The Yolngu people of North-east Arnhem Land, Northern Territory, Australia,have lived with alcohol for just over 30 years. In that short time it has had devastating health, social, family, and cultural impacts. This is particularly the case for a population of Yolngu who permanently or transiently camp on beaches and skirting woodland around the predominantly non-Indigenous Northern Territory township of Nhulunbuy. The Miwatj Health Aboriginal Corporation Outreach Program (Outreach Program) was a response to alcohol use by this Aboriginal community. Miwatj Health Aboriginal Corporation (Miwatj Health) also delivered primary health care to these people and encouraged lifestyle and drinking behaviour change. An evaluation of this program, in consultation with Miwatj Health, was undertaken in 2000-2001.
Purpose of research
The aim of this research was to evaluate the Outreach Program; however, it was more than an evaluation based on the stated objectives of the program. It explored the conception and development of the program, drawing heavily upon the thoughts, concerns and priorities of the Yolngu people involved. Determining the effectiveness or otherwise of an intervention is difficult, for example changes in alcohol consumption may be influenced by a range of factors such as employment, housing and education, as well as or in spite of participation in an intervention program1. Any evaluation must therefore be cognisant of what it realistically can assess. There have been few evaluations of alcohol intervention programs undertaken in a culturally appropriate way1,2. In this evaluation no party was unclear about the intentions of the research, to be of primary benefit to the Outreach Program and the Yolngu community it served.
Perhaps the most serious ethical matter that confronted this research, in a contemporary climate that supports Aboriginal community infrastructure and control, was that the researchers are non-Indigenous3-5. This ethical dilemma was addressed by one of the researcher's affiliation with Miwatj Health and the Yolngu people and the collaborative involvement of Miwatj Health and Yolngu leaders in the planning and conduct of the research.
The research was conducted over a 12 month period from June 2000 to June 2001. Ethics approval was gained from the Monash University Standing Committee on Ethics in Research Involving Humans. Key research techniques used were: unconcealed participant observation, semi-structured interviews, group interviews and opportunistic impromptu discussion, and documentary/archival review6,7. Semi-structured interviews were conducted with key informants, such as Outreach Program staff, Yolngu community members Aboriginal health workers, Miwatj Health doctors, Living with Alcohol representatives, the town administrator, Nhulunbuy police sergeant, the publican and local council officer. Group interviews were conducted with two groups of campers, Outreach Program workers and Aboriginal health care workers. Opportunistic impromptu discussions frequently happened when quietly sitting around or while walking together on a hunting trip; such discussions provided useful information and different perspectives not readily available through more structured research techniques. One of the researchers (BW) became a participant observer, participating in the day-to-day operation of the Outreach Program for several weeks. Gender reflective pseudonyms have been used for those participants who wanted to remain anonymous.
Data from the unconcealed participant observation and interviews was sorted into 10 subsections in a Microsoft Access database and analysed6-8. The sub-sections were based on themes identified in the data and included the perceived aims of the Outreach Program; strengths and weaknesses of the Outreach Program; history of the Outreach Program; staffing issues; funding issues; effects of drinking/camping; ideas for program improvement; other ideas to help campers; the attractions of drinking; the attractions of camping; and other.
The documents and archival literature supplied by Miwatj Health were filed in chronological sequence. Significant information was indexed and summarised to help clarify the history, goals and outcomes of the Outreach Program and important influences in its development and maturation.
Key informants were consulted to verify and comment on the analysis of the data and the research report. This also gave Miwatj Health the opportunity to approve the research findings before publication, and to clarify their expectations of the community report. This process of handing back the findings and analysis of the research project to key informants and stakeholders for verification and comment was an important means of improving the validity and reliability of the research6,7,9. As Munhall writes: '[t]ruth is an interpretation of some phenomenon; the more shared that interpretation is, the more factual it seems to be'10.
The key themes identified in the research have been discussed in a previous article11 which grounded the discussion in a portrayal of the day-to-day operation of the program. In this article we want to focus on one key theme that emerged from our analysis: the shaping of the program to address non-Indigenous concerns, in particular the focus on litter collection.
Miwatj Health Aboriginal Corporation
The Miwatj Health Aboriginal Corporation (Miwatj Health) was established in 1992 under the National Aboriginal Health Strategy (NAHS). It is funded to deliver primary health care and preventive medicine to the Yolngu people over an area that covers 37 900 km2 kilometers with an Indigenous population of over 700012. It is an independent, Aboriginal controlled medical service. Miwatj Health currently operates from its office complex in Nhulunbuy.
The Outreach Program was an initiative run by Miwatj Health under the umbrella of their Health Improvement Program (HIP). It aims to assist and support Yolngu people who choose to camp in and around Nhulunbuy and who are heavy consumers of alcohol. The core activities of the program were: litter maintenance; daily provision of vitamin B tablets and water to campers; diversionary activities for campers, for example, hunting trips; transfer of Yolngu in need of medical assistance or requiring routine medical screening to the Miwatj Health clinic or Nhulunbuy Base Hospital; and provision of health-related education. The program was run by the Outreach Program coordinator and overseen by the Miwatj Health HIP coordinator. The program provided diversionary employment for eight campers (field workers) who help with its daily operations. They were employed 5 days a week for 4 hours each day.
Outreach Program funding and organisational history: The Outreach Program began as a Living with Alcohol (LWA) project, which initially was one of LWA's strategies to service the increasing numbers of drinkers in the town camps. Funding for the Outreach Program came from the Wine Cask Levy (WCL). In July 1995 the Northern Territory introduced a $0.35 per litre levy on wine casks (withdrawn in 1997)13 with the money being used to fund the LWA program. This Program worked with other areas of Government and the community to support activities that reinforced responsible and sensible alcohol use, and aimed to make a substantial and direct contribution to reducing alcohol-related harm in the Northern Territory14.
With the Outreach Program nested within LWA's agenda to handle alcohol abuse in the region, it ensured networking and collaboration between all LWA staff and those dedicated to the Outreach initiative. It was the intention that this cross-sectional collaboration continue between the Outreach Program and LWA beyond its hand-over to Miwatj Health. This was particularly important in view of the homeland rehabilitation program that LWA was developing, because the Outreach Program offered the perfect interface to refer appropriate clients. A lag in the development of their homeland treatment initiative and a more independent approach by Miwatj Health, diminished the opportunity for effective communication and collaboration. This distanced Outreach from the professional support of LWA and a potentially positive cooperative arrangement to manage the welfare of the camper group.
These less than ideal circumstances deteriorated following the dissolution of the Gove Regional Liaison Committee and its Drug and Alcohol Subcommittee, in which Outreach was represented. These committees, with representatives from a number of local businesses, provided insight into the concerns of the broader community, albeit primarily those of the local non-Indigenous community. Nevertheless this chain of events effectively marginalised the Outreach Program from the community and other important local alcohol initiatives.
Handover to Miwatj Health: Until 1996 the Outreach Program operated out of the Northern Territory State Government's LWA Nhulunbuy office. Its handover to Miwatj Health, from the Northern Territory Government Health Service, took place on 18 April 1996. A grant of $50 000 from the WCL, secured by the Alcohol and Drug Subcommittee of the Gove Regional Liaison Committee, was provided to ensure its continuation. The funds were given to the Nhulunbuy Town Corporation who in turn funded Miwatj Health.
Hand-over of the program to Miwatj Health seemingly presented the opportunity for direct Aboriginal control and the benefits of that local control. In effect, however, control remained largely in non-Indigenous hands through the distribution of WCL funding. It was based on non-Indigenous policies and sanctioned through a municipal body (Nhulunbuy Town Corporation) with its own priorities to satisfy the non-Indigenous community. Furthermore, the Outreach Program was subject to external evaluation based on WCL policy by the LWA Program. Yolngu leaders, while supporting collaboration, also cautioned against forming inappropriate partnerships where control remained with non-Indigenous groups. As one community member explained:
Balanda people can't run things without the help of Yolngu people. They know some things but they don't know the people, but it is good to see Balanda and Yolngu working together. (Nanikiya Munungurritj, pers. comm., 2000)
Hand-over of Outreach also came at a time when Miwatj Health was concentrating on establishing its medical and administrative centres and supporting the health activities of communities in the Miwatj region. Core business was establishing the role of the doctors, Aboriginal health workers, and other medical and administrative staff. The place for Outreach was less clear. Ultimately the Outreach Program was transplanted and grafted into an environment that made it difficult to establish its own organizational roots within the larger Miwatj Health body. This organisational complexity, confusion and marginalisation had significant implications for the Outreach Program. It continued to have the effect of sustaining the program within a narrow context and largely left staff to their own devices, with little internal or external professional or collaborative support. It meant that the Outreach Program was relatively poorly and inappropriately resourced.
The litter focus
The primary activity of the Outreach Program was managing the litter problem evident in and around the community of Nhulunbuy. In February 2000, the Outreach Program entered an agreement with the Town Corporation to undertake a rubbish collection contract on the Nhulunbuy town lease, further cementing the litter focus for the Outreach Program.
The specific objectives of the Outreach Program were to:
- decrease the rubbish around the town beach and drinkers' camping and drinking places
- educate the target group on their legal rights and responsibilities under the Liquor Act and other relevant legislation
- develop longer term strategies to sustain reductions in rubbish and levels of public drunkenness in Nhulunbuy, including diversionary and other activities.
Tracing the program's history helps clarify how this non-Indigenous focus became and remained a core activity when for the Yolgnu community controlling litter was not an important role of the Outreach Program.
The intense focus on litter and antisocial behaviour was not shared by the Yolgnu people in the early stages of the Outreach Program. Instead, their concerns were for their people. There was a focus on talking with the drinkers, cultural activities such as hunting and art and crafts, and liaising with the LWA program and the police.
Sober Women's Group
Aboriginal women throughout Australia and the Northern Territory have been actively involved in addressing the problem of alcohol abuse. In North-east Arnhem Land a group of women known as the Sober Women's Group (SWG) have been very active. In October 1996, the Alcohol and Drug Subcommittee of the Gove Regional Liaison Committee agreed that the SWG, following their expression of interest, would assume responsibility for the Outreach Program (Gove Regional Liaison Committee 1996). Two representatives were appointed as joint coordinators. The LWA program and staff of Miwatj Health's new HIP provided direct assistance.
The SWG consisted of mainly older women from remote communities throughout the region and from the larger communities of Yirrkala and Gunyunara. Much of the group's influence came from some members' association with the Uniting Church and formal training with the Council for Aboriginal Alcohol Program Services. Their aim was to assist problem drinkers abstain through cultural counseling and family support. As Gundimulk Marawili, a member of the SWG explained:
We started as the SWG, we started with nothing, no payment or anything like that, just a part of our concern about our people, how we could help our people ... we'd go down to the beach every morning and sit with the people, talk to them, tell them how alcohol is effecting them . . . we as people, people that really, really, really cared to help the people because then again we have to think of themselves that we are the same and equal, we're Yolngu, and that's how I feel as a person, I feel I really want to help my people ... we know that it's hard for us to deal with alcoholic people but the only way to is to sit down . . . feel like them and they can feel that . . . it is a counseling job but this is the only way, Yolngu to Yolngu understanding.
Monthly reports from the SWG indicate a considerable amount of time was spent sitting with the town beach residents and addressing various problems and health issues they were having. From one such SWG report:
We work with the drinkers on town beach . . . educating people, sitting down with the right people to talk about their needs. We want to be close to the people, to be there for these people - to build trust. Before, the people on town beach were tough. They wouldn't listen to anyone. Now, they share their stories with us.
The SWG would encourage dependent drinkers to return to their traditional homelands as a form of cultural rehabilitation. These dry communities are usually far enough away from liquor outlets to 'therapeutically' interfere with drinking habits.
There have always been markedly different perceptions about the purpose of the Outreach Program. Among the local non-Indigenous community, the overwhelming concern was about the anti-social behaviour of the camper group that resulted from intoxication, and for the large amount of litter left in the town precinct and on nearby beaches. To the non-Indigenous population, the behaviour of intoxicated campers was of constant concern; they saw their quality of life and their safety compromised by drunken behaviour. The Nhulunbuy police reported they were frequently called to attend such misdemeanours (M. Reid [Nhulunbuy Police Sergeant], pers. comm., 2000).
The Town Corporation acknowledged the concerns of the non-Indigenous community and recognized the longstanding community anxiety regarding antisocial conduct:
The corporation was very heavily involved in the inception of the Outreach Program ... to deal with alcohol use and abuse in Nhulunbuy itself by the core group of the Indigenous population with specific aims to reducing litter ... (M. Hindle [Nhulunbuy Town Corporation], pers. comm., 2000).
This anxiety was reflected in the Drug and Alcohol Subcommittee of the Gove Regional Liaison Committee who often focused in their meetings on public health and social issues raised by public drunkenness. In a covering letter for a submission for WCL funds for the Outreach Program, the committee proposed that 'better informed drinkers may reduce the level of public disorder and anti-social behaviours by curtailing drinking to appropriate venues and exempt areas'.
Early in the Outreach Program's development, a clear disparity and tension emerged between the stated objectives of the program and what the Yolngu people involved thought was important. The narrow focus on litter management came from the Town Corporation which sanctioned the project funds and the external evaluation of the program by LWA based on WCL funding policy. David Simmons, Miwatj Health Program manager, explained:
. . . the performance indicators are not developed by the people asking for the money, they're developed by the people giving the money. There's nothing cultural in it . . . they're [funding bodies] interested in their values what they want: they want the town cleaned up, the rubbish picked up, the bins out and the people taught how to use the bins ... you can see that very few of these values are Indigenous. (D. Simmons pers. comm. 2000)
These pressures intensified as the program became marginalised within Miwatj Health and increasingly dependent on the WCL funding for program staffing and activity. The narrow focus on litter also found firmer root when Outreach entered an agreement with the Town Corporation to undertake a rubbish collection contract on the Nhulunbuy town lease. Although beneficial in providing top up to Community Development Employment Projects (CDEP) payment for the Outreach workers, it acted to cement the litter management role of the Outreach Program.
The other negative outcome of this increased focus on litter was that the Outreach Program encountered considerable difficulty taking up other initiatives it saw as worthwhile, for example, Deb's Shed. In 1998 Deborah Perry, Mitwaj Health Improvement Program coordinator, developed the idea of 'Deb's Shed'. It was envisaged that the shed would provide a facility for Yolngu visiting Nhulunbuy from their homelands; for educational information concerning health issues and an interface for Aboriginal health workers to monitor clients from the camper group. Despite initial support from many community organisations the project faltered. Peter d'Abbs15 warned of this consequence:
Measures to maintain public order are, of course, a necessary part of social life, and such measures should include, by most people's reckoning, sanction against public drunkenness. However, measures of this kind should not be allowed to undermine no less needed strategies for preventing and controlling alcohol abuse, nor should they be seen as a substitute for such strategies.
Yolngu people speak openly and strongly of the crippling and devastating impact of alcohol on individuals, families and communities. Violence, sickness, death and cultural and spiritual disconnection all feature as strong concerns. Like other sections of Australian society, the personal and social impacts take place in a community where people enjoy alcohol and its effects and still live meaningful, autonomous and happy lives, including some of those people who drink harmfully. For Yolngu people, alcohol forms part of the conjunction of Western and traditional influences they deal with as they forge a contemporary, distinctive and modern Yolngu society. The Outreach Program is one small part of this complex story.
The Outreach Program has achieved some success and made a difference to the lives of a small number of Yolngu who are seriously debilitated by alcohol abuse. However, as this research has found, there is a strong focus by the Outreach Program on reducing litter in and around Nhulunbuy and on reducing antisocial behaviour among the Indigenous camper population. Yolngu, however, sought more from their program than these narrowly defined objectives. There are a myriad of contributing reasons for the litter focus but perhaps most influential has been non-Indigenous perceptions that prevail in the funding protocols.
The Outreach Program was inadequately and, perhaps, inappropriately funded through the WCL and town clean up contract. The result has been a program that is understaffed and focused primarily on objectives that are not considered important by the main stakeholders in the program - the Yolngu. The ability of Indigenous communities to determine appropriate program approaches and implementation is undermined when funding sources place restrictions which reflect non-Indigenous values. The Mitwaj Health Outreach Program is an example of how an Indigenous program can be subverted from its prime objectives and end up fulfilling non-Indigenous values and concerns. Yet there is limited choice for many such initiatives in a funding-scarce environment - to accept funding that allows a program to run in some form, or not to run the program at all? The bigger issue is about the continuing control by the non-Indigenous community, through funding, of an Indigenous community's ability to determine priorities and approaches to issues. Control that ensures any self-determination only occurs within parameters set by the non-Indigenous community.
The challenge for Miwatj Health and the Outreach Program was to revitalise the identity of the Outreach Program and redefine its objectives so that they reflect the concerns of the Yolngu community. Funding and funding sources will be an influential factor in the direction and success of this program.
In November 2001 funding to the Outreach Program, under the Northern Territory Department of Health Alcohol and other Drugs Program (WCL), was withdrawn. In June 2003, the Northern Territory Government announced a $5.25M budget allocation to extend an Northern Territory-wide Community Harmony Strategy which had a strong focus on outreach and withdrawal rehabilitation services for those affected by substance abuse and mental illness16. In Nhulunbuy, the relevant committee was the Harmony Djamamirri Mala Working Group (Harmony Working Group). A key initiative of the Harmony Working Group was the proposed construction of a Substance Abuse Special Care Centre, located within Nhulunbuy. The intention of the proposed centre was to assist in the care, treatment and rehabilitation of people suffering substance abuse in the region in a culturally appropriate way. It would cater for up to 36 individuals at a time and would be attended 24 hours a day, all year round. A key target group of this centre was itinerant campers. Repatriation to homelands was also to be an important objective. It was anticipated that after the centre was constructed, a night patrol program would play an important ancillary role (Harmony Djamamirri Mala. 'Investing in Our Future: A proposal for the establishment of a facility for the care of the casualties of substance abuse' [unpubl.], 2003).
How does this conclude the story of the Outreach Program: is it a new start to dealing with alcohol problems; will it now focus on the Yolngu people's concerns and objectives; and will the Yolngu people be able to maintain control over the direction of the Program? These are important questions for any future evaluation of the Outreach Program.
For one of the authors, Ben Wearne, the Yolngu of North East Arnhem Land have been an important part of his life. He moved with his family to the Gove peninsula in 1979 where his parents worked as teachers. Having grown up in Gove, he knows many of the Yolngu involved and their families through friendship and adoption by kin. This project was his opportunity to, hopefully, provide a positive contribution to the Yolngu community.
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