First Nations Pandemic Planning with Kristy Crooks and Peter Massey

Welcome to Episode 21 of Contain This, brought to you by the Indo-Pacific Centre for Health Security, hosted by Head of Centre, Robin Davies.

Our Centre is based in Canberra on Ngunnawal land, and we work with partner governments in Southeast Asia and the Pacific to anticipate, avert and arrest infectious disease threats. Part of the way we do this is to tap into knowledge from Australia's premier research institutions. 

Today, we hear about some new research that has the potential to change the way public health programs are planned in Australia and our region. 

Kristy Crooks is an Aboriginal woman of the Euahlayi nation. She's working as an Aboriginal Program Manager with the communicable disease team at Hunter New England Health. She's also undertaking a PhD on how to engage First Nations people in public health emergencies. Peter Massey is a Clinical Nurse Consultant and program manager for health protection. Also with Hunter New England Health. He's worked in the Pacific, particularly Solomon Islands in PNG on infectious disease control and tuberculosis recently has been working with Kristy and other Aboriginal health workers and researchers on pandemic preparedness and response. 

For more information about the Indo-Pacific Centre for Health Security, visit our website https://indopacifichealthsecurity.dfat.gov.au.

Connect with us on Twitter via @CentreHealthSec and @AusAmbRHS.

This is our final episode for 2020. Thank you for tuning in, we look forward to sharing more episodes with you in the New Year. 

Transcript

Please note: We provide transcripts for information purposes only. Anyone accessing our transcripts undertake responsibility for assessing the relevance and accuracy of the content. Before using the material contained in a transcript, the permission of the relevant presenter should be obtained.   

The views presented in this podcast are the views of the host and guests. They do not necessarily represent the views or the official position of the Australian Government.

Kristy Crooks  00:01
Our approach goes far beyond basic consultation. So, you know, we're about engaging First Nations people in making decisions about public health emergencies and drawing on the understanding of people's considered views and perspectives to make informed decisions.

Robin Davies  

I'm Robin Davies, the head of the Indo-Pacific Centre for Health Security. Our centre is based in Canberra on Ngunnawal land, and we work with partner governments in Southeast Asia and the Pacific to anticipate, avert and arrest infectious disease threats. Part of the way we do this is to tap into knowledge from Australia's premier research institutions. Today, we hear about some new research that has the potential to change the way public health programs are planned in Australia and our region. 

Kristy Crooks is an Aboriginal woman of the Euahlayi nation. She's working as an Aboriginal Program Manager with the communicable disease team at Hunter New England Health. She's also undertaking a PhD on how to engage First Nations people in public health emergencies. Peter Massey is a Clinical Nurse Consultant and program manager for health protection. Also with Hunter New England Health. He's worked in the Pacific, particularly Solomon Islands in PNG on infectious disease control and tuberculosis recently has been working with Kristy and other Aboriginal health workers and researchers on pandemic preparedness and response.

Kristy and Pete, welcome to Contain This. Kristy, at Hunter New England Health you worked on the Healthy Skin project. Can you tell us what the community told you that was being missed during standard program reviews, and how you use that information to redesign skin treatments?

Kristy Crooks  01:50

Thank you. So our community told us that bacterial skin infections was a problem. They were seeing lots of boils and scabies in young children. And they asked us at Public Health to do something about it. Families identified that they were struggling to treat and many skin infections and that health services didn't seem to work very well. So our work was really initiated in response to requests from the Aboriginal community members, health service providers in the school because it was a real important problem for local community and families to address. So we, our team, worked with the community schools and health service providers to gain a more deeper understanding of their experience of skin infections and to understand what was successful and what was not successful in reducing their recurrence. So in addition to what communities told us, they mentioned some really important strategies that took a holistic approach to treating many skin infections. So the work that we did with Community Health Services and schools was really contributed to ongoing work to develop a more effective and culturally appropriate treatment options for families and communities that centres Aboriginal ways of treating skin infections alongside Western medical approaches, because usual treatment of antibiotics and topical creams didn't seem to work. So we really wanted to place value on what communities understood to best treat skin infections.

Robin Davies  03:25

Can you just say a bit more about why those medical treatments weren't working in that context?

Kristy Crooks  03:46

Yeah, there were lots of barriers that the communities identified. Some of them included [that] primary health care services could be doing more to be proactive and early intervention to identify and assess the skin infections, and there needed to be more awareness-raising and education for families around how best to treat skin infections. And, you know, providing practical support for families with home hygiene measures was really important. You know, communicating messages like not sharing towels, or bedding or clothing and keeping areas clean around the house, especially where kids would play in and wiping down lots of services surfaces. So that sort of information and education really needed to happen in a holistic or holistic way. So usually, treatment alone could not address the social determinants of health.

Robin Davies  04:36

Okay, so it wasn't necessarily that those treatments weren't being appropriately applied. It was more that they were only part of the story that there was a whole lot of other things needed to be happening at the same time.

Kristy Crooks  04:47

That's right. Yeah. So yeah, the communities told us that they needed to be, like I said, a holistic approach to treating it, not just in isolation of Western medical approaches, but also incorporating other approaches like education and improving health services and access to health services and working in collaboration with the schools to assess and identify children who came to school with skin infections.

Robin Davies  05:20

Yep. Okay. Peter turning to you, can you tell us how, how the community came to produce the their own soap.

Peter Massey  05:27

It's a good story. I'm also just kind of backing what Kristy said with some examples, I think there was a to a mom of a two year old who just telling me that they had been on, the child had been on antibodies nine times for skin infections fall up in the first two years of life. And all along that way, I don't think any of the health workers that asked whether they had towels or running water, or soap at home, to be able to support the child as well as having the medicine and it was, again, just seeing things in isolation, rather than what Kristy was talking about is this holistic approach of people, that people's chances in life and being able to support health, across what people see as health, which includes land and culture, and as well as bugs and food and water. So it's, it's all of that. Being able to support people across all of that, as people were in the community were keen to see the service developed. They understood that nine lots of antibiotics in the first two years was not a good thing to do. And so flowing from that people were keen to explore the ways of getting soap used more often. All the mums who spoke with her, they love the idea of kids washing their hands. But just like kids everywhere, they're not so keen about it and when the community we're working with is fairly remote, doesn't have a shop, getting a getting soap was tricky. Plus everything else. And so the community thought, what about using this traditional medicine that people understood was good for skin infections, and combining it with soap? And one of the friends in a nearby town had made some like that and was selling it and they thought that's a great idea. And so the community were thinking that discuss that with us, we thought it was fabulous idea as well. More hand washing, the better we reckon in infectious diseases, but bringing in that the strength of the traditional medicine with it was really important. And so hand washing is really important. One of the important things in it, I think, was for us not to take a scientific method to it, which is, what's the active ingredient in their traditional medicine that helps. And let's distill that and make some money out of it and fix the world's problems. But instead just recognize that the traditional medicine within the cultural setting has some value, and honor that rather than stealing it. And so because community knew that we're working with them and not on them, or to them, that we're working alongside, they were keen to learn how to get out how to make some soap with a traditional medicine. So I remember a couple of weekends, Kristy was trying to work out of the soap recipe and sending me pictures of a kitchen, nearly blowing up almost with the making of the soap, but we were able to find a method that was safe. So Kristy didn't get blown up nor the mums using this simple method of making soap, bringing in a traditional medicine, which had a whole process itself. So it wasn't just grab a couple of leaves and chuck it in. It was a cultural process for gathering the medicine as well, that needed to be honored and included within that soap making process. And the approach we used was train the trainer as really we learnt together with the community how to do that, and then enabled community members to support other community members to make the soap. And so that sort of bubbled out, I guess using a soap term from those small group to nearly every household in the community having some connection with somebody who could make this soap for their kids and their and their families. So important bit there's that we're enablers and facilitators of change that was guided and led by the community. As Kristy was saying was really centering families and culture as integral to that and bringing some Western understanding about the importance of soap and hand washing and putting that together in a way that made sense for families.

Robin Davies  10:05

Okay, so clearly, I should not ask you what was the chemical ingredient in that traditional treatment but I am slightly curious. So we're talking about a sort of herbal medicine of some kind, some sort of plant-based ingredient that was added to the soap. That's right.

Peter Massey  10:21

Definitely you can ask but I won't be able to say. We don't even use the name, because that's definitely not my name, I'm not Gomeroi, it's Gomeroi medicine. So I don't use the name. But it's a plant-based medicine. It's been used for millennia for skin infections, and as a result of this work community, and now in tending the areas where the plant grows even more, because they're using it more. So they need some more of the plant to grow. And so it's got a nice cycle of strength built with that.

Robin Davies  11:03

And is there a sort of virtuous circle going on here? Whatever that ingredient is, it's clearly having some antiseptic effect, but at the same time, it's also just inherently good for people to be engaging in hand washing regularly. And perhaps they're more likely to do so when they have a formulation that they trust. Is that also going on here?

Peter Massey  11:24

Yes, certainly. Yep, that's all of it. And another aspect that people say is they're using a medicine that their ancestors have used and their ancestors have used. And that's the continuation of the songlines and the stories and the people and the culture that's being embraced by this method. So it's presuming the antiseptic, the quality of it, but it's also the spiritual and cultural strength of the process and the connection to culture that brings strength and also it brings people's families' eagerness to be involved and to incorporate that in day-to-day life.

Robin Davies  12:11

And I'm interested in how this sort of cultural knowledge and technique might be shared with other indigenous communities, whether it is shared with neighboring communities in some way. Obviously, you've talked about before community's reluctance to, let's say have a pharmaceutical company come in and analyze the product and extract the intellectual property and so forth. But I'm wondering if there is some other way in which the benefits of this product are shared willingly by the community themselves with neighboring communities.

Kristy Crooks  12:59

Lots of other communities have local traditional bush medicines that they know through the passing of stories down from generation to generation are good at treating skin infections. So this knowledge is passed down, and every area is really different. And people in some communities in the neighboring communities that we'll be working with are already working on making soap and other remedies to treat skin infections as well. So there is the knowledge, the local knowledge within communities. It's just about being those facilitators of change, to enable communities to feel empowered to be able to then learn the different methods and approaches to soapmaking. And then to use those simple methods to then pass on to their families. I was going to say that what was really good about the soap making program that we facilitated with community, they also identified that they wanted to make liquid soap so that they could have readily available in pump bottles for families and households to use. So we, we worked with some, with them to come up with another approach to develop that. And also skin integrity was really important. So keeping the skin nice and shiny, and the community asked us to help them to make some moisturising cream so like I did with the soap, the bars of soap, you know, I did a search and trialled some methods in my kitchen on how to make some moisturising cream. So it wasn't just the bars of soap alone, it was the liquid soap and the moisturising cream that the community identified to use for their families and to be able to share within the schools and the health services as well.

Robin Davies  14:40

And who's actually doing the, the production who's making these various products within the community?

Kristy Crooks  14:47

So we work with the local Aboriginal Medical Service (AMS) within the community and the schools as well some of the school staff were able to help with that. And so we help provide some of the resources, but then through the local community and the AMS that that we're able to provide the funding and ongoing support for the resources and we also worked with the local Aboriginal land council to identify the bush within the community and to be able to go out and source and identify those leaves. To be included into the making of soap.

Robin Davies  15:26

Kristy, your engagement with this community is in part related to your PhD research program. And I understand that research involves a new method of consultation for public health planning, which is the use of community panels. So based on your findings so far, why would you say this approach is particularly appropriate for consulting First Nations communities?

Kristy Crooks  15:54

Our approach goes far beyond basic consultation. So, you know, we're about engaging First Nations people in making decisions about public health emergencies and drawing on the understanding of people's considered views and perspectives to make informed decisions. So usually health services sometimes, you know, they go into a community with an already established program, and you know, they just want to consult or want community to say yes or no to a program, which only contributes to a small amount of change to the study design or the project scope. So the approach we're using is to empower communities to be active and equal participants from the start. And not at the end, which is the way that we see health services have traditionally consulted community. You know, we're developing new ways of understanding and new ways of working so that First Nations people are actively engaged in the decision making process, and to ensure that they have a safe space for their voices to be heard, in preparing and responding to public health emergencies. So the approach that I'm using for my PhD is to use a First Nations community panel as a way of engaging Aboriginal people to make decisions around specific public health and infectious disease emergencies, and a way for community to express their views on such tough topics. So they set up like a legal jury, but they conducted in a different way. And the idea is that members of the public make up panels to make decisions and recommendations to policymakers, and you know, too often to those at the top, making the decisions, making them without little to no involvement of people on the ground, and often don't have a good understanding of the real issues that's happening in communities. So while they, you know, policymakers might hear from a range of public health professionals, they rarely hear from people on the ground locally. So our approach is designed to to allow decision makings to hear Aboriginal and Torres Strait Islander peoples' considered views and informed opinions on public health emergencies.

Robin Davies  18:17

Okay, so in the COVID context, I assume you're talking to them primarily about prevention strategies, but also, are you discussing with them, what would be appropriate sort of treatment options under various scenarios?

Kristy Crooks  18:34

So we've got three different topics for our COVID First Nations community panels, and the first ones looking at the different public health actions to keep families and communities safe. So exploring, you know, enhanced hygiene and cleaning of surfaces as well as limits on social gatherings and wearing face masks. So we've had a public health physician present evidence from across the world, but also locally and within Australia about some of the things that we're doing to keep families safe. And we're asking them to make decisions about what's achievable for families to do, and what's important for families and communities to do with those actions. And identifying also what health authorities such as your department of health and your local Aboriginal community, controlled health services can do to make those actions more achievable for families to undertake. Our second topic is focused on risk communication and governance. So understanding how government authorities can distribute and share messages rapidly to the Aboriginal and Torres Strait Islander communities. So really providing some suggestions and strategies on how authorities can do that, as well as how can authorities build trust with the communities because what we've been told is that there's lots of information out there and it's causing lots of confusion among the communities because the information is changing rapidly as we learn more about the disease. So it's just working through ways of how can community can develop trust, so that they can then share the information. And also talking about COVID transmission in the school sector. So making decisions about what families can do to keep their kids safe from school if there is, you know, community transmission in the school and identifying what supports or learning supports, they might need to ensure continuity of education.

Robin Davies  20:47

I'm very interested to know if there has been much discussion within these panels about COVID vaccination, what sort of feedback you're getting to the idea of vaccination programs in indigenous communities?

Kristy Crooks  21:06

We haven't explored the question of COVID vaccination. But last year, we used a hypothetical scenario of distributing limited vaccine during a pandemic influenza outbreak and asked community panels to make decisions about who should be prioritised to access those vaccines. We, we were in the planning stages of this and then COVID hit. So some of the discussions are really relevant at the moment but we didn't have the evidence at the time to present that to communities because the vaccine is still being developed. But communities because of histories and our experience within the 2009 pandemic, the community panels did see value in being prioritized as a priority population to receive such a vaccine.

Robin Davies  22:06

It strikes me that there are sort of two parallel pathways here in both of your engagement with this and other communities. You talked at the beginning about an approach which really empowers them to apply knowledge and techniques that they already have at their disposal. And that's very powerful in affecting behavior. But then the other pathway, as you said, Kristy is about building trust, building understanding and building trust in circumstances where what could actually be a highly technological solution, let's say it's an mRNA vaccine or something might need to be considered. So it's fascinating to think about how you manage those two things at the same time. But let me ask a final question of you both, which is perhaps it's a little broad, but I'm interested in and what you both have to say about what you see as the essential elements for placing indigenous communities at the centre of public health programs

Peter Massey  23:15

I think, a really important aspect, I think, in public health is just a gathering that social justice framework that public health was built on and drifted away in some ways, just recognizing that every family and person is of equal value. And some people that's not expressed in their health and opportunities people get. And so we focus our energies on where the gaps and the missing parts are. But we do that in a way, this is my view, we do that in a way that doesn't centre me, but actually centres the community. Often health services run by older white men, like me, who take up too much space in policy and decisions. And what we need to do what I need to do daily, and what we need to do as organizations is to get out of the space, and let communities have more of it, and share the decision making together. That's a conscious decision of rebalancing, the power differential between communities, and governments or organizations or even international development programs. It is just getting people's voices more into the space and in a respectful and shared decision making process. So the panels that Kristy is talking about is an example of being able to have shared decision making with it right through the process and not just at the endpoint and with a rubber stamp and it's a real process. But for that to achieve. I need to and we need to back out of the space, but not in a negative way back out in a positive way of being able to then encourage and support communities and Aboriginal and Torres Strait Islander health leaders and nationally, to have more of the and more of a real say and work together with people. So I think for me that's key. Those two steps has social justice and me taking up less space. Having said that I'll shut up and then Kristy say more.

Kristy Crooks  25:23

Thanks Pete. And when we're looking at health as a whole, it's often applied within a Western lens. And, you know, certainly Western lens is applied to Aboriginal health. And, you know, when we're looking at the health statistics alone, and it only shows the disparity in numbers, and it doesn't really reflect on what's going on for Aboriginal and Torres Strait Islander families and communities. And as we've said, before, the strength in our peoples are in our connection to culture and country and family and community. And it's not really reflected in the way that health is looked at the moment. So like Pete said, you know, we need non-Aboriginal people to move aside and make some space for us to then centre our worldviews and our ways of working and being to health. So our knowledge is a valued and respected and, you know, we know how to fix the problems that we experience. So we just need that space and opportunity to be able to thrive and flourish. And that means we have to take the take the lead on this work and do it in a culturally appropriate governance structure where we we're not doing it alone, but we are leading the work. And we can call in our friends like Pete and others in public health and other organizations to be able to do that. But we just need to shift that power, so that where we're leading the way.

Robin Davies  26:52

Of course I'm sitting within a development cooperation agency, in fact, a foreign ministry, but with a development cooperation hat on, and some of what you've both been saying has echoes of, you know, the participatory development sort of paradigm that people have talked about for some time. And, of course, it's extremely hard to find that paradigm really being applied successfully. There's an inherent imbalance really, when development agencies seek to operate in other countries, particularly in very poor communities in other countries, is this something about the way that you work that makes it easier to I guess, address that starting in balance?

Peter Massey  27:49

For me, it's long term relationships with communities and the leaders in communities. So it's not just fly in and try to fix things. And also the approach which is choosing not to be mission-minded that I can go in decide what the problem is and what the answer is, but actually drawing alongside, and making the time. So a normal two year program probably needs four years just because another year of working relationship, understanding stuff together, deciding together, running the program for a couple years, and then evaluating it together for another year after that. It's just giving us those time, communities, countries and organizations to do this properly. And a friend of ours Aboriginal elder said in one of our projects, if you get the process, right, the outcomes look after themselves. And unfortunately, in government, we all about outcomes and we forget them out the process. Some of what Kristy's describing is about starting to get some of that process right. If we can clear the time, make the space then we can get the process right and the outcomes will be heaps better. 

Kristy Crooks  29:07

And even for myself, as an Aboriginal woman, we're working with communities that I don't know. So it's also utilizing local people and champions on the ground. And, like Pete said, over time building those relationships. And now we've got to kind of shift the way that you know, we deliver and disseminate our health programs and research and not to try and stick to the usual timeframe of engaging and just commit to more time to be able to have those conversations with the community so we can build those relationships and rapport, to then be able to facilitate that change.

Robin Davies  29:47

The emphasis on time and being pressed for time really strikes a chord. I think for anyone who works in international development. I think everyone recognizes the importance of trying to build those long term relationships and really staying the course and there are many incentives that work in the other direction. Well, I think that brings us to the end of our allotted time. I really appreciate the opportunity to speak with you both.