Illness Is a Weapon: Indigenous Identity and Enduring Afflictions

5. Noncompliance

ChApteR 5 Noncompliance P harmaceuticals have increasingly become one of the most effective tools to battle disease. However, for many people living in the developing world, the availability of drugs is limited. Although treatments exist for diseases such as HIV and tuberculosis, their high cost restricts use. The World Health Organization (2004) estimates that over one third of the world’s population is denied regular access to medicine. The distribution of pharmaceuticals has become a global health priority in the hope of increasing life expectancy in developing nations. In many settings, access to medication is equated with improved health outcomes. But in Australia’s Northern Territory, where health care and prescription drugs are provided free of charge to Aboriginal residents of remote communities , these individuals continue to suffer from the poorest health in the nation. This chapter reevaluates the assumption that access to pharmaceuticals inevitably results in improved health and illustrates the ways in which structural, experiential, and social contexts imbue medication with multiple meanings. Pharmaceuticals have become a part of everyday life for many people in Lajamanu. Analgesics, cough syrup, and skin ointment were purchased from the shop, while prescriptions were regularly obtained from the clinic. Clinic staff distributed rehydration therapy, skin cream, and antibiotics as well as medication to treat hypertension and diabetes. Given the high rate of chronic illness and morbidity, individuals were often prescribed a variety of pills for extended periods. While pharmaceuticals were widely distributed in Aboriginal communities, nurses complained that a significant percentage of residents were “noncompliant.” Compliance has been defined as “the extent to which an individual’s behavior—in terms of taking medication, following diets, or executing lifestyle changes— coincides with medical or health advice” (Jay, Litt, and Durant 1984, 124). The notion of compliance has been critiqued for advocating unquestioning patient submission to authoritative medical guidance while ignoring the political and economic contexts in which pharmaceuticals 100 are situated (Humphery 2006; Rouse 2010). Mindful of this appraisal, I seek to invoke noncompliance as a local idiom—a term that is frequently utilized by medical staff and researchers across the Northern Territory— rather than a universal prescription. In Lajamanu, noncompliance was most often associated with the use—or rather disuse—of pharmaceuticals. On one of my visits to the clinic, Caroline, a nurse, pointed out five shelves filled to capacity with medications awaiting pick up by patients. This represented prescriptions for approximately 125 people, or about 15 percent of the total population. Every four weeks, boxes containing hundreds of uncollected pills were sent back to Katherine where they were destroyed. As in Lajamanu, high rates of pharmaceutical noncompliance are the norm among Aboriginal people living throughout the Northern Territory (Devitt and McMasters 1998; Mathews 1996; Scrimgeour, Rowse, and Lucas 1997; Taylor 1978). Adherence to some therapies has been found to be as low as 5 percent (Kruske, Ruben, and Brewster 1999). During conversations with medical professionals, excessive rates of noncompliance were blamed for many of the health problems that plagued the Aboriginal population. I was told that noncompliance can allow a disease to worsen, resulting in an increased risk of hospitalization or permanent health damage. Failing to control diabetes can lead to a loss of limbs or eyesight, while not taking a full course of antibiotics has caused the emergence of resistant strains (Mathews 1996, 32). In addition, noncompliance costs health services a great deal. Medical staff expend valuable time and resources treating diabetes complications and other conditions that are considered preventable if pharmaceuticals are taken regularly. The expense of discarding unused pills and funding emergency plane evacuations is one reason that the Northern Territory consistently spends larger per capita sums on Aboriginal health. In an effort to curb the financial and health costs, research has been conducted into the factors that contribute to high rates of noncompliance. In many cases, structural dynamics such as inadequate storage facilities, misunderstandings between nurses and patients, and overwork are blamed (Cramer 2005; Humphery 2006). While there is no doubt that these issues frame responses to medication, the situation is far more complex than most health professionals acknowledge. The distribution, conceptualization, and utilization of pharmaceuticals are meaningful acts through which relationships—local and NoNCoMplIANCe 101 international—are constructed and articulated (Farmer 1999; van der Geest and Whyte 1989; Whitmarsh 2008). Pharmaceuticals are not simply objects that are supplied, stored, and consumed. They are inherently social. Examining clinical consultations, van der Geest (2005) asserts that...