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Aboriginal and Torres Strait Islander people have a life expectancy
15-20 years less than other Australians.1-5 The major reason is their
much higher age-standardised mortality for cardiovascular
disease, including ischaemic and rheumatic heart disease and
stroke.1-5 In August 2000, a
symposium on Indigenous cardiovascular health was held at the Annual
Scientific Meeting of the Cardiac Society of Australia and New
Zealand. The symposium focused on the dimensions of the problem, its
causes and potential solutions.
Overview of Indigenous cardiovascular health: Ian Ring (Head,
School of Public Health at James Cook University, Townsville,
QLD) stated that mortality from ischaemic heart disease in the
Aboriginal and Torres Strait Islander population is nearly twice
that in the non-Indigenous population overall, and six to eight times
higher in those aged 25-64 years.1,2 Rheumatic heart disease
is 11 times more common in the Indigenous population.1,2 Reasons for
the high rate of ischaemic heart disease in the Indigenous population
include their high smoking rates (twice the rate in the
non-Indigenous population), high prevalence of type 2 diabetes (two
to four times higher), obesity, and low rates of physical
activity1,4 — all standard risk
factors for ischaemic heart disease. Improving cardiovascular
health among Indigenous people requires these risk factors to be
modified, with greater focus on the underlying social determinants
of risk behaviour.
Professor Ring also dispelled the myth of "overspending" on
Indigenous health by Federal, State and Territory governments. He
quoted the Deeble Report, which found that health expenditure on
Indigenous people amounts to $1.08 for every $1 spent on the
non-Indigenous population, despite the much poorer health status of
Indigenous people.6 The report also found that,
despite their poorer health, Indigenous people access services
funded by the Medical and Pharmaceutical Benefits schemes at much
lower rates than the non-Indigenous population.4,6
The possibility of change within Indigenous populations is
demonstrated by the significant improvements in total and
cardiovascular mortality which have been achieved in Mäori in New
Zealand and Native Americans in the United States since the
1970s.7 These groups have much lower
rates of cardiovascular disease than Indigenous Australians, in
whom rates have changed relatively little.
Social determinants of Indigenous cardiovascular health: Ian
Anderson (Director, Koori Health Research and Community
Development, University of Melbourne, VIC) noted that the
first, and so far only, Aboriginal and Torres Strait Islander Health
Strategy was developed by the Federal Department of Health and
Aboriginal Affairs in 1989, after extensive consultation with
Indigenous organisations and communities, as well as State and
Territory governments.8 The Strategy stressed the
importance of full consultation with Indigenous stakeholders and of
regional planning initiatives, as well as the need for more
infrastructure for primary care and risk-factor-modification
programs (eg, community-controlled health clinics). The Strategy
also recognised the importance of social determinants of health: 70%
of the federal allocation for implementation was directed to
developing housing and community infrastructure. However, this
implementation has had limited success, and Indigenous health
status has remained largely unchanged since 1989. A new draft
National Aboriginal and Torres Strait Islander Health Strategy has
recently been released for community comments by the Office of
Aboriginal and Torres Strait Islander Health.
Professor Anderson stressed that, while there had been progress in
addressing cardiovascular risk factors in Indigenous people, such
as smoking and diabetes, action on the underlying economic and
educational determinants of health has been limited. A possible
reason is that State, Territory and Federal governments are not
ideally structured to deliver holistic care, with many areas that
affect health (eg, employment, education, transport and social
services) being outside the Health portfolio. Professor Anderson
felt that positive change in these important determinants of
cardiovascular health will require much greater integration of
national health policies for Indigenous people.
Barriers to access and treatment: Why does the Indigenous population
access health services at a much lower rate than the non-Indigenous
population, despite their poorer health? Noel Hayman (Manager,
Indigenous Health Services, Queen Elizabeth II Hospital Health
Service District, Brisbane, QLD) described the barriers to
access and treatment in an urban Brisbane community with a relatively
large Aboriginal and Torres Strait Islander population (about 8%).
He noted that relatively few Indigenous people used the Inala
Community Health Centre, a primary care clinic in the community.
Some of the barriers to access were:
- Lack of
Aboriginal and Torres Strait Islander health professionals at the
Centre. Aboriginal people felt more comfortable if Aboriginal
people were involved in their care. A patient in a focus group
commented: "White people use too many big words, they have lived
different lives, talk down to us."
- Perceived unfriendliness of health centre staff, inappropriate
body language, long waits and an appointment system that was
difficult to adhere to.
- Lack of understanding about the way Aboriginal and Torres Strait
Islander people construct reality, their knowledge and values.
- Difficulty in physical access due to lack of private and public
transport.
Dr Hayman described changes to the Centre which have greatly
increased the number of Indigenous patients. He recommended:
- Employing Aboriginal and Torres Strait Islander people as health
professionals or receptionists.
- Purchasing culturally appropriate health posters and artefacts
for the waiting room.
- Providing cultural awareness programs for all staff, including
non-Indigenous health professionals.
- Disseminating information about available services in Indigenous
communities.
This experience illustrated the way barriers to access can be broken
down if cultural factors are considered when planning health service
delivery.
Challenges in Indigenous cardiovascular health:
Andrew Tonkin (Director of Health, Medical and
Scientific Affairs, National Heart Foundation of Australia,
Melbourne, VIC) lamented the paucity of public health data for
Indigenous Australians. He stressed the need for more data to be
collated and analysed by both government and non-government
agencies to allow more effective planning of services.
As the Indigenous population is young, with 40% aged under 15 years,
there is a great opportunity to implement longer-term strategies for
preventing cardiovascular disease, especially through reducing
smoking and diabetes. However, intervention programs must address
the fundamental disadvantage and poverty which underlie so much ill
health in the Indigenous community. Programs must consider
education, the environment and cultural factors, as well as
traditional health paradigms, if Indigenous cardiovascular health
is to be improved in the long term. Professor Tonkin called for a
substantial increase in funding and training of Aboriginal and
Torres Strait Islander health workers and nurses, who play major
roles in health promotion as well as healthcare.
Conclusions: The symposium was an opportunity to highlight the poor
status of Aboriginal and Torres Strait Islander cardiovascular
health to health professionals. It stressed the need for major
changes to the underlying social and economic determinants of
cardiovascular health to achieve significant improvements. These
changes include improved food and nutrition, housing, education and
employment, as well as health promotion. There is also an immediate
need to improve access to mainstream cardiovascular health
services, as the current considerable barriers to access often cause
the Indigenous population to present in the late stages of
cardiovascular disease.
The importance of cultural sensitivity and awareness in planning
health service delivery to Indigenous people was another important
conclusion of the symposium. The substantial improvement in
Indigenous health in New Zealand and North America has demonstrated
that major improvements are possible in the current unsatisfactory
state of cardiovascular health in Indigenous people in Australia.
Warren F Walsh
Senior Staff Cardiologist
Division of Cardiac Services, Prince of
Wales Hospital, Sydney, NSW
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Sam J Lehman, Robert A Baker, Philip E Aylward, John L Knight and Derek P Chew. Outcomes of cardiac surgery in Indigenous Australians Med J Aust 2009; 190 (10): 588-593. [Capacity to Care — Research]