Katherine Clapham and Diane Gosden, The University of Sydney

Introduction

Aboriginal Health Workers are a group of health practitioners in Australia who work within a broad primary health care and community development health framework. They perform a unique role in the Australian health care system. They integrate Western and traditional approaches to health and bring into professional practice an appreciation of the historical, social, political and economic factors of the appalling state of Aboriginal health in rural, urban and remote Australia (ABS/AIHW 1999; HREOC 1997; NAHSWP 1989; RCADC, 1991).

In an age of economic globalization and market based health care, with ever diminishing budgets for public and community health and increasing emphasis on technological solutions for health problems, Aboriginal Health Workers are something of an anomaly. The spreading of a dominant western ethic has signaled a seemingly inevitable reduction in cultural diversity and the status of culturally specific knowledge. Yet Aboriginal Health Workers uniquely provide culturally sensitive and specific health care with regard to the values and traditions of the individuals, families and communities they serve.

From their inception as untrained 'medical assistants' in the remote areas of the Northern Territory in the 1960's, these 'bare foot doctors' (Soong 1978, 1982, 1983A) now occupy a wide range of roles in the community health sector, and are increasingly graduates of universities. Despite these advances, Aboriginal Health Workers still occupy the lower end of health professional pay scales. They have little professional recognition amongst other health professionals. They are also often caught between the demands of the health service who employ them and the needs of their community - the basis of their survival of past colonization.

Education is often posed as the solution to this dilemma. But what type of education? At the present time globalization is redefining education. Concepts such as lifelong learning, competencies, workplace learning, corporate sponsorships, partnerships and the integration of technology into all aspects of learning have transformed education at all levels. Over the past decade this has taken place within a political context in which market force rationality has pushed public learning institutions to their limits (Gallagher 2000). Increasingly, the trend is towards a diminishment of government investment in public education at all levels and increased privatization and corporate education provision. If education is the solution, then the diminished funding of public education resources poses important questions for disadvantaged groups who have in the past been dependent on the public funding and government taking responsibility for unequal distribution of resources.

At the same time globalization also provides opportunities to Indigenous people. The growth of a vigorous worldwide indigenous movement utilizing the latest computer technology to enhance communication between disparate and isolated and communities over the past decade is one example (Kunitz 2000). There is an increasing interest in sharing indigenous knowledge and seeking radical solutions to health problems based on traditional methods (see for example, http://www.health-sciences.ubc.ca/iah/bridges/index.html

This paper analyses the challenges and dilemmas which Aboriginal Health Workers face in their professional practice, and the educational models needed for them to take up the opportunities offered by globalization. The analysis is informed by research, undertaken by Indigenous and non-Indigenous researchers in 1997-8 involving qualitative in-depth interviews with Indigenous and non-Indigenous health practitioners in rural and metropolitan locations in New South Wales (Clapham et al 2001, Williams et al 1998).

Education and Indigenous health

A number of authors have drawn attention to a lack of formal education as a barrier to social and health improvement (Boughton 2000; Caldwell & Caldwell 1996; Hart 1991; Tsey 1996). In Australia, as elsewhere much of this debate has focused on primary levels of education.

Arguing that improved primary and secondary education impacts positively on health by increasing one's knowledge and skills and consequently one's earning capacity and status in society, Tsey (1996, p.181) makes the important observation that: Among Aboriginal people community health education/ health promotion programs should not just aim at providing health information to people, but more importantly, they should aim at assisting individuals, families and communities to create positive environments for Aboriginal children, the adults of tomorrow, to develop their potential, especially through effective primary and high school education.

Educational attainment is translated directly into better health and must be addressed as a health issue. Better education is related to higher income; better-educated people can afford better access to health services and healthy lifestyles. Higher levels of education have also been shown to lead to a greater awareness of health risks influencing changes in behaviour.

In relation to tertiary education for Indigenous people, the challenge for learning institutions has been not only in making this education accessible to Indigenous people and producing indigenous graduates skilled in a broad range of areas, but also ensuring that the knowledge imparted by those institutions is relevant and appropriate to the particular cultural needs and aspirations of Indigenous people (Bechervaise 1996; Clapham & Farrington 1997; Clapham et al. 1997; Flick 1997; Page et al. 1997; AIHWJ 2000; Daniel DiGregorio et al. 2000).

To work effectively for the health of their communities, Indigenous health workers need an understanding that comes not just from the traditional western sciences, but also from a firm understanding of indigenous ways of understanding health. In addition, there needs to be an acknowledgment of past history and a search for new models for coming to terms with causes of problems that confront Aboriginal communities. A relevant education for Indigenous health workers is therefore one that recognises that, just as education has been a vehicle for the colonisation of Australia, it can also be an important vehicle for the self-determination of Indigenous Australians (Williams 2001).

Aboriginal health workers interviewed in our study repeatedly reported a lack of acceptance by other health professionals of the professional status of the role of Aboriginal Health Workers, and the resultant negative affects from that for their work in Aboriginal health. Achieving recognition as 'truly professional' was thus seen to be vital for effective performance of the Aboriginal Health Worker role, and for the improved health of Aboriginal communities and was often linked to education and training. In general, the need was perceived 'to train up'. An abundance of resources need to be put into Aboriginal Health Worker training. We need to have the knowledge to be able to assess and negotiate services that are appropriate to Aboriginal communities.

Aboriginal Health Workers are not alone in proposing training and education as a solution to Aboriginal health problems. This relationship between health and education is one for which there is much evidence (Blumenthal & Boelen 1999; Caldwell & Caldwell 1996; WHO 1984; World Bank 1993).

Education of Aboriginal Health Workers

Within Aboriginal communities there have always been people who have operated as health workers or healers. Their education for this role took place in a traditional context of health (Nathan & Japanangka 1983; Reid 1982; Soong 1983B). In Western terms however, Aboriginal Health Worker education is usually recognized as beginning during the 1960's when these health workers received an apprenticeship type training as medical assistants (CAS 1996).

From the 1970s the development of Aboriginal Health Worker education varied between the Australian states, with involvement of government and community controlled sectors. In this period, community controlled health services known as Aboriginal Medical Services grew to become major forces in Indigenous health care (Campbell & Ellis 1995; Foley 1991). In comparison to the earlier role of 'medical assistants', the Aboriginal Health Worker role became increasingly one of 'agents of change' drawing strength and direction from community needs and aspirations (Campbell & Ellis 1995).

In the 1980s, Universities increased their involvement and the 1990's then saw a growth in both the number of training and education courses for Aboriginal health workers across Australia. Courses were designed both to meet the needs of specific groups, specialist areas and regions, and to meet the growing demand for training for those employed as Aboriginal health workers in the community or public sectors.

In recent years a concerted effort has been made to provide education and training for health workers at TAFE (Technical and Further Education) colleges and Universities The formal courses offered at tertiary education institutions range from certificate to post graduate level. At the same time, Aboriginal Medical Services and other community controlled health services have continued to offer accredited training to their employees.

Although in principle, articulation between courses has become seen as a necessity in education system, in practice, articulation between the various health worker courses remains problematic. This is particularly pertinent to Indigenous people as many, particularly mature aged Indigenous people, have accumulated Western knowledge through completion of short courses, certificates or on the job training.

In any educational model for the future institutions need to work closely with Indigenous communities. The philosophy which needs to guide health worker practice, that of respect for 'holism in practice, community control and primary health care philosophy' (Con Goo 1999, p.6), also needs to guide health worker education.

Education and training for Aboriginal Health Workers has been the subject of numerous recent reviews at State and Commonwealth levels. The development of national competency standards (CSHTA 1996) has led to increasing emphasis on competency based training (CIRC 2000) to support the establishment of appropriate career structures. Registration and representation for Aboriginal Health Workers, has been widely discussed since 1978 (AHWJ 1978). These reviews have stimulated further critical discussion on Aboriginal Health Worker education and its future direction or directions (for earlier discussions regarding remote area Aboriginal Health Worker education see Torzillo and Kerr 1991; Tregenza & Abbott 1995). Gelonesi & Khavarpour (2000) for example, point to the limitations of the competency based training model presently advocated for Aboriginal Health Workers, arguing that 'the focus is almost exclusively on the practical applications', and that: Very little is said about the cognitive skills that one would expect to be part of the makeup of a professional Indigenous health worker

What they advocate is a more inclusive educational model. Within the present model for consideration, they consider that: More complex aspects of Indigenous health work go unrecognized. More importantly the skills are couched in prescriptive language, thus leaving little room for the natural creativity in behaviour that one would expect in a true professional.

Perhaps a more comprehensive approach is to expand the concept of competencies to include cognitive and academic skills as well basic vocational skills.

Globalization redefining education Significantly, this argument connects with the much broader phenomenon, which is increasingly affecting all societies to varying degrees, ie. a global economy and informatics characterised by an unprecedented flow and exchange of capital, information and cultural communication (Featherstone 1990; Castells 1996; Tomlinson 1999).

This is a crucial issue not often considered in regard to future educational models for Aboriginal Health Workers, yet it is increasingly leading to a world wide transformation of all work and employment practices. There is a justified concern therefore, that just as Aboriginal Health Workers are 'catching up' with education and 'qualifications', they are already being left behind in an age in which vocational qualifications and educational models are being challenged and necessary skills are being redefined (Forester 1985; Castells 1996; Carnoy 1998).

Central to the new globalised informatics economies are new ways of attaining knowledge (Castells 1996). In this information explosion, both the transmission mode and interpretation of the nature of knowledge itself is being redefined (Carnoy 1998). Consequently, it is becoming virtually impossible for any professional in any field to fully know a field. As in all other professional areas, the emphasis in the health professions has moved to problem solving and information literacy.

Any competency based approach to education and training for Indigenous health workers as a path into the future, needs therefore to incorporate or interlink with the kind of education which health practitioners will increasingly need in a globalized world. In that future, the domain of knowledge which practitioners possess, may ultimately be less important than their understanding of 'how to gain knowledge', through a process of 'critically assessing' as well as 'accessing' globally available information.

What new challenges then, will Aboriginal Health Workers along with other health practitioners, have to face as globalization increasing impacts upon educational and employment practices, and what will this signify for the kind of education which they will require in the future? While 'professionalism' has been traditionally organised around the ownership of a particular area of knowledge and expertise, the informatics revolution will increasingly change these aspects of both professional practice and education.

The health professional's competency package of the of the future 'will be constantly expanding and changing to stay current with the rapid degree of technological change and the institutional and organisational changes that accompany it' (Neubauer and Mullavey-O'Byrne, forthcoming). Newly valued skills in graduates therefore particularly include the ability to access and assess information, communicate and respond quickly, change with a changing world, and use the knowledge gained to problem-solve effectively.

Informatics and Indigenous responses For Indigenous people, this scenario is further complicated by the challenges which globalization presents to cultural and local community identity. Many authors have discussed in both academic and popular literature, the threat of a reduction in cultural diversity as an inevitable consequence of the processes of globalization (for some examples, see Friedman 1997; Neubauer 1999; Tomlinson 1999; Zwingle 1999; Klein 2000).

In this regard, Neubauer (1999) argues that the loosers in this process will be those groups, which are already socially disadvantaged since: Virtually everywhere the politics of inequality is played out on a field of race and colour, the new politics of inequality becomes equally a new politics of race

Within this scenario, Indigenous groups are potentially positioned in terms of increasing disadvantage. However, the benefits of globalization have not been entirely lost to Indigenous peoples. One of the surprising developments of the past 10 years has been the growth of a vigorous worldwide indigenous movement utilising the latest technology.

A notable example is the explosion in 'Indigenous' websites. One Australian register http://www.koori.usyd.edu.au/register.html; lists 350 such sites just in Australia. Nor has Indigenous web communication been limited to culture and education. Tourism and commerce have also been a strong focus. In regard to national and international communication, the use of video-conferencing, Indigenous radio and television stations have led to enhanced communication between disparate and isolated and communities in Australia (Langton 1993, p.59). Moreover, the growth of website development across the globe in recent years has encouraged the building up of networks and the fostering of cultural exchanges between Indigenous people and their global communities. An example of this can be seen in the 'Building Bridges' website from The First Nations Longhouse at the University of British Columbia (http://www.health-sciences.ubc.ca/iah/bridges/index.html). Here, a 'Global Outreach Students Association' has been developed. Such networking and exchange can be a powerful influence for Indigenous communities.

With this focus on 'connectivity' (Tomlinson 1999), has come an increasing interest in sharing Indigenous knowledge in seeking solutions to health problems. Aboriginal controlled health ultimately involves Aboriginal health professionals who are adequately resourced to seriously tackle community education and development (ATSIC 1994; O'Neil 1995; Kunitz & Brady 1995). What is needed in Australia is a radical shift in approaches to Aboriginal health and education, which will allow an incorporation of the benefits of globalization to improve Aboriginal health. Such a shift is not advanced by globalization trends because they tend to diminish political will and equity in funding for disadvantaged groups. But ultimately such a shift requires the development of social-institutional collaborations that defy the current course of economic rationalist diminishment of public social justice discourse, and subvert these globalization trends for a socially expansive discourse.

Collaborative Models for Indigenous Communities and Tertiary Institutions How then, within the constraints of this present position in Australia, can Indigenous people best proceed? We have argued that the phenomenon of globalization offers opportunities that can be utilised by Indigenous people for long term improvements in health and education. In Globalisation and Culture, John Tomlinson explores globalization as a modern condition of 'complex connectivity'. By this, Tomlinson means 'the rapidly developing and ever-densening network of interconnections and interdependences' of the modern world (1999, p.2).

Included for mention in Tomlinson's analysis of these networks are the 'social-institutional relationships' proliferating between individuals and collectivities worldwide, as well as the material flows of goods and information. As we have seen, Indigenous communities are already engaging with these networks (Kunitz 2000). In the area of health, the establishment of linkages both between Indigenous communities in different countries, and with a worldwide interest in Indigenous sources of knowledge and healing has already occurred. In recent years, interest has been shown by both mainstream medical and pharmaceutical interests and by alternative health practitioners around the globe, in Indigenous medicines, healing practices and approaches to holistic health. In the area of education, the establishment of linkages between Indigenous communities and tertiary educational institutions is a growing phenomenon.

It is from this phenomenon that we believe the positive aspects of globalization can be harnessed to benefit Indigenous people. We suggest that collaborative educational models developed between Indigenous communities and tertiary educational institutions can redress aspects of disadvantage faced by Indigenous communities. However, the success of such programs involves a shift in many cases from a university culture of isolation to an engagement with and formation of alliances with social communities. It also involves a shift, amidst the market discourse of globalization, from a culture of elitism to an engagement with issues of social justice and disadvantage (WHO 1984; Blumenthal & Boelen 2001; Clapham et al. 1999).

There are elements within tertiary learning institutions that are already struggling to achieve this shift. In the various communities of scholars in tertiary institutions, there are those who are strongly committed to issues of social justice and to Indigenous issues, who support Indigenous leadership, and who are prepared to question the adequacy of present educational approaches to social disadvantage. Often this struggle occurs in isolation and sometimes in a competitive academic environment that does little to encourage collaboration let alone cooperation. Much more can be achieved through the development of social-institutional structures for collaboration and cooperation, in effective alliances and partnerships of these groups with Indigenous communities.

Indigenous people need allies to affect changes in health outcomes. We consider that tertiary institutions are uniquely placed to impact positively on Indigenous health since their resources include strong academic traditions, excellent research capacity, powerful professional organisations, goodwill of staff, social and political influence, and in Australia, although becoming significantly reduced, considerable public funding. We believe that these kinds of initiatives to link Indigenous communities with tertiary educational institutions can provide opportunities and benefits to Indigenous communities, academics and non-Indigenous and Indigenous students alike.

We argue that this requires a respectful and mutually beneficial sharing of the wisdom of Indigenous knowledge with tertiary education students and academia (Smith 1999) and of the knowledge of globalization current educational academic skills with Indigenous students and communities. In Australia, one innovative example of collaboration initiated by an Indigenous community is the Garma Festival of Traditional Culture Academic Program, designed as a springboard for future collaborative programs between the community and the universities (www.yothuyindi.com/foundation/index.html).

New approaches to Educating Health professionals In terms of health education, these models of collaboration could lead to long term benefits for Indigenous people, if the gap that exists between health education and Indigenous health needs can be bridged. In the specific case of the education of health professionals, Indigenous knowledge has already to some extent, been incorporated into the tertiary education of health professionals in Australia. The major way in which it has been incorporated for health professionals other than Aboriginal Health Workers has been through Aboriginal Studies courses or electives or cross-cultural education programs. Many of these educational packages have been developed and delivered, often by Indigenous guest speakers. However, these programs are usually of short duration, infrequent and have uncertain funding.

We argue that a new approach is necessary, one which situates the Indigenous health issues as an integral component in the education of all health professionals, and which fully utilises links between Indigenous communities and educational institutions. A single strategy is unlikely to be sufficient, but overall, in terms of improving Indigenous health outcomes, there is a need for Indigenous health and cultural issues to be incorporated in a more integral and multi-faceted manner through curriculum, teaching practice, and participation in dialogue with Indigenous people.

An embracement of collaborative approaches such as the Garma declaration by tertiary institutions would go a long way towards bridging the discrepancies that currently exist between educational intentions and health outcomes for Indigenous people. Aboriginal Health Workers are often offended when 'western trained' health professionals (and researchers) with little understanding of Indigenous culture, presume to wonder why their complex health problems cannot be easily solved, or attempt inappropriately and simplistically to solve them. As one of the Aboriginal Health Workers interviewed in our study remarked: It comes down to the education of the nation making people doctors, professors and politicians, aware of the need for change in the way that health is delivered to Aboriginal people

New Approaches to Educating Aboriginal Health Workers In contrast to the current education of mainstream health professionals, in Aboriginal Health Worker education, Indigenous knowledge is usually positioned as a core component of a curriculum. However, Aboriginal Health Worker students are not often linked with globalization current educational opportunities in ways that position them advantageously in relation to other health professionals.

As employment practices are changing, new skills are required of health practitioners, and students are increasingly seeking the kind of skills that they need to participate in the new society. Australian universities have been criticised in this regard for their failure to respond appropriately to the 'extraordinary changes' being forced by the globalization phenomenon. As Dale Spender (2000) observes: if there are academics who don't know that the new technologies have changed the nature and availability of the world's knowledge, the students do.

In terms of the new information technologies, Spender argues that too many Australian universities are not adequately connected to the global knowledge economy, with full-time modes of study through a lock step curriculum with pre-requisites and long face to face hours, still the predominate mode of teaching.

For all health practitioners, the requirement to remain current with changing health treatments and information demands improved abilities to access and assess information quickly and to use the knowledge gained to problem solve effectively. These are the kind of skills that are increasingly an integral part of the education of health professionals such as medical students. These are also the kind of skills which all health practitioners, including Aboriginal Health Workers, will increasingly need to rely on in the future. Recent changes in health professional education include moves toward more shared interdisciplinary and generic education for health professionals. More generic undergraduate programs and postgraduate entry to professions allow for more flexibility and movement between health professions and a better understanding of the various contributions of each group of practitioners.

We believe Aboriginal Health Workers need to be incorporated into this 'health care team' approach both at the workplace and in the tertiary learning environment, so that students have the opportunity to meet, understand, value and respect other professional groups as part of their education and clinical placements. This would assist in addressing some of the primary complaints of the Aboriginal Health Workers participating in our study that their role is not understood or appropriately utilised by other health professionals, and that they do not receive respect and recognition for their considerable skills, often gained not only through a four year educational program, but also as a result of a lifetime of interaction and learning at the Indigenous community level.

For Aboriginal Health Workers there is also a constant requirement for knowledge of Indigenous community health models and resources, both locally and globally. In a situation where the provision of health care is itself a social and political engagement, Aboriginal Health Workers need to be able to analyse current methods of organising health systems; to critically evaluate the costs and benefits of those systems for the Indigenous client communities that they serve; and to effect change for the better both at the workplace and in systemic changes to health systems which perpetuate disadvantage to Indigenous people. These skill requirements will be best serviced through the sort of 'competency package' (Neubauer and Mullavey-O'Byrne 2001) which enables them to be aware of global technological change and the resultant political, institutional and social effects for Indigenous people.

Conclusion Tertiary educational institutions through their considerable resources can contribute in a real and powerful way towards overcoming economic and health disadvantage through appropriate educational and research programs. We have argued for the building of social-institutional relationships of connectivity to address social justice issues exacerbated by globalization-influenced economic, political and social changes. In this vein, we have argued for the value of linked educational institution/Indigenous community models of education for both non-Indigenous and Indigenous health practitioners.

The changes occurring in higher education include curriculum changes, the introduction of concepts of life-long learning, flexible delivery, inquiry and evidence based learning, and multi-disciplinary team approaches. Aboriginal Health Workers need to be linked into the advantages of these new kinds of educational models and the opportunities they provide. Education which incorporates the benefits of globalization can position Aboriginal health Workers to realise their potential as agents of change and self-determination.

Appropriate education of non-Indigenous health practitioners, of Aboriginal Health Workers, and consequently of Aboriginal communities is fundamental for improving health and reducing poverty for Indigenous people. In this era of globalization, the possibilities for Aboriginal Health Workers to realise their potential as agents of change and of self-determination depends on careful strategy and the taking up of changing educational opportunities. This is what is needed in order to become a winner in this changing world. Indigenous people have the right to be winners not always just trying to catch up with earlier advances. By incorporating the benefits of globalization, Aboriginal Health Workers can actually in a position to make a leap and become winners and leaders in improving Indigenous health.

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