Volume 184 Issue 10

Objective: To identify the causes of the gap in life expectancy between Indigenous and non-Indigenous populations of the Northern Territory and how the causes have evolved over time.Design and setting: Analysis of NT death data over four 5-year periods, 1 January 1981 to 31 December 2000 inclusive. A decomposition method using discrete approximations (Vaupel and Romo) was applied to abridged life tables for the Indigenous and non-Indigenous populations of the NT.Main outcome measures: Contribution of causes of death, grouped according to global burden of disease groups and categories, to the life expectancy gap.Results: The gap between the life expectancy of Indigenous and non-Indigenous people in the NT did not appear to narrow over time, but there was a marked shift in the causes of the gap. In terms of disease groups, the contribution of communicable diseases, maternal, perinatal and nutritional conditions halved during the 20 years to 2000. Meanwhile, the contribution of non-communicable diseases and conditions increased markedly. The contribution of injuries remained static. In terms of disease categories, the contribution of infectious diseases, respiratory infections and respiratory diseases declined considerably; however, these gains were offset by significantly larger increases in the contribution of cardiovascular diseases and diabetes for Indigenous women and cardiovascular diseases, cancers and digestive diseases for Indigenous men.Conclusions: The main contributors to the gap in life expectancy between the Indigenous and non-Indigenous populations were non-communicable diseases and conditions, which are more prevalent in ageing populations. With the life expectancy of Indigenous people in the NT expected to improve, it is important that public health initiatives remain focused on preventing and managing chronic diseases.

Yuejen Zhao PhD · Karen Dempsey BN, MPHTM, MAE

Objective: To investigate the short-term outcome of critically ill Indigenous patients.Design and participants: Retrospective cohort study using de-identified audit data from a tertiary intensive care unit (ICU) in Western Australia for the 11-year period 1 January 1993 to 31 December 2003.Main outcome measures: Hospital mortality (crude, and adjusted for severity of illness).Results: Of 16 757 ICU patients, 1076 (6.4%) were identified as Indigenous. The Indigenous patients were younger and more commonly had chronic liver and renal diseases. Indigenous people represented 3.2% of the population of Western Australia in 2001, but represented 3.1% and 9.5% of all elective and emergency ICU admissions, respectively. Diagnoses of sepsis, pneumonia, trauma, and cardiopulmonary arrest were common among critically ill Indigenous patients. Following emergency admission, the crude hospital mortality for Indigenous patients was higher (22.7% v 19.2%; crude odds ratio, 1.24; 95% CI, 1.04–1.47) than for non-Indigenous patients. The crude hospital mortality of critically ill Indigenous patients was lower than that predicted by the APACHE II prognostic model and was similar to that of non-Indigenous patients after adjusting for severity of illness and chronic health status.Conclusions: The pattern of critical illness affecting Indigenous Australians in Western Australia was different from that affecting non-Indigenous patients. The crude hospital mortality was high, but similar to that of non-Indigenous Australians after adjusting for severity of illness and chronic health status.

Kwok Ming Ho MRCP, FANZCA, FJFICM · Judith Finn PhD · Geoffrey J Dobb FRCA, FANZCA, FJFICM · Steven A R Webb PhD, FRACP, FJFICM

Each Indigenous health problem calls for its own unique mix of descriptive and intervention research in both clinical and public health fields The Aboriginal and Torres Strait Islander Social Justice Commissioner, Tom Calma, has challenged all governments to commit to achieving Indigenous health outcomes equal to those of non-Indigenous Australian people within 25 years.1 Governments have set similar goals in the past, but have avoided such clear deadlines. What role should research play in a properly funded program for Aboriginal and Torres Strait Islander health equality? Research can provide useful evidence to better target health policy and strategy, and to guide more effective health services. Researchers can also intervene with empirically-based good sense when the debate gets sidetracked by slogans from all points in the political spectrum. The debate will not be depoliticised, but researchers may help in moving it along. In fact, researchers would be wise to be humble about their impact. They only act as small — if sometimes crucial — wheels in the complex social and political machinery that drives the necessary changes to health services and to the broader social determinants of health. They also must bear the legacy of unhelpful or damaging past health research that fuels Indigenous distrust of research and researchers today.2 Since the social changes of the late 1960s, Australian researchers have increasingly turned their attention to the health of Aboriginal and Torres Strait Islander peoples. Indigenous health publications occupied less than one per cent of the pages of the Medical Journal of Australia in the years before 1970, but by the 1990s this had risen to more than four per cent.3 In this issue of the Journal, Sanson-Fisher and colleagues describe the trends in the numbers of Indigenous health publications in Australia, New Zealand, Canada and the United States since 1987 (Indigenous health research: a critical review of outputs over time).4 They do not tell us who wrote these publications, nor do they tell us much about what was written. Nevertheless, they report that the greatest increase in the number of Indigenous health publications was in Australia, where the total number rose from 28 in 1987–1988 to 167 in 1997–1998 then fell to 147 in 2001–2003. Original research publications were dominated by descriptive research. We agree with their concern about the much smaller (albeit increasing) number of publications assessing health interventions, and the consistently low number assessing measurement tools. How do we find the right balance between these different types of research? We need research that assesses new interventions for diseases or clinical syndromes, such as chronic suppurative otitis media, that are common among Aboriginal and Torres Strait Islander peoples, but relatively uncommon in other Australians. We may also need to evaluate the transferability of some well tested interventions when we suspect that they will work differently in an Indigenous health setting, which is the case for chronic disease programs. Often, however, we can readily apply research from other settings without the need for new research. Some descriptive research can still be necessary when it fills gaps in knowledge that undermine the capacity to make good policy decisions. Different problems will require research programs with different mixes of descriptive and intervention research, and different research methods. Health-service providers, policy makers and Indigenous communities can tell us which uncertainties are impeding action to improve Indigenous health, and so need answers from new research programs. The “road map” produced by the National Health and Medical Research Council (NHMRC) describes what areas of new research are agreed to be most useful: from patterns of risk factors to researching resilience and well-being.5 The NHMRC has also produced guidelines to help non-Indigenous researchers build more ethical relationships with Aboriginal and Torres Strait Islander communities.6 The Journal has not just been a passive recipient and publisher of an increasing number of manuscripts about Aboriginal and Torres Strait Islander health. The first of many special supplements on Aboriginal health was published in 1975.7 This issue, like several earlier issues, is devoted to Aboriginal and Torres Strait Islander health. There are other less visible changes at the Journal: editors can now usually recruit at least one Indigenous reviewer for every Indigenous health manuscript. No longer is Indigenous health research only a matter of white researchers writing about Aboriginal people for a white readership:8 there are slowly more and more Indigenous people involved in all stages of the research process — from setting the research question, to doing the research, to writing, reviewing and reading the final publication. There have been changes in how Indigenous health problems are framed in the Journal. Sixty years ago, the Journal reported a conference paper which compared the falling Australian Aboriginal population with the increasing indigenous populations of the United States, Canada and New Zealand.9 The author did not call for more research on health interventions but for more scientific research on “hybrid vigour”, reflecting the prevalent but misguided political obsession with the “half-caste problem”. However, he then moved to a more familiar issue. He linked the unfavourable international comparisons to the “outstandingly mean, neglectful and backward” approach of Australian governments to Aboriginal people: the 63 shillings of Australian government annual spending per Aboriginal person compared with much higher spending in the United States (£23) and Canada (£10). Recent research has documented that Australia now spends only 18% more on health services for each Aboriginal and Torres Strait Islander person than for each non-Indigenous person, in spite of the much greater burden of illness among Indigenous people, and the higher costs of providing services to them, especially in remote areas.10 This descriptive research on expenditure has been invaluable in cutting across polemical argument about the “buckets of money” that are “thrown” at Indigenous health. This descriptive work now needs to be complemented by research that will evaluate financial and administrative interventions in Indigenous health against progress towards the other goal set by the Social Justice Commissioner: equal access to primary health care and health infrastructure within 10 years.

David P Thomas PhD, FAFPHM · Ian P Anderson MB BS, FAFPHM

Objective: To determine the number and nature of publications on Indigenous health in Australia, Canada, New Zealand and the United States) in 1987–1988, 1997–1998 and 2001–2003.Data sources: MEDLINE and PsychLit databases were searched using the following terms: Aborigines or Aboriginal; Torres Strait Islander; Maori; American Indian; North American Indian, or Indian, North American; Alaska/an Native; Native Hawaiian; Native American; American Samoan; Eskimos or Inuit; Eskimos or Aleut; Metis; Indigenous.Study selection: Publications were included if they were concerned with the health of Indigenous people of the relevant countries. 1763 Indigenous health publications were selected.Data extraction: Publications were classified as either: original research; reviews; program descriptions; discussion papers or commentaries; or case reports. Research publications were further classified as either measurement, descriptive, or intervention. Intervention studies were then classified as either experimental or non-experimental.Data synthesis: The total number of publications was highest in 1997–1998 for most countries. The most common type of publication across all time periods for all countries was research publications. In Australia only, the number of research publications was slightly higher in 2001–2003 compared with other time periods. For each country and at each time, research was predominantly descriptive (75%–92%), with very little measurement (0–11%) and intervention research (0–18%). Overall, of the 1131 research publications, 983 were descriptive, 72 measurement and 76 intervention research.Conclusions: The dominance of descriptive research in Indigenous health is not ideal, and our findings should be carefully considered by research organisations and researchers when developing research policies.

Robert W Sanson-Fisher BPsych, MPsych, PhD · Elizabeth M Campbell BPsych, PhD · Janice J Perkins PhD · Steve V Blunden GradDipHealth Admin · Bob B Davis GradDipEpidemiol

Australian Aboriginal people have the highest rates of these diseases in the world This issue of the Journal provides a range of insights into acute rheumatic fever (ARF) and rheumatic heart disease (RHD), highlighting the divergent perspectives of health providers, health care services, researchers and those afflicted with poor health. From the exposé of the realities of biomedical research in remote Aboriginal communities by McDonald and colleagues,1 through discussions with patients and families by Harrington et al,2 and finally a study of the association of ARF/RHD with B-cell antigens by Harrington et al,3 clinical and biochemical aspects of ARF/RHD are explored. We also gain insights into the realities of usually urban, non-Aboriginal researchers working in remote Aboriginal communities; the intercultural gap between urban and remote, and Aboriginal and non-Aboriginal concepts of disease, health and health care. Successive generations of medical students trained in southern Australian hospitals will have seen the advancing age of the cohort of patients with “interesting and educational” murmurs attributable to RHD, to the extent that it is now rare to come across a non-Indigenous Australian with RHD. ARF/RHD is an eradicable condition, rates of which have declined dramatically in industrialised countries where social and economic disadvantage has decreased.4 Importantly, this is not a condition to which Aboriginal people are innately susceptible — in the past, RHD affected all Australians. However, although Australia is among the world’s wealthiest nations, Australian Aboriginal people today hold the dubious distinction of having the world’s highest rates of ARF/RHD.5 In the study by Harrington et al of prophylaxis for ARF, participants describe the broad range of impediments to accessing regular penicillin prophylaxis, highlighting the importance of venturing beyond the new mantra of chronic disease “self-management” and individual autonomy to understand the reasons behind “the problem of non-compliance”.2 An empiric response to non-compliance with ARF prophylaxis is to refer to an individual patient’s autonomy, assuming that failure to attend is a conscious decision based on avoiding the pain of injections. The beliefs and attitudes of those surveyed contradict this premise, raising questions about the concepts of autonomy and paternalism as they relate to Aboriginal health. Cass and colleagues have previously described how communication between Aboriginal Australians and a largely non-Aboriginal health workforce can result in frequent and often unrecognised miscommunication.6 Along with the experience of McDonald et al of what was viewed by some research participants as the unsympathetic behaviour of researchers seeking written consent,1 this challenges all non-Aboriginal Australians involved in health care to respect and reflect the wishes and beliefs of Aboriginal people in both health care and health-related research. Active participation of Aboriginal people is imperative at all levels of health research and health care delivery involving Aboriginal people. Further, as was borne out in the National Aboriginal Community Controlled Health Organisation chronic ear infection trial, Aboriginal control of health care and health research is both attainable and effective.7 The two articles by Harrington and her colleagues further exemplify barriers residents of remote Australia may face in accessing primary health care services.2,3 The vast majority of staff in the community health service described were female and, despite nothing to suggest a substantial female susceptibility to ARF/RHD, only 7% of those surveyed were male.2 Unfortunately, without the views of a significant sample of men, it is not possible to extrapolate these findings beyond women. Aboriginal men bear a disproportionate level of health disadvantage, and impediments they face in accessing health care are a cause of concern and a focus for action.8 The insightful studies seen in this issue of the Journal underscore the importance of recognising, as a minimum standard, the active participation of Aboriginal people through all phases of health research and health service provision involving Aboriginal individuals and communities. Only by doing so will we recognise, celebrate and bridge the intercultural divide as it relates to a chronic disease such as RHD. While the underlying socio-economic determinants of ARF/RHD may be clear, the solutions are neither simple, nor exclusively in the domain of health services and health resources. Primary prevention of ARF/RHD requires broad-scale political commitment to addressing the social, economic and environmental inequities experienced by Aboriginal Australians. In the meantime, there is great capacity for health care providers to concentrate on meeting the needs of those with ARF/RHD through better diagnosis, prevention and access to care.

Graeme P Maguire FRACP, MPH · Carmel Nelson DRANZCOG, FRACGP, FACRRM

Objective: To test the B-cell antigen D8/17 as a marker of past rheumatic fever (RF) in a predominantly Aboriginal Australian population, and to evaluate technical modifications to allow its use in remote settings.Design and setting: Cross-sectional survey in a remote Aboriginal community, a regional tertiary referral hospital and a tertiary paediatric centre in Melbourne.Participants: 106 people, including three with acute RF, 38 with a history of past RF, 20 relatives of these people, and 45 healthy controls.Main outcome measure: D8/17 expression in B cells.Results: Blood was collected from each participant and the expression of D8/17 and CD19 in each sample was analysed by flow cytometry. The mean proportion of D8/17-positive B cells was 39.3% (SD, 11.8) in patients with previous RF, 22.5% (SD, 5.2) in first-degree relatives, 11.6% (SD, 7.2) in controls, and 83.7% (SD, 10.1) in patients with acute RF (analysis of variance test between means, P = 0.001). A cut-off of 22.1% of D8/17-positive B cells to indicate past RF yielded the highest percentage of correct results (95.4%). Delayed staining of whole blood (mean, 0.55 days; SD, 0.2) gave equivalent results to immediate staining, but the D8/17 assay on peripheral blood mononuclear cells was unreliable.Conclusions: The B-cell antigen D8/17 accurately identifies Australians with a past history of RF, and the assay is feasible in remote settings with access to facilities capable of performing D8/17 staining within half a day of sample collection.

Zinta Harrington MB BS, BA · Kumar Visvanathan PhD, FRACP · Narelle A Skinner BSc · Nigel Curtis PhD, FRACP · Bart J Currie FRACP, DTM+H · Jonathan R Carapetis PhD, FRACP

Before embarking on an epidemiological study of acute rheumatic fever in remote Aboriginal communities, researchers engaged in the processes of community consultation, consent and household enrolment. Community expectations and time constraints are not necessarily those of the funding bodies, and a considerable investment of time and local engagement was required before the project proceeded with local support. The remoteness of the communities, harsh climate and limited infrastructure made working conditions difficult. Nevertheless, the study was completed and the results are being returned to the local councils and households. The research team continues to maintain its relationship with each study community.

Malcolm I McDonald FRACP, FRCPA · Norma Benger BFineArts, DipHealthPromotion · Alex Brown BMed, MPH · Bart J Currie FRACP, DTM · Jonathan R Carapetis PhD, FRACP

Aim: To identify factors that affect rheumatic fever prophylaxis for remote-living Aboriginal patients, and to determine the proportion who received adequate prophylaxis.Design and setting: Interview (with analysis based on principles of grounded theory) of patients with a history of rheumatic fever or rheumatic heart disease and their relatives, and health service providers in a remote Aboriginal community; audit of benzathine penicillin coverage of patients with rheumatic heart disease.Participants: 15 patients with rheumatic heart disease or a history of rheumatic fever, 18 relatives and 18 health care workers.Results: Patients felt that the role of the clinic was not only to care for them physically, but that staff should also show nurturing holistic care to generate trust and treatment compliance. Differing expectations between patients and health care providers relating to the responsibility for care of patients absent from the community was a significant factor in patients missing injections. Neither a biomedical understanding of the disease nor a sense of taking responsibility for one's own health were clearly related to treatment uptake. Patients did not generally refuse injections, and 59% received adequate prophylaxis (> 75% of prescribed injections).Conclusion: In this Aboriginal community, concepts of being cared for and nurtured, and belonging to a health service were important determinants of compliance.

Zinta Harrington MB BS, BA · David P Thomas FAFPHM, PhD · Bart J Currie FRACP, DTM+H · Joy Bulkanhawuy

The 2006 Dr Ross Ingram Memorial Essay Prize has been won by Dennis McDermott for his essay Unknown family at the taxi stand, published in this issue. Dennis is a Koori psychologist and conjoint senior lecturer in Indigenous health at the University of New South Wales. He is also a published poet, including a collection entitled Dorothy’s skin, published in 2003. Unknown family at the taxi stand uses stories from the author’s own family to flesh out some of the complexities of mental ill-health in Indigenous Australians. Dennis wrote and submitted the essay in the belief that . . . narrative can carry a complexity that epidemiology lays out as so many bones. Coolly useful as data are, when statistics have real human faces there’s a chance that a lost emotional resonance might return. For Gubbas (non-Indigenous Australians) to come to grips with what’s happening in Indigenous health in this country doesn’t require a bleeding heart. It does require new means to “de-Other” Indigenous Australians — to situate us, and our experiences, inside the national consciousness. Blackfella health won’t change until we are no longer the exotics of our own land. The Dr Ross Ingram Memorial Essay Prize is awarded for the best essay by an Aboriginal or Torres Strait Islander person on Indigenous health. It carries a prize of $5000 (donated by the Australasian Medical Publishing Company). For details on how to enter next year, see our website (www.mja.com.au). Thanks to our external panel of judges and to Dennis, as well as our runner-up Marshall Watson (whose essay A journey of Indigenous identity will be published in the MJA later this year) and all the other entrants who shared their stories of sorrow, discovery, joy and hope with us. The universe is made of stories, not atoms. (Muriel Rukeyser)

Ruth M Armstrong

The summer before last, two members of my family died. For an extended Aboriginal family, the fact that they died within 6 weeks of one another wasn’t unusual — no less hurtful, but not out of experience. Blackfellas, unfortunately, bury often. Both deaths were unexpected: my mother’s, from postoperative complications, and my never-met, distant in-law’s, from violence. My mother’s was unusual (she’d made it to 87), my unknown relative’s less so: shocking, distressing to all connected to her, but not unheard of for black women, or men, in their twenties. It was unclear whether the violence was self- or other-inflicted — the stories of the male relative who found her and the cops differed (“there was a piece of rope”/“there was no rope to be seen”). What was not in dispute was the fact that two young boys, who had accompanied the relative to the woman’s front door, now carried the picture of her legs protruding from a door frame down the hall. This is a difficult essay to write, even to justify: it’s personal — involving current and possible future pain for people I’m close to and care about — yet it relates to concerns that I research and talk about professionally all the time. As a Koori psychologist who has worked for some years teaching Indigenous health to medical students and registrars and Indigenous wellbeing to mental health professionals, it’s undertaken in the belief that narrative can carry a complexity that epidemiology lays out as so many bones. Coolly useful as data are, when statistics have real human faces there’s a chance that a lost emotional resonance might return. For Gubbas (non-Indigenous Australians) to come to grips with what’s happening in Indigenous health in this country doesn’t require a bleeding heart. It does require new means to “de-Other” Indigenous Australians — to situate us, and our experiences, inside the national consciousness. Blackfella health won’t change until we are no longer the exotics of our own land. * The Great Dividing Range. My Aboriginal country is in New South Wales, west of the divide.* The day I was due to fly to New Zealand, to spend a few days with my Wellington-based partner before she headed to Europe to give a paper, my mother’s condition worsened. I grabbed a flight to my old home town instead. My mother died the next day. After a few days, out-of-town relatives arrived for the funeral. My partner crossed the Tasman and brought my daughter and grandniece up with her from Sydney. On our way from stocking up on groceries at the local ShoppingWorld, we noticed a public phone by the exit. We thought a quick call or two might help sort out our travel mess, but were there for the next hour. While my partner worked through the complexities of rescheduling a later departure for her conference in winter-dark Copenhagen, I watched people in sun-dresses, shorts and thongs drift out of the glass doors into the dry, inland heat of the car park. Hearing the sound of running feet, I turned to see two small girls in vividly coloured tutus coming down the last avenue of shops. Once through the exit, they took off for the taxi stand, ballet slippers in hand, some way ahead of their mother, who followed with stroller and shopping bags. There was a momentary halt inside the taxi shelter while slippers were pulled over bare feet and ribbon wound around calves, then they were out and dancing. One tutu, a full-on orange, glowed in the late-afternoon light like a fiery variety of gum blossom. The younger one’s was a complementary wattle. Both were fluorescent against deep-brown limbs. While their mother bent to the small figure in the stroller, the girls pirouetted behind the shelter, arms curved against the blue sky, calling out to each other as they turned. A few minutes later a taxi turned up and off they went to their lesson. A few weeks after the burial, I thought I was done with the visceral jolt of sudden death, at least for a while. Grief was a different beast, to be grappled with in the coming months. When my partner returned from Europe, I flew with her to New Zealand to begin a 6-month sabbatical term looking at Indigenous mental health internationally. But my private and professional life kept overlapping. My thoughts kept coming back to my mother. Just a year before, my sister and I had battled to have my mother taken off antidepressants. After caring for her terminally-ill second husband for some years, she’d developed a reactive depression. There had been no consultation with family before she’d been prescribed SSRIs (selective serotonin reuptake inhibitors), nor when she was maintained on them for some years after her husband’s death. Maintained, but not monitored. The family was left to puzzle the restless, even manic, energy and the apparent lack of empathy in a normally loving woman — the SSRI stimulant effect at work. After professional weight was used to have these concerns taken seriously, she was taken off her medication, abruptly (without her knowledge and, again, without family consultation), enduring a roller-coaster of withdrawal emotionality until we twigged what was happening. And there I was, in Aotearoa (New Zealand) and soon off to Canada to look for pointers, to ponder the central puzzle: does the fact that we do mental health badly in Australia fully explain how we get blackfella mental health so comprehensively wrong? Once in a while, when I became too sombre, I’d conjure up the pure joy of that scene in the ShoppingWorld car park. I had no idea who the young Aboriginal family I’d seen at the taxi stand were, and, seemingly, they had no particular connection to me. I described them to my sister and found an unexpected one. The mother of the young girls and the child in the stroller was, in fact, the sister of a particular in-law: they were unknown family. The vibrancy and sense of possibility emanating from the tutu sisters seemed a hopeful sign. Professionally, in my teaching, I found it easy to point to Aboriginal resilience and give example after example of positive programs that were being piloted. Yet the shut-down of serious reconciliation in Australia and the decade-long growth of historical revisionism — the refusal to consider Indigenous/settler history and contemporary Indigenous health on the same page — had made it increasingly hard to maintain that hope. Creating a positive future for the current generation of Aboriginal children had felt, more and more, a hard ask. I didn’t know whether to feel quaint or subversive, giving seminars on the inescapable nexus — even in the clinical setting — between politics and Indigenous health outcomes. But I became increasingly convinced that, along with conceptual freshness, a sophisticated political boldness was vital, particularly in relation to turning around Indigenous mental distress. A few weeks after I’d commenced my sabbatical, my sister called. My newly-found relative was dead. The picture was confused: she was estranged from the children’s father, he was out of jail, there’d been disturbances, she was found on the floor of her house. What was indisputable was that she hadn’t made 30, that the dancers and a younger child were motherless and that the two little boys at the door had seen too much. Investigations take time: I still don’t know what really occurred, but, regardless of what actually happened on the day, I could sense what might have happened on all the prior days. While I’d been working on a research project in south-west Sydney, it was put to me that the most commonly used instrument to pick up postnatal depression (PND) in Aboriginal mothers, the Edinburgh Scale, couldn’t be relied on to sift out Aboriginal mothers at risk. The community nurses and infant mental health workers reported too much background “noise” to pick up a clear PND “signal”: the women were routinely carrying such an accumulated load of mental distress that it was hard to sort out birth-related changes. Whether it’s the NSW Chief Health Officer reporting on levels of east-coast Aboriginal mental distress, or Western Australian studies on the everyday stress levels and burden of negative life events borne by Nyoongah kids, a similar picture emerges. The greatest difficulty in improving Indigenous mental health is not finding data, but finding mechanisms to convince governments — ultimately, the program funders, workforce developers and agenda-setters — and, in particular, the current federal government, that to connect the unresolved trauma of dispossession, child removal, missionisation, racism and over-incarceration to contemporary distress is not adopting a “black armband view of history”. The dots are on the page. There is a lack of political will to join them up. When you make the connection between psychoneurobiological research, historical data and Aboriginal testimony, what emerge are the processes by which the long, slow legacy of colonisation and the human consequences of “virtual” apartheid are enacted: the physiologically and psychologically corrosive stress of having to deal, daily, with racist acts; the multiplier effect of the actions of each paedophile nun or unchecked abusive lay children’s home worker; the undischarged body memory of beatings at Cootamundra Girls’ Home, Kinchela Boys’ Home or Beagle Bay; the brutality of Grafton Gaol or the Palm Island lock-up; the lack of both identity and hope when your comings and goings, your bank account, your ability to marry — your life — are controlled by the mission manager. When eyes aren’t averted, these processes become clear. Let’s take just one process: a check of major newspapers for the summer of 2005–06 would show a number of current Australian governments denying even the existence of entrenched racism in this country, let alone the cumulative effects of its operation. Unless you’re the one on the receiving end, the one on the performing end makes sure it’s difficult for anyone else to perceive the racist act. Even more rarely do we connect racism, and constant discrimination, to physical and mental health consequences. Racism takes an invisible toll. When you’re the last one served in the sandwich shop, when you’re on the corner waiting for the lights to change and the abuse from a wound-down car window slaps you in the face, or when you’re young and brown and profiled by the cops as you perform your bravado shuffle down Glebe Point Road, it piles up in your head and chest. † University of New South Wales. In December 2005, as I walk home from the Coogee shops to my flat, I pass a sooty smear on Arden Street, the residue of a recently fire-bombed van. Across the road are the gas barbecues behind the beach, where every night an easygoing smorgasbord of UNSW† students cook up their diverse fancy. Both events are the real Australia: we are both a tolerant and a racist society. The bogey-man is currently “of Middle Eastern appearance”, although he shape-shifts: when I was growing up, he looked aggressively out from May Gibbs’ books, the bushy-eyebrowed, spindly-legged and nulla nulla-clutching Big Bad Banksia Man. Maybe Jung was right when he said that part of really growing up is reclaiming our own projections. Yet all the Australian Prime Minister’s 2006 Australia Day address can offer is racism as a “behavioural problem”. The solution, as ever in our country, is more “punishment”. But a century of research on behavioural change tells us that punishment doesn’t change behaviour. At best, it temporarily amends it, drives it underground, ahead of a later, volcanic re-emergence. In 2006, health professionals must work in a climate reductive of complexity. There is certainly no will to explore the reality of Australian racism, let alone its hard-to-pin-down, but profound, impact on physical health and what blackfellas prefer to call social, spiritual and emotional wellbeing. If we health professionals are to genuinely care for our patients and clients, the times call for informed, professional boldness. Not only is the “political” an everyday element in our funding and workforce shortfalls, but in our governments’ data-denying intellectual shortfall. Reversing Indigenous mental distress requires awareness that new mechanisms of consensus building, beyond mere lobbying, need developing before we can effectively discharge our duty of care. In 2006, the political is the clinical. We need — sorely need — a bridge between Western ways of approaching mental health and a body of Indigenous knowledge on maintaining, or recovering, wellbeing. We need to reconceive what actually underlies Indigenous mental distress before we can reconceptualise our praxis and develop the infrastructure to support a renaissance of wellbeing. Understanding is insufficient: the task requires recognising and incorporating the complex transgenerational effects of colonisation on blackfellas. The final step — no mean feat — would be the “de-Othering” of Indigenous Australia. You’ve got relatives out there.

Dennis McDermott BEc, BA(Hons)(Psych), MA

Objective: To describe the implementation of an integrated Aboriginal health curriculum into the medical course at the University of Western Australia (UWA) and the early effect on students’ perceptions of their knowledge and ability in the area of Aboriginal health.Design, setting and participants: Final-year medical students at UWA in 2003 (first cohort) and 2004 (second cohort) were surveyed by questionnaire (with answers on a five-point Likert scale) to assess their attitudes to various aspects of Aboriginal health. A subset of students provided open-ended comments on key priorities in Aboriginal health, cultural security and suggestions for Aboriginal health policy.Interventions: Integrated learning experiences were implemented within each year of the medical course, based on specific learning outcomes in Aboriginal health.Main outcome measures: Changes in students’ self-perceptions of their preparedness for and future commitment to working for change in Aboriginal health.Results: Response rates were 76% and 85% in the 2003 and 2004 cohorts, respectively. Compared with first-cohort students, second-cohort students were more likely to agree with items relating to their preparedness and ability to work with and care for Aboriginal and Torres Strait Islander people (P < 0.05); second-cohort students also reported greater preparedness to advocate and improve the health of Aboriginal people (P < 0.05); 65% of respondents in the second cohort (versus 34% in the first) agreed they had a social responsibility to work for change in Aboriginal health (P < 0.05).Conclusion: With a relatively small amount of targeted and structured teaching and learning in Aboriginal health, significant shifts in students’ self-perceived levels of knowledge, skills and attitudes are possible.

David Paul MB BS, BPolicyStudies(Hons) · Sandra Carr RN, RM, MPH · Helen Milroy MB BS, FRANZP

The first Aboriginal medical service was established in the Sydney suburb of Redfern in 1971, with the aim of improving access to health services for the local Aboriginal community by creating a culturally appropriate environment. Since then, there have been many changes to primary health care arrangements for Indigenous Australians (and even now, the Aboriginal medical service sector is only part of the story). However, the important concepts behind the establishment of the first service remain. According to the National Aboriginal Community Controlled Health Organisation, the national body representing Aboriginal community controlled health services (ACCHSs) throughout Australia (http://www.naccho.org.au), an Aboriginal medical service is “a primary health care service initiated and operated by the local Aboriginal community to deliver holistic, comprehensive and culturally appropriate health care to the community that controls it (through a locally elected board of management)”. There are currently over 130 Aboriginal medical services in Australia, varying greatly in size and staffing levels. These services are unique in their management and funding structure, and their community base. As the provision of adequate primary care for Indigenous people has been identified as one of the cornerstones of improving their health, we asked representatives of two large ACCHSs in north Queensland — general practitioners, Aboriginal health workers and managers — to tell us about their community, their service and their roles. A tale of two cities: Townsville and Cairns Townsville and Cairns in north Queensland are among nine Aboriginal and Torres Strait Islander (ATSIC) Regions that account for almost 48% of Australia’s Indigenous population.1 The Townsville region has a population of 325 000, with an Indigenous population of 16 875 (5.2%), while the Cairns region has a population of 196 000 and an Indigenous population of 17 049 (8.7%). Townsville Aboriginal and Islanders Health Services (TAIHS) is a large Aboriginal community controlled health service situated in one of the inner suburbs of Townsville. Its over 150 employees provide medical and dental care, social and emotional wellbeing services, a youth shelter, a volatile substance use service, crisis accommodation and child protection services. The medical unit at TAIHS provides comprehensive primary health care, with a staff of 36, including nine general practitioners, four registered nurses (three Indigenous), six Aboriginal health workers, a dietitian and a psychotherapist. In addition, visiting specialists (general physician, endocrinologist, ophthalmologist and psychiatrist) and allied health professionals (podiatrist, child health nurse, psychologist and midwife) complete a team able to provide a range of health care and lifestyle modification programs. WuChopperen in Cairns is another large Aboriginal community controlled health service. It has a staff of around 90, with five full-time equivalent GPs, three registered nurses, seven Aboriginal health workers and sessional allied health providers. WuChopperen has developed two other, now autonomous, Aboriginal community controlled health services in Far North Queensland, Mulungu (in Mareeba) and Mamu (in Innisfail), and currently has a satellite clinic at Atherton. The range of programs provided is very wide, including a social health and youth health service, and health services for illicit/licit drug use, family violence and prison health. Visiting specialists are called on when available. 1. Australian Bureau of Statistics. Population distribution, Indigenous Australians, 2001. Canberra: ABS, 2002. (Catalogue No. 4705.0.)

Helping patients sort out the complexities of life, even if in small steps, can be a source of great satisfaction Aboriginal community controlled health services (ACCHSs) across Australia are supported by predominantly non-Indigenous doctors. As of 2005, there were between eight and ten Indigenous doctors working in ACCHSs. For many non-Indigenous doctors, working in an Aboriginal health service has been a choice to do something different and to try to make a difference. One of us (K S P) moved to Townsville from Sydney. Working for the Townsville Aboriginal and Islanders Health Services (TAIHS) provided an opportunity to combine general practice with interests in maternal and child health and clinical research. For Indigenous doctors, the reasons for working in an ACCHS are varied, but generally centre on wanting to work closely with their community. The other author (M W) is one of two Aboriginal GPs working at WuChopperen Health Service. Communities and family members, but also the medical community and government, expect Indigenous doctors to work directly in primary health care. In taking on this role, Indigenous doctors need to be able to respond to a variety of community, leadership and role-model pressures, but their value to the local community is measured not only by their natural cultural communication skills, but by the capacity development among Indigenous people that they represent. OpportunitiesIndividual level: the art of medicineThe practice of medicine in an ACCHS challenges even the most highly trained clinician. The number, complexity and interaction of problems presenting in any one consultation1 require listening skills, a depth of clinical knowledge, familiarity with evidence-based medicine, and the ability to formulate feasible management plans2 — and all these skills are needed all the time. A constant challenge is to tease out the subtleties in communication. Inherent in this is the ability of the practitioner to engage in empowerment strategies with Indigenous patients, and a big part of the job is advocacy on behalf of patients, helping them to negotiate parts of the health system compromised by institutionalised racism.3 Diseases such as impetigo, diabetes, and chronic obstructive airway disease are well recognised, but often not only their prevalence but their severity at initial presentation is overwhelming. There is also the need to rapidly acquire the knowledge to manage less familiar diseases, such as rheumatic fever (and its sequelae), syphilis and tuberculosis. Working with teamsACCHS doctors work in multidisciplinary teams. Aboriginal health workers’ and registered nurses’ knowledge of both the cultural and social aspects of a patient’s background are vital to patient management, and they often work independently on aspects of the care plan. ACCHSs are often well supported by visiting specialists and allied health professionals, allowing GPs to work within a truly multidisciplinary primary health care team. Outreach work It is unlikely when working in an ACCHS that the whole week will be spent in the same office. Visits to “parkies” and “grass camps” (people living in town parks and fringe dwellings), sessions in jails, and visits to outlying communities are just some of the possible outreach scenarios. Quality improvement, population health and research programsThe futility of practising medicine only on an individual level quickly becomes apparent and, once an ACCHS doctor is established within a community, it is possible to branch out into quality improvement and population health programs. This requires working with the community and the myriad funding bodies to develop, for example, programs for Pap smear screening, smoking cessation or diabetes care. This not only benefits the community and enhances service capacity, but also allows GPs to develop skills that may prolong their involvement in Indigenous health. It is relatively common to conduct research in larger ACCHSs, and opportunities exist for GPs to access research funding and training. DifficultiesCultural safetyThere are two relevant aspects of cultural safety. The first is the more traditional view of cross-cultural communication;4 the second concerns the culture of being a doctor. In the ACCHS setting, doctors will often have a different cultural background to their patients, and English may not be the first language of the patient or the doctor. Consequently, cross-cultural training programs provide orientation in cultural background, language concepts, communication and relationships within the local Indigenous community. Cross-cultural education outlines the history of white colonisation of Australia, the effect of subsequent government policies on the local community, the cycle of poverty, local communication issues, and local customs for births, deaths and illness. Not all cultural awareness programs are alike, so, while education provides an important introduction, cultural awareness accumulates with experience, but only develops fully if the doctor is prepared to respect and learn from the community and, importantly, if the community will mentor and assist the doctor. The second aspect of cultural safety is the culture of medicine that many doctors are used to and have been trained in. This can cause difficulties coping with the unfamiliar clinic environment — its very high workloads, poor infrastructure, multiple and chaotic medical records, lack of structured clinical sessions with no appointment systems, patients arriving en masse in bussed transport, and apparently poor patient compliance (which often can be explained by difficult dosing regimens, and a lack of common reality and priorities). While these issues may appear insurmountable to a new GP, leadership and a quality improvement approach can result in more controlled working environments. Trauma and griefThe recent history of Queensland Aboriginal and Torres Strait Islander communities, like those in Townsville, is one of loss of land (often accompanied by violence), forced removal, and detention of differing clans in missions and reserves, with consequent loss of culture, autonomy, identity and life skills. Many patients come from such traumatised family backgrounds.5,6 Dealing constantly with traumatised patients and the resulting problems of unemployment, poor education, substance misuse and violence can become a threat to the wellbeing of the ACCHS staff, especially the GPs. The high mortality rates in Indigenous populations become starkly evident. In any context, it is difficult for GPs to see relatively young patients die of preventable diseases, but the monotonous regularity of community funerals can become depressing. Indigenous doctors, who may also be from the local community, can experience this from both a medical point of view as well as from family involvement. It is important that GPs are able to recognise their own reactions to trauma and grief and take appropriate action. While counselling is available, regular periods of leave are probably necessary for survival in the job. Lack of autonomyThe stressors of mainstream general practice — job demands, time pressures and perpetual change — are well known. These also affect GPs working for ACCHSs, but the strongest predictor of job satisfaction has been identified as being in control of the job.7 The major stress for GPs working for an ACCHS is the loss of autonomy in practice management. ACCHSs are governed by community-elected boards, who make many of the decisions GPs in mainstream practices would ordinarily make themselves. Some board members are highly trained in the health field, others are not, and their decisions may or may not be in line with GPs’ perceptions of how a medical clinic should operate. This lack of autonomy can make the implementation of change difficult when the ultimate decision for acquisition of equipment, recruitment, conference attendance, or participation in research and population health programs lies with the board. The stress is minimised if GPs enjoy good working relationships with their senior managers, chief executive officers and boards. Community politics may also influence some decisions, which can be difficult to comprehend until an understanding of the broader context of Indigenous control and empowerment has been gained. RemunerationWhile remuneration levels in some centres are improving, through support from, for example, the Rural Incentive Payments Scheme,8 GPs in the larger urban ACCHSs are often not as well paid as their mainstream colleagues. This reinforces the perception that the work they are engaging in is less valuable and has led to a high turnover of doctors and difficulty in attracting Australian-trained GPs. To attract and retain more Australian-trained doctors, a review of remuneration is needed. Career paths and ongoing trainingThe better supported ACCHSs are an ideal environment for training, not just in general practice, but also in specialties such as public health, general medicine and cardiology. This would provide a new source of doctors for the Indigenous community. The burden of disease encountered on a daily basis would, with remote supervision, provide excellent training for registrars. While there is growing support from the Royal Australian College of General Practitioners in cultural safety, peer networks and mentoring, in many areas GP registrars are not allocated to ACCHSs as a priority. If the Colleges could develop training paths that encompass terms in ACCHSs, it would not only enrich the pool of doctors trained in caring for Indigenous people, but also enhance the quality of medical care for Indigenous communities. Public health registrars, with their population health skills, could be a valuable asset to the larger ACCHSs. There have been some moves to offer integrated general practice and public health training, but this has left many GPs in the ACCHS sector faced with the decision of whether to stay or leave when they reach an advanced stage of their training. ConclusionWhile every GP will have a different experience within an ACCHS, a few will truly become part of the community. Many doctors will develop close friendships with both staff and families that can be especially rewarding. Sharing the highs and lows of the Indigenous community, especially with respect to sport and music and their role in mainstream Australian culture, strengthens the bonds some doctors have with their roles in ACCHSs.

Kathryn S Panaretto MB BS, MPH · Mark Wenitong BMed

Working in one’s own community can be rewarding but stressful; there is a perception that you are “everything to everyone” Aboriginal health workers (AHWs) have usually lived in the community they work in and have developed lasting relationships with the community and with the various government agencies. One of us (M M) has lived in Townsville for 12 years and the other (L H) for 4 years (having grown up in the town of Hughenden, 370 km west of Townsville). These ties to the community and health networks provide us with a real sense of what is going on and what is needed at a grassroots level. There are many reasons for AHWs choosing to work in an Aboriginal community controlled health service (ACCHS). The opportunity to work with their community, as mentioned, is a strong motivation. Others may be “head-hunted” (as we were) or may have practical reasons for wanting to move to larger centres. One of us (M M) gained a great deal of experience working as an enrolled nurse in a small regional hospital for 10 years and was looking for a new challenge. Working with the Townsville Aboriginal and Islanders Health Services (TAIHS) provided an opportunity to participate in a holistic health service planned by the community. For others, it may be the opportunity to participate in research projects and community development projects. Some health workers at TAIHS have moved down from more remote areas, such as the Torres Strait, to be near their family and further their education. OpportunitiesClinical experienceHealth workers at ACCHSs, unlike those in mainstream services, are free to use their clinical skills and are called on to perform a wide range of procedures. For example, we are able to administer childhood vaccinations under the supervision of a doctor, take Pap smears, take blood, and perform health checks. Opportunities exist to experience a broad clinical program or pursue an area of interest, whereas health workers in the government sector are often tied to specific clinical areas or to non-clinical work, such as transport and social assistance. Empowerment and autonomy It has been very empowering as Aboriginal women to be involved in the many programs run through TAIHS. The ACCHS setting allows more autonomy in setting up and implementing health programs. At TAIHS, we have planned and successfully run programs such as a breastfeeding peer support program, a smoking cessation project, a human papilloma virus project (which has increased the number of women having Pap smear screening), and a walkabout project (increasing physical activity). These programs also allow for innovative approaches to raise awareness within the community. For example, at TAIHS, the health workers have initiated a community breakfast for breast cancer week, and participate in a weekly local radio health segment. DiversityHealth workers in ACCHSs also deliver outreach services to the wider community, including prisons, fringe camps and youth detention centres, and have the opportunity to travel to workshops and conferences to expand their knowledge and skills as well as build professional networks. Community controlInevitably, working in Indigenous health, there will be cultural clashes, but these are easier to mediate in the ACCHS setting. The state health system’s mainstream perspective, less flexible management, and lack of cultural sensitivity can make dealing with cultural clashes more difficult. DifficultiesRole definition and recognitionACCHS health workers carry a great load of community expectation. We are asked to take on many roles at once, and are seen as being “everything to everyone”. Older staff members may not respect the contribution of younger workers; they may carry their role as elders into the workplace, and this can cause problems. Working in the community sector involves working with multidisciplinary teams. Some professional staff — both nurses and doctors — can be ignorant of the AHWs’ skills and abilities, opting to work with a registered nurse instead. Difficulties in teamwork can be frustrating and can affect service delivery. A continued source of stress is the lack of national qualifications and recognition of competencies of AHWs. For example, those trained in taking Pap smears and giving vaccinations can only use these skills in an ACCHS setting because their training is not recognised in other heath sectors in Queensland. Although AHWs are accepted into training courses, sit the same exams and develop the same level of competence, only registered nurses gain formal recognition across all sectors. RemunerationThe health service union award, under which AHWs work, has not been updated since 1992. In the past decade, there have been significant changes to education for AHWs and increased levels of responsibility in the clinical environment. Remuneration in the community sector is not progressing in line with government-employed health workers. ACCHS health workers have higher levels of clinical skills and responsibilities than our colleagues in state health. Service delivery in the two sectors is very different, with state health focusing on a disease-model approach while the ACCHS approach is broader, encompassing a social model of health. There are a number of enrolled nurses working as AHWs. This is because the training is short and hospital-based (and in remote areas it is more likely there will be a hospital than an ACCHS). When enrolled nurses move into ACCHSs, both parties are disadvantaged because, although enrolled nurses participate in care-planning activities, they are not issued with provider numbers and are unable to bill under Medicare. Living and working in the communityBearing the load of community expectation can be very tiring when combined with the responsibilities of work and family. We cannot go out after work and relax, as community members may want to unload their problems on us. When there is family conflict in a community, people can distance themselves from the ACCHS if the health worker belongs to a different clan. There may be concerns that confidentiality is not adhered to, despite health workers being committed to professional codes of conduct. These issues can be frustrating and may damage health workers’ sense of their own professionalism. The community grapevine can add to the pressure by exaggerating things out of all proportion. The futureWe are hopeful that we will finish our studies, complete our Bachelor of Nursing Science degrees and one day work as chief executive officers of TAIHS. As joint CEOs, we would strongly advocate for improving the recognition of AHWs and for more equitable pay structures, while continuing our work with the community.

Melvina Mitchell EN · Lynette M Hussey EN

As Indigenous CEOs, we train non-Indigenous doctors in cultural safety, and rely on them to integrate Aboriginal health workers into the multidisciplinary team Aboriginal community controlled health services (ACCHSs) are generally managed through an elected board of directors and an appointed chief executive officer (or equivalent). In taking on such roles, managers face competing professional, community and political demands and requirements. The CEO is a member of the Aboriginal or Torres Strait Islander community in which he or she lives, and is also managing a major health service for their community. The demands placed on individuals in these circumstances, as well as the expectations to achieve outcomes often beyond their immediate control, are significant. The CEO is constantly balancing individual clients’ needs with community expectations for an accessible high quality health service. The reasons for choosing to work in this area are varied and are driven by personal, organisational and community goals. This is consistent with the findings of a report based on interviews with 41 Aboriginal and Torres Strait Islander health managers.1 The report revealed that the distinctive features of the managers include: a very strong personal motivation to assist the Aboriginal and Torres Strait Islander community; a willingness to take on a leadership role and initiate change within the community; a direct sense of responsibility and accountability to the community; and a desire to work outside the bureaucratic processes that often create barriers to success. Meeting the community’s needs Although ACCHSs were set up primarily to deliver comprehensive primary health care services, the responsibility of many of them now extends to child protection services, drug and alcohol programs, aged care, and housing and infrastructure and schools-based programs. This has significant management implications in terms of the multiple funding sources, the need to administer a wide range of programs, the increased staff size and skill mix, the physical infrastructure required, and the complex reporting requirements. The accessibility of health services for Aboriginal and Torres Strait Islander peoples is affected by a number of factors, including the distance to and availability of health professionals. The employment of Aboriginal and Torres Strait Islander staff has long been recognised as an important factor in accessibility of services. Unpublished data from the Department of Health and Ageing and the National Aboriginal Community Controlled Health Organisation suggest that in 2000–01, 67% of full-time equivalent positions in federally funded Aboriginal primary health care services were held by Aboriginals and Torres Strait Islanders. However, examination of the workforce composition shows that most Indigenous staff (97%) were employed as health workers or field workers, while non-Indigenous staff were more likely to be employed in professional positions. Most doctors (98%), nurses (87%), allied health professionals (89%) and dentists (88%) were non-Indigenous.2 Therefore, in the Aboriginal medical services, there may be three strata of employees. Tsey has described the pyramid structure of most of the services, with a small group of Aboriginal managers at the top of the pyramid, a middle stratum occupied by predominantly non-Aboriginal professional staff, and a bottom stratum of predominantly Aboriginal workers who occupy semi- or non-professional roles.3 Thus, the CEO is faced on the one hand with the need to train their non-Indigenous staff in cultural safety, and on the other hand must rely very heavily on them for service provision and integration of Aboriginal health workers into the multidisciplinary team. Similarly, the CEO might be obliged to act as a manager for an Indigenous relative or close community member. Prioritising needs and resourcesThe explosion of activity in relation to new policy initiatives and program development in Aboriginal and Torres Strait Islander health has resulted in increased opportunities to access funding, but it has also created many vertical programs within the services. As a result, a large amount of new money has been allocated on a short-term basis or for pilot programs, making it difficult to sustain any gains made. The management challenges associated with such growth include future planning (when there is a high dependence on “soft” money), the accountability requirements of multiple funding sources, and the inefficiency of having to maintain systems to achieve this. Other challenges relate to managing staff in a climate of uncertain job security, and the workforce implications of funding new positions with ill-defined skills levels, training needs and career pathways. Finally, to access the additional funds, staff resources are needed for writing funding submissions and fulfilling the requirements of the granting bodies, a task that usually has to compete with clinical priorities. An area in which services often struggle is obtaining access to specialist and allied health services. To address this, we are trying to improve linkages with mainstream service providers and foster relationships that allow for some flexibility in how and where services are delivered. For example, considerable barriers to accessing maternal and child health services were overcome in Townsville by arranging for a child health nurse to work four mornings per week at Townsville Aboriginal and Islander Health Services. The importance of Indigenous community controlThe ACCHS model essentially requires that ownership and management of the health agency are vested in the local Indigenous community, generally through a local Indigenous board of management. This arrangement allows the local community to decide on its priorities, policies, management structure, staff and service profile, within government funding guidelines. The model has features in common with the community controlled primary health care services that have contributed to health gains in other indigenous peoples. International comparative analyses4,5 demonstrate the success of community controlled models of health care, when governments have been engaged in the development of effective and efficient systems. For example, through the 1976 Indian Health Care Improvement Act in the United States, appropriated resources were used to expand health services, build and renovate medical facilities, provide safe drinking water and sanitary disposal facilities, and establish programs to increase the number of Native American health professionals.4 The future of Aboriginal community controlled health servicesThe first of a series of reports on expenditure on Indigenous health identified the specific areas in which spending inequities have occurred.6 As a result, major reforms and changes have been implemented. However, achieving a balance between time allocation for strategic initiatives and meeting acute clinical care needs remains a major challenge within many services. While Aboriginal medical services only represent one sector of the health system with responsibilities in Indigenous health, they tend to attract the most attention when the government is seeking to explain the relative lack of progress in health outcomes. We need to recognise that while ACCHSs are an essential component of the health system, they do not have exclusive responsibility for Indigenous health. It is time for the entire system to embrace and respond to its responsibilities for the health of Indigenous Australians. The ACCHSs are well placed to support such an integrated approach.

Cindy Shannon DSocSc, MBA · Adrian Carson · Rachel C Atkinson MBA, BSocWk

To the Editor: The Ear, Nose and Throat Department at the Royal Darwin Hospital services an area of about 550 000 km in the Northern Territory. As part of our remit involves dealing with conditions affecting the organs of speech and hearing, a proportion of our patients have communication handicaps. We have frequently encountered the use of “Hand Talk” among Indigenous patients with communication handicaps, and we feel this merits highlighting to your readership. Hand Talk is an established sign language within and between Aboriginal groups in the NT. Although various groups have different signing systems, there are enough similarities between them to enable inter-group communication. Its existence is thought to date as far back as other spoken Aboriginal languages that have now been lost. Theories about its conception include a means of overcoming language barriers between different language groups, a silent form of communication during hunting expeditions, a means of conversation for women during long periods of mourning when speech is prohibited, and a means of communication for deaf or aphonic individuals.1 While completely separate from established Western sign languages, Hand Talk is a sophisticated and intricate means of communication that allows complex interactions to take place and proficient individuals to integrate into their society.2 In the course of our service delivery in Darwin and to outlying districts, we have been struck by both the frequency with which Hand Talk is used in an impromptu manner and the proficiency users exhibit in communicating with it. The significance of this requires an appreciation of the difficulties of applying Western-type communication rehabilitation to Indigenous Australians in remote regions. For example, providing hearing aids, a basic and standard form of communication rehabilitation in urban areas of Australia, can face numerous obstacles in a remote setting. These include lack of a service provider and technical and maintenance support, poor compliance, and logistical problems (something as simple as running out of hearing aid batteries can be a major problem for those in remote areas). While no data are available on the ubiquity of Hand Talk, it clearly represents a valuable part of Aboriginal culture with an important practical function in a situation where Western models of communication rehabilitation are difficult to apply. While attempts to improve conventional communication rehabilitation should continue, these should be combined with efforts to foster Hand Talk through education and facilitating its dissemination by existing users so it does not suffer the fate of other lost Indigenous languages.3

Patrick Jassar · Garrett F Hunter

A 40-year-old Indigenous woman with type 2 diabetes presented with a 6-month history of intermittent left flank pain. She reported worsening pain of 2 days’ duration associated with fever, nausea, vomiting and reduced urine output. Clinical examination revealed tenderness over the left loin. An x-ray (not shown) and computed tomogram of the abdomen (Box) suggested a diagnosis of emphysematous pyelonephritis. Over the next few hours, the patient developed septic shock. In view of the severity of the emphysematous pyelonephritis, as evidenced by the extent of gas in the renal system on imaging and the development of septic shock, an urgent laparotomy and left nephrectomy were performed. Escherichia coli was isolated from blood cultures and from tissue of the necrotic kidney. After surgery and with antibiotic treatment, the woman made a slow recovery. Emphysematous pyelonephritis is a rare, severe gas-forming infection of the renal parenchyma, typically seen in people with diabetes. Radiologically, four classes of emphysematous pyelonephritis are described on computed tomography:1 in Class 1 and 2, the gas is localised to the collecting system and the renal parenchyma, respectively, without extension to the extrarenal space; in Class 3A, as seen in this case, there is extension of gas or abscess into the perinephric space, and in Class 3B, to the pararenal space; bilateral emphysematous pyelonephritis or emphysematous pyelonephritis of a solitary kidney represents the most severe form of the disease (Class 4). Emphysematous pyelonephritis is associated with a high mortality rate (40%) when treated with antibiotics alone.1 Although milder forms of the disease (Class 1 and 2) have been successfully treated with a combination of percutaneous drainage and antibiotics, these modalities alone may not be sufficient in more severe presentations of the disease or in patients presenting with septic shock. In such patients, early nephrectomy is recommended.1,2 Computed tomography scan There is necrosis within the renal parenchyma, with mottled gas radiating from the medulla to the cortex. Gas locules and a crescent of subcapsular gas are present in the perinephric space.

John V Peter MD, DNB, FRACP · Vishwanath Biradar MB BS, DNB · Sandra L Peake BM BS, FJFICM, PhD

Each year up to a quarter of all young Aboriginal men have direct involvement with correctional services, and Aboriginal prisoners currently represent 22% of the total Australian prisoner population. The high rates of repeated short-term incarceration experienced by Aboriginal people in Australia have a multitude of negative health effects for Aboriginal communities and the wider society, while achieving little in terms of increased community safety. Well identified health and social priorities for Aboriginal people affected by incarceration include housing and tenancy support; mental health and wellbeing, including family violence, grief and loss support; substance misuse support; general health services, including hepatitis C management; and social inclusion, including the need for family and community integration, skills development and employment. The post-release period is a crucial time for the provision of integrated health and social services to address these priorities and to break the cycle of incarceration. To achieve significant health gains for Aboriginal people, there is a need to develop a broader collaborative approach to primary health care, incorporating social health and justice perspectives as fundamental components of health care planning. Health and human services have a critical role to play in developing community-based solutions to reduce excessive incarceration rates for Aboriginal people.

Anthea Susan Krieg BM BS, BSc, MPH

Binan Goonj. Bridging cultures in Aboriginal health. A K Eckermann, T Dowd, E Chong, et al. Sydney Churchill Livingstone, 2005 (xvi + 216 pp). ISBN: 0729537714 I clearly remember what a strong impression the first edition of Binan Goonj. Bridging cultures in Aboriginal health made on me at the outset of my career in Indigenous health research. This second edition retains much of the balanced and erudite style of the feted first edition. With Binan Goonj meaning “hearing but not listening”, cross-cultural communication is the raison d’être of this book. The text begins with an excellent introduction to the historical and sociopolitical context of Aboriginal health (something notably absent from many other texts in this field). A conversational style blends with challenging questions, activities and case studies to make the book an ideal teaching aid. Poignant narratives of continuing Indigenous disadvantage and marginalisation are accessibly combined with sophisticated social, psychological and anthropological concepts; and an emphasis on cultural adaptability/vitality and Indigenous diversity transcends both anachronistic myths of Aboriginality and the “deficit model” that continues to trouble public health. The remedies presented in this book focus on comprehensive primary health care, community participation, holism, trust, cultural safety and empowerment. Although recognising the social determinants of Indigenous health, the book would be better subtitled Bridging cultures in Aboriginal healthcare, as it is primarily aimed at non-Indigenous health care providers rather than professionals in other sectors that have an enormous influence on Indigenous health. The text is also blemished by a smattering of avoidable inaccuracies and careless assertions that may mislead the unfamiliar, and irritate the advanced, reader. These include a definition of scientific racism that encompasses any scientific research undertaken about Indigenous people (p. 9), and the erroneous claim that Aboriginal life expectancy has not improved for generations (p. 65). Overall, this book eschews much of the tired rhetoric of the Aboriginal health arena for an unflinching account of the facts, fallacies and future directions of health for Indigenous Australians. Yin C ParadiesPhD Student, Menzies School of Health Research, NT and University of Melbourne, VIC

Yin C Paradies

Med J Aust 2006; 184 (10 Suppl).