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Medical research perspectives

Medical Research Perspectives

John D Mathews
Med J Aust 1998; 169 (11): 625-629.

Medical Research Perspectives

The Menzies School of Health Research offers a new paradigm of cooperative research

John D Mathews

The Menzies School has addressed problems in Aboriginal and tropical health through research that requires cooperation between disciplines as well as improved communication and trust between researchers, Aboriginal people and the wider community.

MJA 1998; 169: 625-629

Introduction - The politics of Aboriginal health - Success in interdisciplinary and crosscultural collaboration - Some research highlights of medical importance - The Menzies School's work in central Australia - Research highlights in tropical and international health - Resources and links - Cooperation is the secret of success - Looking ahead - Acknowledgements - References - Author's details
- - More articles on Aboriginal health


Introduction
The Menzies School of Health Research, in the Northern Territory, has been a surprisingly successful research investment. The dividends since 1985 include increased understanding of Aboriginal and tropical health problems, the transfer of knowledge and skills into training and improved health services, and some 70 research publications each year.

The Menzies School is a brave and cooperative venture of the Northern Territory Government, the Menzies Foundation (commemorating the name of our longest-serving prime minister), and the University of Sydney. I was appointed as Foundation Director and we moved to Darwin in January 1985, in quixotic mood, and not knowing what to expect. My wife had found a Thomas Keneally quote:

. . . the north is littered with the detritus of great hopes, and Darwin is still an outpost . . . but with a sense of destiny that would have done Athens credit.1

We were naive enough to ignore the implicit warning, and to dream of Athens in the north.

To Darwin I brought a research background in medicine and epidemiology; experience from New Guinea, the Walter and Eliza Hall Institute and Oxford; and 10 years as an NHMRC Fellow at the University of Melbourne. My first dream for the Menzies School was to establish a centre of research excellence. The second dream was to somehow make a difference in Aboriginal health. The potential nightmare was to work out how to realise each dream without jeopardising the other.


The politics of Aboriginal health
Countries with the least education and income tend to have the poorest health, and within any one country persons with the least education and income tend to have the worst health. Box 1 shows the causal linkages between education, income and health in any society, and Box 2 shows how the social dislocation suffered by Aboriginal Australians since colonisation has specifically contributed to their poor health.2

The poor health of Aboriginal Australians is primarily due to social and environmental disadvantage. It is not due to any absolute lack of knowledge about the causes of their ill-health (Box 3), but to the fact that Aboriginal people have had limited access to health resources and knowledge because of their own poverty and educational disadvantage. There has also been limited understanding of Aboriginal health issues by those responsible for funding decisions, compounded by inadequate knowledge and training of health advisers and providers.

Unfortunately, the poor state of Aboriginal health has also been perpetuated by disagreements about what should be done and how, who should do it, and who should pay for it. This lack of consensus, amounting to a modern Babel (Box 4), is only now beginning to be resolved.

The Menzies School has contributed to the debate on Aboriginal health by helping to fill gaps in understanding, communication and implementation. It has attracted expert staff to the Northern Territory, driven research to identify areas of unmet health need, tested innovative health interventions, and been an evaluator, critic and advocate for Aboriginal health policy.


Success in interdisciplinary and crosscultural collaboration
The success of the Menzies School has been driven by the quality of our staff, the challenges faced, and by the added value that comes from collaboration and communication between diverse disciplines. Above all, success would have been impossible without the expertise and commitment of Aboriginal staff and colleagues. Major contributions have been made by Lorna Fejo, Jessica Bujevich, the late Sally Ross, Louisa Collins, Daisy Yarmirr, Josie Crawshaw, Annie Bonson, Geoffrey Angeles, Mai Katona and many others. Their achievements have been to communicate the health priorities and values of Aboriginal people to non-Aboriginal researchers, to facilitate research projects in a culturally appropriate manner, and to work with other Aboriginal people to show how knowledge and research findings can be fed back to communities and applied to achieve practical health benefits. Recently, the Tiwi Health Board has played a key role in codifying the many sensitive issues that arise in crosscultural research and providing a framework for future research in a Legal Agreement signed with the School (Box 5).


Some research highlights of medical importance
(See also Box 6)

Understanding streptococcal infection and rheumatic fever At any one time, up to 60% of Aboriginal children in bush schools have skin sores infected with group A streptococci, and there are occasional epidemics of acute poststreptococcal glomerulonephritis. Bart Currie, Jonathan Carapetis and colleagues have shown that the same communities suffer from the highest rates of rheumatic fever in the world. To overcome the limited awareness of rheumatic fever and the low rates of compliance with penicillin prophylaxis, Geoffrey Angeles, Norma Benger and other members of our Aboriginal Unit have developed The Rheumatic Fever Story, a successful education program (booklets, songs and videos) for patients, relatives, health workers and the wider community.

K S Sriprakash, a talented molecular geneticist, has led molecular studies of group A streptococci, detecting as many as 13 immunologically distinct types present at the same time in a single bush community of a few hundred children, with a total of about 100 different types circulating through Aboriginal communities in northern Australia, many that have never been identified elsewhere. Candidate nephritogenic strains have recently been identified. This work is linked to studies of the epidemiology and population biology of group A streptococci in Aboriginal communities, to studies of treatment efficacy, and to studies directed towards vaccine development with Michael Good and the Cooperative Research Centre for Vaccine Technology in Brisbane.  

Understanding endemicity of respiratory bacteria For Aboriginal children, persistent otitis media is a major cause of illness, hearing loss and educational disadvantage. Amanda Leach, Judith Boswell, Terry Nienhuys and others have shown that otitis media develops in all Aboriginal infants within a few weeks of birth immediately after nasopharyngeal colonisation with Streptococcus pneumoniae and Haemophilus influenzae. Although each infection seems to be eventually cleared by the host response, there are some 30 different serotypes of pneumococcus and at least 50 types of haemophilus which can queue up to infect every child in every community. The persistence of nasal infection and respiratory disease is associated with the persistent colonisation by such multiple bacterial strains into adult life. Cross-infection is driven by overcrowding, poor hygiene and the large numbers of bacterial strains circulating. Detailed modelling suggests that each strain is maintained indefinitely, even in relatively small populations, because there are always a few carriers of each strain left to infect susceptible newborn infants. Furthermore, with the carriage of multiple serotypes or strains at the same time by the same host individual, some of the strains are "hidden" from the immune system, giving them an extra survival advantage. Likewise, antibiotic-resistant strains "hide" behind sensitive strains, only to be revealed by antibiotic treatment.  

Understanding scabies in dogs and people Skin infections associated with scabies infestation are frequent in Aboriginal communities, particularly among children. Because dog scabies was thought to be a source of infection for people, scabies control programs have sometimes treated dogs rather than people. Now, using molecular genotyping, Shelley Walton and colleagues have shown that populations of scabies mites from dogs in Australia and America do not overlap with scabies from people in those same areas. This strongly suggests that scabies from dogs are not driving human scabies in remote communities and that control programs for human scabies must focus on people. Jonathan Carapetis and Daisy Yarmirr, in cooperation with Aboriginal and health service colleagues, have shown that community-based treatment with pyrethrin can reduce both scabies and streptococcal impetigo.  

Understanding renal disease and cardiovascular disease Mortality from renal failure for Aboriginal Australians is very high and rising. Up to 50% of Aboriginal adults have proteinuria and in some communities 2% are receiving renal dialysis to stay alive. Paul van Buynder and colleagues identified obesity, hypertension and non-insulin-dependent diabetes mellitus (NIDDM) as risk factors for proteinuria in Aboriginal communities. Modelling studies with Alison Goodfellow and others suggest that proteinuria develops from very early in life in those with evidence of past infection with group A streptococci. Wendy Hoy and colleagues have shown that low birth weight is predictive of NIDDM, proteinuria, and presumably renal disease, and have suggested that the risk factors for renal disease can also help to explain the high rates of cardiovascular disease in Aboriginal adults.  

Causes of disease acting from early in life The role of low birth weight as a predictor of poor health in later life has attracted much recent attention, and is of particular importance for Aboriginal Australians. Wendy Hoy and others have shown that the combination of low birth weight with adult obesity appears to confer the highest risk of NIDDM, proteinuria and other disorders. Sue Sayers has shown that high rates of Aboriginal low birth weight are due to intrauterine growth retardation, possibly resulting from maternal malnutrition, infection and substance abuse. Thus, low birth weight may be best regarded as a marker of those adverse influences in pregnancy that are the actual mediators of adverse health effects in later life. This hypothesis would explain how poor health can pass from generation to generation, and may provide another reason why health has been slow to improve for many Aboriginal Australians.  

Early treatment of renal disease The epidemic of Aboriginal renal disease should eventually be controllable through public health measures such as improved nutrition and infection control, particularly in pregnancy. In the meantime, there is a strong rationale to provide "best-practice" clinical treatment, not previously available for Aboriginal people. Accordingly, Wendy Hoy, as an adjunct to the NHMRC-funded research program, has introduced treatment with ACE inhibitors for Tiwi people with early renal disease. Compliance is good, and treatment markedly reduces the rate of deterioration of kidney function, which will in turn prolong life and reduce the escalating social and financial costs of dialysis services.


The Menzies School's work in central Australia
We have a small research unit in Alice Springs to complement our major operation in Darwin. Major contributions include those of Tim Rowse (historical, social and nutritional studies), David Scrimgeour, Robyn McDermott, Ilan Warchivker and John Wakerman (evaluation studies), and Komla Tsey (health and education).


Research highlights in tropical and international health
David Kemp, FAA, joined the School as Deputy Director in 1992, with support from the Wellcome Trust and from the Howard Hughes Institute to continue his fundamental work with falciparum malaria, and to commence new molecular studies of haemophilus, donovanosis, and scabies. This year saw the culmination of his 10-year search, begun at the Walter and Eliza Hall Institute, to find the cytoadherence gene in Plasmodium falciparum that is believed to explain the stickiness of red blood cells in cerebral malaria. The new gene, designated CLAG, was identified and sequenced, and a CLAG knock-out was shown to have lost the stickiness phenotype. The team has subsequently identified additional genes, similar to CLAG, elsewhere in the malaria genome, opening up exciting new possibilities for treatment or prevention of cerebral malaria.

Other malaria projects in Indonesia are funded by a grant from the Northern Territory Government to mark the 50th anniversary of Indonesian independence and a US National Institutes of Health grant to Nick Anstey, and are being carried out in cooperation with Emiliana Tjitra and Indonesian colleagues.


Resources and links
(See also Box 7)
The achievements of the Menzies School have depended on the generous financial support of the Northern Territory Government and the Menzies Foundation, competitive grants from the National Health and Medical Research Council and other agencies in Australia and overseas, and private and corporate donations. In 1998, the annual budget was $6 million to support about 100 employees and postgraduate research students.

The School has also enjoyed the goodwill and cooperation of Territory Health Services and other arms of government, Aboriginal communities, medical services and organisations, the National Heart Foundation and other non-government organisations, the University of Sydney, the Northern Territory University, and Flinders University Clinical School at the Royal Darwin Hospital.

The Menzies School became the lead agency in a successful bid to establish the Cooperative Research Centre for Aboriginal and Tropical Health in 1997. Through its Board, chaired by Dr Lowitja O'Donoghue, and with a majority of Aboriginal members, the Cooperative Research Centre has an agenda to discover and disseminate knowledge about Aboriginal health problems, to provide more research and training positions for Aboriginal people and to facilitate Aboriginal control of the planning and implementation of health research and health services.

From 1994, the School has taught postgraduate coursework in public health to help develop skills in the local health workforce. Now, in partnership with the Northern Territory University, the School is promoting a broader vision of public health education through a Faculty of Public Health. This Faculty will continue postgraduate teaching and promote access to accredited courses at multiple levels and to short courses to meet the needs of teachers and educators, administrators, Aboriginal people and others in need of public health knowledge and expertise.


Cooperation is the secret of success
The Menzies School has become a leader in tropical and Aboriginal health research, not only through the talent and commitment of individuals, but also because of its capacity to encourage cooperation between disciplines, and to build and sustain cooperative partnerships with Aboriginal stakeholders, health services and governments in northern and central Australia.

This cooperative research paradigm, linking the laboratory with the clinic and the community, has delivered important understandings and contributed to more effective strategies for training of health staff, and to improved health promotion, prevention and treatment strategies. Despite its short-term opportunity costs, cooperation in health research pays off in the longer term by helping to translate modern scientific knowledge into direct community benefit, just as natural selection has discovered that cooperative processes provide pay-offs in the longer term in most otherwise competitive biological and social systems. Indeed, interactions that balance competition with cooperation turn up in all evolving systems to achieve a balance between short term returns (efficiency) and longer term strategic outcomes.


Looking ahead
The multidisciplinary focus of the Menzies School of Health Research has more than justified the vision of its founders by delivering value for money to its stakeholders and the wider community. However, as the School faces the new millennium, it needs
  • to serve the community with a broad public health perspective while maintaining the deep biomedical expertise that underpins strategic research
  • to be an academic critic of health policy, while working in partnership with health services to promote necessary improvements
  • to persuade funding agencies to recognise the value of, and to pay the full opportunity costs of, cooperation and collaboration between different disciplines and organisations
  • to maintain its cohesion, corporate identity, shared values and vision for the future.
Talent and enthusiasm are always welcome!


Acknowledgements
This summary is based on the work of many colleagues to whom I am deeply indebted. Special thanks to Coralie Mathews, Bart Currie, Dave Kemp and Lindy Warrell for reviewing the manuscript, and Debra Davis for its preparation.


References
  1. Keneally T. Outback. Sydney: Coronel Books, 1983.
  2. Mathews JD. Historical, social and biological understanding is needed to improve Aboriginal health. Recent Adv Microbiol 1997; 5: 257-334.


Author's details
Menzies School of Health Research, Darwin, NT.
John D Mathews, AM, MD, Professor and Director.
Reprints will not be available from the author. Correspondence: Professor J D Mathews, Menzies School of Health Research, PO Box 41096, Casuarina, NT 0811
Email: johnATmenzies.su.edu.au




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1: Social determinants of good health

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2: Historical impacts of colonisation upon Aboriginal health

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3: Lessons about Aboriginal health and research

Aboriginal health is limited more by the failure to apply knowledge that already exists than by the lack of knowledge itself. Aboriginal people have always understood this, and they have been naturally suspicious of research projects that seem to serve the interests of researchers more than those of Aboriginal people. The most relevant research questions are:

  • How to ensure that existing knowledge is taken up and acted upon by public sector decision-makers and managers and health professionals.
  • How to ensure that Aboriginal people have access to the knowledge and resources that they need to use to improve their own health.
  • How to plan specific research projects to make a difference by
    • finding better ways of working across cultural boundaries.
    • improving access to knowledge, resources, education and health services for Aboriginal people
    • providing social or biomedical insights about better ways to promote health or prevent or treat disease for Aboriginal people.
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4: The modern Babel

The biblical Tower of Babel (Genesis, xi) is the traditional metaphor for the schisms in language, beliefs and culture in the modern world. It reminds us that without a common language and shared concepts, we are unable to understand each other.

In the Northern Territory in 1985 many different voices were speaking about Aboriginal health. Those on the political right tended to blame the victims, and saw the emergence of Aboriginal control as a threat. There were differences between levels of government. Some officials lacked appropriate expertise and were unused to problem solving, let alone to academia. Some health professionals were escaping from academia, or had a postmodern scepticism about science and medicine. Some romantics said that traditional Aboriginal people should be taught as little as possible about Western culture. Urban Aboriginal people voiced their hurt from discrimination or family experiences as stolen children. At the same time, Aboriginal health workers had strong cultural skills, but only limited health training. Traditional Aboriginal people, with insufficient support to deal effectively with the outside world, saw a progressive erosion of their culture and values.

In such a Babel there could be little consensus about how to improve Aboriginal health. Without consensus, our political masters had a continuing excuse to ignore many issues. As a result, the poor state of Aboriginal health has continued to burn into the conscience of Australia. It is likely to be long remembered as the worst-ever failure of our nation.

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5: Creative partnership - Tiwi Health Board and the Menzies School of Health Research

Ms Alberta Puruntatameri and Dr Val Asche signing the Legal Agreement between the Tiwi Health Board and the Menzies School of Health Research, 22 October 1998.

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6: Some important research areas at the Menzies School

Cultural understandings of Aboriginal illness and death (Tarun Weeramanthri, Ada Parry, Norma Benger, Clifford Plummer, Vicky Nangala-Tippett and others)

Education and health

  • Otitis media and hearing disability contribute to poor educational outcomes (Anne Lowell, Terry Nienhuys, Judith Boswell, Joan Koops, Al and Lesley Yonowitz)
  • Poor education contributes to poor health (Komla Tsey)
Social and environmental determinants of health
  • Community comparisons (Estrella Munoz, John Mathews and others)
  • Environmental health study (Katherine Henderson, Ross Bailie)
  • Melioidosis and contaminated water supplies (Mark Mayo, Bart Currie and Nick Anstey)
Studies of substance abuse and appropriate interventions
  • Evaluations of community interventions for alcohol (Peter d'Abbs, David Scrimgeour)
  • Health effects and interventions for petrol sniffing (David Scrimgeour, Chris Burns and Bart Currie)
  • Health effects of kava drinking and policy implications (John Mathews, Malcolm Riley, Estrella Munoz, Peter d'Abbs, Chris Burns, and Alan Clough)
Interventions to improve Aboriginal health
  • Community Nutrition Program at Minjilang (Mandy Lee, Annie Bonson, Daisy Yarmirr and others)
  • Strong Women, Strong Baby, Strong Culture Program Evaluation (Lorna Fejo, Dorothy Mackerass and others)
  • Diagnosis and treatment of donovanosis and sexually transmitted diseases (Frank Bowden, Jenny Carter, David Kemp and colleagues)
  • Improved diagnosis and treatment of otitis media (Amanda Leach, Al Yonowitz, Peter Morris, Harold Koops and colleagues)
  • Treatment of trachoma with azithromycin (Andrew Laming, Annie Bonson and colleagues)
  • Smoking prevention (Rowena Ivers, Ross Bailie and the National Heart Foundation)
Health service research and evaluation
  • Best practice procedures (Bart Currie, David Scrimgeour, Peter Morris)
  • Evaluation and planning of service models (David Scrimgeour, Chris Burns, John Wakerman and others)
  • Health economic aspects (Robyn McDermott, Ilan Warchivker, John Wakerman)
  • Coordinated care trials evaluation (Peter d'Abbs, Ross Bailie).
See http://www.menzies.su.edu.au for a much more detailed account of the work of the Menzies School over the last five years. See also reference 2.

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7: The Menzies building

The Menzies School of Health Research was able to secure generous joint funding from the Northern Territory and Commonwealth governments for its new building in Darwin, opened in November 1996.

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John D Mathews