Ripple effects: integrating international medical graduates from refugee backgrounds into the health system in Australia.

The field of 'refugee health' is generally understood in terms of the efforts of health professionals from a host country to provide care for humanitarian entrants. This paper attempts to undermine that idea, focusing instead on the service that health workers from refugee background communities are able to render, both to their own communities and to broader society, when barriers to their participation are made more equitable. The point of departure for this Practice paper is the 2019 pilot 'Observership Program' that was initiated by Mater Refugee Health in Brisbane, Australia. This was in response to, and in collaboration with, international medical graduates from refugee backgrounds. The two doctors who advocated for the programme had already independently embarked on a series of advocacy initiatives aimed at facilitating health workforce participation for members of their communities. In what follows we: outline the barriers to their medical registration and employment in Queensland, Australia; describe the process of setting up a 9-month clinical observership for two participants; and we reflect on the implications of the programme from a health policy and systems perspective. Ultimately, our contention is that because health systems are complex and adaptive, increased health workforce participation by members of marginalised communities has the potential to change the culture of the health system, making it more adept and responsive. Such, we propose, are the 'ripple effects' of addressing the obstacles to health workforce participation by members of refugee background communities.

Picturing sanity, in black and white.

This speculative work grapples with a riddle: if white supremacy is noxious, and if it is inescapable, is apparent black health, black sanity, in fact healthy? In order to help the reader appropriately appreciate the feat that is black sanity, I begin with a treatment of Fyodor Dostoevsky's literary character, Mr Golyadkin. I go on to extend my claim that Golyadkin's ill health or lack of sanity can be understood in terms of the violation of the norms of sociality, onto Antonin Artaud. Dostoevsky and Artaud therefore provide case studies with which it is possible to begin to develop an outline of the bounds and mechanics of white sanity. I juxtapose this outline to readings from a selection of works by African writers-Bessie Head, Véronique Tadjo and Dambudzo Marechera. This culminates in an interrogation of Franz Fanon's metaphorisation of disability. I grapple especially with the ethical and existential implications of his understanding of black amputation. The conclusion that I eventually reach is another riddle, which may or may not amount to a restatement of the riddle with which I begin.

Black to the Future: Making the Case for Indigenist Health Humanities.

This paper outlines the development of Indigenist Health Humanities as a new and innovative field of research building an intellectual collective capable of bridging the knowledge gap that hinders current efforts to close the gap in Indigenous health inequality. Bringing together health and the humanities through the particularity of Indigenous scholarship, a deeper understanding of the human experience of health will be developed alongside a greater understanding of the enablers to building a transdisciplinary collective of Indigenist researchers. The potential benefits include a more sustainable, relational, and ethical approach to advancing new knowledge, and health outcomes, for Indigenous people in its fullest sense.

Being Seen by the Doctor: A Meditation on Power, Institutional Racism, and Medical Ethics.

The following pages sketch the outlines of "a Canaanite reading" of the health system. Beginning with the Black person-African, Afro-diasporic, Aboriginal, and Torres Strait Islander-who is seen by a health professional, the functions and effects of the racializing gaze are examined. I wrestle with Al Saji's understanding of "colonial disregard," Whittaker's insights into the extractive disposition of settler institutions vis-à-vis Indigenous peoples, and Saidiya Hartman and Fred Moten's struggle with the spectacular. This leads me to conclude that the situation of the Black within the health system is a tragic one. The prescription for the path out of this tragedy that I settle on, responding to Okiji's opening call, is found in Vernon Ah Kee's "Unwritten" series.

Closing the gap between rhetoric and practice in strengths-based approaches to Indigenous public health: a qualitative study.

OBJECTIVE: To understand strengths-based practice as articulated by urban Indigenous community workers and to consider its application for public health approaches to Australian Indigenous health advancement. METHODS: Semi-structured interviews with community workers from an urban Indigenous community. Interviews were video and audio recorded and transcribed verbatim. Data were analysed using thematic analysis, using an Indigenist research framework. RESULTS: For our participants (11 Indigenous and one non-Indigenous), a strengths-based approach was fundamental to their practice. This approach reconfigured the usual relationship of client and service provider to fellow community member. They understood the strength of Indigeneity that empowers individuals and communities. They were not blinkered to the challenges in the community but resisted defining themselves, their community or their community practice by these deficits. CONCLUSIONS: Our participants had a sophisticated experiential understanding that a strengths-based practice is not simply a 'culturally acceptable' way for non-Indigenous peoples to work for Indigenous peoples, but rather it is the only way of working with Indigenous people. Implications for public health: Strengths-based practice requires a reconfiguring of relationships of power, of attending to structure over stereotypes, and privileging Indigenous ways of knowing, being and doing. This reconfiguration is an ethical prerequisite for an approach that is genuinely strengths-based.

Beyond the pipeline: a critique of the discourse surrounding the development of an Indigenous primary healthcare workforce in Australia.

A central strategy in addressing health disparities experienced by Indigenous people has been based on a concern with workforce improvement. In this paper, the Indigenous Australian healthcare workforce literature since 1977 is reviewed and its scope of concern, as being often limited to questions of 'supply', is critiqued. The pipeline metaphor, whether used explicitly or implied, regularly focuses attention on closing the gap on Indigenous representation within the health workforce. The exception though is the discourse concerning Indigenous Health Workers (IHWs), where questions concerning the legitimacy of the role continue to abound within a workforce hierarchy where community knowledge, though shown to be crucial to culturally safe health service provision, is trumped by the other health professions whose knowledges and legitimacy are not in question. This contrast exemplifies the need to examine the working of power not just 'supply'. The pipeline metaphor is disrupted with concerns about a range of other 'gaps' - gaps in the recognition of Indigenous knowledges, in organisational structures, in governance and in self-awareness by the health professions of their whiteness. As the health system continues to measure workforce development in terms of pipeline capacity, our study questions what happens beyond the pipeline.

The Convention on the Rights of Persons with Disabilities: a foundation for ethical disability and health research in developing countries.

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) has foregrounded disability as a human rights and equity issue, elevating it to a priority global research area. Academics from Western universities are likely to play an increasing role in disability health research in developing countries. In such contexts, there is a need to bridge the gap between procedural ethics and the realities of disability research in cross-cultural contexts. We provide guidance on engaging in ethical disability health research that intersects with and upholds the CRPD. We highlight challenges and tensions in doing so, underscoring the need to be sensitive to the sociocultural and political context of disability that determines how ethical research should proceed. We conclude with 5 recommendations.

Mental health issues decrease diabetes-specific quality of life independent of glycaemic control and complications: findings from Australia's living with diabetes cohort study.

BACKGROUND: While factors associated with health-related quality of life for people with chronic diseases including diabetes are well researched, far fewer studies have investigated measures of disease-specific quality of life. The purpose of this study is to assess the impact of complications and comorbidities on diabetes-specific quality of life in a large population-based cohort of type 2 diabetic patients. METHODS: The Living with Diabetes Study recruited participants from the National Diabetes Services Scheme in Australia. Data were collected via a mailed self-report questionnaire. Diabetes-specific quality of life was measured using the Audit of Diabetes-Dependent Quality of Life (ADDQoL) questionnaire. The analyses are for 3609 patients with type 2 diabetes. Regression models with adjustment for control variables investigated the association of complications and comorbidities with diabetes-specific quality of life. Next, the most parsimonious model for diabetes-specific quality of life after controlling for important covariates was examined. RESULTS: The expected associations with better diabetes-specific quality of life were evident, such as increased income, not on insulin, better glycaemic control and older age. However, being single and having been diagnosed with cancer were also associated with better ADDQoL. Additionally, poorer diabetes-specific quality of life was strongly sensitive to the presence of diabetes complications and mental health conditions such as depression, anxiety and schizophrenia. These relationships persisted after adjustment for gender, age, duration of diabetes, treatment regimen, sampling region and other treatment and socio-demographic variables. CONCLUSIONS: A greater appreciation of the complexities of diabetes-specific quality of life can help tailor disease management and self-care messages given to patients. Attention to mental health issues may be as important as focusing on glycaemic control and complications. Therefore clinicians' ability to identify and mange mental health issues and/or refer patients is critical to improving patients' diabetes-specific quality of life.

Closing the Gaps: competing estimates of Indigenous Australian life expectancy in the scientific literature.

OBJECTIVE: Closing the gap in life expectancy between Indigenous and other Australians within a generation is central to national Indigenous reform policy (Closing the Gap). Over time, various methods of estimating Indigenous life expectancy and with that, the life expectancy gap, have been adopted with differing, albeit non-comparable results. We present data on the extent of the gap and elucidate the pattern of use and interpretations of the different estimates of the gap, between 2007 and 2012. METHODS: An extensive search was conducted for all peer-reviewed health publications citing estimates of and/or discussing the life expectancy of Indigenous Australians, for the period 2007-2012. RESULTS: Five predominant patterns of citation of the gap estimates were identified: 20 years, 17 years, 15-20 years, 13 years, and 11.5 years for males and 9.7 years for females. Some authors misinterpret the most recent estimates as reflecting improvement from the 17-year figure, rather than the result of different methods of estimation. Support for the direct methods used to calculate Indigenous life expectancy is indicated. CONCLUSIONS AND IMPLICATIONS: A specific estimate of the life expectancy gap has not been established among stakeholders in Indigenous health. Agreement on the magnitude of the gap is arguably needed in order to evaluate strategies aimed at improving health outcomes for Indigenous Australians. Moreover, measuring progress towards 'closing the gap' depends on the availability of comparable estimates, using the same techniques of measurement to assess changes over time.

Living with diabetes: rationale, study design and baseline characteristics for an Australian prospective cohort study.

BACKGROUND: Diabetes mellitus is a major global public health threat. In Australia, as elsewhere, it is responsible for a sizeable portion of the overall burden of disease, and significant costs. The psychological and social impact of diabetes on individuals with the disease can be severe, and if not adequately addressed, can lead to the worsening of the overall disease picture. The Living With Diabetes Study aims to contribute to a holistic understanding of the psychological and social aspects of diabetes mellitus. METHODS/DESIGN: The Living With Diabetes Study is a 5-year prospective cohort study, based in Queensland, Australia. The first wave of data, which was collected via a mailed self-report survey, was gathered in 2008, with annual collections thereafter. Measurements include: demographic, lifestyle, health and disease characteristics; quality of life (EQ-5D, ADDQoL); emotional well-being (CES-D, LOT-R, ESSI); disease self-management (PAM); and health-care utilisation and patient-assessed quality of care (PACIC). 29% of the 14,439 adults who were invited to participate in the study agreed to do so, yielding a sample size of 3,951 people. DISCUSSION: The data collected by the Living With Diabetes Study provides a good representation of Australians with diabetes to follow over time in order to better understand the natural course of the illness. The study has potential to further illuminate, and give a comprehensive picture of the psychosocial implications of living with diabetes. Data collection is ongoing.