Volume 188 Issue 10

The Prime Minister has issued a formal, unqualified apology to Australia’s Indigenous peoples for past mistreatment, particularly for the sufferings of those who were affected by the forced removal of children from their families. The Apology needs to be seen as the first step in a reparations process that adheres to human rights principles, involves Australians at all levels, is sustainable and upholds self-determination. The Apology is the first of five steps recommended in Bringing them home: the report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from their Families. Further steps are: guarantees against repetition, measures of restitution, measures of rehabilitation, and monetary compensation, but the Prime Minister has steadfastly refused to discuss reparations or compensation. Monetary compensation has been recognised internationally as an essential component in the redress for similar experiences of the forced removal of children. As long as the final steps in reparation remain unresolved, they will obstruct our pathway to a future that embraces all Australians.

Lisa R Jackson Pulver PhD, MPH, GradDIpAppEpi · Sally A Fitzpatrick

Low socioeconomic status and assumptions about Indigenous people may be jeopardising their access to care In this issue of the Journal, the case–control study by Coory et al1 shows that Indigenous people in Queensland are less likely than non-Indigenous people to receive adequate management for lung cancer, even after controlling for geographic location and socioeconomic factors (→ Survival of Indigenous and non-Indigenous Queenslanders after a diagnosis of lung cancer: a matched cohort study). Other studies and reports have also shown that Indigenous people have a lower cancer survival rate and are much less likely to be offered diagnostic and therapeutic procedures,2-6 but the study by Coory et al is the first to show a clear treatment bias for cancer. Why are Aboriginal people less likely than other Australians to receive treatment for lung cancer? Drawing on my experience in Aboriginal health over the past 20 years, I think there are some likely explanations for this finding, most of which Coory et al have considered. Late diagnosis is a key factor leading to poorer treatment outcomes and lower survival rates for Indigenous people.1,5 As Indigenous people do not have the same level of access to primary medical care as non-Indigenous people, early detection of cancer by general practitioners is less likely. In spite of significant additional Australian Government funding provided through the Office for Aboriginal and Torres Strait Islander Health (OATSIH) (an additional $500 million recurrent since 1995), the gap in access to primary medical care resources appears to be still widening, primarily due to worsening access to the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme, which is not compensated for by the OATSIH funding.2,7 The “Close the Gap” campaign recently announced by the federal government is indeed timely.8 Achieving better participation rates in cancer screening programs has also been recognised as an important issue, and systemic changes are needed.2 In the Northern Territory, breast cancer rates are increasing significantly among Aboriginal women, with a 223% increase reported between 1991 and 2001.3 However, for many Aboriginal women, access to mammography services remains poor. For example, the mammography screening service visits Alice Springs three to four times a year for 3 weeks at a time, but often with only a few weeks’ notice. Women who are more organised and literate can read the advertisements in the newspapers and make their own appointments at short notice, but many Aboriginal women do not do this. Health services can try to contact them to let them know, but this is not always effective. It would be possible to redesign the system to give much better access for Indigenous women, and this needs to occur. For example, the service could again be provided from the more culturally secure local Aboriginal women’s health service, Congress Alukura, on a regular planned basis. This would better utilise transport services, Aboriginal liaison officers and the Patient Assisted Travel Scheme (PATS) to improve attendance for Aboriginal women. Coory et al consider the possibility that access to specialist care could be one of the issues involved. Schemes such as PATS9 allow rural and remote residents to have access to specialists in major centres, but I think it is very likely that Indigenous people from rural and remote areas do not receive the same access to care through such schemes as other rural and remote residents. In addition, the gap fees charged by private specialists in all localities present a more significant economic barrier to many Indigenous people, who are therefore much more reliant on the public hospital outpatient system, with its substantial delays. In Alice Springs, for example, men with raised prostate-specific antigen levels have been waiting 6–12 months or longer to see a urologist and have a prostate biopsy in order to be given a definitive diagnosis and treatment for prostate cancer. If patients can afford to pay about $300 to have the procedure done privately, they are sent by PATS to see a urologist in Adelaide, thus avoiding a long waiting period. However, public patients do not have this option. Although steps are now being taken to reduce the barriers that have led to these unfortunate delays, this is occurring as the result of a complaint from the Central Australian Aboriginal Congress in December 2007, rather than in response to an analysis of routine data, which could have revealed the problem much earlier. It is very unlikely that this type of problem is unique to Alice Springs. What we do not know is whether there is a differential waiting time for Indigenous men compared with non-Indigenous men, or whether the system equally disadvantages all men who do not have private health insurance. Is there a systemic bias against Indigenous men that needs to be better understood and addressed? The results from the study by Coory et al add to other evidence suggesting that barriers to care for Indigenous people need to be systematically explored throughout the Australian health system. Whether it is cancer treatment, access to renal transplantation,10 access to prostate biopsies for suspected cancer, or a range of other key endpoints, it seems that the system is not working well for Indigenous people. A final question that was not considered by Coory et al is whether cancer specialists themselves make different decisions about the appropriateness of certain treatment options for Aboriginal people based on their own assumptions about the socioeconomic and cultural circumstances of Indigenous people. I learned this lesson many years ago when two of my Aboriginal patients with rheumatic heart disease and atrial fibrillation died suddenly and unexpectedly in their early forties, from intracardiac clots. These women had been seeing the visiting cardiologist every 6 months and seeing me as often as needed in between. The use of warfarin in such patients was not yet standard practice at the time, but the cardiologist had already been routinely prescribing warfarin for non-Aboriginal people in these situations for about 12 months. He had never suggested warfarin treatment for these women because he assumed that they would not be able to take it safely and that they would have nowhere to store the drug, thus putting children at risk because of the possibility of them accessing and accidentally taking warfarin tablets. This was the late 1980s, and as a GP who was unaware of recent evidence confirming the benefits of warfarin in such patients, I was assuming I would be getting the best practice advice from the visiting cardiologist. It was not until after the women had died that I spoke to him and discovered the assumptions he had made in deciding against warfarin treatment. These types of assumptions may also be being made by specialists about other routine treatments. In the NT, this situation has been improved over recent years through a range of initiatives, including the strengthening of links between key specialists and Aboriginal health services. Many specialists, including cardiologists, now routinely provide services through Aboriginal health services. However, this still needs to occur more widely and to include a broader range of specialists. Given the evidence now available on the differential survival rates for Indigenous people with cancer, it is imperative that better data be routinely collected on the comparative rates of access to specialists and key diagnostic and therapeutic procedures in secondary and tertiary hospitals. State and territory governments could be induced, as part of the Australian Health Care Agreements, to collect more rigorous data in this area. The Australian Health Care Agreements are agreements reached between the Australian Government and the state and territory governments on the health system. They provide a mechanism through which the Australian Government can influence the states and territories, through financial levers, to improve key health system outputs such as equity of access to specialist services and procedures. Key data to be collected would include the comparative times on waiting lists for specialist appointments in public hospitals; the rate of access to key diagnostic procedures; the frequency of giving radiotherapy and chemotherapy for specific cancers (where these treatments are known to be effective); and the rate of surgery performed on patients with cancers amenable to treatment. These types of indicators have been suggested by Aboriginal health services for more than a decade. It is too often assumed that Indigenous people do not wish to travel long distances to access care and be away from their families, or that they have different priorities in life and do not value treatment for illnesses that are likely to be terminal. While poorer compliance or higher refusal rates for treatment may be pertinent factors in some cases, it is important not to assume these types of explanations when there are obvious systemic barriers to accessing care in the current health system. Once these barriers have been addressed, any remaining barriers, if they actually exist, can be explored and dealt with separately.

John D Boffa MB BS, MPH

Objective: To compare survival of Indigenous and non-Indigenous lung cancer patients and to investigate any corresponding differences in stage, treatment and comorbidities.Design and setting: Cohort study of 158 Indigenous and 152 non-Indigenous patients (frequency-matched on age, sex and rurality) diagnosed with lung cancer between 1996 and 2002 and treated in Queensland public hospitals.Main outcome measures: Survival after diagnosis of lung cancer; effects of stage at diagnosis, treatment, comorbidities and histological subtype on lung cancer-specific survival.Results: Survival of Indigenous lung cancer patients was significantly lower than that of non-Indigenous patients (median survival, 4.3 v 10.3 months; hazard ratio, 1.48; 95% CI, 1.14–1.92). Of 158 Indigenous patients, 72 (46%) received active treatment with chemotherapy, radiotherapy or surgery compared with 109 (72%) of the 152 non-Indigenous patients, and this treatment disparity remained after adjusting for histological subtype, stage at diagnosis, and comorbidities (adjusted risk ratio, 0.65; 95% CI, 0.53–0.73). The treatment disparity explained most of the survival deficit: the hazard ratio reduced to 1.10 (95% CI, 0.83–1.44) after inclusion of treatment variables in the proportional hazards survival model. The remaining survival deficit was explained by the higher prevalence of comorbidities among Indigenous cancer patients, mainly diabetes.Conclusion: Survival after a diagnosis of lung cancer is worse for Indigenous patients than for non-Indigenous patients, and differences in treatment between the two groups are mainly responsible.

Michael D Coory FAFPHM, PhD, AStat · Adele C Green MB BS, PhD, FAFPHM · Janelle Stirling MPHC · Patricia C Valery MD, MPH, PhD

Objective: To compare infection-related mortality rates and pathogens isolated for Indigenous and non-Indigenous adult patients at Alice Springs Hospital (ASH).Design, participants and setting: Retrospective study of inhospital deaths of adults (patients aged ≥ 15 years) associated with an infection during a medical or renal admission to ASH between 1 January 2000 and 31 December 2005.Main outcome measures: Admission- and population-based infection-related mortality rates and mortality rate ratios (MRRs) for Indigenous versus non-Indigenous adults.Results: There were 513 deaths, of 351 Indigenous and 162 non-Indigenous patients. For Indigenous patients, 60% of deaths were infection-related, compared with 25% for non-Indigenous patients (P < 0.001). The admission-based infection-related MRR for Indigenous versus non-Indigenous adults was 2.2 (95% CI, 1.6–3.1) (15.3 v 6.8 deaths per 1000 admissions; P < 0.001). After adjusting for age and year of death, the population-based infection-related MRR was 11.3 (95% CI, 8.0–15.8) overall (351 v 35 deaths per 100 000 population; P < 0.001) and 31.5 (95% CI, 16.1–61.8) for patients aged < 60 years. The median age of patients who died with an infection was 49 (interquartile range [IQR], 38–67) years for Indigenous and 73 (IQR, 58–80) years for non-Indigenous patients (P < 0.001). For Indigenous patients, 56% of infection-related deaths were associated with bacterial sepsis, with half of these due to enteric organisms. Other deaths followed chronic hepatitis B infection, invasive fungal infections and complications of strongyloidiasis.Conclusion: Indigenous patients at ASH are 11 times more likely than non-Indigenous patients to die with an infectious disease. This racial disparity reflects the ongoing socioeconomic disadvantage experienced by Indigenous Australians.

Lloyd J Einsiedel PhD, FRACP · Liselle A Fernandes BMedSci(Hon) · Richard J Woodman PhD, MBiostat

Objective: To quantify the impact on the Western Australian health care system of hospitalisations due to interpersonal violence, and to identify risk factors for a repeat hospital admission for interpersonal violence.Design and setting: A population-based, retrospective study of interpersonal violence in WA using linked data (1990–2004) from the Western Australian Mortality Database, the Hospital Morbidity Data System and the Mental Health Information System.Main outcome measures: Number of hospitalisations and associated length of stay; risk factors for repeat hospitalisation.Results: Over the period 1990–2004, there were 36 934 hospital admissions due to interpersonal violence, with 11 507 of these hospitalisations due to a subsequent episode of interpersonal violence. The average length of stay was 2.6 days (SD, 4.9 days). People who were more likely to be readmitted for interpersonal violence included women (adjusted hazard ratio [AHR], 1.31; 95% CI, 1.23–1.39), Indigenous people (AHR, 1.37; 95% CI, 1.28–1.46) and patients with a mental illness (AHR, 1.46; 95% CI, 1.37–1.54). People with more affluent backgrounds tended to have a lower risk of being readmitted than people in the most disadvantaged socioeconomic group.Conclusion: Greater priority should be directed towards the primary prevention of violence. Groups at high risk, such as women, Indigenous people and those with a mental illness, should be targeted for special attention.

Lynn B Meuleners PhD · Delia Hendrie MSc · Andy H Lee PhD

Objective: To describe rates of hospitalisation for head injury due to assault among Indigenous and non-Indigenous Australians.Design, setting and participants: Secondary analysis of routinely collected hospital morbidity data for 42 874 inpatients at public and private hospitals in Queensland, Western Australia, South Australia and the Northern Territory for the 6-year period 1 July 1999 – 30 June 2005.Main outcome measures: Rates per 100 000 population of head injury due to assault by Indigenous status, age, sex and location of residence.Results: The overall rate of head injury due to assault was 60.4 per 100 000 population (95% CI, 59.8–60.9). The rate among the Indigenous population was 854.8 per 100 000 (95% CI, 841.0–868.9), 21 times that among the non-Indigenous population (40.7 per 100 000; 95% CI, 40.2–41.2). Most Indigenous (88%) and non-Indigenous (83%) victims of head injury due to assault were aged between 15 and 44 years. The peak incidence among the Indigenous population was in the 30–34-year age group, whereas that among the non-Indigenous population was in the 20–24-year age group. Indigenous females experienced 69 times the injury rate experienced by non-Indigenous females.Conclusions: Indigenous people, particularly women, were disproportionately represented among those hospitalised for head injury due to assault. Head injury imposes a substantial burden of care on individuals and communities. Along with the costs of treating head injury, these are good reasons to strengthen efforts to prevent head injury generally, with special attention to high-risk population segments.

Lisa M Jamieson PhD · James E Harrison MB BS, MPH · Jesia G Berry BHSc(Hons), GDPH

When I first learned about the Dr Ross Ingram Memorial Essay Competition through the Healthy Vibe section of Deadly Vibe magazine, I realised it was an opportunity to publicly discuss an issue of significance to all Australians, Indigenous and non-Indigenous alike. Specifically, the issue is about cardiovascular health, rehabilitation and, more to the point, the levels of participation and non-compliance with treatment of people affected by cardiovascular disease. Like Ross Ingram, the Koori GP after whom the essay competition is named, I have been directly affected by heart disease. As I read about Dr Ingram and how heart disease cut short a dedicated young Indigenous leader’s life, I decided to do something to sound a warning and be a positive influence on others. I tell my story to raise awareness of cardiovascular disease, which is claiming the lives of our brothers, sisters, uncles, aunties and grandparents. I would also like to discuss what actions we can take to help our people, the Indigenous community and ourselves. First I will give some background information about myself. I am 41 years young, of Aboriginal and Australian South Sea Islander descent. At 39 years of age, I experienced an acute myocardial infarction (commonly referred to as a heart attack). I mistook the severe chest pain for heartburn or indigestion, and did not present to a GP until the following morning. On examination it was clear that I was experiencing acute coronary syndrome. Within less than an hour, I was an inpatient in a hospital coronary care unit receiving all the necessary acute care available. Eventually I was diagnosed with cardiovascular disease (ischaemic heart disease). I was told I had a 99% blockage of the left anterior descending coronary artery and that 10% of my heart was damaged irreparably. Surgery was ruled out, as the affected area was “dead” because I had not recognised the symptoms of a heart attack at the time. Had I sought medical assistance earlier, I might have received thrombolytic medication designed to dissolve the blockage. I did not know any of this information — knowledge is power. I was in total shock and denial when told by the attending GP what was happening inside my body. I thought, “This doesn’t happen to youngish people like me — only to older people in their 60s and 70s!” However, on reflection, all the signs were there: I smoked 30–40 cigarettes per day; I used and abused alcohol habitually and heavily; My diet included anything, any time I wanted, regardless of nutritional value; I had not exercised regularly for over 10 years; and Both my parents had experienced cardiovascular health conditions. On reflection, my behaviour seemed as if I was determined to self-destruct. After adjusting to the new reality that I had experienced a heart attack and survived, I realised it was time to make some deadly serious lifestyle improvements as soon as possible. The changes I made included decisions to attend and complete cardiac rehabilitation, to seriously consider therapeutic lifestyle changes and to comply with all prescribed medications and subsequent follow-up appointments. After I was discharged from hospital, I quit smoking immediately (and have not looked back); completed a hospital-based cardiac rehabilitation program; began to exercise regularly (resulting in gradual loss of 20 kg of excess weight); stopped all use of alcohol; and adopted a low-sugar, low-salt and low-fat diet, including avoidance of red meat and experimentation with low-fat, low-calorie, vegetarian alternatives. From my perspective, I have been given a second chance. I tell people (anyone who will listen) that surviving a cardiac event can present opportunities to make quality-of-life improvements. A heart attack need not be a death sentence. My health and fitness levels have improved dramatically. I have 10–15 kg more to lose, but I know it’s possible now. I have also experienced a spiritual awakening that, in turn, has led me to renew my faith and commit to a purpose-driven life. Despite all this, it took a surprising amount of time to regain my confidence and a healthy level of self-assurance. When this finally happened it was, I think, an outcome of participating in rehabilitation and self-management measures, like taking greater responsibility for my future health. A major factor in my recovery was support from family and friends. It was the existence of these interdependent relationships that was very important in helping me to find my equilibrium again. Cardiac rehabilitation and Indigenous health management in the broader context of cardiovascular health have become important matters for me since my recovery. Even though I have plenty of fight in me, I am always conscious of the need to not overcommit myself. All the while, there is a sense of impending urgency to give back to others in the Indigenous community who also need assistance. I think of others who don’t know or understand what is happening to their bodies. They may not know how to cope with surviving a cardiac event or heart surgery, and may not be aware of what they can do to reduce the risk of future cardiovascular damage. The journey from cardiac patient to cardiovascular health advocateThere were many uncomfortable changes after my heart attack. I was left without a job, as my previous employer decided I was an unacceptable risk as a fly-in-fly-out plant operator on Cape York Peninsula. My personal and social life disintegrated due to psychological aspects such as unanswered questions, post-traumatic stress, self-imposed social isolation, depression and anxiety. Eventually it was family and true friends that made the difference by being there when it really mattered. Prior to operating machinery for mining companies, I had been an Indigenous community development worker, so I decided it was time to do a refresher course at TAFE* to update skills I hadn’t used for over 10 years. With updated community services knowledge and abilities, I approached the Cardiac Rehabilitation Coordinator at Cairns Base Hospital and the Wuchopperen Health Service, offering to serve as a volunteer in some capacity. Their eager response was surprising and welcome. They were keen to try something different to improve Aboriginal and Torres Strait Islander (ATSI) cardiovascular health. We discussed employment in a mentoring/coordinating role in an Aboriginal Medical Service-based outpatient cardiac rehabilitation program. * A Technical and Further Education college. We had several discussions by phone and email about matters that concerned me. I noticed that many of the Indigenous people admitted to the coronary care ward did not go on to attend rehabilitation sessions. I noted the age differences between Indigenous and non-Indigenous people affected with cardiovascular disease, and thought about the reasons why I had not enjoyed the hospital-based cardiac rehabilitation sessions. I was very curious about what was happening to all those Murri and Islander people once they were released from hospital. Indigenous cardiovascular health began to affect me again personally only a few months later, with my older brother (aged 45) experiencing heart problems resulting in several unstable angina events, arrhythmias leading to unconsciousness, and several minor heart attacks. He required triple coronary artery bypass graft surgery and a permanent pacemaker, and has to take medication for the rest of his life. My brother refused to attend rehabilitation and is non-compliant with his medication. He stubbornly believes the heart surgery and the insertion of a permanent pacemaker were a cure-all for his heart problems. He is living on borrowed time as it is, yet he casually spouts that his days are numbered, like everyone else’s, surgery or not. This difficult reality has driven me to become more involved in Indigenous health. Today I am employed with Wuchopperen Health Service, based in Cairns, as a health worker in the chronic disease management program area. I work with the Continuous Improvement Program team as program coordinator for the Healthy Hearts Cardiac Rehabilitation Program. This is a community-based outpatient cardiac rehabilitation (OCR) program operating from an Aboriginal-controlled community health organisation (ACCHO), working in partnership with the Cairns Base Hospital’s Cardiac Rehabilitation Unit to provide a culturally appropriate and relevant program focused on ATSI people. The availability of this support through an Aboriginal health service, as opposed to a hospital, is a major positive point for ATSI people attending the Healthy Hearts program. To date, there have been over 30 people attending regular exercise sessions and education days held at Wuchopperen Health Service since the program began in August 2006. I have been able to assist the cardiac rehabilitation coordinator with a Cardiac Rehabilitation for Indigenous Communities project that is jointly funded by the Australian Government Department of Health and Ageing and Queensland Health. This project is about training staff like me at Wuchopperen and also at the pilot sites of Yarrabah, Coen and Thursday Island. The overall aim of the cardiac rehabilitation project is to enable the delivery of flexible OCR models to these Indigenous communities. I assist the project when and how I can as a cultural adviser, contributing to or participating in cardiac rehabilitation training. Our program provides an Indigenous OCR program role model for similar emerging programs. We have been contacted by over a dozen services seeking advice and information about setting up ATSI OCRs. I have since become the Indigenous representative for the Queensland Cardiac Rehabilitation Association (QCRA), allowing me to raise matters from an Indigenous perspective in a state forum, attend a Queensland Cardiac Rehabilitation Collaborative forum as a guest speaker and contribute Indigenous-related articles to the national newsletter of the Australian Cardiovascular Health and Rehabilitation Association. I enjoy my role and believe that my story also demonstrates the level of interest and support in northern Queensland for workable solutions to very difficult health issues. Recently, I have been seeking to promote the Wuchopperen Health Service Healthy Hearts program through interviews with media groups such as the Brisbane Indigenous Media Association, the local Bumma Bippera Media broadcast service and the national Indigenous newspaper Koori Mail. I think it’s really important to advertise positive things happening in the Indigenous community. In closingIn the past few months, two young men I knew (seemingly fit and healthy) have died from coronary arrest in their mid to late 30s. It is a very sad thing when young Indigenous men leave their wives, children and extended families at such an early age. I am certain that, throughout Australia, many Indigenous families can tell similar stories — but this does not have to continue. It serves as a reminder of why I got involved in this quite serious business, and why people like my two young friends and my non-compliant brother need help. Health crisisEvery article written on Indigenous cardiovascular health problems inevitably calls for an urgent long-term solution. As an inpatient and now as an allied health worker, I can understand both sides of the coin. I deal with people associated with a health system in which the following issues are a daily reality: Tyranny of distance issues; Chronic comorbidities that result in surgery being contraindicated for ATSI people; Non-compliance with medication and follow-up appointments; Mistrust of hospitals by Indigenous people; A high proportion of Indigenous people refusing to undergo cardiac investigations; An unacceptably high rate of people refusing cardiac surgery; Long waiting times for life-saving surgery; Low uptake and follow-through of lifestyle changes and behaviour modification; Unwillingness to attend traditional hospital-based and ACCHO-based cardiac rehabilitation; and Primary, secondary and tertiary prevention measures missing their mark. These are only some of the issues I have become aware of in my work as an Indigenous health worker. I am sure there are far more qualified, knowledgeable people in the health field who can discuss the issues and solutions in more detail than I can. These people need to stand up and speak out too. Regardless, the issues raised represent serious unmet needs that require an urgent solution. Without a concerted effort, I predict the consequences will be dire for the Indigenous community throughout Australia. Governments, health departments, ACCHOs and the Indigenous community must demonstrate they are absolutely serious about improving the future health of Indigenous Australians. All groups mentioned have a role, particularly governments and Indigenous people. What’s needed is strong leadership from both sides and a coordinated effort, including, for example, examining funded regionalised agreements between ACCHOs and government health service providers and non-government organisations as a possible way forward. These kinds of partnerships and other creative solutions ought to be given due consideration before being dismissed. The issue of Indigenous health has always been controversial, certainly in my lifetime, and no doubt will continue to be so until the powers that be, namely federal and state health departments, decide to stop the blame-shifting and buck-passing and work together for the greater interest to create policy-driven outcomes, accordingly matched by funding and providing the right people and the necessary resources. Any review of past and current data relating to Indigenous cardiovascular health makes it clear that it’s time for all of our leaders to show some heart and exercise the political will needed to engage cardiac service/support providers and consumers in a long-term, committed, national response.

Barry N Fewquandie

The following is an extract from a highly commended essay in the Dr Ross Ingram Memorial Essay Competition Ali had the arms of a fisherman, the legs of a sailor, for so long a time he lived from the riches of the sea. Working from sunrise to sunset on the turn of tides with hooks and lines and nets he made his living. Once he was a young man, now he is an old man, but his eyes shine bright when he talks about the sea and he caught with his hands, the fish that fed the islands. Ali Drummond is a young man when he talks about the sea. — Old men and the sea from the album Island way, by Seaman Dan, Karl Neuenfeldt and Kyana-Lili Neuenfeldt Pearson (2005) Left to right: Samantha Faulkner, Ali Drummond and Vicky Duff (Samantha’s mother) at the book launch of Life B’long Ali Drummond: a life in the Torres Strait. What began as a half-finished open letter to the Prime Minister about Aboriginal and Torres Strait Islander health and an attempt at my personal reflections ended with this story about my grandfather. I thought to myself, “Why go global and try to cover everything when you can go local and talk about something you know enough about to write convincingly and from the heart?”. The other plus is that it is a good news story — a success story. It is something that we can all use and learn from, one way or another. Therefore, the following words I present are a mere snapshot about the life of my grandfather, Ali Drummond. Who is Ali Drummond you ask? He is a 90-year-old Aboriginal man who was born on Thursday Island and lived there for most of his life. Yes, 90 years old, which is quite a feat, considering that most Aboriginal and Torres Strait Islander people have a life expectancy of about 17 years less than the non-Indigenous population. He has led a full and active life. He worked in the Torres Strait as a pearl shell diver both pre- and post-World War II. During World War II he worked with the Civilian Construction Corporation building dams, gun emplacements, forts and repairing roads. He witnessed the bombings by the Japanese on Horn Island. He then went on to cut cane by hand in Far North Queensland, and later returned to Thursday Island and worked on the wharfs. Life b’long Ali Drummond: a life in the Torres Strait, by Samantha Faulkner with Ali Drummond, is published by Aboriginal Studies Press and available for purchase at http://www.aiatsis.gov.au/aboriginal_studies_press/ find_a_book/biography__and__autobiography/ life_blong_ali_drummond and all good bookstores. (Canberra: ASP, 2007 [140pp, $24.95]. ISBN 978 0 85575 556 0.) My grandfather is an ordinary person, a quiet achiever. He was awarded the Civilian Service Medal 1939–1945, 1998 NAIDOC Sportsperson of the Year Award for his achievements in lawn bowls (at the age of 80 years), and a Senior Australian Achiever of the Year Award in 1999. These good stories are important to tell and share with our family and community. Stories of resilience and strength are important for us all to celebrate our continued survival.

Samantha Faulkner

Research in Aboriginal health may be hampered by a lack of experience with the process of collaboration with Aboriginal communities, and additional ethics approval requirements. Awareness of resources and advice from Aboriginal mentors with in-depth knowledge of clinical and research issues can greatly assist researchers. A collaborative approach between researchers and Aboriginal communities is pivotal to developing a research project consistent with Indigenous cultural values and health concepts, with the potential to improve services and outcomes for Aboriginal peoples. Planning and broad consultation can ensure that research is feasible, ethical, culturally sensitive and beneficial. This article outlines lessons learned from personal experience of developing a project in Aboriginal health, which we hope may serve as a practical guide for others.

Anne P F Wand B(Sc)Med(Hons), MB BS(Hons) · Sandra J Eades BMed, PhD

Accurate data about Indigenous child health is vital to enable us to understand its current state, to acknowledge achievements, and to determine how to reduce inequalities between Indigenous and non-Indigenous children. We have identified a paucity of national, or nationally representative, data relating to Indigenous child health outcomes, and significant deficiencies in available data. A coordinated national approach will help address current data limitations, including lack of identification of Indigenous status, lack of currency, and lack of information about specific health disorders affecting Indigenous children. To ensure that health data collected are relevant and useful, Indigenous communities must have a role in data collection and management.

Emily Fremantle BA(Hons) · Yvonne A Zurynski BAppSc, MAppSc, PhD · Deepika Mahajan BSc(Hons), MSc, PhD · Heather D’Antoine BAppSc, MHEc · Elizabeth J Elliott MD, FRACP, FRCPCH

Oral health problems faced by Indigenous peoples are worsening and require practical long-term solutions In the 1970s, reports noted that oral health was one area in which Indigenous children enjoyed an advantage over other Australian children.1,2 However, as research improved our understanding of oral diseases, interventions to prevent common oral diseases like dental caries became available to most Australian children and oral health steadily improved. Furthermore, the dental caries that was experienced by most Australian children began to be effectively treated by ready access to dental care through school dental services or private dentists. As Indigenous children were largely unable to access these services for geographical and/or financial reasons, their oral health has worsened over time, with the result that Indigenous children now have poorer oral health than non-Indigenous children.3 Indigenous children are on a trajectory of developing further caries through to adulthood, with increasing numbers of teeth affected and eventually extracted. The teeth that are retained will also suffer from much higher levels of periodontal disease, which is likely to be earlier in onset and of greater severity than periodontal disease in other Australian adults.4 This may be the result of complications arising from other non-dental chronic diseases such as diabetes. The higher prevalence and severity of periodontal disease may subsequently place these Indigenous adults at risk of further chronic degenerative diseases such as diabetes and cardiovascular disease. Child oral healthA recent study showed that, compared with non-Indigenous Australian children, Indigenous children are now more likely to have dental caries at all ages. At the age of 6 years, 72% of Indigenous children had some tooth decay compared with 38% of other Australian children.4 The number of teeth with caries experience (ie, with past and/or present caries) among Indigenous children is about twice the number in non-Indigenous children, in relation to both deciduous and permanent teeth. Indigenous 6-year-olds have an average of 3.7 teeth with experience of caries compared with 1.5 teeth for other Australian children.5 Among 12-year-old children, the relative difference is somewhat less (1.3 compared with 0.8 teeth, respectively). The proportion of caries experience that is untreated is also higher among Indigenous children. Without early diagnosis and prompt treatment, multiple affected teeth present with advanced decay and tooth breakdown. This translates into higher numbers of young Indigenous children in remote areas undergoing hospitalisation for treatment under general anaesthetic.6 Solutions lie with caries prevention through adapting successful fluoride programs to the physical and social circumstances in which these children live. A number of approaches are being implemented, including fluoridating water supplies in larger remote communities with deficient levels of fluoride, clinical trialling of 6-monthly applications of fluoride varnish to the teeth of preschool children by primary health care workers, and introducing tooth-brushing and drinking water programs in preschools and schools. Adult oral healthThe National Survey of Adult Oral Health 2004–067 in Australia found that Indigenous adults have a higher perceived need for dental treatment than other Australians, particularly for dentures, fillings and extractions. More Indigenous than non-Indigenous adults reported that they were in urgent need of treatment. Although cohorts of Indigenous adults have similar overall past and present experience of caries to that of other Australian adults, they have higher levels of untreated caries and missing teeth and lower numbers of filled teeth.7 These findings indicate poorer access to timely dental care, resulting in either no care or care that is delayed until the disease process has reached an advanced stage and tooth extraction is required. These dental problems have further repercussions, with more Indigenous people avoiding certain foods because of dental problems, more ranking oral health as fair or poor, and more reporting experience of toothache.7 Indigenous adults have a higher prevalence of severe periodontal disease than non-Indigenous adults and are more than twice as likely to have advanced periodontal disease (after controlling for a number of sociodemographic characteristics).4 Periodontal disease accounts for 30% of tooth loss,8 contributing to the higher number of missing teeth in Indigenous Australians. The increased severity of periodontal disease and tooth loss for adults with non-insulin-dependent diabetes mellitus in Indigenous communities in Central Australia was first identified 20 years ago (Bruce Simmons, Dentist, Northern Territory Health, unpublished data, 1988). To this association between diabetes and risk of periodontal disease has more recently been added an association between periodontal disease and poor control of diabetes.9 Solving the oral health problems faced by Indigenous adults requires two complementary approaches. Firstly, access to dental care needs to be greatly improved. While the experience of dental caries among Indigenous people is no higher than among non-Indigenous Australians, the delay in accessing any care and the resource constraints of the services involved lead to high rates of tooth extraction and its consequences among Indigenous people. Specific dental care could reduce the progression or recurrence of destructive periodontal disease. Secondly, there is an imperative to integrate dental care with medical care, including dental disease in a group of related chronic degenerative diseases. Periodontal disease in Indigenous adults needs to be included alongside nutrition, obesity and diabetes in community health promotion programs. Some possible ways to address these issues are to include oral health in the training and practice of primary health care workers in Indigenous health, to develop pathways to providing priority dental care involving dentists and allied dental professionals, and to ensure that programs have strong community participation, capacity building and skills development for all major health problems.

Kaye F Roberts-Thomson BDSc, MPH · A John Spencer MDSc, PhD, MPH · Lisa M Jamieson PhD

Objective: To determine whether installation of swimming pools in remote Aboriginal communities reduces infection-related outpatient attendances and prescription of antibiotics.Design and setting: Swimming pools were opened in Jigalong and Mugarinya, Western Australia, in September 2000. We examined local clinic records to document illnesses occurring in children and adolescents under 17 years of age between 1998 and 2005. In Jigalong, we examined records of those enrolled in an ongoing study evaluating the effect of swimming pools on health. In Mugarinya, we examined clinic records of those residing there permanently.Main outcome measures: Clinic attendance rates for skin, middle-ear and respiratory tract infections and trauma, and prescription rates for antibiotics were analysed by using a community-based selection method in Jigalong, and a clinic-based selection method in both communities for comparison of the two communities and the two methods.Results: We examined records of 131 children in Jigalong and 128 children in Mugarinya. After the pools had been installed, clinic attendance rates for skin infections declined by 68% in Jigalong and by up to 77% in Mugarinya. In Jigalong (where the pre-pool prevalence of infections was higher than in Mugarinya), rates of antibiotic prescription declined by 45%, as did clinic attendance for middle-ear infections (61% reduction) and respiratory tract infections (52% reduction).Conclusion: Swimming pools in remote communities are associated with reduced prevalence of skin infections. Where disease prevalence is high, pools are also associated with reduced rates of antibiotic prescriptions and middle-ear and respiratory tract infections. In communities with resident health staff, examination of clinic records is an efficient method of monitoring the effects of public health interventions on the burden of infectious diseases.

Desiree T Silva FRACP, MPH · Deborah Lehmann MB BS, MSc · Mary T Tennant RN, BAppSc, MPH · Peter Jacoby MSc · Helen Wright MB BS, FRACP · Fiona J Stanley MD, FAFPHM, FRACP

Objectives: To determine the risk of otitis media (OM) associated with passive smoking in young children, and any competing effect between passive smoking and childcare attendance.Design, participants and setting: Prospective cohort study of 100 Aboriginal and 180 non-Aboriginal children born in Kalgoorlie Regional Hospital between 1 April 1999 and 31 January 2003. These children underwent routine clinical examinations by an ear, nose and throat specialist up to three times before the age of 2 years, and tympanometry at routine field follow-up visits from the age of 4 months. Childrens’ mothers were interviewed at 1–3 weeks postpartum to provide sociodemographic data.Main outcome measures: Associations between OM and exposure to environmental tobacco smoke (ETS) and childcare attendance.Results: 82 Aboriginal and 157 non-Aboriginal children attended for routine clinical examinations. OM was diagnosed at least once in 74% of Aboriginal children and 45% of non-Aboriginal children; 64% of Aboriginal children and 40% of non-Aboriginal children were exposed to ETS. Exposure to ETS increased the risk of specialist-diagnosed OM in Aboriginal children (OR, 3.54; 95% CI, 1.68–7.47); few attended childcare. Non-Aboriginal children exposed to ETS but not attending childcare were at increased risk of OM (OR, 1.91; 95% CI, 1.07–3.42) while those attending childcare had no increased smoking-related risk. Tympanometry was performed on 87 Aboriginal and 168 non-Aboriginal children; a type B tympanogram (suggesting fluid in the middle ear) was also associated with passive smoking in Aboriginal children.Conclusions: Reducing the exposure of children to ETS is a public health priority, especially for the Aboriginal population. A smoke-free environment will help reduce the burden of OM.

Peter A Jacoby MSc · Harvey L Coates MS, FRACS · Ashwini Arumugaswamy MB BS, BMedSci · Dimity Elsbury RN · Annette Stokes AHW · Ruth Monck RN, RM · Janine M Finucane RN · Sharon A Weeks MSc · Deborah Lehmann MB BS, MSc

Objective: To determine the extent to which depressive symptoms are associated with heavy cannabis use in an Aboriginal population in Arnhem Land, Northern Territory.Design, participants and setting: Cross-sectional study involving interviews with 106 Indigenous participants (57 males, 49 females) aged 13–42 years in three remote Aboriginal communities in Arnhem Land, NT, Australia.Main outcome measures: Measures of depressive symptoms (a raw score of ≥ 6 out of a possible 18 on a modified version of the Patient Health Questionnaire-9) and self-reported heavy cannabis use (six or more cones daily).Results: After adjusting for other substance use (tobacco, alcohol and lifetime petrol sniffing), age and sex, heavy cannabis users were four times more likely than the remainder of the sample to report moderate to severe depressive symptoms (odds ratio, 4.1; 95% CI, 1.3–13.4).Conclusions: Given its high prevalence in Indigenous populations, the development of clinical and prevention strategies for cannabis misuse are warranted.

K S Kylie Lee BMus(Hons) · Alan R Clough PhD · Muriel J Jaragba Cert III (Mental Health) · Katherine M Conigrave FAChAM, FAFPHM · George C Patton MD, FRANZCP

Objectives: To define and compare the prevalence, risk factors and understanding of hepatitis C transmission among Aboriginal and non-Aboriginal young offenders.Design, participants and setting: Cross-sectional study of young offenders (aged 12–19 years; median age, 16.6 years) in custody or serving community orders with the New South Wales Department of Juvenile Justice who participated in a physical and mental health survey between March 2002 and December 2005, and who provided blood samples for analysis of biochemistry, bloodborne viruses and sexually transmitted infections.Main outcome measures: Risk factors and prevalence of hepatitis C antibody positivity.Results: Of the 1042 young offenders studied, 709 provided blood samples, 179 (25%) of whom identified as Aboriginal. Aboriginal adolescents had more markers of social disadvantage and higher rates of hepatitis B (9.6% v 5.2%; P = 0.04) than non-Aboriginal young offenders. Hepatitis C rates were high in both groups (7.3% v 5.3%; P = 0.33). Risk factors for hepatitis C were the same in both groups, the most important being injecting drug use (OR, 19; P < 0.001) and prior use of heroin (OR, 15; P < 0.001). Current custodial sentence doubled the risk of hepatitis C. Knowledge of hepatitis C transmission was very poor in both groups, with over 50% not knowing how it is transmitted and fewer than 10% able to identify sharing needles as a risk.Conclusions: Hepatitis C rates are extremely high in all young offenders, and interventions to halt its spread are urgently needed. Aboriginal adolescents, who are over-represented in this population, are particularly at risk.

David van der Poorten BSc(Med), MB BS, FRACP · Dianna T Kenny PhD, MA(ScCouns), BA(Hons) · Jacob George PhD, FRACP

Objectives: To describe delivery of child health services in Australian Aboriginal communities, and to identify gaps in services required to improve the health of Aboriginal children.Design: Cross-sectional baseline audit for a quality improvement intervention.Setting and participants: 297 children aged at least 3 months and under 5 years in 11 Aboriginal communities in the Northern Territory, Far West New South Wales and Western Australia in 2006.Main outcome measures: Adherence to guideline-scheduled services including clinical examinations, brief interventions or advice on health-related behaviour and risks, and enquiry regarding social conditions; and recorded follow-up of identified problems.Results: Documentation of delivery of specific clinical examinations (26%–80%) was relatively good, but was poorer for brief interventions or advice on health-related behaviour and risks (5%–36%) and enquiry regarding social conditions (3%–11%). Compared with children in Far West NSW and WA, those attending NT centres were significantly more likely to have a record of growth faltering, underweight, chronic ear disease, anaemia, or chronic respiratory disease (P < 0.005). Only 11%–13% of children with identified social problems had an assessment report on file. An action plan was documented for 22% of children with growth faltering and 13% with chronic ear disease; 43% of children with chronic respiratory disease and 31% with developmental delay had an assessment report on file.Conclusion: Existing systems are not providing for adequate follow-up of identified medical and social problems for children living in remote Aboriginal communities; development of systems for immediate and longer-term sustainable responses to these problems should be a priority. Without effective systems for follow-up, screening children for disease and adverse social circumstances will result in little or no benefit.

Ross S Bailie MD, MPhil, FAFPHM · Damin Si MMed, MPH, PhD · Michelle C Dowden RN, GradCertPublicHealth, MPH · Christine M Connors MB BS, MPH, FAPHM · Lynette O’Donoghue BSc, DipIndigHlthProm, BAppSci · Helen E Liddle BA · Catherine M Kennedy BSc(Hons), MSc · Rhonda J Cox Cert III/IV(AHW) · Hugh P Burke MB BS, MPH, FAFPHM · Sandra C Thompson MB BS, FAFPHM, PhD · Alex D H Brown BMed, MPH, FCSANZ

Aboriginal healthworkers. Primary health care at the margins. Bill Genat with Sharon Bushby, et al. Perth: UWA Press, 2006 (xiii + 226 pp). ISBN 978 1920694 76 0. This book is a little gem. It could not be more timely and essential a read for anyone interested in how best to deliver preventive, truly holistic and primary health care to Australian Aboriginal families and communities. Bill Genat uses ethnographic methods to study the roles, challenges and lives of five urban Aboriginal health workers, each of whom have between 10 and 20 years working experience. The book describes Aboriginal health worker practice at the grass roots, with many real-life case studies demonstrating breakdowns in family caring and the outcomes of intergenerational exclusion and oppression. It describes clearly the challenges faced (and not always overcome) by these women as they strive to help the families for whom they are responsible with all the variety of situations they face. The section describing how Aboriginal health workers are neither valued nor appropriately used by either the health system or the doctors, nurses and others is captured in the opening quote: This book is unique, and a “must read” for anyone working in Aboriginal health, for those in charge of health systems, and for students interested in ethnographic methodology and the social sciences. It would be great if it were read by politicians too, who then might understand that an important piece of the jigsaw to “solve” poor Aboriginal health status is staring them in the face.

Fiona Stanley

Currently, only 0.18% of doctors and 1.1% of medical students in Australia are Indigenous. There are relatively few Indigenous students enrolled in tertiary health studies, and only 120 enrolled in medicine across Australia. The University of New South Wales (UNSW) currently has 19 students, enrolling eight students into first year medicine this year, with half offered residential scholarships at Shalom College through the Shalom Gamarada Ngiyani Yana scholarship program. Shalom Gamarada runs in partnership with the UNSW’s Shalom College, Nura Gili Indigenous Programs Unit and the Muru Marri Indigenous Health Unit, and has done so from 2005. We have been able to assist 15 students to study medicine, optometry and medical science. Each scholarship is valued at $15 000 per year and covers full board and tutoring support at the College on the university’s Kensington campus. Conditional on passing their examinations, each student awarded a scholarship has tenure until they complete their degree. Currently, there are eight Indigenous students on scholarships residing at Shalom College — seven medical and one optometry, with four in first year, two in second year, one in third year and one in fourth year. When it commenced in 2005, the program was initially funded solely by the annual Shalom Gamarada Ngiyani Yana Aboriginal Art Exhibition and sale, with proceeds from the first exhibition (in 2005) funding the initial intake of recipients. Some of the paintings from the upcoming exhibition appear below. In 2006 and 2007, however, the program received considerable support from the corporate sector and from individuals providing named scholarships in honour of relatives, events or organisations. This year, we also announced our very first endowed scholarship, worth $22 000 per year — $15 000 for the residential component and an additional $7000 to assist the scholarship holder with other expenses. The 2008 exhibition will be held from 21 July to 27 July and will be officially opened by David Gonski AC, Chancellor of the UNSW and Dr Tamara MacKean, President of the Australian Indigenous Doctors’ Association. A panel discussion on Indigenous health and another on Aboriginal art will be held on the final day of the exhibition, from 2pm. Artist: Jan Billcan Artist: Cory Surprise Artist: Gloria Petyarre Artist: Shorty Robertson Artist: Shane Pickett Artist: Regina Wilson

Lisa R Jackson Pulver · Hilton Immerman OAM

The WHO recommends whole-of-community antibiotic treatment for chlamydial eye disease (trachoma). a recent article suggested the same approach should be taken to manage endemic chlamydial disease when the same organism is sexually transmitted. This controversial approach has sparked debate. (MJA 2008; 188: 182-184) Sandra C Thompson, Darryl M Kickett and Timothy G Leahy — Med J Aust 2008; 188 (10): 620. Michael S Gracey and Randolph M Spargo — Med J Aust 2008; 188 (10): 620-621. David J Scrimgeour — Med J Aust 2008; 188 (10): 621. Bryan G Walpole — Med J Aust 2008; 188 (10): 621. Francis J Bowden and Katherine Fethers — Med J Aust 2008; 188 (10): 621.

To the Editor: Bowden and Fethers’ provocative recommendations for mass antibiotic treatment to reduce the prevalence of sexually transmissible infections (STIs) in remote Aboriginal communities is based on the failure of the current approach of screening and treatment of individuals to reduce STI prevalence.1 However, approaches that address a single health issue in isolation will not succeed in improving Aboriginal health. The biomedical approach proposed could reduce the likelihood of a sexually active person becoming infected with an STI, but, in our experience, many Aboriginal people object to the “sheep-dip approach” of mass indiscriminate treatment. Moreover, it is ethically difficult to justify giving a cocktail of four antibiotics with potentially adverse side effects to all people in a population when only one or two out of 10 will benefit. The proposed staggering of doses would only increase the difficulty and reduce compliance. The people who don’t participate in current programs are the same people who would be least likely to comply with a new program. The greatest merit of Bowden and Fethers’ proposal is in addressing the social determinants of poor health. The ancillary “life skills” programs they suggest could also be useful, and to this we could add interventions with the core groups2 and multifaceted interventions to reduce the use of alcohol and other drugs that fuel disinhibited and violent behaviour, including sexual abuse. Most importantly, tackling STIs in isolation will fail to bring about improvements in the many areas of Aboriginal health requiring attention. Arguably, given the profound health inequalities experienced by Aboriginal Australians, the best approach would be to resource culturally secure, comprehensive primary health care services adequately,3 at a level greater than that available for urban middle class Australians. This has not yet been achieved in remote areas. Yet the complexity of Aboriginal social and health issues demands the most experienced and skilled health professionals rather than the current workforce, which is characterised by high turnover and consists too often of overseas-trained medical staff, nurses on short-term contracts and Aboriginal health workers, many of whom suffer from illness or family trauma. Before contemplating mass community treatment, priority must be given to improving the social determinants of health, enabling Aboriginal people to have control over their own lives. This would effectively involve Aboriginal leadership at community level generating Aboriginal-led solutions. This would have a longer-term effect on health improvement and ensure good access to quality primary health care that could respond to the complex needs of Aboriginal people.4 It would require continuity of care from committed, appropriately trained health professionals who understand and work within the values and priorities of Aboriginal people. Aboriginal people want primary health care that delivers culturally secure, empowering and holistic care.5 Mass treatment fails in this. Enhancing multidisciplinary primary care with linkages to the community outside the clinic could help address the many other causes of chronic illness that contribute to the shameful gap in morbidity and life expectancy between Indigenous and non-Indigenous Australians.

Sandra C Thompson · Darryl M Kickett · Timothy G Leahy

To the Editor: The proposal by Bowden and Fethers1 to abandon “screen, treat and contact trace” methods of managing endemic sexually transmissible infections (STIs) in remote Indigenous communities and replace them with mass treatment programs in groups with defined threshold prevalence levels is flawed. Primacy must go to the question of why some STIs are so prevalent. Why deal only with the consequences rather than the causes of STIs? Without resolving these questions, the problems will persist. Bowden and Fethers’ approach has serious shortcomings. A major one is sweeping aside the concepts of one-on-one advice, counselling, opportunities to cooperate with health staff, avoidance of hazardous behaviours, and maintenance of effective follow-up. These cornerstones of public health strategies to control STIs depend on the ability of health professionals to establish meaningful relationships with Indigenous people. Transient populations move frequently between towns and remote communities. Therefore, the authors’ strategy neglects the serious risk to remote communities from inadequately controlled reservoirs of STIs that allow the diseases to be repeatedly reintroduced from rural or remote towns. The authors say, ironically, “Let’s not talk about sex”, but an essential part of the public health response to STIs must be to talk about sex. It is our observation that many Indigenous people are more comfortable talking about this subject than other Australians. Another risk in the authors’ approach is to overlook detection of HIV infection. Their proposal could also be interpreted by many Indigenous people as suggesting that they no longer need worry about STIs because the new blanket approach from their health carers will protect them from all such infections. Our long experience working in remote northern Western Australia suggests to us that a mass treatment approach would not resolve the problem of STIs. Control of many of the main chronic diseases of Indigenous people living in remote areas can be significantly enhanced by increased Indigenous community involvement, decision making, and trusting collaboration with health professionals.2 Crucially, additional government commitment is urgently needed to provide enough locally stable and adequately trained staff, facilities, and related resources to control these persisting problems in remote Australia.

Michael S Gracey · Randolph M Spargo

To the Editor: It was pleasing to see Bowden and Fethers raising the issue of public health approaches to sexually transmissible infection (STI) control in remote Indigenous communities.1 However, their suggestion that mass treatment programs would be more effective than screening programs is flawed. They note that screening programs have had some success in reducing the prevalence of STIs, but that an unacceptable prevalence persists. Rather than rejecting screening as an appropriate strategy, it would be more useful to investigate the reasons why screening programs have had limited success. It is likely that the main drawback has been inadequate coverage, and one of the main reasons for this is that there are hard-to-reach groups who are not being included in screening programs. In particular, this would include people with alcohol problems or other addictions, whose lifestyle makes them more at risk for STIs. People in this group, who often live a transient or homeless lifestyle in regional centres, have problems of access to health care and health programs. A mass STI treatment program would not overcome this difficulty and would be just as likely as current screening programs to miss this crucial target group. What is needed is better support for comprehensive primary health care programs, to allow an extension of current health programs to reach out to these groups. Bowden and Fethers suggest that screening programs are inadequate because of problems with current levels of staffing and health infrastructure. This is what needs to be addressed. Greater support for community-controlled comprehensive primary health care, to ensure adequate levels of staffing and infrastructure for STI screening (including outreach programs for hard-to-reach populations), would produce better results from STI screening and would also allow better control programs for other health problems. Furthermore, it would help reduce the problem of increasing antibiotic resistance that is likely to result from mass treatment programs.

David J Scrimgeour

To the Editor: With their radical population-based approach, Bowden and Fethers1 bring a refreshing perspective to the management of sexually transmissible infections (STIs) in Indigenous communities — normally a taboo subject with those at risk and their families. I recently participated in the federal government’s Northern Territory Emergency Response, and was told, both centrally and locally, that looking for STIs was off limits, as it might destroy the trust of Aboriginal communities. This meant that I could neither enquire about nor examine children or adolescents below the umbilicus. I noted that most teenage girls had contraceptive implants (a good public health measure), but no STI prophylaxis. I think this is a failure of the Response.

Bryan G Walpole

In reply: Although the title of our article was intentionally provocative, our suggested rethink of current approaches to control of sexually transmissible infections (STIs) in remote communities emphasises the role of individual autonomy and consent, education, health promotion and community involvement. We do not dismiss one-on-one advice, counselling, follow-up, the need for meaningful relationships with Indigenous people, or the risk of an HIV epidemic. However, we do suggest that there should be a separation of the strictly medical components of the strategy from the community development components. Furthermore, in the presence of endemic disease, we propose that presumptive treatment should be based on an assessment of risk made at a community level rather than at the individual level, and that removing the otherwise unavoidable delays between screening and treatment may be a more effective first step in reducing the burden of STIs in remote populations. A “screen, recall, treat and contact trace” approach works to some degree in the mainstream population, in which the prevalence of STIs is much lower than in remote communities, but what is considered “best practice” in suburban Australia does not automatically translate into best practice in the bush. We acknowledge the logistic difficulties of offering any type of broadly based community program in remote areas and we specifically address the problem of treating hard-to-reach groups in communities. We recognise the risk of giving a false sense of security to the target audience, but current approaches provide people in remote areas little protection from STIs. The recent roll-out of the human papilloma virus vaccination in young women could be similarly criticised, but it is possible to implement a biomedical intervention and still continue with education and health promotion. The question of antibiotic resistance is an important one. The aim of increasing the intensity of treatment over a defined time period is to reduce the total amount of antibiotics prescribed in the longer term. An increase in the level of resistance is the price that is paid for a reduction in the prevalence of disease in any population receiving antibiotics. Nevertheless, we indicated the need for monitoring of resistance patterns in any trials that are undertaken. The eradication of the eye disease trachoma is dependent on the availability of clean water and better housing, but while this crucial infrastructure is being built we have to continue to treat the condition where it occurs and apply “traditional” public health approaches to population-level control. We think it is reasonable to consider doing the same for STIs.

Francis J Bowden · Katherine Fethers

To the Editor: Recent media reports1 of events in Aurukun, Palm Island and other Indigenous communities in Queensland may have left the impression that most Indigenous people in the state live short, violent lives in remote, dysfunctional communities. However, census data from the Australian Bureau of Statistics (ABS) contradict one aspect of this impression: in fact, few Indigenous people live in remote communities, with the majority widely spread through the general population (Box). Over the past 10 years, the Indigenous population of Queensland has increased by 33.7% (Box). However, the number of people living in Aboriginal and Torres Strait Islander land council areas was almost stationary, dropping from 17 855 in 1996 to 17 739 in 2006, and the proportion of Indigenous people living in these areas decreased from 18.7% to 13.9% over the 10 years. The other six out of seven Indigenous people lived in the general community (Box). Twenty-four per cent lived in Brisbane city; suburb-by-suburb analysis showed most lived in less affluent areas of Brisbane but, even in these, the percentage of Indigenous people was only 1%–8% in each area. There are no major ghettos. In 2006, 32.4% of Indigenous people lived in south-east Queensland (classified as the “Brisbane Indigenous Region” by the ABS, Box); there is no land council area in this region. On North Stradbroke Island, a group of 366 Indigenous people living in the general community comprised 18% of the local population, but in all other locations the percentage of Indigenous people was well under 10%. Indigenous Australians have also moved to other cities in Queensland. In 1996, 42 571 Indigenous people (44.6% of the state’s Indigenous population) lived in a major city (Brisbane, the Gold Coast, Toowoomba, Rockhampton, Townsville or Cairns). By 2006, 61 672 Indigenous people lived in these cities. This is below the 67.1% for all Queenslanders, but is still nearly half (48.3%) of the Queensland Indigenous population. In the 1996, 2001 and 2006 ABS censuses, an Indigenous person was defined as someone who had ticked one of three boxes on the ABS census form stating that he or she is Aboriginal, Torres Strait Islander or both. All censuses have problems with accuracy of the data submitted and missing returns;2 however, as the results presented here were determined using the same methodology, show linear trends across the datasets, and identify only broad trends, I believe they are robust. Much of the increase in the Indigenous population is probably due to the higher birth rate of Aboriginal and Torres Strait Islander people (26.4/1000 v 12.9/1000 in the overall Queensland population).4 However, “migration” — people reclassifying themselves as Indigenous — may also contribute. These census data show that, as with other Australians, there is a net movement of Aboriginal people from rural to urban areas. Anecdotally, many people move from Indigenous communities and other rural areas to relatives in “town”; some stay for only a short time, but others remain in the city. This move is sometimes to the rural or urban fringe, but more often is into a stable integrated family group. Most Indigenous people in Queensland are widely spread through the general population. ABS census data on Queensland Indigenous people* 1996 2001 2006 Queensland population Total 3 368 850 3 655 139 4 046 880 Indigenous (% of total population) 95 518 (2.8%) 112 772 (3.1%) 127 684 (3.2%) Brisbane population Total 1 468 617 1 605 650 1 782 973 Indigenous (% of total population) 21 462 (1.5%) 26 453 (1.6%) 30 769 (1.7%) Indigenous population (% of Queensland Indigenous population) Brisbane 21 462 (22.5%) 26 453 (23.5%) 30 769 (24.1%) Brisbane Indigenous Region† na 36 323 (32.2%) 41 369 (32.4%) Major Queensland cities‡ 42 571 (44.6%) 52 385 (46.5%) 61 672 (48.3%) ATSI land council areas§ 17 855 (18.7%) 16 567 (14.7%) 17 739 (13.9%) ABS = Australian Bureau of Statistics. na = not available. ATSI = Aboriginal and Torres Strait Islander. * Data are collated from numerous sections of the 1996, 2001 and 2006 ABS censuses.2 † The Australian Indigenous Geographical Classification used by the ABS.3 ‡ Includes Brisbane. § Population for ATSI land council areas is total population.

Alan E Dugdale

To the Editor: As a junior doctor working in Central Australia, who has spent the past year rediscovering my own Aboriginal heritage, I read the recent articles on the Northern Territory intervention- with interest. All authors agree that the current state of health in NT communities is shameful, and that the causes include a wide range of social determinants. However, beyond these similarities there is almost complete discordance between the article by Glasson (of the NT Emergency Response Taskforce) and the other three articles by NT-based doctors (Tait, Boffa et al, and Brown and Brown). Glasson paints a demeaning and misleading picture of NT communities as exhibiting “a complete breakdown of normal mores”. This fits snugly with the “white blindfold” view, described by Tait, that will only further disempower marginalised Aboriginal people and communities. Glasson ignores the vast accumulated knowledge and successes attained by Aboriginal community-controlled health services (ACCHSs) and health workers, relegating their contribution to a half-sentence in his acknowledgements. Boffa and colleagues clearly outline the remarkable successes of ACCHSs and their repeatedly ignored calls for more resources. Glasson leaves no room for real community participation, and justifies the government’s heavy-handed approach as necessary for such a “crisis”. Brown and Brown describe convincingly the absolute necessity of Aboriginal rights and participation in any intervention conducted on their behalf, and the valiant long-term struggles by Aboriginal people to tackle the current situation. In response to the government’s intervention, in June 2007, Mark Wenitong, President of the Australian Indigenous Doctors’ Association, expressed concerns that remain relevant today: “As medical professionals, we question the notion that you can treat poverty, dispossession, marginalisation and despair (the root causes of substance misuse and sexual, physical and emotional abuse) with interventions that further contribute to poverty, dispossession, marginalisation and despair.” Indeed, the Ampe akelyernemane meke mekarle: “little children are sacred” report was very clear about the necessary approach to addressing the issues it raised: “What is required is a determined, coordinated effort to break the cycle and provide the necessary strength, power and appropriate support and services to local communities, so they can lead themselves out of the malaise: in a word, empowerment!” My experience working in NT Government hospitals and ACCHSs has revealed both the enormous challenges facing Abori-ginal people in the NT, and their remarkable resilience and capacity to achieve against all odds. As health professionals and Australian citizens we must recognise these efforts and support interventions that are evidence-based, respectful, and conceived in partnership with Aboriginal communities and their ACCHSs. Without this, the most expensive intervention will only ever amount to a superficial facelift.

Hamish R Graham

In reply: While I acknowledge the arguments many have put forward that the Northern Territory Emergency Response (NTER) has been too rapid and implemented without optimal community consultation — which some perceive to have disempowered Indigenous people — I stress the need to continue and indeed step-up momentum so that communities can regain control of their own futures as soon as possible. The positive impact of the NTER measures in creating better health, social and economic outcomes for Indigenous Australians will only be realised with the total support and focused energy of those “on the ground”, charged with delivering vital primary care and secondary intervention in NT communities. Without the continued engagement of these hardworking individuals who are able to establish the trust required to build bridges into these communities, the initiative is not sustainable. It is into the hands of those who live and work in Aboriginal communities that the NTER Taskforce and government agencies will pass the baton of change — we hope they will run with it.

William J H Glasson