Health Affairs

Tess Lea has written a book of frightening import and importance.

Despite

its subtitle, Bureaucrats and Bleeding Hearts: Indigenous health in northern Australia (UNSW Press, 2009) is not so much a direct examination of the state of Indigenous health affairs in the Northern Territory as it is an ethnography of those who are charged with "ending Aboriginal disadvantage in the frontier north of Australia." Lea herself is the Director of the School for Social and Policy Research at Charles Darwin University, previously co-author Learning Lessons: an independent inquiry into Aboriginal education in the Northern Territory (1999) and co-editor Moving Anthropology: critical Indigenous studies (2006).

Bureaucrats and Bleeding Hearts is not another recitation of the parlous state of Indigenous health: that is almost an assumed premise. Rather, it is an attempt to understand how the government tries to cope with the task of organizing itself to address the issue, and how the people who make up the Territory Health Service (THS) cope with both the challenges and the stresses of the work. It examines how the structures and demands of the bureaucracy affect the people who work for it, how such structures influence solutions, and how the entire need to take action in itself generates what Lea describes as the self-replicating process of the need for further action.

And yet the book is not simply a treatise of criticism Lea never loses sight of the earnest dedication and the idealism of the people who sacrifice so much of themselves to the Territory Health Service and its mission. With years of involvement in social policy and as a practicing anthropologist who has turned her gaze not on the exotic other but on the very institutions she herself works for, Lea undertakes the nearly impossible challenge of understanding how her own culture operates in its confluence with Aboriginal society.

[It] would not have been enough for me to describe the faults of governmental policies. This is a book about the existence of the state with the self and the self within the state. My subject has not been the artifice of bureaucratic constructions but their social life, and how they are brought to life by social beings. This is art and artisanry, artifice and facticity, coalescing into powerful systems of cultural reproduction that come together in the orchestral work of upholding the developmental state. A sense of wonderment is called for, even if the cultural mastery at play here remains uncelebrated within anthropology, which only sees a non-fantastic rationality in need of correction (pp. 235-36).

For over a decade, Lea has been closely involved with THS, shadowing health workers on assignment in remote communities and in Health House, the Darwin central office and administrative soul of the organization. She has taken part in bush orientations in communities and on mudflats, often grueling exercises that test physical and emotion endurance. She has also participated in countless workshops aimed at defining problems, inventing solutions, and building esprit de corps amongst the workers.

It is especially in these workshops that a picture of the bureaucracy emerges that evokes my assessment of "frightening." It is frightening because it is so familiar and rings so true. But Lea's portrait reveals how the necessary structures of any bureaucracy inevitably turn back upon themselves and threaten to strangle their intended outcomes.

The workshops allow their participants to raise issues, to vent their emotions, to figure out what to do next. Participants in one workshop described early on in the book respond to their leader's call to verbalize their experiences; the leader (Bob) then summarizes their stories into bullet points on the communal whiteboard. One participant has this to say:

I feel frustrated being seen as a service deliverer, as a doctor first, there only to see sick people. All I see are people with pus, with sores. As a visitor I cannot spend time with people working on more chronic issues.

Bob writes:

>> inability to work up programs

And the trauma for [our] families is unreal. I take it out on my kids ... abuse them for being so privileged. I really coped very badly. I couldn't talk to my husband for at least the first hour after I got back. I would have to take myself out of the house, go for a walk, go to the gym, something .... It was so hard.

Bob writes:

>> lack of debriefing opportunities (pp. 89-91).

The requirements of reducing the complexity and chaos of everyday life to manageable bullet points, to the essence that can be captured and addressed by a program generic enough to be widely applicable, drains the life, the very reality out of the experience of these dedicated workers. Is it at all surprising then that programs born of such brainstorming sessions ultimately fall short of effective solutions to real world challenges? A few pages later Lea laments the way in which these exercises lead to "institutional self-perpetuation."

It is here, I want to argue, here within the selection of hardships to relate (in the well-proportioned anecdote and the emotions attested, in the sympathetic reception and the confirming responses of other), that the complex regulation of the 'romance of raw experience' is accomplished. It is here that the genesis of institutional self-perpetuation and its obscuring from itself can be located. The trick is to recognise the heavy-handed stamp of the ordinary in the extraordinary public health professional. And further to see that these constraints arise out of the close inspection and recuperation of failure.... (pp. 94-95).

In other words, the work of enunciating the further work that still needs to be done is itself an endpoint.... It is through talking that specially chosen words are bestowed with their magical ability to 'make a difference on the ground'. It is through talk work that professionals create shared grammars of both complaint and diagnosis in parades of collective analysis which are immersions in techniques for recuperating past failure into the need to do more of the same (p. 107)

The gap, the difference between Aboriginal lives and bureaucratic imagination is a theme that Lea sounds repeatedly. Those who routinely enjoy good health,whose bodies are not sending out distress signals hourly and daily, can find it hard to incorporate (in its literal sense of "bringing into the body") the experience of chronic disease, no matter how good their intentions. On the other side, those who are forever sick are not impressed by statistics and health information. For health professionals, the overwhelming data about Indigenous ill-health sound an alarm that the sickly themselves may not be able to hear.

It is the avalanche of catastrophe and opportunity that animates health statistics, and which convinces health professionals that a key requirement of betterment is that Aboriginal people know how sick they are through an appropriately alarming rendition of the statistics. ... Our own cultural fascinations are held to fascinate others, and not for the first time (pp. 132-33).

Ironically, attempts at cultural sensitivity can further widen the gap. Lea notes how rare it is for health workers to ever enter the homes of the people they seek to treat. Aboriginal visits to Visiting Officers' Quarters are often treated as intrusions to be quickly resolved. Instead the health officers meet with selected Aboriginal individuals, often those already most at ease with English and Western concepts of health and nutrition, in carefully selected, neutral, and largely whitefella physical spaces like clinics or community centres.

And then there is the episode of the "cursed store" in Numbulwar. Nutritionists were eager to restart a program of healthy eating habits that had been waylaid when the community stored was closed after it was put under a curse by one of the elders. A new store was under construction; the old store stood closed and increasingly dilapidated. The nutritionists carefully avoided probing the sensitive backstory; instead of focusing on the "issues of all-consuming importance in the micro-politics of Aboriginal communities" (p. 166), they focused on menus, food groups, and binders full of laminated photographs of healthy tucker. The health professionals were respecting the privacy of their clients and refusing to invade what they clearly saw as private space. They probably could not do otherwise, but they also lacked any understanding of the reasons why the first store had been cursed and abandoned, the electricity shut off, the food still rotting in the disabled freezers.

In this very respect for what Lea calls "the mystery of Aboriginal difference" lie the seeds of failure for those who wish to do things with Aboriginal people rather than for them, or worse, to them. The crippling legacy of colonialism overburdens bureaucrats whose hearts, in the best sense, bleed for their clients. And at the same time, the demands of the bureaucracy squeeze the life out of their experiences when it comes time to make policy.

Much has been made recently of the failures of the last thirty years, the failure of policies of self-determination and passive welfare, of the liberal bleeding-heart consensus, of policing and regulation. Those who decry the social engineering of those failures suppose that now that they have recognized the futility of these regimes, the better way will shortly emerge or is indeed already apparent. Lea implicitly suggests that perhaps the next solution, grounded as it inevitably will be in the logic of intervention, is likely to fail just as miserably.

Lea herself proposes no such solutions. Her aim here is to illuminate the logic we cannot see in the system that we are part of. She does not take sides; she critiques, but she does not condemn.

Amidst the intense factionalism about approach and political commitment, there is a tremendous standardisation in the logic which explains the need for our interventions, for our very positioning as concerned helpers. It is, as we have seen, such a readily ... generalisable logic that it can be inserted into any situation, with out the need for specific knowledge, of these particular people, their place, their contemporary context, specific histories or intimate local concerns (p.210)

It is a metaphysic which cannot for a moment entertain an order of socio-economic co-existence with Aboriginal people that excludes institutional intervention; a metaphysic which would ask, as pre-emptory response to even this critique, but what else would you have us do? For doing nothing has now become unimaginable (p. 212).

The special genius that Tess Lea brings to Bureaucrats and Bleeding Hearts is that, throughout, her focus is on "specific knowledge, of these particular people, their place, their contemporary context"; she looks clear-eyed at black and white, left and right. If abstraction is the enemy, the challenge is to construct ways of thinking that can function successfully in the structural and perhaps unavoidable straightjacket of institutional logic. In a pair of playful sub-heads to her final chapter, Lea acknowledges "I've met the state ... and she's an anthropologist." She exempts no-one, least of all herself, from the need to examine the issues unblinkered and focused on the concrete, the intimate, and the immediate.

Posted: Sat - September 5, 2009 at 12:39 PM

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Health Affairs

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