to our culture in places like Melbourne. Can you say something more about the content of that? What are we bringing to the whole of Australia when we are doing work on those tensions, say between education and culture?

JB: We’re potentially part of addressing the inequalities that affect all Australians. Aboriginal people are just an extreme example of that. To some extent you can assess the quality of any society by how it deals with its most disadvantaged people – Aboriginal people, refugees, old people, disabled people. If you look at that Australia’s not doing very well at all. We’ve become not a very compassionate society and disadvantaged people do very badly in this country. This is why I think it’s incredibly important for young people to get out and work with disadvantaged people because it’s by working with the most disadvantaged people that the problems become clear and you can see where you need to work.

QUESTION: How can young people do that without becoming self-regarding oriented toward having experience? How can they do it in a way makes a proper difference to engagement?

JB: I think they need to commit themselves to enough of a period of time to build the sort of relationships with people that are going to enable you to effectively work at a structural level and not just a one on one level. You start off one on one, but that gives you a fantastic entrée into building relationships with people and if you’re working in the right sorts of organisations like community controlled organisations you can then use and with those relationships have an effect on the structural determinants and that’s one of the great opportunities. That doesn’t exist at The Alfred – it’s very difficult, you can do it but it’s much more difficult.

QUESTION: What motivates you?

JB: I think I’ve got a high degree of compassion and empathy for people and there’s so much disadvantage that’s still there, but in twenty years we’ve made a difference, we’ve been able to help people, but there’s still a large amount of disadvantage that can be addressed, it’s fixable. I think there’s a great hope.

There’s still a large amount of disadvantage that needs to be addressed and the experience I have puts me in a position where I can help work out what needs to be addressed. I think there’s a big difference that can be made quite quickly by staying in the area where I am. Whilst I’ve thought about changing and doing different things, I just think historically I’ve got so much experience and knowledge in this particular area and the potential to make change is only partly realised, which is very exciting and motivating.

QUESTION: What’s your message to young Australians?

JB: Young Australians – particularly those that have been fortunate enough to get through school and uni and get some qualifications and skills – should never be satisfied going into a job that they’re not completely committed to or they feel is not giving them a depth of meaning or satisfaction that they think it’s possible to find. I think one can find deeply satisfying work and in order to do that leaving your family and friends, where you’ve grown up, going to a whole new environment  and working with extremely disadvantaged people can be a very important experience in helping you to find out how you best can contribute to the world and the society you live in.

It’s very useful for yourself and your own development but also for disadvantaged people, for people with skills to experience working for a period of time , probably a minimum of two years, to find out what there is to learn. Getting out there and working for disadvantaged  communities has double benefits, both for the community and yourself in terms of what you learn.