Inequality and mangoes in the Wild West: An elective perspective
Kununurra, at the top end of Western Australia, is a stark place. Red dust, mangoes, boab nuts, and the sibilance of deafening cicadas. Brilliant sunsets and fearsome lightning storms. Air so thick in the wet season it feels as though you could slice through it with the ragged, broken edge of a turfed XXXX beer can. Baubles hang on boab trees at Christmas. The occasional croc attack might be the nonchalant topic of yarns weaved between yawns of people sitting in the shade, listless in their efforts to escape the unrelenting heat.
I was lucky enough to spend three weeks there at the end of 2014 (my third year) on an elective placement. Coming from my beloved, yet sheltered Tasmania, I was ignorant enough not to have any correct preconceptions about Kununurra and its people. Tassie has also had a unique history with regard to its Indigenous population so our present situation is different to that of the mainland. Although I had listened to lectures on the cultural and geographical determinants of health in the early years of med school, it was only when witnessing firsthand the discrepancies in health outcomes between rural and urban, as well as Indigenous and non-Indigenous Australians, that I started to understand how rife inequality still is. Perhaps I should be ashamed of my naïvety as it was, but I’d rather use it as a basis to discuss these inequalities and my experiences. Australia still has huge gaps in health outcomes and without personally experiencing this it’s easy to become blinkered and immune. Australia is not necessarily a lucky country. It is sprawling and diverse, with ingrained inequality that should be confessed and addressed.
Kununurra has a population of about 7000 and was originally set up as a town for workers in the Ord River Irrigation Scheme. The name means “Big Waters” in the local Miriwoong language, and it’s pretty much the big smoke of the East Kimberley. Kununurra is home to many members of the Malngin, Miriwoong, Wadainybung, Dulbung, Gidja, and Kuluwaring groups.  There are three pubs and three bottle shops, one small hospital with a five bed emergency department, and a service that picks up drunk people off the street at night and takes them to a place where they can dry out. There’s a Subway and the singularly enticing Rosie’s Chicken at the servo, but happily not yet a McDonald’s or KFC. I point this out because large fast-food chains serve up super-sized helpings of poor health outcomes in the communities they penetrate. [2,3] This, combined with the fact cooking skills have been lost through generations of previously institutionalised Aboriginal people, creates the ultimate combo of cardiovascular risk, diabetes, and obesity. A basket of healthy food at the supermarket is around 20% more expensive than in the city, leaving many people with even less choice. 
My experience in Kununurra was often confronting and sad, leaving me with a deep impression of the past and present traumas. For example, I met a twelve-year-old Indigenous girl who tried to hang herself – she was one of many. A doctor told me the tiny hospital had seen nine suicides in three months. Sadly, because of the small population, there is no mental health facility in Kununurra and psychiatric patients are sometimes flown to Perth, Broome, or Darwin which may require sedation, for safety. Face-to-face mental health services are generally rare in remote Australia, which is nonsensical since rates of suicide increase with geographical isolation. Rates of suicide are 66% higher in remote places than in the city and 2.7 times higher for Aboriginal and Torres Strait Islander people, and highest in Indigenous youth. 
Rates of drinking are also higher in rural areas than in Australian cities, for many reasons. However, it is very important to mention that Indigenous Australians are 1.4 times more likely than non-Indigenous people to abstain from alcohol altogether. Even so, it is a dangerous cocktail of easy accessibility, unfortunate role modelling, boredom, and cultural decimation, as well as so many other complex risk factors, that mean that those who do drink are 1.5 times more likely to drink at risky levels. 
I saw so many medical, psychological, and relationship problems related to alcohol in Kununurra. I saw a lot of alcohol-related injuries in the emergency department – injuries from fights, car and motorbike accidents, as well as simply tripping over and kicking stuff. I heard stories of family violence. I also saw many kids with physical and behavioural signs of Foetal Alcohol Spectrum Disorder (or “Fazz-Dee” as it is referred to with dismayed familiarity), which has implications for mental health, education, drug and alcohol abuse, and crime. 
I saw a 14-year-old girl have her Implanon changed. She had recently been released from gaol and she liked it there because it gave her relative safety, three meals a day, and her own room with a TV. Implanon (also known as “Slutstick” in the local slang) is the first and only type of contraception you can see or feel on the person’s body. One of the doctors I worked with said this may, horribly, increase the risk of rape.
I spent a day with a community nurse who was going around the town, changing people’s ulcer dressings. Much of the housing in Kununurra is new, and much of it is already wrecked. I didn’t understand why, but the nurse suggested it was related to alcohol use. At one house we stopped at, there was an immaculately dressed, yet frustrated woman holding a takeaway coffee in her hand. She was a social worker, and her job that morning was to get the little boy in the household to school. It was difficult: his mum was sleeping off a heavy night of drinking and he couldn’t find his shoes. The scene spoke loudly of rifts and differing agendas.
Speaking of rifts, Australia still struggles with huge differences in lifespan. We may have among the longest average lifespan, but we still have a gap of up to four years’ difference between rural and metropolitan areas.  The lifespan gap between Indigenous and non-Indigenous people is worse: 11.5 years for males and 9.7 years for females.  The life expectancy for Indigenous Australians is 67.2 for males and 72.9 for females, which is about on par with many developing countries worldwide. [10,11] Lifespan is just one way of demonstrating the differences in health outcomes across Australia and should serve as a serious reminder that we still have a lot of work to do in making Australia as equal and developed as we would like to imagine it is.
“Take any pathology from a textbook,” one doctor said to me, “and look at the age of onset. Here – you need to take ten or twenty years off that. So there’s people with chronic kidney disease in their forties, sometimes their twenties. People have heart attacks in their thirties.” I didn’t quite believe him until I saw that Kununurra has as big a dialysis clinic as Hobart does. In fact, rates of end-stage kidney disease can be up to four times higher in remote parts of Australia compared to metropolitan areas, which has serious consequences on quality and quantity of life for individuals in those communities. 
I met an Indigenous lady in the Kununurra emergency department who looked incredibly weathered and whom I innocently imagined to be about 90 years old. She had congestive heart failure secondary to chronic hypertension and rheumatic heart disease, atrial fibrillation and she was on warfarin. But what dose of warfarin? There were discrepancies between her Webster pack, her doctor’s progress notes and her medical records. No one, let alone the patient herself, had any idea what was going on. Her INR was eight, when it should be between two and three. In her case, her alcohol use and the fact that she travelled from a nearby community with different doctors were the main problems causing the confusion. I was shocked to learn that she was only 60. There were countless others like her.
All this also reminded me that we are, as doctors in training, taught on a basis of ideals. The ideal HbA1c or blood glucose level. The ideal blood pressure. An acceptable number of years lived. These ideals are targets, but there were rarely any bullseyes in Kununurra. It seemed too easy to say, well, this is a different population, so the numbers are different. But I also thought, why lower the standard because of the social and political history of the region? The professionals I shadowed took all this into account and just got on with things.
I was very impressed by the health workers I met in Kununurra – midwives, doctors, nurses, podiatrists, physios and others. There’s a saying that the only people who get jobs in the Wild West are missionaries, mercenaries and misfits. Those that don’t fit in the city. Or worse, that “Kartiya [which means ‘non-Indigenous people’ in some north-western Indigenous languages] are like Toyotas: when they break down, we get a new one”.  My experience was the opposite: on the whole the professionals I met are incredible, culturally sensitive, passionate and welcoming people. Most of them live in Kununurra long-term, despite short-term locum stereotypes. They are generalists who make the most of the few resources they have. They made their jobs look rewarding and even sexy. Yes, they are mostly non-Indigenous: currently, only 1% of the health workforce is Indigenous.  Hopefully this is changing with slow-yet-celebrated increases in numbers of Aboriginal and Torres Strait Islander medical students and doctors. 
While in Kununurra I came to realise that the meaning of ‘health’ for Indigenous people in the region differed from my own. A sense of belonging and of being on country was important, and this has effects on mental and physical health.  Even direct questioning can be confronting for Indigenous people – yet it is an everyday technique of history taking. The Western paradigm of health and healthcare fails to take into account these fundamental differences, which leads to a lack of necessary services. Australia needs more Indigenous doctors and impassioned advocates to guide us on these matters.
My time was marvellous as well as confronting. I was privileged to hear stories and meet people, gather different perspectives and increase my confidence in medicine. Friends and I explored Lake Argyle and the surrounds of Kununurra. I got to fly to a remote community and help out in clinics with the Royal Flying Doctors. We did veranda clinics on some cattle stations the size of Tasmania, which was no big deal to anyone except me. We swatted flies while we discussed blood pressure tablets and aphthous ulcers. I was lucky enough to see meet some famous Aboriginal painters and see them working. I went to a whole-day Fazz-Dee workshop, focussing on a culturally sensitive approach to it, how to recognise it and how to educate mothers and families.
I went to Kununurra as a blank slate, simply from having experienced nothing like it before. I left humbled, indebted and passionate, having pieced together a bit of an understanding of the challenges faced by the community, as well as an aptitude for plucking high-up mangoes out of trees. The Wild West can be beautiful, but its social circumstances are not pretty. We live in a country that still struggles with many problems and I hope that this snapshot of my experiences serves as an honest memo. As students, it is difficult to see that our contribution is meaningful, but it is still important to go on placements even if just to listen, observe, absorb stories and try to understand. But as future health professionals, we’re well-placed and arguably obliged to act.
Conflict of Interest
 Barber K, Rumley H. Gunanurang: (Kununurra) Big River Aboriginal cultural values of the Ord River and wetlands – a study and report prepared for the water and rivers commission. 2003 [cited 2015 April 20th]. Available from http://www.water.wa.gov.au/PublicationStore/first/51768.pdf
 Saunders P, Saunders A, Middleton J. Living in a ‘fat swamp’: exposure to multiple sources of accessible, cheap, energy-dense fast foods in a deprived community. Br J Nutr. 2015 Apr 17; 1-7.
 Thornton LE, Jeffrey RW, Crawford DA. Barriers to avoiding fast-food consumption in an environment supportive of unhealthy eating. Public Health Nutr. 2013 Dec. 16 (12): 2105-13.
 National Rural Health Alliance Inc. Obesity in rural Australia. Deakin West ACT: September 2013 [cited 2015 April 20th]. Available from http://ruralhealth.org.au/sites/default/files/publications//nrha-obesity-fact-sheet.pdf
 National Rural Health Alliance Inc. Mental health in rural and remote Australia. Deakin West ACT: September 2015 [cited 2015 June 15th]. Available from http://ruralhealth.org.au/sites/default/files/publications/fact-sheet-mental-health-2015.pdf
 National Rural Health Alliance Inc. Alcohol use in rural Australia. Deakin West ACT: March 2014 [cited 2015 June 15th]. Available from http://ruralhealth.org.au/sites/default/files/publications/nrha-factsheet-alcohol.pdf
 Government of Western Australia Department of Health. Child and youth health network: foetal alcohol spectrum disorder model of care. Perth WA: 2010 [cited 2015 June 29th]. Available from http://www.healthnetworks.health.wa.gov.au/modelsofcare/docs/FASD_Model_of_Care.pdf
 National Rural Health Alliance Inc. Kidney disease in rural Australia. Deakin West ACT: March 2013 [cited 2015 June 15th]. Available from http://ruralhealth.org.au/sites/default/files/publications/nrha-factsheet-35.pdf
 National Rural Health Alliance Inc. Measuring the metropolitan-rural inequity. Deakin West ACT: September 2010 [cited 2015 June 15th]. Available from http://ruralhealth.org.au/sites/default/files/fact-sheets/Fact-Sheet-23-%20measuring%20the%20metropolitan-rural%20inequity_0.pdf
 Australian Bureau of Statistics. The health and welfare of Australia’s Aboriginal and Torres Strait Islander people: life expectancy. Canberra ACT: February 2011 [cited 2015 June 21st]. Available from http://www.abs.gov.au/AUSSTATS/abs@.nsf/lookup/4704.0Chapter218Oct+2010
 World Health Organisation. Life expectancy at birth. 2015 [cited 2015 June 21st]. Available from http://gamapserver.who.int/gho/interactive_charts/mbd/life_expectancy/atlas.html
 Mahood K. Kartiya are like Toyotas. Griffith Reivew: 2012 [cited 2015 April 20th]. Available from https://griffithreview.com/articles/kartiya-are-like-toyotas/
 Australian Government Australian Institute of Health and Welfare. Indigenous Australians. Canberra: 2015 [cited 2015 June 21st]. Available from http://www.aihw.gov.au/indigenous-australians/
 Australian Medical Association. Indigenous doctors double. Barton ACT: 2014 Oct 28th [cited 2015 April 20th]. Available from https://ama.com.au/ausmed/indigenous-doctors-double
 Australian Indigenous Health Info Net. Background information. 2015 [cited 2015 June 29th]. Available from http://www.healthinfonet.ecu.edu.au/other-health-conditions/mental-health/reviews/background-information