How can modern medicine include traditional bush healers whose spirits fly around at night diagnosing people’s problems? Georgina Kenyon reports.

The stifling outback heat of the early evening feels just ripe for trouble. It’s Friday night and still over 35°C in the town of Alice Springs in Australia’s Northern Territory. It is market night, and the pubs and streets are full of people. I hear glass shattering and a man and woman yelling at each other in the front yard of a nearby house. A group of young white men walk past me: “It’s going down!” they laugh. More yelling comes from inside the house as the police pull up. “Pikaringkupai,” an elderly indigenous man says quietly. It means ‘fight’. “Drugs, marijuana,” he adds, shaking his head. He walks past me, heading down to the Todd river, typically empty of water, where indigenous people are camping among the old red gum trees. Many have come for cultural reasons, such as attending funerals and ceremonies that go on for weeks, sometimes longer. Others have come to visit relatives in hospital and have nowhere else to stay. Heading away from town, I hear a woman screaming. Dingoes and wild dogs start howling from the nearby MacDonnell Ranges; police cars, sirens deafening, speed past and stop at a row of houses ahead, all hidden from view by tall corrugated iron barriers.

© David Maurice Smith/Oculi The following morning I pay a visit to the Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women’s Council Aboriginal Corporation (NPYWC). Their one-storey rectangular white building, built around a shady courtyard, is a tiny oasis of tranquillity in Alice Springs. I have come to hear about the work of the ngangkari – Aboriginal healers of the deserts of central Australia – and how they might be able to help ‘close the gap’ in the health and wellbeing of indigenous people. One of the ngangkari I meet is Josephine Watjari Mick: “I can help with pain, I help people with pain in their heads,” she tells me through a translator. “So many young people here are in pain, mental pain.” Mick was born in Pipalyatjara in the outback, more than 500 km south-west of Alice Springs. Like most ngangkari, she is a senior member of her community, over 60 years old, although she can’t be sure of her age exactly because people born in the outback often don’t have records of their births. “We grew up in families where we watched each other, kept an eye on our family and kids,” she says. “But now, drugs and TV have started the breakdown of family. Also, the cost of these drugs, like marijuana, adds to the stress when someone gets hooked – it puts families under more stress when there is no money left.” Domestic violence, drug abuse and mental health problems are challenges in many outback communities, as well as in Alice Springs. Arguments and threats often spiral out of control very quickly, she explains. Ngangkari healer Josephine Watjari Mick © David Maurice Smith/Oculi Ngangkari treat mental health and physical problems using plants, minerals, animal products and spiritual healing, drawing on knowledge passed down verbally from generation to generation for an estimated 60,000 years. The NPYWC ngangkari tell me they do not directly treat drug addiction or other diseases such as diabetes that they say were unknown in indigenous communities before European settlement brought new social problems and diets high in processed sugar and flour. But they will treat people suffering from mental distress or physical conditions such as injuries and trauma, muscular diseases, and issues surrounding pregnancy. Their approach to mental health in particular has been praised in Australia and beyond. But although their role in helping indigenous communities is acknowledged by parts of the medical establishment, some ngangkari advocates believe more formal integration is needed to address entrenched health inequalities between indigenous and white Australians. Statistics from the Australian Institute of Health and Welfare show that the life expectancy of indigenous people is about 10 years less than that of nonindigenous people (69.1 years compared with 79.7 for men; 73.7 compared with 83.1 for women), and indigenous people generally have worse health throughout their lives. There are many reasons for this gap: some cultural, some genetic (such as a greater propensity for developing diabetes) and many social. In these very remote areas, people rely on small health clinics; often staffed by nurses, not all of these clinics have a permanent doctor, but the Royal Flying Doctor Service is available to fly people to hospitals in Alice Springs or Adelaide if required. Even so, indigenous people often delay turning to Western medicine, sometimes due to cultural tensions (although there are efforts to introduce more indigenous health workers and community-led healthcare services across Australia), other times due to a simple lack of transport. As a result, poor remote communities tend to have lots of problems with skin and eye infections, while diabetes, kidney disease and pneumonia are also particularly common. Successful treatment is more difficult to achieve if there is a delay before seeing a doctor, but there can be other challenges to indigenous people’s health, such as a lack of money, lack of work, or the feeling that they have to live in a foreign culture. If someone continues to be ill despite getting medical attention, indigenous people will often say that person has ‘lost their way’, lost their connection to their homeland, and that maybe a ngangkari will be able to help them instead.

© David Maurice Smith/Oculi To the ngangkari, the outback’s semi-arid landscape is a rich kitchen and pharmacy – a medicine chest to heal body and soul. Different plants are used to treat everything from headaches to respiratory problems like colds. Even caterpillar nests are used as a kind of burns dressing. Pantjiti Unkari McKenzie, another ngangkari, tells me about some of the treatments she uses with her patients. Heating the leaves of the desert fuchsia, a scrubby plant also known as emu bush that grows to over a metre and a half high, produces steam that people can inhale to treat chest infections, or it can be used to make a rub to help sore muscles and joints. “We call it irmangka-irmangka,” she says. In the office at the NPYWC, they are making up a batch. The plant has been cooked with oil (butter or beeswax can also be used) and the result is sitting in a bucket on a large table. I dip my finger in the lurid yellow-green gel-like substance: it smells fresh and sweet. It will be spooned into small glass jars and sold in shops and tourist hotels around Australia for people to massage into their skin to treat sore muscles and headaches. Rubbing, massage and touch – pampuni – are all important in ngangkari practice, along with singing and dancing – inma – and a blowing technique that is a bit like soothing a child by blowing on a graze. But plants are a vital component. The desert fuchsia is also known as ‘medicine number one’ and, like many of the plants used by ngangkari, it contains active compounds with medicinal potential. Plants from all over the world have provided treatments for mainstream medicine, not least Australia’s native eucalyptus tree, which has decongestant properties. In recent years, scientists have identified antibacterial compounds in the desert fuchsia, and the World Health Organization has reported on the antiviral potential of the Casuarina tree, native to Australia and other countries. An Aboriginal ‘pharmacopoeia’ documenting indigenous medicines, their active compounds and their traditional uses was published in 1988, and the Commonwealth Scientific and Industrial Research Organisation (CSIRO) is currently working with indigenous people on a new atlas of medicinal plants to preserve more of this knowledge in print. Medicinal activity and 60,000 years of practice are not enough for ngangkari treatments to be recognised and regulated as part of mainstream healthcare, however, and some campaigners feel this is a big problem for the health of indigenous people. According to the Australian Therapeutic Goods Administration, compounds require rigorous clinical testing or a proven record of over 75 years of safe use before they can be marketed and used as medicines. Traditional use by Aboriginal people is not in itself proof of safety, and it is impossible to show effectiveness without extensive documentation – not practical in a culture with an oral tradition and no written records. An alternative approach would be to register ngangkari healing as a complementary therapy, which requires only proof of safety. Although this route led to the acceptance of acupuncture in the Australian healthcare system, it is an expensive, laborious process, and it would be difficult to account for different practices among the ngangkari. Ngangkari healer Pantjiti Unkari McKenzie © David Maurice Smith/Oculi But perhaps the biggest disconnect between the ngangkari and the mainstream Australian health system is the ngangkari’s concept of reality, which can be described as magical realism or a spirit world. “If you ever see a ngangkari shouting and beating a tree with a stick, it could mean that the tree has bad spirits hiding there. We know it is there because the hair on the backs of our necks stands up,” McKenzie tells me. “Many people are sad and distressed because of harmful spirits.” A lot of indigenous people still feel part of this reality, although they integrate it into modern life, freely switching back and forth between thinking they are in the spirit world and functioning in the present. Like many people, regardless of spiritual or religious beliefs, they can hold seemingly contradictory ideas at the same time: “It’s like when my Christian husband died,” says McKenzie. “He went to heaven.” Their tolerance is not fully reciprocated. Ngangkari have received awards for their work, notably the 2009 Mark Sheldon Award for contributions to indigenous mental health in Australia or New Zealand and the 2011 Sigmund Freud Award from the City of Vienna. But while the Australian government recognises and respects many traditional practices, the regulatory systems that have developed around Western medicine have no room for the spiritual dimensions of traditional healing, and the medical profession has profound concerns about such approaches. Eva O’Driscoll, Director of Communications for the Australian Medical Association (AMA) in South Australia, says the AMA would be “wary” of recommending ‘alternative’ therapies, including ngangkari, unless the treatments had been fully regulated. “There have been instances of some tragic outcomes when people have not followed the guidance of doctors when they have been diagnosed, for example with cancer,” she explains. So while acupuncture, part of traditional Chinese medicine, has been integrated as a regulated complementary therapy in Australia, the homegrown ngangkari continue in an ad hoc way. A general practitioner is free to recommend that a patient see a ngangkari if they are depressed or feel disconnected from their culture, but the cost is not covered in the same way as medical treatments, and fees paid to healers can vary widely. If they are contacted privately, or working in the bush, the fee is often set by the ngangkari according to what the patient can afford, which sometimes means the ngangkari works for free. Even in states like South Australia, where the state health department often does cover ngangkari treatments, there is no coordinated payment system. Some ngangkari do not have bank accounts to pay cheques into, and many live in poverty, even though they are working, because payment is so irregular. Ngangkari feel they are highly trained, having learned so much about medicinal plants and health. Inconsistent pay and a lack of acceptance of their work are all part of the ongoing unfairness, they say, between indigenous and nonindigenous people in Australia. Although some ngangkari, like the NPYWC group in Alice Springs, are happy enough with the current system, other campaigners say change is urgently needed if their knowledge, skills and culture are to be effective in helping to improve the physical and mental health of indigenous people.

© David Maurice Smith/Oculi Born in Rome, Francesca Panzironi came to Sydney to study law. After 10 years in academia, she is now an independent researcher and the Chief Executive Officer of the Anangu Ngangkari Tjutaku Aboriginal Corporation (ANTAC) in South Australia. ANTAC advocates for the rights of ngangkari, pushing for their methods and practices to be absorbed into mainstream healthcare, or at least for them to receive consistent government funding to practise. Panzironi lives for part of the year in Adelaide and for part in Fregon in the remote north-west of South Australia in the APY lands (where the indigenous languages Anangu, Pitjantjatjara and Yankunytjatjara are spoken). Permits are needed to travel through the area if you do not live there. After many emails and phone calls, I finally set up a meeting with her and some of the ngangkari she works with so that I can arrange a visit to the APY lands myself. Unfortunately, it is not to be. “Bad time to travel to the APY lands,” Panzironi informs me when I arrive at her home in Adelaide. “Men’s business time, cultural time, the roads can be closed.” And the ngangkari I’d been expecting to meet, stopping over on their way to an indigenous conference in Peru, are out shopping. I say nothing; perhaps I had misunderstood on the phone. Two small pale blue desert finches chirp in a small white cage by the window in Panzironi’s modern home–office apartment. I ask her why she thinks she has been accepted by the ngangkari as an advocate even though she is European and not of their culture. “I ask for nothing and I want nothing from them, I fit in,” she replies. She talks about the APY lands being a place of mercenaries, misfits and missionaries, a wild frontier. What the local people dislike, it seems, is when white people go and get paid a lot of money in Sydney using their ngangkari knowledge to write a PhD and become an expert. “Whereas I’ve gone the other way: from academia to the APY lands.” Panzironi is convinced the ngangkari are needed to bring down the high rates of morbidity and mortality among indigenous people. The fact that ngangkari often already live in remote communities means they are more accessible and could help people get earlier treatment. Ngangkari, she says, have a ‘team-based approach’ to healthcare, meaning they accept that both Western and traditional methods can be beneficial when a person is ill. After treating a person spiritually and psychologically, the ngangkari might treat the person’s physical problems as well, but will just as often recommend they see a Western doctor, too. “Ngangkari are kind of like a mixture between a general practitioner and a psychiatrist all in one,” she explains. “Their medicine is holistic in nature, concerned with a person spiritually and physically, and this is important to many indigenous people.” In particular, Panzironi says mainstream doctors can misdiagnose mental disorders among indigenous people because of a lack of understanding of their culture. Spiritual disorders, grieving and palliative care are all culturally sensitive, but can be misinterpreted by Western doctors – she has heard of people being diagnosed with psychosis when they believed “a bad spirit had been put on them”, a belief that would be understood very differently in indigenous culture. Her vision, therefore, is a ‘two-way’ healthcare model that provides spiritual healers “hand in hand with Western medicine”, and she has called on the government to take on board her ideas. She believes the gap will close when both the traditions and healthcare of indigenous people are taken seriously by the government. Her proposals would require funding for the systematic provision of Aboriginal traditional healers in the South Australian health system, and a consistent fee-for-service payment schedule, negotiated in partnership with the ngangkari, Aboriginal community-controlled health services and mainstream health services. Another important recommendation is a database of ngangkari consultations, akin to a patient’s records held by their general practitioner, to document treatments and results. But, Panzironi says, the government has yet to respond to her recommendations and has not made any comment about her 2013 publication ‘Hand-in-hand: report on Aboriginal traditional medicine’. South Australia Health (SA Health), the state government health department in Adelaide, says it already provides strong medical and cultural services. “We are committed to ensuring the South Australian health system is responsive to the needs of Aboriginal people through supporting Aboriginal people’s access to culturally respectful, appropriate and relevant services,” says April Lawrie-Smith, Director of its Aboriginal Health Branch. SA Health also says that some of the recommendations in Panzironi’s report were addressed in 2011, when it established its Traditional Healer Brokerage Program. This enables referrals for indigenous clients to access the services of traditional healers. SA Health recognises a number of organisations providing ngangkari services, including ANTAC, and these organisations can bill SA Health to cover the cost of a healer. This is not true in all of Australia’s states, however, and formal regulation and inclusion in Medicare, Australia’s universal healthcare scheme, would be an issue for the federal government. When I ask the national health department in Canberra, it confirms that the federal government is not currently considering including the ngangkari in Medicare.