Victims or victimised?

Dr Pascale Allotey, Key Centre for Women's Health, spoke at the Year two Annual Forum about the engagement of migrant and refugee women with the health system.

A copy of Dr Allotey's speech is detailed below.

Victims or victimised?

The engagement of migrant and refugee women with the health system.

This presentation is a combined effort with Mmaskepe Sejoe, the program advisor for women's health and the family and reproductive rights education program, known as FARREP and Samia Baho, the state coordinator of FARREP. Those who know them will also notice that they are both not here – having decided to put me up as the proverbial sacrificial lamb which given my name I suppose is appropriate. But I am hoping to survive to tell the tale. This presentation and another paper I am presenting are based largely on what I would describe loosely as case work that I undertake as part of my broader research program. I am not a case worker, in fact the university of Melbourne prides itself in not doing case work. But I nonetheless see this as an important part of the research in that my active involvement with women in the community and service sectors helps to identify the gaps in the system in a way that would be otherwise difficult to identify through standard research methods.

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When I first thought of the title for this presentation, I was feeling particularly upset and frustrated because we were trying to support a woman in a particularly abusive relationship who was also facing deportation having come to Australia through an arranged marriage but was also at risk within the refugee camp where she was living. I will present some of the details later but in summary we could not find anyone to support her unless we could show that she was in absolute dire straits. I think her words were:

"If I don't have one eye hanging out with a leg broken in 3 places, no one is going to listen to what I have to say"

This was particularly sad coming from someone who demonstrated a level of resilience that I personally couldn't muster from a paper cut, let alone if I had to go through what she was experiencing. I am therefore not going to focus on victims or vulnerable populations, or the immediate structural issues that victimise them, but on the systems that we create and sustain that demand victimhood and therefore further victimise the victims. And I think I just won a bet; I told my husband I could use the victim in a sentence 5 times!

Multiculturalism in Australia recognises, accepts, respect and celebrates our cultural diversity.

The implementation of the multicultural policy, specifically as it relates to human services, is based on the facilitation of communication between mainstream health and welfare services and minority ethnic communities. The process is dependent on the interpreter, a topic which I believe Voula will be addressing so I will defer to her expertise there. More recently, this role is played by the bicultural worker or cultural broker. The more recent buzz word is language facilitator which allows the multilingual member of staff to play multiple roles without being paid interpreter rates.

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Projects are funded where possible, sometimes continuing, but more often than not, short term, usually part time. The consideration of CALD communities is usually an add on to various projects and programs and this is reflected in the funding.

There are important reasons for this.

• Only a quarter of the population were born overseas or have a parent born overseas so it is hardly worth any greater investment than is currently offered.
• Working cross culturally is expensive and by our current standard indicators, is not cost effective to invest heavily in CALD communities.

But I think that fundamentally we are still grappling at least in public health with the question of mainstreaming issues for minority groups in the interests of provide everyone with equal services versus the provision of services that specifically cater to the needs of minority groups in the interests of equity of access to the services.

Before anyone takes me to task on that I do realise that this grossly oversimplifies the issues but I only have 15 minutes so I will beg your indulgence on that.

The point is that the system we have by and large provides assistance to those from minority communities to assist them to access mainstream services.

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How well is this working?

Let me illustrate.

Compared to most countries, we have a wonderful health system. There is no doubt about that. Lets take just the maternity and obstetric system – I was a midwife in a previous life so it remains one of the clinical areas that I am still passionate about.

We know so much more through research and clinical practice about how to optimise the joy of motherhood.

Antenatal care – we can now combine cost effectiveness with personal choice and pregnant women have the option of shared care with their general practitioner.
Problems during pregnancy are dealt with by a very capable team of geneticists, screening services, counselling services, midwives, obstetricians, and so it goes on. Research tells us that women a mother has a still birth, her outcomes are better if she is able to bond with and then farewell her dead infant. Similarly research has shown that postnatal depression is reduced and mother-child bonding enhanced in caesarean sections for instance if the mother undergoes trauma counselling following the procedure. Now that is a record to be proud of.

If this worked for CALD women, I would not be here. Years of research with Horn of African and Middle Eastern migrant and refugee women demonstrates that women do not know about these services, the services are not offered to them or they are not offered in a manner that is culturally relevant or appropriate. One of the most consistent issues that arises for me is the one about counselling and emotional support. There appears to be a common misperception that immediate family support precludes the need for formal counselling. In fact, some extended family members are walking out of the hospitals traumatised not only by the procedures and the amount of blood they have seen, but also by witnessing the distress of the patient. Patients are traumatised by the procedure and by having to worry about the mother or aunt who should not have seen her in that state. If she is lucky, and insists on it, she may have access to some counselling through an interpreter but my understanding is that the perception has become such that most don't bother. This is an issue not just in the hospitals but also for instance with the emergency services where victim support and victim referral for women who have experienced violence both within and outside the home is not offered because the services are not able to cope with CALD women and providers argue that CALD women never use it anyway.

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The foundation house was discussed and is well known in its support for torture and trauma survivors but not for its role more generally in supporting mental health, stress and illness.

The appropriateness of services, where available, has also been raised. With victim support for instance women who attended a group session reported that through an interpreter, the counsellor focussed on the importance of not blaming oneself and feeling personally responsible. In discussions afterwards, the women reported that they do not blame themselves; they get angry – they get angry because there was information out there that they could have accessed that could perhaps have prevented the incident and there was no way of knowing that the information was there, or they could access it. I was given this quote which I hope is an accurate translation of an Arabic saying.

The law does not protect the ignorant.

Ignorance is disempowering.

Ignorance when you know you are ignorant and can't do anything about it is crippling.

Another example that is often raised about inappropriate counselling is for instance teaching women that they have the right to say no – when there is no where else for them to go than back to their homes

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• Exceeding expertise – if we went back to the hospital example for instance, most service providers, particularly in maternal health, have a bicultural worker, often FARREP on staff. These workers are employed on the basis of their knowledge and skills, usually in the social work or related health or welfare sector. Bicultural workers in institutions are responsible for working with clients and providing information through just about every area of specialisation; from genetics through routine antenatal care through to obstetric surgery. Very little training is provided and worker often feel overwhelmed by the level of responsibility expected of them. There are senior professional staff in some areas of any given hospital who will not provide advice about a different area of specialisation and yet bicultural staff are expected to in their support of clients. One could question what this says about acceptable standard for different patients
• Personal trauma – many of the workers have reported having to suppress personal trauma which is often revisited when they work with other vulnerable women
• Debrief systems – debrief systems have not been put in place within the workplace that supports
• Staff development – despite the breadth of the work they are meant to perform, bicultural workers often do not have the opportunities for formal training and there fore very little by way of career prospects. From the first example I mentioned, the women, lets call her betty, was facing deportation as I mentioned and ended up in the refugee review tribunal. She was asked to provide statutory declarations from 3 competent people. Examples of competent people given by the tribunal included a refuge manager, registered nurse or registered social worker. Betty was referred immediately to the bicultural worker when she reported to the refuge because she was from a CALD background. Funding had since run out and the worker no longer had a position with the refuge. While it was possible to trace her, she was not 'competent' to provide the stat dec. the manager said she had not been directly involved in the case and was therefore not prepared to commit to writing a formal document. So what sort of system sets up supports that when tested internally, do not provide acceptable standards?

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The flip side to that is the amount of investment in informal training given building capacity that will not be used beyond the duration of the 3 month funded project for instance. There are casual workers who have undergone training as trainers in everything from industrial relations and child protection to family planning and domestic violence. Without the offer of permanent employment, they could just as well end up in a cleaning job or on a factory floor, all very noble professions but a wasted investment to the work force.

Career structure

Moving forward

When we were discussing this paper, one of the questions I asked was what are the solutions we propose? And we decided that would be the wrong way to approach this. What we need to do is:

• Listening and hearing – not just tokenistic consultations but really attempting to understand not just what the problems are, but also the proposed ways of thinking about solutions. It is clear that resources are limited, but it is also clear that we have growing communities with increasing social distance from previous waves of migrants to Australia. Regardless of visa status, there are state obligations to protect and there is no denying that service provided particularly human services are an investment in the future. To put it into strict economic terms, A poor investment will not yield great returns - it makes good common sense to understand the nature of the product in which we want to invest.
• Information delivery
  • information needs are very different across generations – younger women are more receptive to sexual health information for instance that is frankly making their mothers' hairs stand on end. Information delivery in that instance could be improved by involving mothers in some way in the program. We need to work with communities to plan the best way to do this. We can then provide the information and foster harmony in the family.
  • Information based on duration in Australia. Information about how things work is something most people born here take for granted. Most migrants, particularly with minimum social distance and who speak English are also able to pick up information through interaction across social groups. Learning is cumulative particularly the strategies that help us to build resilience and cope with everyday life. We seem to have lost sight of that in education programs and expect that the provision of mountains of brochures or a burst of community workshops will help us to meet our obligations of information, education and communication to CALD communities. I think this is another area to which we could give a little bit more thought.
• Genuine participation
• Review roles of bicultural workers

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