Western health professionals often experience difficulties in service delivery to Aboriginal people because of the disparity between Aboriginal and Western health belief systems. This article reviews the literature which considers ‘traditional’ Aboriginal health beliefs and medical systems. The traditional Aboriginal model of illness causation emphasises social and spiritual dysfunction as a cause of illness. Supernatural intervention is regarded as the main cause of serious illness. There are gender divisions in Aboriginal society that impact on the delivery of Western healthcare. Management strategies such as preventative care, bush medicine, and the role of traditional healers are discussed. These belief systems are considered with particular reference to their interactions and implications with regard to the Western medical system. This information provides a framework to allow improved understanding by health professionals of the health-related decisions made by Aboriginal people.
Health professionals often experience difficulties with providing care to Aboriginal people because of the cultural distance between mainstream culture and Aboriginal culture, particularly in regard to health belief systems. The disparity between Aboriginal culture and mainstream Western culture appears to magnify the difficulties encountered in any cross-cultural health service delivery setting.
In the 200 years since colonisation, the lifestyles of Australian Aborigines have undergone significant change. Despite the immense changes and stress forced upon Aboriginal people, they have been very successful in maintaining much of their culture despite periods of cultural suppression. In particular reference to health care, it is evident that Aboriginal people have passively resisted many Western beliefs and practices.1>
The ‘traditional’ beliefs of Aboriginal people have adapted to the changing circumstances in which they live. While Aboriginal viewpoints of treatment have changed over this time, there has been less change in beliefs regarding the cause of illness.2> This may be because the health beliefs continue to play a role in providing meaning to events and thereby helping people to cope with serious illness and death.2>
This review will consider many of the aspects of traditional health beliefs and practices of Australian Aborigines reported in the literature with a view to aiding understanding by health professionals of their present attitudes and behaviours in regard to health care. The vast majority of the literature considers the health beliefs of Aboriginal people from rural and remote regions rather than metropolitan locations. It is likely, therefore, that the information presented will have more relevance to health professionals working with Aboriginal people in rural and remote regions. The Aboriginal model of illness causation, including supernatural intervention and treatment methods, and the interaction and dissonance of the health-related beliefs of Aboriginal people and Western health professionals will be discussed.
TRADITIONAL ABORIGINAL HEALTH BELIEFS
There is a variety of health-related beliefs held by Aboriginal people throughout Australia and the material presented is a representative sample which highlights the differences between Western and Aboriginal health-related beliefs. It is based on literature describing the ‘traditional’ culture of Aboriginal people from a variety of locations across Australia. There is a lack of material which describes the health beliefs of Aboriginal people living in urban settings. For these reasons this paper provides information about the foundation on which present beliefs have (or have not) been incorporated. There is limited information regarding the specific health beliefs of Aboriginal people today or of the variety of health beliefs within the general Aboriginal population.
There is a danger of generalising from the anthropological literature and applying this information to specific individuals or communities. The literature may be based on a different group of Aboriginal people and even within a specific group culture there will be different levels of belief expressed by individuals.2> The cultural diversity, particularly in regard to health beliefs, between Aboriginal groups and communities has been acknowledged by many.3,4> The information presented, however, provides a framework which should allow improved understanding by health professionals of the health-related decisions made by Aboriginal people.
Aboriginal model of causation
The traditional health beliefs of Aboriginal people are interconnected with many aspects of Aboriginal life such as the land, kinship obligations, and religon.5> The sociomedical system of health beliefs held by Aboriginal people places emphasis on social and spiritual dysfunction causing illness. This approach emphasises that ‘individual wellbeing is always contingent upon the effective discharge of obligations to society and the land itself’ (p.598).6> A person’s social responsibilities and obligations may take precedence over their own health because of the priority given social relationships in this model.
Many of the Aboriginal medical belief systems described in the literature have similarities despite being from different parts of the country.2,4,5,7–11> The integration of information from multiple sources can be compiled within the framework used by Mobbs (see Table 1).12>
Table 1. :
Framework outlining ‘traditional’ Aboriginal health beliefs
This framework is not meant to represent any definitive picture of beliefs in any particular Aboriginal community as there will be variation between and within communities, and these categories will shift with time. Rather, it provides an overview with specific examples of the way Aboriginal people have categorised illness (natural, environmental, direct supernatural, indirect supernatural and emergent or Western causes). It is important to recognise that these categories are not mutually exclusive, indeed there may be beliefs relating a single clinical entity to multiple possible causes.13>
An alternate model divides people into four broad categories in regard to their health: (i) the strong — normal condition, able to cope mentally and physically with daily tasks; (ii) the weak — minor illness that requires rest and specific treatment for condition (e.g. headaches, toothaches, etc.); (iii) the wounded — have cuts, bruises and wounds from fights or accidents; and (iv) the sick — spiritual and supernatural influences cause illness that does not resolve without assistance.21>
Both models regard supernatural intervention as the main cause of serious illness. The belief in causation is divided into ultimate causes (e.g. breach of a taboo) and proximate causes (e.g. motor vehicle accident) of illness, injury or death.2,4,22>
These models provide a basis for the understanding of specific Aboriginal health beliefs and the differences between Aboriginal and Western models of health. Understanding of the traditional Aboriginal models of illness causation will assist in clinical interactions by Western health professionals.
Sorcery and supernatural intervention are part of the perceived reality of Aboriginal life,11> and in Aboriginal society explanations in terms of sorcery are often used. The deaths of infants or the very old or chronically ill are considered to be in the normal course of events, while deaths outside these groups may have a supernatural influence, especially if they are regarded as premature, unexpected and sudden.23> It is important to note that the belief in supernatural causes of illness may not be restricted to Aboriginal communities in rural and remote regions.24>
There are many beliefs associated with supernatural interventions and sorcery: sorcery exists in many forms, its effect is to manipulate and alter behaviour and cause morbidity and mortality; sorcerers can be specialists or non-specialists; distant groups have the most virulent sorcery and are the most feared; many diseases come from dangerous, secret sacred sites — they are manifestations of the forces or power emanating from those sites; unskilled or uninitiated people may release forces from a dangerous site, by disturbing the site; sorcery is carried out in secrecy; retribution sorcery is directed serially at members of a family or lineage therefore the serious illness or death of one member is followed by the illness and death of others; and a traditional healer can apply counter measures to identify the cause and source of illness and death but the healer should not interfere if it is the result of legitimate punishment.25>
Several authors recount details of the techniques used in sorcery.1–4,8,9,22,23,26> Sorcerers are generally held to be outsiders,23> usually from distant communities or country outside the direct knowledge of the group.2,18,26>
The concept of supernatural intervention and sorcery plays an important function as ‘it explains why one person and not another died or became ill at a certain time and not at another’ (p.39).23> It provides the explanations of ‘why me’ and ‘why now’, which is unable to be answered in terms of Western medical theory. It provides the answer to the ultimate cause of the event.
The ill effects of sorcery will not necessarily be felt only by the ‘offender’, but may also be felt by their family and descendants.27> While the thought of sorcery is prominent in Aboriginal life, people do not live in constant fear of sorcery.27> Sorcery is usually an explanation which is applied retrospectively to explain deaths, serious illness or injury.27>
Sorcery ‘is the central element in a theory that links illness and death to personal and social conflict or to the breach of ritual proscriptions’ (p. 127).27> It, therefore, acts as a mechanism of social control8,9,23,25,26> as it constitutes a real threat to those tempted to break the law or neglect their personal, ritual or social obligations.23> ‘It also reinforces the interdependence and identity of family and lineage in the face of a potential threat of outside attack, and induces caution with unknown people, places and situations’ (pp. 148–149).25>
Aboriginal customary law views sorcery as illegal but it is felt to be on the increase,28> especially in Yolngu society in Arnhem Land.29> Sorcery is being used as an alternative to lawful punishment by the keepers of traditional Aboriginal law due to the fear of non-Aboriginal law. The keepers of the law know that to apply traditional punishment (e.g. spearing in the thigh) would be to risk conflict with non-Aboriginal law as the wider Australian legal system may not recognise the original violation.29>
This increase in sorcery has several negative effects: as it is an illegal action it leads to an implicit acceptance of lawlessness by the community; people’s confusion about the cause of death or injury (assuming sorcery to be involved) leads them to not taking responsibility for sickness, disease, or substance abuse (a frustration expressed by health professionals);30> families of law-breakers are concerned they will bear the brunt of the punishment; much energy and time may be spent on speculation about whether sorcery is to blame when someone becomes sick or is injured in an accident.29>
Supernatural intervention plays a very important role in the traditional health beliefs of Aboriginal people as it may provide the ‘ultimate’ reason why a person became ill. All health professionals interacting with Aboriginal people should have an appreciation of the effects this may have on the provision of healthcare.
Men’s business/women’s business
In Aboriginal culture, there are clear-cut divisions between men’s and women’s role in society. Women’s business includes all aspects of reproduction: menstruation, pregnancy, childbirth, contraception, abortion and female ceremonial business.31–33> Food taboos are still prevalent, especially during mourning, pregnancy, lactation and menstruation.20,34> Men’s business involves hunting, conflicts, the land, male anatomy and male ceremonial business.31,35>
Breaches of these traditional divisions (e.g. female nurse washing elderly initiated male Aboriginal, a female nurse teaching an Aboriginal man self-catheterisation or a male doctor undertaking a vaginal inspection) is likely to cause great distress and ‘shame’.35,36> Shame is a complex concept that is difficult to translate into non-Aboriginal English.31>
The concept of shame ‘describes situations in which a person has been singled out for any purpose, scolding or praise or simply attention, in which the person loses the security and anonymity provided by the group’.37> It is experienced in situations in which one does not know the rules for doing the right thing, where whatever one does would be wrong because one should not be in the situation37> or by a person who acts, or who is forced to act, in a manner that is not sanctioned by the group and that is in conflict with social and spiritual obligations.6> Every health professional treating Aboriginal people should have an appreciation of this concept because of its influence on the provision of services.
By preference, same-sex staff should attend to patients, especially during toileting and showering,38> and any gender-specific problem should be treated by someone of the same sex.6>
TRADITIONAL ABORIGINAL MEDICAL SYSTEM
The manner in which traditional health beliefs work as a form of social control is most evident when the ways to prevent illness are considered. ‘Good health is associated with strict adherence to approved patterns of behaviour and avoidance of dangerous people, places and objects’ (p.148).25> Preventative measures to ensure wellbeing are based on laws governing behaviour and may include: avoiding certain foods which are prohibited during ceremonies or life crises (e.g. pregnancy or menstruation); obeying ritual prescriptions and taboos; taking care not to abuse one’s land or trespass on the territories of others; avoiding prohibited sacred sites or approaching them with ritual protection; observing debts and obligations to others; containing anger, violence or jealousy; exercising caution in interactions with strangers; taking steps to avoid sorcery or open conflict with others learning the hazards within the environment; avoiding all actions that might endanger the health of the family; observing the formalities and obligations of kinship; respecting and honouring the dead; and safeguarding oneself against attack by leading an exemplary moral life, employing counter spells and charms.2,4,9,39,40>
The methods of preventing illness link in directly with what are regarded as the ultimate causes of illness under the Aboriginal model of causation of illness.
TRADITIONAL ABORIGINAL MEDICAL TREATMENT
Numerous authors comment on the use by Aboriginal people of their traditional medicine system. The 1987 Review of Rehabilitation Services in the Northern Territory found that traditional Aboriginal medicine is widely practised in the Northern Territory.41> More recent confirmation is also available4,14,18,20,42,43> and the role of traditional healers has been formally recognised by the Territory Health Service.44>
Traditional Aboriginal medical treatment includes bush medicines, the traditional healer, singing/chanting, and external remedies.
There are a multitude of substances used for bush medicine and many are symptom specific.1,4,17,19,45> In most regions of the Northern Territory, more than 22% of Indigenous people had used bush medicine in the last 6 months when surveyed.46> The decreased use of bush medicine seems to be because Western medicine is easier to access, not because of a lack of faith in its efficacy.17>
Information regarding bush medicine is common knowledge and is possessed by every adult.1,17,39,47> Examples of bush medicine include herbal preparations, diet, rest, massage, restricted diet and external remedies such as ochre, smoke, steam and heat.2,4>
Traditional healers are held in high regard.39,48> The profession tends to be male dominated, although there are female healers in some communities.4,5,45> While any person may prepare and use bush medicine, traditional healers have exceptional knowledge and powers17> that can be used to aid people (see Table 2). Traditional healers are trained to remove the influence of sorcery and evil spirits and to restore the wellbeing of the soul or spirit.49>
Table 2. :
The powers and healing techniques of Aboriginal traditional healers
Two of the most common diagnoses are the presence of foreign objects in the body and that there is something wrong with a body organ.19> A frequent technique commented upon in the literature is to suck or rub over the affected area to remove foreign objects which are causing the illness. These objects are believed to have been placed in the person’s body by supernatural intervention.
Traditional healers have a variety of roles, including: providing strong spiritual and social support;2,48> determining the ultimate cause of a serious illness or injury;1,2,4,5> determining cause of deaths at an ‘inquest’;1,2,4,5> and employing counter sorcery to remove the evil influences causing illness.2,5>
The role of traditional healers in the areas of impairment, disability and handicap is unclear.14>
Traditional healers have a number of characteristics which aid them in their healing roles: they share a common language and world view with their patients;3,4,45> there is an expectation of relief from the patient;3,45> the patient receives treatment in a familiar, supportive, non-threatening environment;39> and there is usually already a close relationship between the healer and patient with resultant faith in the healer.39>
There are also groups of people within the community who are not traditional healers but who have healing powers.1,2,4,5> Tynan details the specific roles and powers of these groups.5> Initiated older men knowledgeable in ritual life may care for the sick (usually close kin) by singing for the patient. These healing songs are ‘owned’ by the singer who inherits ‘ownership’. It is incorrect and ineffective to sing a healing song that belongs to someone else.5> Older women may inherit healing songs which do not remove the influence of sorcery but act to strengthen the patient to combat the effects of sorcery.5>
While there are numerous preventative strategies in Aboriginal medical systems, treatment generally involves the use of bush medicine for specific symptoms and injuries, with traditional healers being required to deal with any matter thought to have occurred due to supernatural intervention.
INTERACTION OF ABORIGINAL HEALTH BELIEFS WITH THE WESTERN MEDICAL SYSTEM
There is poor compatibility between the underlying values of the Western medical system and traditional Aboriginal health beliefs.
Western medicine is primarily interested in the recognition and treatment of disease. Traditional medicine seeks to provide a meaningful explanation for illness and to respond to the personal, family and community issues surrounding illness. Traditional medicine explains not only the ‘how’ but also the ‘why’ of a sickness’ (p. 33).49>
Aboriginal people use the strategy of domain separation to divide illness into Aboriginal and Western causes. This involves thinking in terms of separated cultural or social domains and deciding when to apply the rules of each domain (e.g. Aboriginal or Western).53> This strategy occurs not only in the area of health beliefs but also in other areas as a response to cultural uncertainty, to reduce social complexity and stress, and to deal with social dilemmas.53>
There is a variety of behavioural patterns of seeking medical assistance that traditional people use during illness: sequential (use one practitioner then another kind: for example, Western then traditional or vice versa); compartmental (using traditional medicine for conditions which have established traditional explanations); and concurrent (concurrent use of traditional and modern forms of health care).54>
All these patterns are apparent among Aboriginal people.2,4,5,15,19,39,47> This model is best expressed in Table 3. Western medicine has been incorporated at the same level as herbal medicine.49> In cases where an injury is the result of a payback punishment (an act of retribution),31> it may be suffered without recourse to Western medicine.5>
Table 3. :
Model of Aboriginal behavioural patterns of seeking medical assistance
Generally, a combination of traditional and Western medicines is used.2,5> Western medicine may relieve symptoms and provide explanations for the mechanism of how something occurred, while traditional explanations provide the reason why it occurred and are able to address the ultimate cause. In cases of supernatural intervention, Western medicine is used to treat the symptoms and to hasten the cure, provided it does not conflict with traditional beliefs, but it is not able to remove the cause of the illness.5,11> In contrast, only Western medicine can affect emergent Western illnesses.11,18>
Implications for health care of Aboriginal traditional health beliefs
In any health-related situation, Aboriginal people should be provided with a clear explanation of the illness or death and of the cause. This biomedical explanation should respect any traditional explanations of the causes of illness and death offered by the patient or family.23> Discussion about treatment should respect the family’s wishes regarding the patient’s care,23> including the use of traditional Aboriginal medicine. In certain circumstances, a family may embrace a biomedical explanation to evade the political difficulties which could attend a social and spiritual account.18>
Differences in perceptions regarding the cause of ill health or disability will affect management, compliance and how the person reacts to their illness or disability. This is especially the case if management is based upon assumptions underlying Western culture. Health professionals should make an effort to understand and link into the belief system of their patients to ensure they have maximum effect.
Aboriginal patient and health professional interactions
Difficulties arise in interactions between Aboriginal patients and health professionals when the health professional offers a version of reality that is different from the patient’s experience. It is important to explore the patient’s viewpoint to achieve congruency of meaning. The methods of eliciting the patient’s explanatory model proposed by Kleinman et al. provides a starting point in this process.55> The lack of a common conceptual framework within which patient and practitioner can interact may result in decreased compliance and satisfaction.
It is vital for health professionals to develop skill in communication across cultural differences, as trusting relationships with Aboriginal patients are essential in the provision of any treatment.12,42> The tendencies to pathologise culture,51,56> to use cultural differences as an excuse for different levels of service57> or to become inhibited by the fear of being culturally inappropriate18,57> must be avoided.
An appreciation of the Aboriginal model of illness causation, including the key role of supernatural intervention, the knowledge of the variety of Aboriginal medical treatment methods and the role played by traditional healers will assist health professionals in cross-cultural interactions with Aboriginal patients. The differences in Aboriginal and Western health beliefs provides an indication of the broader differences in world view between these cultures.
I would like to thank Dr Lorraine Sheppard for her support and assistance.