Volume 190 Issue 10

In 2006, with outstanding cooperation from Department of Corrective Services staff at Cessnock Correctional Centre, two Justice Health staff made a huge step in walking together in the constant fight for Aboriginal health. In a mere six and a half hours, 88 Aboriginal offenders — 100% of the Aboriginal population in that centre — were screened for markers of kidney disease. We had been fighting for years to get renal screening into the jails. Finally it happened! A special renal screening research project funded by the Hunter New England Area Health Service was to be carried out in three facilities in the Hunter Valley and northern New South Wales: Cessnock, St Heliers (Muswellbrook) and Tamworth. We were offered five days to do three jails. If anyone could pull it off, I reckoned I could. I’ve been an Aboriginal Health Worker in the system since 1985, longer than most of the “lifers” — but they let me out from time to time, I like to remind everyone. I did some serious thinking and strategic planning on just how to pull this off at the Cessnock site. I had 66 Aboriginal patients spread over five wings and various other locations, and no nurse or place to do the screening. A well-meaning officer jokingly said to me on hearing about it, “How many you wanting to do?” “Sixty-six, officer — the lot”, I answered. He laughed and retorted, “Impossible, you’ll never do it . . . I’d say 30, tops . . . and three days. It’s a bet”. They were fighting words. “You’re on.” That was how this story started. What I first needed was a nurse and a place to do it. I fronted the clinic and did some passionate Aboriginal-kidney-health-at-an-all-time-low talking to the Justice Health Nursing Unit Manager. She was already four nurses down that day, but after some drastic roster raping and creative roster placing, I got my Aboriginal male nurse for the project. We needed a toilet for collection of specimens. Urine testing is not the easiest thing to do in a hurry. Next we needed to give the patients-to-be an incentive. I headed into the prison-yards — “Calling all Kooris!” I’d kick that Koori grapevine into gear fast to get the word out. The bait was a Koori-coloured red, yellow and black water bottle. One each. It wasn’t much, but then most of these guys have almost nothing. To make sure everyone knew what was happening and how important it was to get 66 permission forms signed beforehand, we arranged afternoon tea for the next day. Hot buttered damper with syrup and billy tea were promised. That hit the spot. Full turn-up next day and 66 names and forms were signed and collected, with spares kept at the ready for any new arrivals. The officer’s challenge was taken by all offenders with wry grins and much laughing as hot buttered damper with syrup was consumed with lots of lip-smacking and licking of fingers and enthusiastic agreement as we planned D-Day down to the minute. The jobs of rounding everyone up and getting them from point A to point B were allocated. Twelve patients at a time was agreed — ready to roll out, bladders brimming, as others returned. They were ready — all they needed was complete cooperation from all officers concerned on the day. D-Day arrived. By 7.30 am I was already in the yards as the wings were emptying for breakfast. We rallied the Kooris to win the bet as soon as methadone parade was over. We had 66 for sure, and others signing on, as the transports arrived with more offenders. It was shaping up well. By mid morning, the Aboriginal Delegate (the community leader of all Aboriginal offenders of the centre) had 22 more signed permissions: 100% of the Aboriginal population in the Cessnock facility, now 88 in total. All in. “Bring it on Aunt, we’re ready for them!” The war cry went up. Something was about to break the boredom that day. Everybody knew it and was ready to play a part — not just the Kooris. The operation was fully planned for speed. As each patient arrived in the allotted clinic area, I would give him a specimen cup to write his name and ID number on; record his height and weight; then send him on to the nurse to have his specimen tested and blood pressure taken. Each patient was warned — any abnormality and he would be listed to see the doctor. After receiving their water bottles, each group returned to the yards to spread the word of encouragement and help rally the rest. When the queue got down to five, the Aboriginal Delegate and I would take off down the “avenue” to gather the next 12. This is where the story gets humorous. Some of the old laggers who were taking it easy, sitting in the sun on the walls along the avenue and generally bored silly with the monotonous routine of their surroundings, started to take a keen interest in the comings and goings and the unusual enthusiasm of the Koori lads that morning. At this point they decided to get in on the act too. As they spied them striding fast (you don’t run inside jails) towards the avenue gates, the laggers would call out, “Come on you Koori lads, Aunt is coming for you, boots and all”. Fact is, Kooris never hurry for anyone or anything, it’s kind of a principle — but when they heard that call, “there was movement in the yards, for the word had passed around, that Aunt was coming fast and the boots were gaining ground”, they were gathering and forming up already in lines. The old laggers sitting on the walls were well into the game by now and sent out a new call to the avenue rover: “Hey chief, they’re on their way back now . . . big bunch of ’em coming up fast”. This alerted the rover to open up each of the three security gates promptly for us to pass through. On the third trip down, the old laggers called out in jovial fashion, “Go Aunt, go! We’re taking book on this, you know”. That called for some laughter and cheering as the patients passed each time. The applause and calls of encouragement from the crowd, which had now swelled considerably, added a definite flavour to the day. Our project had become a talking point. Some officers remarked later that the Aboriginal health exercise lifted morale that week for the whole jail. It had been all good. By lunchtime, we were out of resources. Hunter Area Health had only sent 50 packs. We’d ordered more, but were still waiting for them. I phoned again — they were on their way. We still had two wings and the work crews to get through. Cuppa was in order, but then word came — “The parcels are here and on their way down!” Yes! The officers were met halfway. They had two big bags of water bottles and the testing gear. Cheers rang out from the avenue throng and the officers were heroes for a minute or so. Because of the tight security in the next areas (Maximum), it took a little longer, but we finished by 2.30 pm, still with time to catch the Aboriginal lads returning from work in their assigned prison duties for the day. Because of prison staff shortages, early lockdown in Maximum meant they had to be escorted individually down two flights of stairs to take part. With great officer cooperation, it happened. We needed to complete the project before total jail lockdown at 4.00 pm, and we did. Hoping we’d managed to test everyone, the pair of us wearily trudged back through the long jail yards past all five wings to the clinic. Our step lightened as we heard the inmates calling to us, “Good on you fellas, did you get them all? . . . Deadly job you two, a great day!” Everyone wanted to know if they had reached the goal, headed by the officer who’d bet we couldn’t do it. With a grin on his face he asked if we’d done all 66 prisoners, looking very confident we hadn’t. I was happy to bring him up to date. Count done: 100% of current Aboriginal offenders had participated and all had been tested. By the clock, we had done 88 patients in six and a half hours! The officer was astounded: “That was some feat you two pulled off . . . I can’t believe it . . . glad I didn’t put money on it!” The serious side of the screening research project showed itself in the results. Of the 88 Aboriginal offenders, 14 screened positive for microalbuminuria and many more were positive for other high-risk chronic illnesses such as hypertension and diabetes. The next two jails visited were St Heliers and Tamworth. At St Heliers, all 37 Aboriginal offenders were screened. Of these, 13 tested positive, and again many were referred for other high-risk illnesses. At Tamworth, 42 Aboriginal people were screened (one refusing), with 14 being positive and one dangerously positive. In all, over the three sites, 167 renal screenings were carried out, resulting in 42 abnormal kidney readings. As a result of this successful renal screening project, one new Aboriginal position has been created for the area: the Coordinator Aboriginal Renal/Health Promotion will be working with the Aboriginal Health team for two years within the existing 16 Aboriginal Chronic Care Program sites. The Program gives us vital information on the cardiovascular health of Aboriginal offenders well in advance of onset of cardiovascular disease. The renal health component is a nice addition to the Program. Aboriginal people normally don’t access the mainstream Justice Health centres in the jails because Aboriginal staff from many external Aboriginal Medical Services can’t regularly visit the centres any more due to a lack of staff and funding. This is why we need Aboriginal Health Workers in every jail, especially in those with a high percentage of identified Aboriginal offenders. Change — stalled a decade ago — is slowly starting to happen again. Twenty per cent of the male client base and 31% of the female client base in NSW prisons are Aboriginal people, with levels as high as 50% in younger offenders. Despite the Royal Commission into Aboriginal Deaths in Custody1 20 years ago, which recommended that culturally appropriate medical care be provided to offenders, with access to Aboriginal Health Workers wherever possible, and despite what you read in annual reports since then, Justice Health 10 years ago adopted an unofficial policy of mainstreamed take-it-or-leave-it medical service to Aboriginal offenders. It is now slowly moving away from this stance by employing its own Aboriginal Health Workers as part of the health centre staffing profile, beginning with one of the newer facilities at Wellington in midwestern NSW. Visiting Aboriginal Medical Services staff should be welcome to work with members of their community who are in jail, but clearly, Aboriginal Health Workers are needed within the system itself, trained to go into the yards with the Aboriginal Delegates to encourage the brothers to access and be tested at the Health Centre. The hardest part of the process is moving the prisoners within the jail. Locked gates, classification, segregation, non-association, constant lockdowns, inter-jail transfers without notice, request forms denied or simply lost — all add to the burden of self-destructive thinking that offenders bring into jail with them. Even knowing of a serious medical problem, they will often give up and cease to care. Aboriginal people in general, and prisoners in particular, are also dealing (or not dealing, as the case may be) with the blight of long-term systemic racism. A popular notion (unfortunately given scientific credibility by Charles Darwin) is that they are the lowest form of human life — one step above the apes: [H]ow little can the hard-worked wife of a degraded Australian savage, who uses hardly any abstract words and cannot count above four, exert her self-consciousness, or reflect on the nature of her own existence? [quoting Büchner] . . . At some future period . . . the civilised races of man will almost certainly exterminate and replace throughout the world the savage races.2 I commend you instead to the words of Kevin Gilbert — a self-educated Wiradjuri man and former offender — writing 100 years later, after doing 15 years for murder: As Aborigines began to sicken physically and psychologically, they were hit by the full blight of an alien way of thinking. They were hit by the intolerance and uncomprehending barbarism of a people intent only on progress in material terms, a people who never comprehended there could be cathedrals of the spirit as well as of stone. Their view of Aborigines as the most miserable people on earth was seared into Aboriginal thinking because they now controlled the provisions that allowed blacks to continue to exist at all. Independence from them was not possible. White people’s devaluation of Aboriginal life, religion, culture, and personality caused the thinking about self and race that I believe is the key to modern Aboriginal thinking. As Robert Kantilla said, “Suffering is that the white people class them as the lowest person on earth”. My thesis is that Aboriginal Australia underwent a rape of the soul so profound that the blight continues in the minds of most blacks today. This psychological blight, more than anything else, causes the conditions we see in reserves and missions today and is repeated down the generations . . . [T]hey have been patterned into that stereotype, and they do live it.3 No more is needed to explain the present and ongoing over-representation of Aboriginal people in the prison population, or their generally poor health. And the solution? Kevin Gilbert goes on to say that it starts with your education, and I agree. But it’s a special education. It’s a pity I don’t have room to quote him more, because he just blows Charles Darwin away. And healthwise, whether you’ve been injured by a truck or by generations of white racism, it’s the same solution, believe it or not — education. Kooris, Gooris, Murris and all Aboriginal people, your health education can start right here, with you learning these principles: Recovery and ongoing maintenance of your good health starts, first and foremost, with a free decision by you to take primary personal responsibility for it. Yes, you can do it, and yes, you are worth it. You need education — information, strategies, and especially role models. Find them, and stick with the strength, or else . . . For the many Aboriginal people locked in prison — especially those also locked in their self-destructive rituals of negativity, resentment and blame — experience shows that the process of health education in prison is only likely to start when they are targeted, brought together and encouraged into the caring hands of Justice Health’s wonderful Health Centres, with their specially trained and enthusiastic Aboriginal Health Workers.

Beverley F Spiers BEd(Aboriginal Adult Ed), GradDipAdultEd

I don’t know where I would be — six years’ study is a long time — and the fact that I have had a home, with meals, on campus lets me do the job I have to do to pass my exams. I have been here for four years now, and I have had the time to work hard at uni, and work out where I want to go when I graduate. The scholarship — without question — has allowed me to stay at uni and get on with my dream of becoming a doctor. I really want to go into public health when I finish — and make a difference to my people. — Josef McDonald, fifth year medical student Josef is one of 22 Aboriginal students enrolled in medicine at the University of New South Wales (UNSW), and one of 10 students who hold a Shalom Gamarada Ngiyani Yana residential scholarship. There are many reasons why Indigenous health professionals are part of the critical path to wellness for Indigenous Australians. Indigenous health professionals can provide a shared understanding of the circumstances of other Aboriginal and Torres Strait Islander people who enter the health system, and bring a diversity of understandings and views around health that enrich the academy initially and the profession over time. Like so many Indigenous students, Josef is one of the few in his extended family who have been able to finish high school and enter university. Josef’s sister, 9 years his senior and herself a success story, is an engineer. While at university, she worked every night to support herself — an experience familiar to many students. There are few scholarships and awards that can help Indigenous students pursue their dreams of becoming health professionals — Josef and his college cohort are certainly aware of this and of the role they each play in providing encouragement to others from their families and communities who also wish to enter tertiary education in the future. “I’m the same as anybody that has a dream. The only difference is that I’ve been given the opportunity to achieve mine,” says Jenna Owen, the first Aboriginal student at UNSW to study optometry. Jenna will be one of only two Aboriginal optometrists when she graduates, and is the first person in her large extended family to attend university. Each residential scholarship is valued at $15 000 per year and covers tuition and full board at Shalom College on the university’s Kensington campus. Each student awarded a scholarship has tenure until they complete their degree. These scholarships are funded mainly from the proceeds of the annual Shalom Gamarada Ngiyani Yana Art Exhibition and show (http://www.shalomgamarada.org/). The art show is run in partnership with Shalom College, and two distinct Aboriginal units on campus, the Muru Marri Indigenous Health Unit and the Nura Gili Indigenous Programs at UNSW. The first exhibition was held in 2005, and it has run annually since. This year, as in the past, the artists themselves, through their agency as the creators of the artworks, make a deliberate contribution to improving Aboriginal health outcomes. This year, the show will focus on two distinct areas —the Yuendumu community in the Western Desert region of the Northern Territory and the artists of Bidyadanga in northern Western Australia. All of our works are sourced from community art centres and we expect to have about 130 pieces on display this year, some of which can be seen in this issue of the Journal (see below), with prices ranging from $150 to $50 000 or more. The opening ceremony will be held at 5pm on Sunday 19 July, with guest artist Daniel Walbidi from Broome, and Yuendumu art centre coordinator Cecilia Alfonso as guest speakers. Shalom Gamarada allows the public to see a broad range of current contemporary and traditional art. People can meet representative community members and artists and learn about collecting art and hear about the current thinking in health, and all proceeds go to help grow more Indigenous health professionals — all of this makes this particular week-long event unique. Details of the Exhibition and show Open: 10am to 6.30pm each day from 19 July to 26 July Address: Eric Caspary Learning Centre, Shalom College, University of New South Wales, Kensington (enter via Barker St) Art Panel: art centre managers from Peppimenarti, Yuendumu and Bidyadanga, 3pm Sunday 19 July 2009 Health Forum: 3pm Sunday 26 July 2009 More information: visit http://www.shalomgamarada.org/ or call Professor Lisa Jackson Pulver on 02 9385 1769. Artist: Liddy Napanangka Walker Artist: Shorty Jangala Robertson Artist: Jan Billycan Artist: Jan Billycan Artist: Weaver Jack Artist: Jan Billycan Artist: Joanne Currie Nalingu Artist: Shorty Jangala Robertson

Lisa R Jackson Pulver

Indigenous Australians die of asthma at more than three times the rate of the rest of the nation The recently released Australian Centre for Asthma Monitoring (ACAM) report Asthma in Australia 2008 focuses attention on several important and novel findings about asthma among Indigenous Australians (see Box).1 This is the third report in the 2-yearly series from ACAM, and brings together analyses of routinely collected national data, including data from Australian Bureau of Statistics national health surveys, and current information from published articles. Asthma is clearly identified in the report as a prevalent health problem in the Indigenous population. It is one of the two most common causes of hospitalisation of Indigenous Australians, second only to renal dialysis.2 It is also the second most common self-reported long-term illness among Indigenous Australians, and the mortality rate due to asthma among Indigenous Australians is 3.2 times that of other Australians.1 However, in contrast to the attention given to other medical conditions over-represented among Indigenous Australians, such as cardiovascular disease and diabetes mellitus, disproportionately little attention is given to respiratory disease, including asthma. In contrast to lower prevalence rates reported in the past,3,4 the prevalence of asthma among Indigenous Australians (16.5%) is now higher than among other Australians (10.2%), particularly in adults older than 35 years and those living in urban locations.1 Furthermore, the report shows that the prevalence of asthma in Indigenous adults older than 55 years is higher than the prevalence seen in children. This is in stark contrast to the data for other Australians and from other countries, which show the prevalence of asthma to be higher in children than in adults. We can only speculate about the reasons, but these may include the cumulative effects of three factors: life-long exposure to pulmonary toxicants, such as tobacco smoke and infections; uncertainty among Indigenous Australians about the nature of the disease and of the diagnosis (probably a very significant factor, particularly in the very young and the elderly); and long-term undertreatment of asthma. Uncertainty about the diagnosis is an issue as most of the prevalence data are based on self-reported questionnaire data from the National Aboriginal and Torres Strait Islander Health Survey 2004–05,5 and are not confirmed by clinical examination. Although this survey was conducted on a representative sample of Indigenous people (respondents totalled 10 439), with oversampling in remote communities, there remains a need for well conducted epidemiological studies of asthma and wheezing illness in urban, rural and remote Aboriginal populations that include objective measures, such as results of lung function and airway hyper-responsiveness tests. The problems of smoking and poor access to high-quality health care for Indigenous Australians are well known and similar to those affecting minority groups in many other affluent countries.6 Indigenous Australians have very high rates of smoking, a particular concern in relation to asthma. Intrauterine and postnatal exposure to environmental tobacco smoke has serious implications for lung health in young children, especially the many who suffer frequent wheezing illness and persistent lower respiratory tract symptoms. Concurrent smoking and asthma are associated with accelerated lung function decline, and the report highlights the very serious lung-health consequences of the high smoking rates in Indigenous Australians, for children and adults. Chronic obstructive pulmonary disease (COPD) and lung cancer are other important adverse lung outcomes largely attributable to smoking. Hospitalisation rates for asthma are disproportionately high among Indigenous Australians, as are rates of absences from work or school because of asthma. This occurs despite rates of possession of asthma action plans among Indigenous patients (24.9%) being similar to those among other Australians (22.5%).1 A possible explanation is the underuse of appropriate medications and devices. Indigenous Australians are less likely to use inhaled preventer medications for asthma. Studies in different regions of Australia, from the Australian Capital Territory to northern Queensland, have confirmed high levels of parent-reported asthma and symptoms such as wheeze in Indigenous children compared with other children, and relative underuse of preventive treatments for asthma.7,8 However, Indigenous adults, especially those older than 55 years, have high overall usage of medications for airway disease.1 Indigenous people with asthma also have a high prevalence of comorbid conditions that may complicate the management of asthma; in particular, comorbid heart disease, cerebrovascular disease and diabetes mellitus are likely to affect asthma management.1 Furthermore, Indigenous Australians report poorer quality of life than other Australians with asthma, suggesting asthma has a more serious impact in the Indigenous community than in the non-Indigenous community.1 These data and other findings described in Asthma in Australia 2008 have important implications for setting priorities and selecting initiatives to promote lung health in Indigenous communities. A start should be made with research into and implementation of more effective and tailored interventions to minimise tobacco use, particularly in settings where high levels of exposure have such deleterious consequences for healthy lung growth, and aggravating effects on respiratory symptoms in children with wheezing illness. Once symptoms are present, further attention is required to ensure that Indigenous Australians receive optimal care for their asthma, particularly to improve inhaler use and maintenance of long-term medication regimens. There are difficulties in accurately diagnosing the cause of airway symptoms such as cough and wheeze in young children. As diagnosis drives the management of asthma, it is important to conduct research into and promote accurate diagnosis of asthma and related conditions, such as chronic suppurative lung disease and bronchiolitis and, in older people, COPD. In remote Indigenous communities, asthma-like symptoms may be the presenting features of these other respiratory conditions in both children and adults.9 Reasons for the high prevalence and morbidity of wheezing illness and asthma, particularly in the very young (younger than 1 year of age) and older Indigenous people, are not known, and require research and clinical attention. The high rate of hospitalisations for asthma, more than twice that of other Australians, suggests there is a need for careful and systematic investigation to develop interventions most likely to benefit the Indigenous community. These are needed to help improve the quality of medical care and preventive strategies for children and adults at risk of asthma exacerbations and hospital admission. Attention to the presence of comorbidities is advocated both clinically and at a health service policy level. This may include health practitioners incorporating asthma management into cardiovascular and diabetes care plans and vice versa. To rectify the disparity in asthma and asthma-related outcomes in the Indigenous population, a complex multilevel framework10 is likely to be required, firstly to understand the reasons for this disparity, and then to develop the most appropriate strategies to overcome it. Opportunities need to be taken to significantly improve the quality of asthma-related care using culturally appropriate programs when they become available. Urgent research into and policy development for the “how to” and “what” of these programs are required. Recent data have shown the efficacy of culture-specific asthma programs compared with “usual care”.11 The Thoracic Society of Australia and New Zealand and the Australasian Sleep Association are about to release a report entitled Respiratory and sleep health in Indigenous Australians,12 and the major respiratory advocacy organisations are planning an Indigenous Lung Health Summit to consider the areas most in need of action and to prioritise new initiatives. The initiatives we have recommended here, if undertaken, would be small but important steps in reducing the health gap between Indigenous and other Australians. Asthma in Australia 2008: major findings1 Prevalence of asthma is higher among Indigenous Australians (16.5%) than it is among other Australians (10.2%). Indigenous Australians are twice as likely to be hospitalised for asthma and three times as likely to die of asthma as other Australians. Among adults, 48.2% of Indigenous Australians with asthma smoke, compared with 23.8% of other Australians with asthma. Indigenous Australians with asthma are three times as likely to have diabetes mellitus as other Australians with asthma.

Christine R Jenkins AM, MD, FRACP · Anne B Chang MPHTM, PhD, FRACP · Leanne M Poulos BMedSc(Hons), MPH(Hons) · Guy B Marks PhD, FRACP, FAFPHM

Objectives: To analyse rates of avoidable hospitalisations in Aboriginal and non-Aboriginal residents of the Northern Territory, 1998–99 to 2005–06, and to consider the implications for primary care interventions.Design and setting: Retrospective descriptive analysis of inpatient discharge data from NT public hospitals.Main outcome measures: Avoidable hospitalisations by age, sex, Aboriginality and condition, with annual time trends.Results: Between 1998–99 and 2005–06, Aboriginal people in the NT had an avoidable hospitalisation rate of 11 090 per 100 000 population, nearly four times higher than the Australian rate of 2848 per 100 000. The rate for non-Aboriginal NT residents was 2779 per 100 000. During this period, the average annual increase in avoidable hospitalisations was 11.6% (95% CI, 11.0%–12.1%) in the NT Aboriginal population and 3.9% (95% CI, 3.3%–4.5%) in the non-Aboriginal population. The greatest increase occurred in those aged ≥ 45 years, and was primarily attributable to diabetes complications.Conclusions: The significantly higher rates of avoidable hospitalisations in NT Aboriginal people reflect the emerging epidemic of chronic disease in this population, highlight barriers to Aboriginal people accessing effective primary care, and emphasise the extent of potential health gains with appropriate interventions.

Shu Q Li MPH, MB, BNursing · Natalie J Gray MIPH(Hons), MB BS(Hons), BSc/LLB(Hons) · Steve L Guthridge MB BS, MPH, FAFPHM · Sabine L M Pircher MPH, BNutrDiet

Objectives: To determine whether teenage pregnancy and Indigenous status are associated with increased risk of adverse pregnancy outcomes.Design, setting and participants: A cross-sectional descriptive analysis of nulliparous women with singleton pregnancies who delivered at the sole tertiary obstetric hospital in Western Australia between June 2004 and September 2006, using data obtained from computerised midwifery records.Main outcome measures: Maternal risk factors, pregnancy characteristics, and obstetric and perinatal outcomes for teenage and adult pregnancies.Results: Of the 4896 births reviewed, 560 (11%) were to teenage mothers. Teenagers were more likely to be Indigenous and to experience maternal risk factors such as anaemia and smoking. Indigenous women were more likely than non-Indigenous women to be smokers, with young Indigenous teenagers (aged 12–16 years) being most likely to smoke (odds ratio [OR], 6.29; 95% CI, 3.99–9.92). Perinatal outcomes for teenage and adult births were similar, while adjustment for smoking and Indigenous status changed the observed association for the Indigenous population of preterm delivery < 37 weeks’ gestation (OR, 1.31; 95% CI, 1.01–1.71), admission to special care nursery (OR, 1.41; 95% CI, 1.10–1.81) and low birthweight (OR, 1.43; 95% CI, 1.10–1.87). However, older teenagers (aged 17–18 years) were the group at highest risk of stillbirth (OR, 1.99; 95% CI, 1.03–3.76).Conclusions: These results improve our understanding of the obstetric and medical issues associated with teenage pregnancy and birth in WA and how we might tailor our approach to care. Indigenous teenagers need special attention, and there is significant scope for public health interventions around anaemia and smoking in this population.

Lucy N Lewis RM, BSc(Health Sciences), MN · Martha Hickey MB ChB, MD, FRANZCOG · Dorota A Doherty BSc(Hons), PhD · S Rachel Skinner MB BS, PhD, FRACP

The goal of “closing the gap” in life expectancy between Indigenous and non-Indigenous people by 2030 is probably unattainable. Despite our best efforts, it is implausible that, within 21 years, preventive strategies, social or medical, will extinguish all excess expression and risk of chronic disease, the greatest contributor to excess Indigenous deaths. Developing systems to supply optimal primary care, as we currently know it, will take time. In addition, we have an incomplete understanding of the nature of excess risk, and lack remedies to totally contain it. Furthermore, vertical imprinting of excess risk will take some generations to ameliorate. To avoid failure by specifying unattainable goals, emphasis should be given to process measures that will lead to better outcomes. It is self-evident that sustained change requires better education, nutrition, employment opportunities and infrastructure. Within the health system, access to good quality, integrated primary care, needs-based health services funding, and an urgent and intensified focus on areas with the highest mortality rates, are top priorities.

Wendy E Hoy BScMed, MB BS, FRACP

Economic interventions to improve access to healthy food Poor nutrition is a major determinant of excess morbidity and mortality among Aboriginal and Torres Strait Islander peoples,1 contributing to over 16% of the burden of disease.2 In this issue of the Journal (page 549), consistent with the “economics of food choice” theory,3 Brimblecombe and O’Dea report that the diet of a remote Aboriginal community was high in energy-dense, nutrient-poor foods — the cheapest options to satisfy hunger.4 This energy–cost differential restricts access to healthy food, and helps explain the persistently poor dietary patterns and deplorable health status of remote Indigenous communities.4 Placing nutrition issues in an economic framework highlights the investment required to improve Indigenous nutrition.4 But what has been learned to date about where resources should be directed? Despite the high costs and limited availability of healthy foods in remote community stores, surprising achievements have been made in some areas. Community dietary patterns were found to respond directly to improved stock management and food supply,5,6 and multistrategy, community-directed nutrition programs in some remote communities resulted in marked and sustained improvements in anthropometrical, biochemical and haematological risk factors for chronic disease.7,8 Knowledge gained from such studies has broadened the focus of Indigenous nutrition initiatives to include the “supply side” (improving food quality and access to healthy food in remote communities) as well as the “demand side” (promoting nutrition through behaviour change). In 2003, the FoodNorth study provided a comprehensive analysis of remote food supply issues, barriers and leverage points for improvement.9 More recently, the Remote Indigenous Stores and Takeaways Project developed nine practical resources, including a freight-improvement toolkit and a buyer’s guide, to assist remote stores to stock, promote and monitor the sale of healthy food.10 A major barrier is that community stores are seen as small businesses rather than as essential services, like health and education. Encouragingly, several submissions to the recent House of Representatives Inquiry into community stores in remote Indigenous communities detail specific approaches to secure both health and viable business outcomes.11 Remote store groups that combine buying power and operational efficiency (eg, the Arnhem Land Progress Association and the Retail Stores group in Queensland) have shown the benefits of store nutrition policies.9 Outback Stores, a company established by Indigenous Business Australia in 2006, included provision of nutritious food as a key goal, and provides one potential model to support sustainable employment and economic development in independent remote stores.12 The National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000–2010 provided a broad framework for nutrition interventions, addressing both supply and demand issues.13 However, implementation of the strategy has neither been sustainably nor well resourced and remains fractured and opportunistic. Therefore, what is still urgently required is systematic, widespread, sustained implementation of evidence-based nutrition interventions. Brimblecombe and O’Dea now rightly highlight the need to also include innovative economic interventions.4 In Northern Territory communities, it has been estimated that up to 36% of the family income is needed to purchase food,14 which is at least double the proportion required by non-Indigenous Australians.15 One of the proposed “Close the Gap” equity targets was that, by 2018, 90% of Indigenous families could access a healthy food basket for under 25% of their income.16 However, nutrition issues were not included in the final National Indigenous Reform Agreement of the Council of Australian Governments. Globally, the dominant economic intervention affecting food pricing is national taxation on food to raise general revenue.17,18 In Australia, the basic foods required to maintain health were mostly exempted from the Goods and Services Tax (GST), and the price of these foods was expected to fall after the introduction of the new tax system in 2000.19 However, in Queensland from 2000 to 2001, the price of a basket of healthy foods increased by 12%, more than twice that of less healthy options.20 This highlights the unpredictability of complex economic systems and the need for rigorous testing of economic solutions to increase access to healthy food.18 Such testing is imperative within remote communities, but baseline data are not readily available as Australia lacks a comprehensive food and nutrition monitoring and surveillance system. It is also crucial that economic interventions support broader models of sustainable development in remote communities. Potential economic instruments include greater differential national taxation on energy-dense, nutrient-poor food (the “fat tax”), and subsidisation of healthy food through freight, in-store pricing and/or direct commodity subvention systems. There is a case for combining both approaches17 to better influence diet among lower socioeconomic groups18 and within relatively closed systems, such as schools and workplaces.17 The provision of free fruit in such settings has also produced sustained benefits in some countries.21 Improving remote area housing to include infrastructure for storage and preparation of food is also vital; in one study, this was serviceable in less than 6% of houses.22 Local food production, including that of traditional foods, may hold promise in some areas. Training and employment of Indigenous nutrition workers23 to deliver services, including budgeting programs like Indigenous FOODcents,24 are also required. Welfare reform and income management programs have great potential in some areas. However, in communities where incomes are quarantined and welfare recipients are required to spend a significant proportion of their income on food and other essentials, good public policy dictates that governments must also ensure that a healthy food supply is actually available and affordable in those communities. For the most vulnerable, food supplementation programs,25,26 if desired and controlled by the community, are warranted. The value of such assistance is greatly increased where food costs are high, and can immediately improve recipients’ dietary quality.19 Within a multistrategy approach, economic interventions tailored to community needs will assist low-income Indigenous Australians in remote communities to obtain the food they need for good health. “Best buys” of such an approach are listed in the Box. Solutions must involve sectors beyond health, including food producers, transporters and retailers, educators, economists and policymakers. “Best buys” to improve Indigenous nutrition and health 1. Continue and expand the reach of successful interventions Increase demand for healthy food Brief nutrition interventions and early interventions in primary care, including “well persons” health checks and follow-up action Prenatal, antenatal and postnatal nutrition programs; culturally appropriate infant growth assessment and action programs; and promoting breastfeeding and appropriate introduction of solid foods27 School-based nutrition-promotion projects, and community food-literacy and budgeting projects Improve supply of healthy food Use of resources developed by the Remote Indigenous Stores and Takeaways Project10 to improve store management practices, and transport and stocking of healthy food Local food gardens and traditional food procurement projects Increase capacity to achieve the interventions given above Train and employ an Indigenous nutrition workforce Improve housing, including food-storage, preparation and cooking facilities Develop a national, coordinated monitoring and surveillance system for food and nutrition 2. Trial economic interventions for widespread roll-out, if successful Food supplementation for women, infants and children Free fruit and vegetables for remote schools and other settings Freight subsidies for getting basic healthy foods to remote areas In-store price “mark-up” of less healthy items, and lower price margins on healthier foods Expansion of the current national differential taxation system to further favour competitive retail pricing of healthy foods

Amanda J Lee PhD, BSc(Nutr), GradDipDiet · Dympna Leonard MPH, BSc(Diet) · Aletia A Moloney MCommNutr · Deanne L Minniecon MHSc(HealthProm)

Objective: To explore the relationship between dietary quality and energy density of foods (MJ/kg) and energy cost ($/MJ) for an Aboriginal population living in a remote region of northern Australia.Design: For a 3-month period in 2005, we collected food and non-alcoholic beverage supply data from food outlets available to the study population. From these data, we compared the energy density of foods with their energy cost.Main outcome measures: Energy density and energy cost of food purchases.Results: The diet of the study population was high in refined carbohydrates and low in fresh fruit and vegetables. Foods with high energy density were associated with lower costs and contributed disproportionately to energy availability.Conclusion: The energy–cost differential between energy-dense, nutrient-poor foods and energy-dilute, nutrient-rich foods influences the capacity of Australian Aboriginal people living in remote communities to attain a healthy diet. This is consistent with the “economics of food choice” theory, whereby people on low incomes maximise energy availability per dollar in their food purchasing patterns, and has particular relevance for developing nutrition policy and strategies in Aboriginal communities, where poor nutrition is a major determinant of preventable chronic disease.

Julie K Brimblecombe PhD, MPH, GradDipNut · Kerin O’Dea AO, BSc, PhD

Objective: To evaluate the extent to which the current Pharmaceutical Benefits Scheme (PBS) guidelines for patient eligibility for lipid-lowering medication are applicable to Aboriginal people in Central Australia.Design, setting and participants: A 10-year cohort study of 659 Aboriginal people who participated in population-based cardiovascular disease (CVD) risk factor surveys in 1995 and who were free of CVD at baseline, for the period from 1995 to 2004–2005 or until first CVD event. Evidence of atherosclerotic CVD (ischaemic heart disease, ischaemic stroke, and peripheral vascular disease) was sought from hospital, primary health care and death records. PBS eligibility was assigned according to the current PBS criteria, which were amended in 2006 to include Aboriginal-specific criteria, using participants’ baseline (1995) and 10-year follow-up data.Main outcome measures: Proportions of PBS-eligible and PBS-ineligible participants who had CVD events during the study period; sensitivity and specificity of the criteria.Results: Of 42 participants who had CVD events during the study period, 35 were PBS-eligible (incidence, 1130/100 000 person-years; relative risk compared with PBS-ineligible population, 4.87 [95% CI, 2.19–10.80]) and seven were PBS-ineligible. PBS eligibility was associated with older mean age (37 v 32 years) and male sex (48% v 37%), with 50.7% of participants (334/659) meeting eligibility criteria. The mean high-density lipoprotein cholesterol level at baseline was very low in both groups (0.81 v 0.87 mmol/L). The current PBS guidelines have low specificity (52%) in this population, which was found to improve (to 71%–82%) by incorporating additional non-lipid criteria (age and multiple non-lipid risk factors).Conclusion: The current PBS lipid treatment criteria, which include any Aboriginal person with diabetes and less stringent cholesterol thresholds than the previous version, identify a group at very high risk of CVD. Global risk assessment may better identify those at risk.

Joanne N Luke BSc, MPH · Alex Brown BMed, MPH, FCSANZ · David N O’Neal MB BS, FRACP, PhD · Kerin O’Dea AO, BSc, PhD · Alicia J Jenkins MB BS, MD, FRACP · Margaret Kelaher BSc(Hons), PhD · James D Best MB BS, MD, FRACP · Kevin G Rowley BAppSci, GradDipEpi, PhD

Objective: To identify factors associated with antenatal smoking and explore characteristics of smoking behaviour among pregnant Aboriginal and Torres Strait Islander women.Design and setting: Cross-sectional study using interviewer-administered questionnaires of 145 pregnant Aboriginal and Torres Strait Islander women attending a health service in Far North Queensland between November 2005 and December 2006.Main outcome measures: Prevalence of self-reported smoking; predictors and patterns of smoking in early pregnancy; and relationships between smoking and the prevalence of predisposing, enabling and reinforcing factors, including women’s knowledge about and attitudes towards smoking and the risks involved.Results: Of 145 women, 41% (n = 60) reported being daily or occasional smokers. Knowledge about harms of smoking was generally high. Women who were smokers had a significantly higher rate of smoking partners (n = 36) than women who were non-smokers (n = 31) (77% v 41%, P < 0.001). Level of daily stress was significantly higher among smokers than non-smokers (P = 0.001).Conclusion: Shifted population norms among Aboriginal and Torres Strait Islanders are accompanied by a shift in the factors that can effectively differentiate between smokers and non-smokers within this population. Rather than the traditional, mainstream predictors of antenatal smoking, interventions with Aboriginal and Torres Strait Islander women should focus on the social environment, and the influences of social networks and partners on the behaviour of individuals.

Conor Gilligan PhD · Robert W Sanson-Fisher PhD · Catherine D’Este PhD · Sandra Eades PhD · Mark Wenitong MD

Objective: To evaluate the role of the adult health check for Aboriginal and Torres Strait Islander people aged 15–54 years, in an urban Indigenous primary health care setting.Design, setting and participants: Cross-sectional study of Indigenous patients recruited opportunistically from the Inala Indigenous Health Service between 1 June 2007 and 31 July 2008.Main outcome measures: Newly identified cardiovascular risk factors, investigations ordered and performed, interventions and new diagnoses made.Results: 413 patients out of a possible 509 consented to participate (93% were Aboriginal). High prevalences of cardiovascular risk factors such as smoking (67%), being overweight and obese (61%), harmful levels of alcohol consumption (36%), and depression (23%) were found. The adult health checks resulted in new investigations (in 82% of participants), lifestyle advice (67%), vaccinations (42%), referrals (62%) and new medications (49%). New diagnoses resulting from the health checks included depression (6%), a harmful level of alcohol consumption (4%), chlamydia infection (4%), hypertension (3%) and diabetes (3%). Pap smears were performed in 47% of women as a result of the health check.Conclusions: The adult health check for Aboriginal and Torres Strait Islanders aged 15–54 years is a viable vehicle for evaluating health status, identifying chronic disease risk factors and for implementing preventive health care.

Geoffrey K P Spurling MB BS, FRACGP · Noel E Hayman MB BS, MPH, FAFPHM · Anna L Cooney RN

A holistic approach to education at Yipirinya School represents an extraordinary opportunity to deliver health care to Indigenous children Last year, during a visit to Alice Springs, we witnessed first hand the consequences of inadequate provision of health care for Indigenous children. Although we are all specialist doctors, we were travelling in our capacity as fathers, accompanying our sons in a school-based “service” program.1 We experienced a unique, independent Indigenous school that we believe could provide a nexus for delivering health services to students and their communities. New models of service delivery are required to improve Indigenous health outcomes, and we believe that crossing bureaucratic boundaries between health and education might permit such progress. Yipirinya School does not have a student fee structure, hence has limited funding.2 The school is comprised of a child care centre, preschool, primary school and growing secondary section, and enrols about 200 seriously disadvantaged Indigenous children from the Alice Springs region, including 20 town camps and eight outstations within 75 kilometres. We lived and worked at Yipirinya for 10 days, in a group consisting of 20 fathers, our adolescent sons, and support staff. Our involvement with this community was privileged and rewarding yet, at times, distressing and confronting. We arrived wondering how a group of affluent, non-Indigenous outsiders could help, let alone engage, the local people. During our stay, we went on school bus runs into camps, served meals, assisted in class, played football at lunchtime, and gradually seemed to make friends. At night, before retiring to our swags in the school gymnasium, we reflected on events that had disturbed us — the ravenous appetite of a hungry child at breakfast, the filthy dwelling to which we delivered a 6-year-old in the afternoon, or the child who was misbehaving in class because of domestic violence. Were we ultimately successful in engaging with the locals? If the tears shed on our departure (by ourselves and our new Indigenous friends) were a measure, we succeeded. Although we helped with teaching, we also learnt. We learnt about the community’s pride in Indigenous life, culture and their land, and also learnt of stark gaps between us. As doctors, we were particularly dismayed by the stark contrast between the access to health care of the students of Yipirinya and that of our own sons. Might this school represent an opportunity for more effective delivery of health services to its students? The school authorities had previously thought so and, independently, we came to the same conclusion. At Yipirinya, there is a holistic approach to schooling: five separate bus runs pick up and drop off children each school day, as few would otherwise attend; children receive a sit-down breakfast and lunch; clothing is provided when needed, especially on cold winter days; basic hygiene is directed by dedicated and friendly teachers; and an academic program embraces conventional and Indigenous education. For many children, this represents a temporary release from an otherwise chaotic lifestyle; on some days it may simply represent a place to eat, sleep and feel safe. Yipirinya enrols more Indigenous students from town camps and outstations than all Alice Springs government and private schools combined (personal communication, Ken Langford-Smith, Principal, Yipirinya School). The school represents a central node from which nutrition, washing, clothing and education are regularly provided for these disadvantaged children. However, because of the independent status of Yipirinya, together with sporadic and diminishing support from local health services, there is no school nurse to provide care beyond that given by teachers. The provision of health care through the school, encompassing education, prevention, and acute medical or nursing care, would narrow the existing service gap. Perhaps more importantly, an extraordinary opportunity exists for more effective delivery of paediatric, and ultimately even adult, health care to those living in camps and outstations. Yipirinya is a highly respected and culturally sensitive organisation, with Indigenous language speakers and elders who could help to facilitate and support the provision of effective health services. We hope that our own approaches to Northern Territory health officials, together with recent submissions from Yipirinya, will lead to the provision of a dedicated full-time school nurse. We are certain that this will improve regional Indigenous health care services — starting with the children. Finally, we came across this situation and the opportunities presented by chance. Opportunities must surely exist in schools and communities elsewhere to more closely align Indigenous health care and education, and thereby improve the wellbeing of children and families living in these disadvantaged communities.

Geoffrey M Forbes MB BS, MD, FRACP · Stephen J Davis MB BS, MRCP, FRANZCR · Martin D Robson MB BS, FFA · Anthony F Connell BSc, MB BS, FRACS · Peter C Richmond MB BS, MRCP, FRACP

Objective: To investigate associations between “caring for country” — an activity that Indigenous peoples assert promotes good health — and health outcomes relevant to excess Indigenous morbidity and mortality.Design, setting and participants: Cross-sectional study involving 298 Indigenous adults aged 15–54 years in an Arnhem Land community, recruited from March to September 2005.Main outcome measures: Self-reported involvement in caring for country, health behaviours and clinically measured body mass index (BMI), waist circumference, blood pressure, type 2 diabetes status, albumin to creatinine ratio (ACR), levels of glycated haemoglobin (HbA1c) and high-density lipoprotein (HDL) cholesterol, lipid ratio, score on the five-item version of the Kessler Psychological Distress Scale (K5), and 5-year cardiovascular disease (CVD) risk.Results: Controlling for sociodemographic characteristics and health behaviours, multivariate regression revealed significant and substantial associations between caring for country and health outcomes. An interquartile range rise in the weighted composite caring-for-country score was significantly associated with more frequent physical activity, better diet, lower BMI (regression coefficient [b] = − 2.83; 95% CI, − 4.56 to − 1.10), less abdominal obesity (odds ratio [OR], 0.43; 95% CI, 0.26–0.72), lower systolic blood pressure (b = − 7.59; 95% CI, − 12.01 to − 3.17), less diabetes (OR, 0.12; 95% CI, 0.03–0.52), lower HbA1c level (b = − 0.45; 95% CI, − 0.79 to − 0.11), non-elevated ACR (OR, 0.28; 95% CI, 0.13–0.60), higher HDL cholesterol level (b = 0.06; 95% CI, 0.01–0.12), lower K5 score (b = − 0.97; 95% CI, − 1.64 to − 0.31) and lower CVD risk (b = − 0.77; 95% CI, − 1.43 to − 0.11).Conclusions: Greater Indigenous participation in caring for country activities is associated with significantly better health. Although the causal direction of these associations requires clarification, our findings suggest that investment in caring for country may be a means to foster sustainable economic development and gains for both ecological and Indigenous peoples’ health.

Christopher P Burgess FRACGP, MPH · Fay H Johnston PhD, FAPHM · Helen L Berry PhD · Joseph McDonnell MSc · Dean Yibarbuk · Charlie Gunabarra · Albert Mileran · Ross S Bailie MB ChB, FAPHM

Objective: To report Aboriginal patients’ views about effective communication between Aboriginal people and health service providers in Western Australian hospital settings.Design, setting and participants: Qualitative study involving indepth interviews between 1 March 2006 and 30 September 2007 with 30 Aboriginal people affected by cancer from across WA.Main outcome measures: Aboriginal patients’ views about the quality of communication within the hospitals, factors impairing communication and suggestions for improvement.Results: Factors crucial to effective patient–provider communication such as language, shared understanding, knowledge and use of medical terminology require attention. Additionally, communication between Aboriginal people and health care professionals needs to be understood within a broader sociocultural and political context. Fear of the medical system and of being disempowered; mistrust; collective memories of the experience of colonisation and its aftermath; lack of understanding of Aboriginal customs, values, lifestyle and the importance of family and land; and experiences of racism were key issues impairing communication. Health service providers’ inability to interpret non-verbal communication and the symbolism of hospital environments also posed problems.Conclusion: Key areas for the attention of health service providers in communicating and caring for Aboriginal people in the hospital setting include culturally sensitive and empathetic personal contact, acknowledgement and respect for Aboriginal family structures, culture and life circumstances, an understanding of the significant role of non-verbal communication, and the importance of history, land and community. Employing more Aboriginal health workers in hospitals, and allowing Aboriginal people to participate at a decision-making level in hospitals is likely to improve Aboriginal people’s access to cancer treatment, and would be important symbols of progress in this area.

Shaouli Shahid MSS, MA, BSS · Lizzie D Finn PhD, MAppPsych, MA · Sandra C Thompson PhD, MPH, FAFPHM

Both more Indigenous doctors — for the sociocultural capabilities they bring — and better sociocultural education of all medical students will be needed to “close the gap” When Prime Minister Kevin Rudd and representatives of Australian health leadership signed a statement of intent to close the Indigenous health gap by 2030, they committed to putting in place by 2018 the primary health services and other health infrastructure necessary to achieve this goal.1 Although health service development has been key to the national policy agenda in Indigenous health since the National Aboriginal Health Strategy in 1989, a high level commitment to workforce development was not in place until the Australian Health Ministers’ Advisory Council endorsed the Aboriginal and Torres Strait Islander Health Workforce National Strategic Framework in 2002.2 This priority was subsequently reinforced when the National Indigenous Health Equality Council was established in 2008 — with a significant focus on workforce strategy.3 There are two key issues in Indigenous medical workforce development — the relative undersupply of Indigenous Australian doctors, and the need to equip all Australian medical graduates with the skills, knowledge and attributes to provide quality health care to Indigenous Australians regardless of where they present in the health system. Indigenous Australians represent 1.9% of the total population aged 15 years and older, but only 1% of the total health workforce.4 In 2006, there were 100 Indigenous Australian medical practitioners (0.2% of the total), including 40 medical specialists.4 In 2008, the Australian Indigenous Doctors’ Association (AIDA) estimated that there were 125 graduates, with another 125 in training (an estimate consistent with figures previously published in the Journal).5,6 According to 2006 census figures, the proportion of doctors in the Australian population was 0.27%, while the proportion of Indigenous doctors in the Indigenous population was 0.019%.5 Increasing the participation of Indigenous people in the health workforce is an important workforce development strategy, as well as an important goal to pursue for equity reasons. Indigenous Australians can contribute to improved quality of care by aligning their technical and sociocultural capabilities to maximise patient or population health outcomes. The presence of Indigenous practitioners in the health workforce adds a collegiate dimension to relationships between non-Indigenous practitioners and Indigenous Australians, and this has the potential to facilitate reform in health care practice. To that end, the leadership provided by Indigenous practitioners in health research and education is also important. However, the responsibility for quality health care for Indigenous people is one that must be shared. Non-Indigenous colleagues play a critical role, which is why all graduates need to be equipped to work across the entire range of Australian sociocultural contexts, including in Indigenous health. The Indigenous health medical workforce agenda has been implemented through a broad partnership that includes AIDA, Medical Deans Australia and New Zealand and the Australian Medical Council. This has resulted in a suite of tools for supporting medical school reform and revised standards and procedures for medical school accreditation.7-10 There have been two recent developments that we anticipate will provide further impetus in curricula development. The first is the development of the Critical Reflection Tool (CRT).11 The CRT was developed to support medical schools in their efforts to implement the national Indigenous health curriculum framework and their initiatives to support Indigenous students. It was designed to cover the broad context of medical schools in implementing an Indigenous health reform agenda. The CRT provides an opportunity for medical schools to critically analyse factors such as their structural relationship with existing Indigenous health units, and the aspirations of the medical school as articulated through mission statements, through to the detail of the curriculum itself (including teaching and learning, assessment, implementation and review and evaluation) and Indigenous student recruitment and retention initiatives and strategies. All medical schools in Australia and New Zealand were invited to trial the CRT in October 2007 through to June 2008, and 12 of 21 schools were able to provide feedback within the timeframe required. Trial findings endorsed the content of the CRT. The second development supporting curricula development is the creation of the Leaders in Indigenous Medical Education (LIME) Network for medical educators, specialists in Indigenous health, policymakers and community members with an interest in quality Indigenous health content in medical education.12 Medical Deans Australia and New Zealand established the LIME Network to provide a forum for medical educators in Indigenous health, promote the exchange of best practice and facilitate professional development. The Network hosts a biennial conference to facilitate dialogue on Indigenous health between medical educators, colleagues across the other health disciplines and community partners.12 There is still much work to be done to increase Indigenous participation in the health workforce, and to develop medical schools into places that produce a workforce fit to meet the needs of Indigenous Australians. Clearly, there is a significant undersupply of Indigenous doctors, but as yet there are no nationally agreed targets. This is an important policy agenda and a brokered agreement on targets by key stakeholders would enable a more robust framework for monitoring change. Targets should be achievable and take into account high school retention rates, tertiary readiness, potential pathways and population demographics. Nationally, the track record for medical schools in recruiting and retaining Indigenous students is very mixed. Institutions such as the University of Newcastle, the University of Western Australia, James Cook University and the University of New South Wales clearly lead the field.6 There is a debate about whether strategy should focus on building the programs within schools with a proven record of success, or whether all medical schools should be encouraged to do better. Our view is that the system should enable Indigenous students to select the university that will maximise their opportunities for personal success. However, this would require more universities to develop the comprehensive integrated programs that develop pathways through secondary education, promote health sciences as a career choice for Indigenous Australians and provide robust support for the academic and social development of enrolled students. Graduate attributes are arguably the best marker of efficacy in curriculum reform. The CRT provides a framework for internal reflection by medical schools on their structures, curricula, and recruitment and retention strategies, to maximise their potential to graduate Indigenous and other students who can contribute to “closing the gap”.

Ian P S Anderson MB BS, FAFPHM · Shaun C Ewen BAppSc(Physio), MMIL · Debra A Knoche BA(Hons)

Objective: To determine the incidence of coronary heart disease (CHD) events in an urban Aboriginal population.Design, setting and participants: Cohort study of 906 Aboriginal people without CHD from 998 who had undergone risk-factor assessment in the Perth Aboriginal Atherosclerosis Risk Study (PAARS) in 1998–1999. PAARS cohort data were electronically linked to a range of databases that included Western Australian hospital morbidity data and death registry data. We analysed data from January 1980 to December 2006 to identify previous admissions for CHD from 1980 to baseline (1998–1999) and new events from baseline to 2006.Main outcome measure: First CHD event (hospital admission or death).Results: There were 891 linked records for the 906 participants without previous CHD. The event rate was 12.6/1000 person-years (95% CI, 10.2–15.6/1000 person-years). Annual CHD event rates ranged from 8 to 18/1000 person-years. After adjustment for age (sex was not associated with the risk factors assessed), factors associated with risk of a CHD event in the PAARS cohort were a history of diabetes, overweight or obesity (indicated by body mass index), smoking, and hypertension, but not waist circumference. People with these risk factors were 1.9–2.7 times more likely to experience a CHD event. Compared with previously published information from a remote Aboriginal community in the Northern Territory, the incidence of CHD events among urban-dwelling Aboriginal people was not significantly different (P > 0.05 overall and for subgroups defined by age and sex).Conclusions: City-dwelling Aboriginal Australians have an incidence of CHD events comparable to that of Aboriginal people living in remote northern Australia.

Pamela J Bradshaw PhD · Helman S Alfonso MSc, PhD · Judith C Finn RN, MEdStud, PhD · Julie Owen DipT, MPHC, PhD · Peter L Thompson MD, FRACP, MBA

Objective: To describe baseline characteristics, operative events and late mortality among Indigenous Australians undergoing cardiac surgery.Design, setting and participants: Prospective study of consecutive patients undergoing cardiac surgery at Flinders Medical Centre in Adelaide between January 2000 and December 2005.Main outcome measures: Operative (30-day) mortality and late mortality after cardiac surgery.Results: Of 2635 patients undergoing cardiac surgery, 283 (10.7%) were Indigenous. Indigenous patients were substantially younger than non-Indigenous patients (mean, 47 [SD, 14] years v 65 [SD, 12] years; P = 0.001) and were more likely to have diabetes (39.6% v 27.3%; P = 0.001), renal dysfunction (3.2% v 1.2%; P = 0.009), and valvular surgery (53.0% v 23.1%; P < 0.001). There was a non-significant trend toward excess operative mortality in Indigenous patients (Indigenous 2.5% v non-Indigenous 1.3%; hazard ratio [HR], 1.67 [95% CI, 0.74–3.75]). But in the under-55-years age cohort, the difference between the two groups was highly significant (Indigenous 3.3% v non-Indigenous 0.4%; HR, 7.99 [95% CI, 1.66–38.50]), even after adjustment for euroSCORE (the European System for Cardiac Operative Risk Evaluation). Survival at 1 and 5 years was 94.0% and 80.6%, respectively, for Indigenous patients compared with 96.7% and 87.7%, respectively, for non-Indigenous patients. There was an excess in euroSCORE-adjusted mortality in the Indigenous cohort overall (HR, 1.46 [95% CI, 1.03–2.07]) that strengthened when restricted to the under-55-years cohort (HR, 6.9 [95% CI, 1.42–33.5]).Conclusion: Indigenous Australians present for cardiac surgery nearly 20 years earlier than non-Indigenous Australians and experience excess age-stratified operative and late mortality.

Sam J Lehman MB BS, FRACP · Robert A Baker PhD · Philip E Aylward MB BS, FRACP, PhD · John L Knight MB BS, FRACS · Derek P Chew MB BS, MPH, FRACP

Objective: To determine whether the current planned transfer of pregnant women from Cape York communities to Cairns at 36 weeks’ gestation for birthing is medically appropriate.Design and setting: Retrospective audit of travel details and demographic and obstetric outcome data on all women from Cape York communities who travelled to Cairns for late pregnancy care and birth at Cairns Base Hospital in 2006.Main outcome measures: Length of stay in Cairns; gestational age at birth.Results: In 2006, 172 women from 14 Cape communities travelled to Cairns to give birth. Of these, 76% identified as Aboriginal or Torres Strait Islander, 20% as Caucasian and 4% were from other ethnic groups. The mean time of stay in Cairns before birth (range) was 24 (0–86) days. Eleven women (6%) gave birth between 36 and 37 weeks of pregnancy; this point marked the beginning of a significant rise in births for increasing gestational ages.Conclusion: Aiming for 36 weeks’ gestation for transfer is medically appropriate, but results in long periods of separation of women from Cape communities from family and friends, with detrimental social, cultural and financial consequences. Reopening maternity units in towns serving the Cape communities could reduce the number of women from the region having to travel to Cairns for pregnancy care and birth.

Joanna L Arnold MB BS, FRANZCOG · Caroline M de Costa FRANZCOG, FRCOG, MPH · Paul W Howat MB BS, FRANZCOG

Objective: To describe diagnoses and correlates of middle ear disease in Aboriginal primary school children in a targeted school-testing program in Perth, Western Australia.Design and setting: Analysis of records of ear testing carried out over a 6-year period in three primary schools in Perth.Participants: Aboriginal children of primary school age (4–12 years) who attended the schools on the day of testing. Data on middle ear disease and hearing impairment were available for 119 and 94 children, respectively, from their first test.Main outcome measures: Proportions of children with middle ear disease and hearing loss.Results: Middle ear disease was diagnosed in 50 children (42.0%; 95% CI, 33.0%–51.4%). Rates were lower in older children (P = 0.002) but did not differ according to season of testing. Hearing loss (mild or moderate) was detected in 18 children (19.1%; 95% CI, 11.8%–28.6%). Hearing impairment was also less prevalent in older children (P = 0.007) and had no association with season of testing.Conclusions: Middle ear disease is a significant problem for Aboriginal children in Perth, and is associated with mild–moderate hearing loss. Health authorities must continue to focus on appropriate identification and management of the disease in this population.

Corinne J Williams BAppSci(Speech and Hearing), BA(AS)(Hons), PhD · Harvey L Coates AO, MS, FRACS · Elaine M Pascoe BSc(Hons), MBiostats · Yvonne Axford · Irene Nannup

In 1994, only 12 Indigenous people attended the mainstream general practice in Inala, south-western Brisbane, Queensland. An Indigenous community focus group and telephone interviews revealed deficits such as: few items (eg, artwork) that Indigenous people could identify with; lack of Indigenous staff; staff perceived as unfriendly; inflexibility regarding time; and intolerance of Indigenous children’s behaviour. Access to the Inala Indigenous Health Service by Indigenous people improved when these issues were addressed, and has grown significantly every year from 1995 to 2008. Other important factors in improving access include: energetic Indigenous leadership; enabling bulk billing to increase funding; moving to a stand-alone clinic; and engaging with teaching, research and community programs. A Centre of Excellence in Indigenous Primary Health Care is envisaged as the next innovation required to improve access and quality of service, and to close the gap between Indigenous and non-Indigenous health outcomes.

Noel E Hayman MB BS, FAFPHM, FRACGP · Nola E White RN · Geoffrey K Spurling MB BS, DTM

To the Editor: The Australian Medical Council (AMC) now includes Indigenous health in its accreditation standards for medical schools,1 with guidelines stating that medical curricula must contain the “. . . appropriate use of educational expertise, including the educational expertise of Indigenous people, in the development and management of the medical course [emphasis added]”.1 These AMC requirements arose from the Indigenous Health Curriculum Framework, which was endorsed by the Committee of Deans of Australian Medical Schools.2 The second encounter of the Indigenous Simulated Patient Program at the University of Melbourne In the second encounter, the “patient” is concerned both about the conflicting information they have been given concerning diabetes and the need to attend multiple clinics. The “patient” attempts to explain that family and work obligations mean they cannot wait in outpatient clinics all day. The students in this session are encouraged to work with the “patient” to problem solve the issues that arise. The “patient” has been instructed to provide realistic reasons why these solutions will not work for them, highlighting possible differences in family responsibilities and living arrangements for some Indigenous community members, and demonstrating the conflicting priorities and expectations between the “patient” and the medical system. The University of Melbourne School of Medicine developed the Indigenous Simulated Patient Program in 2002 as one element of an integrated Indigenous health curriculum. The Program meets some of the goals of the framework by acknowledging and incorporating the educational expertise of Indigenous people, exposing students to Indigenous peoples’ lived experiences and world views, and by linking the simulated patient experience with other teaching content regarding the many ways in which history has affected Indigenous health. Indigenous simulated patients are used both early and late in the medical course. The early patient scenario is used within an uncomplicated communication skills tutorial, in which students practise their developing patient-interviewing skills and discover that the “patient” is Indigenous. The later scenario is more complicated (Box) and builds upon the first experience. In both scenarios, students are encouraged to ask the Indigenous patient, both in and out of character, questions about their personal experiences. The aim is to use the Indigenous Simulated Patient Program to help students understand that they will encounter Indigenous patients in their clinical studies and as junior doctors, and that these patients will have both the same and different issues from non-Indigenous patients. Solutions need to be tailored to meet the individual needs of the patient, and should include lessons from previous teaching within the curriculum — for example, the role of Aboriginal health workers in hospitals. The impact on Indigenous community members who participate in the program has been strongly affirming, with one actor commenting, “Today I felt like I really contributed to the training of medical students in issues that were important to me and my community”. Students also rate the experience very highly.3

Shaun C Ewen · Margo E Collins · Jennifer A Schwarz · Eleanor M Flynn

To the Editor: The Hon. Kevin Rudd, Prime Minister of Australia, addressed federal Parliament on 26 February 2009 regarding the Closing the gap on Indigenous disadvantage: the challenge for Australia report.1 In his speech, he asserted that government strategy to close the gap will focus on the treatment of Indigenous Australians’ illnesses “largely through the mainstream health system, because that is where 70% of Indigenous people are treated”.2 Unfortunately, the 70% figure is an urban myth based on one poorly worded question in the Australian Bureau of Statistics (ABS) National Aboriginal and Torres Strait Islander Health Survey 2004–05.3 At the National Aboriginal Community Controlled Health Organisation (NACCHO), we are concerned about the use of distorted evidence regarding the health of Aboriginal peoples, in particular the use of questionable data to formulate policies that undermine investment in Aboriginal community controlled health services (ACCHSs). In the ABS survey, a small sample of the Indigenous population were asked “Where do you usually go when you have a problem with your health?” The respondent was permitted one answer from choices that included: an Aboriginal medical service (AMS); a hospital; a doctor or general practitioner (outside hospital or AMS); traditional healer; other; or nothing. Such a question is bound to elicit misleading answers when, for example, a patient who sees his or her regular GP at an AMS selects “GP” rather than “AMS”. The technical distinction between these options is not clear, and the degree of reproducibility and reliability with which surveyors clarify the options is untested. Other Australian studies of primary care contradict the ABS findings. A recent study using 2007–08 data of the Bettering the Evaluation and Care of Health (BEACH) program found 0.9% of GP encounters are with Aboriginal and Torres Strait Islander patients.4 Over a 10-year period, this proportion has ranged from 0.7% to 1.6%.5 More than 70% of general practices do not see a single Indigenous Australian, and for the vast majority of those that do, less than 5% of their total encounters are with Indigenous Australian patients.6 In contrast, ACCHSs delivered 1 680 000 episodes of patient care to about 257 000 Aboriginal and Torres Strait Islander clients for the year 2005–06.7 Against an estimated national Indigenous population of 517 000, this indicates about 50% of Indigenous Australians use ACCHSs. ACCHSs also have more clients with complex disease than do private general practices,8,9 which supports our belief that ACCHSs target those who are “hard to reach”. Closing the gap in Aboriginal disadvantage depends on supporting Aboriginal communities towards their greater participation in primary health care. The right of Aboriginal peoples to participate in decision making that affects their health and wellbeing is the principle at stake here. The ultimate expression of this principle is community control and governance. This makes ACCHSs different to general practices, and it’s that difference that can close the gap.

Sophie Couzos · Dea Delaney Thiele

To the Editor: I read with interest the article by Andreasyan and Hoy,1 in which lower Aboriginal mortality rates were found in “very remote areas” compared with “remote areas” in the Northern Territory. In a previous article,2 I reported a similar finding from national data, based on information published by the Public Health Information Development Unit at the University of Adelaide.3 Thirty years ago, in this Journal, Morice outlined the health benefits that accrue for Aboriginal people moving away from larger settlements to live in smaller, decentralised communities where they can care for their country.4 There is an increasing literature to demonstrate that Aboriginal people living in smaller communities have better health than those living in larger settlements and regional towns. These findings have policy relevance, but they appear to be ignored by policymakers. The current Australian Government is continuing previous policies that do not support decentralised communities, but rather encourage their residents to move to larger communities or regional centres, where mortality is higher. These policies appear to be heavily influenced by allegations based on narrow economic arguments that the lack of “jobs” in small remote communities is a reason for them to be closed down.5 A minister in the previous federal government derided smaller remote communities as “cultural museums”.6 It is disturbing to note that a recent major Australian Government policy announcement stated that funding for the next 6 years . . . will support improvements to the delivery of services across 26 remote locations across the Northern Territory, Western Australia, Queensland, New South Wales and South Australia. These locations represent some of the largest concentrations of Indigenous Australians in remote Australia.7 Apparently, over 1100 smaller communities will not receive new funding. This is likely to accelerate the drift from small communities to larger settlements and towns, increasing exposure to health risks. Evidence from the Journal and elsewhere suggests that this drift will increase Aboriginal mortality. The current Australian Government has made a commitment to “close the gap” between Aboriginal and non-Aboriginal life expectancies. The Prime Minister has also stated that his government’s policies will be based on evidence.8 Yet current policies ignore the evidence for the health benefits that accrue to Aboriginal people living in small decentralised communities. These policies also ignore the known health risks associated with larger settlements. Consequently, such policies may widen rather than close the gap.

David J Scrimgeour

To the Editor: The recent article by Parker1 presents an interesting case for the establishment of a national academic college of Aboriginal and Torres Strait Islander health. The notion has been considered within Aboriginal health policy forums in the past, and the federal parliamentary Inquiry into Indigenous Health2 noted that an exploration of the merits of creating a new medical specialty for health care providers to Aboriginal and Torres Strait Islander peoples was arguably favourable. On the other hand, the concept has not gained significant support from some existing medical colleges. Broadly, the arguments supporting a college of Aboriginal and Torres Strait Islander health are that the subject is a national health priority,3 the subject has its own specialised literature, practice within an Aboriginal cultural framework is a specialised activity,4 technical aspects of health care delivery often require specialist knowledge,5 and providers of health care for Aboriginal and Torres Strait Islander peoples often act as consultants for other practitioners and policy development.6 The contrary view is that Aboriginal and Torres Strait Islander health is a health science sub-discipline within general practice, and that existing structures satisfy training needs. In terms of academic education in relation to the health of Indigenous Australians, Aboriginal community-controlled health organisations have had substantial experience and success over the past 25 years — primarily in the provision of accredited Aboriginal and Torres Strait Islander health worker training, but also in undergraduate and postgraduate training in medicine, nursing and allied health. Aboriginal representative bodies such as the National Aboriginal Community Controlled Health Organisation (NACCHO) and its Affiliates are already the arbiters of standards, benchmarks, codes of ethics, policies and protocols that define health care delivery to Indigenous Australians. With appropriate additional resourcing, it would be feasible to build on such existing expertise and infrastructure to develop a national Aboriginal and Torres Strait Islander health college. Ultimately, consistent with international principles of self-determination, Aboriginal community-controlled health organisations, NACCHO and Torres Strait Islander authorities should determine whether or not to progress the processes required for establishing an Aboriginal and Torres Strait Islander health college. They should also, as a corollary, determine the structure, function and membership of such a college, if it were to be developed.

John Daniels · Sophie Couzos

To the Editor: Compared with non-Indigenous Australians, Indigenous Australians are more likely to smoke, drink at risky levels and use illicit drugs.1 These alcohol and other drug (AOD) use patterns contribute to or exacerbate a wide range of health conditions and are significant contributors to premature death and morbidity among Indigenous Australians.2 Some attention has been paid to the efficacy of Indigenous-specific AOD programs,3 but there has been little investigation into the capacity of mainstream AOD services to respond to the needs of Indigenous Australians. To address this deficiency, we conducted a national postal survey of workers employed in agencies listed in the 2001 clients of treatment service agencies (COTSA) database. A total of 1345 workers employed in 369 agencies responded (a response rate of 38%). Most respondents (86%) indicated that their agency provided services to Indigenous clients, and that there was either strong (53%) or some (38%) need for such services. However, almost two-thirds (64%) felt that Indigenous clients’ needs were only partially met, and 9% reported that such needs were not met at all. Private sector workers were significantly less likely to report that their agency provided services to Indigenous clients than workers in government agencies and non-government organisations (NGOs) (χ2 = 102.4; effect df = 3; respondents = 1335; P < 0.001). NGO workers were significantly more likely to report a strong need for the provision of AOD services to Indigenous Australians than government and private agency workers (χ2 = 22.2; effect df = 6; respondents = 1110; P < 0.001). Workers in remote locations were significantly more likely to report a strong need for AOD services for Indigenous Australians than workers in other locations (χ2 = 24.9; effect df = 8; respondents = 1108; P = 0.002). Nearly two-thirds of all respondents reported they had no (18%) or limited (44%) access to AOD resources designed specifically for Indigenous Australians. NGO and private agency workers were significantly more likely than government workers to report limited or no access to resources designed to meet the needs of Indigenous Australians (χ2 = 17.8; effect df = 6; respondents = 1168; P < 0.001). These findings indicate a clear need to improve the capacity of mainstream AOD treatment agencies, especially those servicing remote areas, to respond to the needs of Indigenous Australians. Until improvements are made, AOD problems will continue to erode the health and wellbeing of Indigenous Australians, with predictable outcomes in relation to injury, mental health, parenting and contact with the criminal justice system. As recently highlighted by Indigenous spokesperson Mick Dodson,4 initiatives, beyond support for Indigenous workers and communities, are required to improve mainstream services for Indigenous clients in a culturally sensitive and appropriate manner.

Ann M Roche · Kenneth J Pidd · Vinita Duraisingam

To the Editor: Silva and colleagues examined the effects of swimming pools on antibiotic use and clinic attendance for infections in two Aboriginal communities in Western Australia from 1998 to 2005.1 They concluded that swimming pools led to large decreases in clinic attendances for skin infections, respiratory tract infections, and antibiotic use. The huge health and social disadvantage suffered by Indigenous children is well documented, and any interventions that demonstrate health gains should be recognised. This study highlighted important issues and the results suggested some positive outcomes. However, two weaknesses of the study deserve comment — the lack of a control community without a pool, and the selective use of baseline years. In the absence of a control community (without a pool), these results could reflect documented secular trends in Aboriginal child health overall. For example, there was a 48% overall decline in hospitalisations for childhood pneumonia in four jurisdictions, including WA, between 1998 and 2005.2 This is not significantly different from the 52% reduction reported by Silva and colleagues. Second, the selective use of baseline years potentially obscures more modest results. The authors use 1998–1999 data for the figure (Box 3) and 1999–2000 as the baseline in the main results table (Box 4). The use of the second time period (1999–2000) gives more favourable results than if the previous year had been used. By interpolation, using the first period as baseline would reduce the effect size from 68% to 35% reduction for skin infections in one community (Jigalong). In the second community, rates of skin infections were actually increasing after 2002. Swimming pools in remote Aboriginal communities appear to have many benefits, including increased showering, school attendance and enjoyment among children. We believe that this study has not demonstrated a health impact of swimming pools in these communities that is different from trends elsewhere. That said, swimming pools are a “public good” that should be available to all Australian children, especially those living in very hot places where there are few alternative recreational opportunities. Arguments about direct health benefits should not be a requirement for one group of disadvantaged Australians when we do not feel we need to make the same arguments for other Australian children.

Yvette Roe · Robyn A McDermott

Planning the next steps in an Indigenous-led journey Tom Calma, 19 Aug 2008, Victorian Government and Opposition signing of the Statement of Intent. Courtesy: Lara McKinley, Oxfam Australia. When Prime Minister Kevin Rudd made his much anticipated formal Apology to Indigenous Australians in early 2008, he described it as a first step [towards] a future where we harness the determination of all Australians, Indigenous and non-Indigenous, to close the gap that lies between us in life expectancy, educational achievement and economic opportunity. Every journey requires preparation before the first step can be taken, and this one was no exception. In his 2005 Social Justice Report, the Aboriginal and Torres Strait Islander Social Justice Commissioner, Tom Calma, highlighted the huge gap in health and life expectancy between Aboriginal and Torres Strait Islander peoples and the rest of the Australian population, and issued an inspiring challenge for closure of the gap within 25 years. By early 2007, “Close the Gap” had become a national campaign supported by more than 40 Indigenous and non-Indigenous organisations and many thousands of individual Australians, and at the end of the same year the Council of Australian Governments promised that all Australian states would work with (and fund) Indigenous communities to address this issue. Soon after Rudd’s Apology, the government signed a Statement of Intent with peak Indigenous health bodies to work together to achieve equality in health status and life expectancy, and established the National Indigenous Health Equality Council. In the past year, targets have been set and considerable funding allocated for ongoing Close the Gap initiatives. The journey has indeed begun! Scattered throughout this special MJA Indigenous Health issue are brief contributions from some of the key organisations in the Close the Gap campaign (Social justice, Psychology, National Indigenous Health Equality Council, Dentistry, Aboriginal community controlled health services, Oxfam Australia, Nursing, Australian Indigenous Doctors’ Association). We asked each of them to outline one or two things that will make the most difference in the short term to the longer-term goal of closing the gap. Ranging from personal, through practical to political, their responses share a common thread: the importance of true partnerships with Aboriginal and Torres Strait Islander peoples at every step along the way. Closing the gap began as an Indigenous-led movement, but it has now inspired Australians at every level and become the foundation for unprecedented political focus on our nation’s biggest challenge. Many of the contributors of these short pieces are telling us that they know what to do next to keep us on track to reach our final destination. Partnerships with and continued leadership by Aboriginal and Torres Strait Islander peoples will be key to the journey’s success.

Ruth Armstrong

We need a stronger focus on the social determinants of health Since 2006, Australia’s peak Indigenous and non-Indigenous health bodies, non-government organisations and human rights organisations have worked together on the Close the Gap campaign for Aboriginal and Torres Strait Islander health equality by 2030. The key elements of their approach are: A comprehensive national plan of action that is properly resourced and that has the goal of closing the health and life expectancy gap between Indigenous and non-Indigenous Australians within a generation. This is vital to ensure that governments work towards Indigenous health equality in a coordinated fashion (including the many reform processes currently underway), and that none of the determinants of Indigenous health inequality are missed. A partnership for Indigenous health equality between government and Indigenous peoples and their representatives. Within the national plan, a targeted approach to achieving Indigenous health equality, focusing on a wide range of health conditions and health determinants. The campaign partners have developed a comprehensive set of Close the Gap National Indigenous Health Equality Targets (http://www.humanrights.gov.au/social_justice/health/targets) to guide this target-setting process. These were presented to the Australian Government in July 2008. Support for Aboriginal community-controlled health services. The good news is that Australian governments have already committed to this approach through: Bipartisan support for the Close the Gap Statement of Intent, signed by the Prime Minister in March 2008 (see: http://humanrights.gov.au/social_justice/health/statement_intent.html) — this alone represents a historic turning point in the approach to Indigenous affairs in this country; and Commitments by the Council of Australian Governments, where Australian governments have committed to closing the life expectancy gap within a generation, halving the mortality gap between Aboriginal and Torres Strait Islander and non-Indigenous children under 5 years of age, and the provision of record levels of new funding to support this. However, despite substantial investments in Indigenous health as a result of the campaign, progress has been slow in turning the commitments around planning and partnership into action, and there needs to be a stronger focus on the social determinants of health rather than simply a health sector response. This remains the challenge of the campaign partners over 2009–2010.

Tom Calma

Addressing psychological distress is key The enormous disparities in social and emotional wellbeing and mental health outcomes, and an apparent worsening of the circumstances of many Indigenous communities, were two of the major reasons that prompted Indigenous psychologists from all over the country to form the Australian Indigenous Psychologists Association (AIPA) in 2008, under the auspices of the Australian Psychological Society. AIPA has the dual aims of increasing the number of Indigenous psychologists and addressing the widening gap in social and emotional wellbeing and mental health outcomes for Indigenous peoples. The National Aboriginal and Torres Strait Islander Health Survey 2004–05 showed that just over one-quarter (27%) of Indigenous adults reported high or very high levels of psychological distress. This proportion was similar to that in New York City 8 months after the attack on the World Trade Center. Regardless of the causes, people who find themselves psychologically overwhelmed or struggling to cope suffer high levels of psychological distress. Such distress is a clear global indicator of poor social and emotional wellbeing among Indigenous Australians, and needs to be addressed early to prevent an increasing burden of mental illness among Indigenous peoples. The integration of culturally appropriate social and emotional wellbeing and primary mental health care services into Aboriginal community-controlled health care settings is essential in addressing the high levels of psychological distress among Aboriginal and Torres Strait Islander peoples. There is evidence that Indigenous peoples do not have universal access to these services, which should be available to all Indigenous populations in urban, regional or remote Australia. Preventing psychological distress is likely to result in a range of beneficial health as well as mental health outcomes for Aboriginal and Torres Strait Islander peoples, and could make a major contribution to closing the gap in life expectancy between Indigenous and other Australians.

Patricia Dudgeon

Guiding policy to end Indigenous health disadvantage The National Indigenous Health Equality Council (NIHEC; http://www.nihec.gov.au/) was established in July 2008 to advise the Australian Government Minister for Health and Ageing. Most of its members are Indigenous Australians, with expertise drawn from across the Aboriginal and mainstream health sectors and Australian Government. The Council’s terms of reference focus on: Its role in the development and monitoring of progress towards a set of health-related goals and targets to support the government’s commitments to Indigenous life expectancy and child mortality. Providing national leadership in responding to the government’s commitment to closing the gap of Indigenous disadvantage by advising the government on working towards the provision of equitable and sustainable health outcomes for Indigenous Australians. Providing strategic advice on: the commitments made under the March 2008 Statement of Intent on achieving Indigenous health equality; the development and monitoring of health-related goals and targets to support the government’s commitments to life expectancy and child mortality; priorities for Aboriginal and Torres Strait Islander health, including strategies for meeting targets agreed upon by the Australian Government and the Council of Australian Governments (COAG); monitoring progress towards closing the gap of Indigenous disadvantage; and any specific matters referred to it by the government and the Australian Health Ministers’ Advisory Council. As a first priority, NIHEC was asked to make recommendations on workforce development and sustainability, including advice on pathways to increase Indigenous workforce representation. Recent NIHEC initiatives include projects to: Map workforce development initiatives (the “Helicopter Project”); Articulate the parameters of a forward-looking workforce agenda in Indigenous health (the “Visions/Futures” Project); and Develop a national instrument for Aboriginal and Torres Strait Islander health goals and targets. NIHEC has also agreed to provide strategic advice supporting the implementation of COAG’s 2008 $1.5 billion investment in Indigenous health.

Ian Anderson

Enhancement of public dental services will improve dental care to the most disadvantaged Aboriginal and Torres Strait Islander peoples have higher levels of dental disease, including more untreated tooth decay and gum disease, than other Australians. Those who do receive treatment have fewer preventive appointments and many more extractions. The impact on general health of dental disease is significant. When inadequately treated, dental diseases can result in higher rates of malnutrition, low birthweight, preterm births and cardiovascular disease. Many Indigenous Australians have insufficient teeth to eat nourishing foods. To close the gap in oral health for Indigenous Australians requires: fluoridation of community water supplies; more Indigenous dentists, dental therapists and dental hygienists; coherent oral health promotion strategies and an Indigenous oral health dataset; and high-quality, comprehensive and culturally appropriate oral health care services organised and coordinated on a regional basis. These goals require federal government resources and coordination. The proposal of the National Health and Hospitals Reform Commission to provide Medicare funding for dentistry will not help close the gap. Schemes based upon universal access, such as Medicare, do not serve disadvantaged groups well. Pharmaceutical Benefits Scheme data, highlighted by the Close the Gap campaign, show per-capita spending on Indigenous health to be half that of spending on non-Indigenous health, despite an incidence of ill health three to four times higher for Indigenous Australians. Medicare-funded dentistry will primarily benefit the better-off in Australian society, and Indigenous Australians will be, in relative terms, further disadvantaged. To provide dental care to the most disadvantaged, current government spending of $1.5 billion on dentistry must be used to build up public dental services. Funds made available by ending the Medicare Enhanced Primary Care dental program, the Medicare Teen Dental Plan, and the private health insurance rebate would, along with existing resources, enable the reinvigoration of public dentistry. Indigenous Australians could then access the culturally appropriate, comprehensive, high-quality care that ought to be a hallmark of public dentistry.

Christopher J Bourke

Aboriginal and Torres Strait Islander peoples have a right to full participation in decisions affecting their health During 2008, the Council of Australian Governments (COAG) made several large-scale funding commitments to close the gap in life expectancy between Aboriginal and non-Aboriginal peoples, and to improve Indigenous child health. These commitments represent a significant first step, but the funding package was devised without the full and active involvement of Aboriginal and Torres Strait Islander peoples — the process failed to comply with the Close the gap statement of intent, which commits all partners to ensuring “the full participation of Aboriginal and Torres Strait Islander peoples and their representative bodies in all aspects of addressing their health needs”. The challenge now is to turn the COAG proposals into programs that will work for the Aboriginal community, particularly for those who are most disadvantaged. To this end, committing to the partnership forums established over the past 10 years between Aboriginal community controlled health services (ACCHSs) and state, territory and Australian Government health departments will be critical. At the national level, ensuring the effectiveness and appropriateness of federal programs is difficult, given there has never been a formal partnership between the Australian Government and the Aboriginal community on health matters. A national framework agreement between the Department of Health and Ageing and the National Aboriginal Community Controlled Health Organisation (NACCHO) will ensure Aboriginal and Torres Strait Islander peoples are in control of their health. NACCHO represents over 145 ACCHSs across Australia, which provide the vast bulk of comprehensive primary health care to Aboriginal peoples. Making sure the programs that result from the COAG commitments are in large part realised through the ACCHSs is critical to closing the gap in Aboriginal disadvantage. A national framework agreement between NACCHO and government will ensure Aboriginal and Torres Strait Islander peoples have the right to full participation in health service design, delivery, monitoring and evaluation. Such an agreement will set the stage for improvements in four key areas: joint planning processes to allow for full participation in decision making and priority setting; transparent and regular reporting; improved service delivery through greater cooperation among key players, and more efficient coordination; and better understanding among key players of one another’s roles and responsibilities. Every inquiry over the past 30 years has confirmed that ACCHSs are the most effective means to close the gap.

Mick Adams

Indigenous health groups know what to do to be effective The Close the Gap campaign has been a major success. With around 1400 community events across the country on three annual National Close the Gap Days, and the gathering of more than 130 000 signatures demanding action from the Australian Government, Oxfam Australia has seen the breadth of support from Australians everywhere. By signing the Close the Gap pledge, signatories have called on the government to develop a comprehensive National Action Plan with Aboriginal and Torres Strait Islander peoples and their representative bodies, increase Indigenous community participation and control in the delivery of health services, and address the critical social issues of housing, education and self-determination. As well as engaging the public, the Close the Gap coalition of more than 40 Indigenous, health and human rights groups has engaged the government. The Council of Australian Governments is holding a special Close the Gap meeting later this year and has earmarked an extra $4.6 billion to close the gap in life expectancy, education and employment, including $1.6 billion for Indigenous health. In March last year, the federal government also signed a pact (the Statement of Intent) with leading Indigenous health groups, showing its intent to create a national action plan in partnership with peak Indigenous health groups. However, after more than a year, we are still waiting for the national plan and the partnership to eventuate. Peak Indigenous health groups have created a comprehensive list of targets they would like to achieve in a plan and are inviting the government to engage with them, as was promised. These Indigenous health groups — such as the National Aboriginal Community Controlled Health Organisation and the Australian Indigenous Doctors’ Association — know what to do to be effective. For instance, the Victorian Aboriginal Health Service in Melbourne has immunisation rates that show an average of 91% of their child patients are fully immunised, compared with rates of less than 50% for Aboriginal children across Victoria. We are asking the government to rethink their relationship with Indigenous Australians, involve them in decision making that affects their lives and work together in partnership to create a national action plan to close the gap.

Andrew Hewett

It’s about change, and we must start with our own attitudes The Close the Gap campaign has brought public focus to the appalling health outcomes of many Aboriginal and Torres Strait Islander peoples. The initiative is welcomed by the Congress of Aboriginal and Torres Strait Islander Nurses (CATSIN) for its collaborative and inclusive approach, and for the determination (so far) with which its goals are being pursued. However, the potential of many Close the Gap programs, both pilots and those already underway, is being curtailed by some campaign shortcomings, perhaps the most obvious arising from stereotypes of Indigenous peoples that persist among health workers. The list of achievements is long. Swimming pools in remote communities improve kids’ health, school attendance and participation. For example, the pool at Yuendumu, built only after years of hard work by the community and a hefty contribution of money raised locally, shows what can be achieved irrespective of the level of government assistance. The provision of local peritoneal dialysis services means people do not have to leave their communities for extended periods to have haemodialysis. Diabetes mellitus is being prevented in some people by regular testing, early intervention and applying effective public health principles. Possibly the most damaging oversight relating to the campaign is the failure by each health professional to critically analyse his or her own personal and professional attitudes and set of norms. For instance: at the “front end” of rheumatic heart disease and hearing loss are runny noses, sore throats and ears, and skin damage, including scabies and impetigo. The long-term consequences of these “simple” childhood illnesses must be considered, and all cases must be recognised and treated by health professionals. Health professionals and the community alike have normalised the snotty-nosed Aboriginal child with open sores on arms and legs. This stereotypical view of Aboriginal children somehow allows obvious illness to go untreated. There is a further dimension to stereotyping “Aboriginal health and welfare”. What we would not tolerate in the non-Aboriginal and Torres Strait Islander kid, we tolerate as normal in the Aboriginal and Torres Strait Islander kid! We have even used unwell children as subjects in health promotion literature. There are glossy photos in current Close the Gap literature showing children with snotty noses and open wounds on top of old scars on limbs. Have those children been treated? Why was it okay to take the photo without first wiping the toddler’s nose? Because of our attitudes and stereotypes, these conditions are untreated and unnoticed. Further, we perpetuate stereotypes in bold colour photos without a second thought. Perhaps reflection on how our own attitudes influence practice is a starting place. The only way to achieve different outcomes is to practise differently. We must start with our own attitudes.

Robyn Coulthard

Education, role models, cultural safety and mutual respect can go a long way I would describe myself as an Aboriginal man who loves being a doctor. I love working one-on-one with my patients and feel a sense of satisfaction in the knowledge that, in my own small way, the work that I do contributes towards closing the gap between Indigenous and non-Indigenous health outcomes. It was a long journey to get to where I am today. I was always interested in becoming a doctor, but I thought that it was only for “rich people” or “doctors’ kids” — not someone like me. After completing my Year 10 certificate, I became an apprentice fitter machinist in a coal mine. My dreams of becoming a doctor might have ended there had I not seen Dr Louis Peachey and Dr Sandra Eades, the first Indigenous medical graduates from the University of Newcastle, interviewed on The Ray Martin Show. On that fateful day in the 1990s, Louis and Sandra’s confidence, determination and passion made me realise that I could do it too. My story, and those of other Aboriginal and Torres Strait Islander doctors like me, illustrates the importance of education, good role models and cultural safety — all the things that the Australian Indigenous Doctors’ Association continues to advocate. Today, our organisation is proud to boast of the 130 Aboriginal and Torres Strait Islander doctors and a further 130 medical students around the country. These are pleasing figures, but there is still much work to do to raise them to reach parity with the proportion of doctors per head of population. “Close the Gap” is not a mere slogan. The opportunity to contribute towards growing the next generation of Indigenous doctors is the reason I took up my current post as Associate Professor of Indigenous Health at the University of Newcastle. One of the things that I try to convey to students is the importance of an all-of-system response. In other words, we’re all in this together — it’s not just up to Indigenous people to make a difference; everyone in the health system needs to contribute to close the gap. Another important aspect is two-way respect. When health professionals go to communities, it is expected that they show respect, but it is also reasonable that community members show them respect too. I think that’s a fair starting block upon which to build relationships.

Peter O’Mara

Crime, Aboriginality and the decolonisation of justice. Harry Blagg. Sydney: Hawkins Press, 2008 (232 pp). ISBN 978 187606 719 9. Widely published, Harry Blagg is one of Australia’s eminent researchers on criminal justice in Aboriginal communities. His Crime, Aboriginality and the decolonisation of justice is both confronting and thought provoking. Every page had me thinking that people who work in the health sector should read this book. There are such parallels. While Blagg does not specifically write about health, I became more and more aware of the dynamic interaction between justice and health — ill health and crime. Blagg demonstrates a profound failure in the systems of justice in Australia for Aboriginal people, and this systemic failure is also applicable to health. There is much to learn. For example, much of the money in the justice system is spent at the rear end, within corrections, where funding is often channelled into preventive measures — prevention attended to too late. When Blagg writes about prison as a source of pain but not shame, with terms of reference that are different from those prescribed by white society, he is illustrating a great tragedy. He says prison becomes a place for acquiring some of the bounties of white society: food, medical services, education, meeting classificatory kin, conducting family business, taking a break and drying out. He acknowledges the cost to Aboriginal families and communities. However, Blagg does not point out that prison has another, deeply disturbing outcome. It is where extreme violence is learnt, and where sexually violent behaviours can be transferred back into communities. Blagg refutes allegations that Aboriginal customary laws condone violence against women and children, pointing to the wealth of research to the contrary. He suggests these laws contain considerable potential for renewal and healing. The book, while easy to read if you know the subject, will confront some readers and cause them to think more deeply about the “decolonisation” of justice. Hopefully, some readers might choose to also think more deeply about the deconstruction of the medical system, so that the development of hybrid initiatives of health and wellbeing might also be possible. At $49.95, the cost is a little more than I would have anticipated for a book of just over 200 pages. Nonetheless, it is good value for money. It has me thinking of links between law and health and the need to explore rather than ignore liminal spaces between Aboriginal notions of ceremony as forms of transition, including syncretic changes in status relationships between social domains — social domains that construct justice and health, or crime and ill health.

Judy Atkinson

My story. Aboriginal and Torres Strait Islander women sharing their experiences of breast cancer. A resource for health workers. Val Alberts, Project Coordinator. Sydney: National Breast and Ovarian Cancer Centre, 2008 (DVD and booklet). Cancer has not been a high priority on the Indigenous health agenda in Australia, despite being a major cause of death. Disparities in cancer mortality between Indigenous Australians and other Australians are not the result of a higher incidence of cancer among Indigenous people overall, but exist for reasons such as lower participation in screening; delayed presentation with symptoms; and poorer uptake of treatment. There have been few resources specifically for Indigenous people with cancer, so this 14-minute DVD, My story. Aboriginal and Torres Strait Islander women sharing their experiences of breast cancer, is a welcome contribution. Six Indigenous women talk about how they came to be diagnosed with breast cancer and their subsequent journeys through treatment. The stories are engaging and rich in important health messages — Indigenous people do get cancer; Indigenous women should participate in mammography screening; don’t ignore symptoms; early diagnosis is important for cure; involving family members helps them know what you’re going through; one cancer doesn’t mean you won’t get another; it’s normal to be scared; breast prostheses help you feel and look better. To reinforce the importance of early diagnosis, the women point to their own survival — they wouldn’t be alive to tell their story unless treated early. The presentation also touches on issues of family history. Several scenarios mention the role that men can play in helping women with breast cancer — encouraging them to seek health care for symptoms, attending medical appointments to provide support, and helping children and other family members to understand. Produced by James Cook University, the DVD has a Far North Queensland feel, with scenes of palm trees and beaches. It has an authenticity and positivity that contribute to it being a valuable health promotion and educational resource for Indigenous people. At the same time, its messages are universal, and the DVD will have broad appeal, especially among the nation’s many breast cancer support groups. An accompanying booklet means people are not reliant on having a DVD player to acquaint, or re-acquaint, themselves with the stories of the women. Here’s hoping for more such endeavours to cover a wider range of cancers, and to convey cancer messages and education for Indigenous men.

Sandra C Thompson

Holding men. Kanyirninpa and the health of Aboriginal men. Brian F McCoy. Canberra: Aboriginal Studies Press, 2008 (xviii + 278 pp). ISBN 978 0 85575 658 1. The health of Aboriginal men is a critical issue in the discourse on Aboriginal affairs and policy. The important issues here, though, the author suggests, are not merely the biomedical aspects of health. They are the relational, social and cultural contexts and constructs of Aboriginal men’s health. The cultural process of “nurture” or “Kanyirninpa” (holding) is part of such a construct. Brian McCoy brings an interesting perspective as he is a Jesuit priest and an academic researcher, and has been everything from a footy coach to an Aboriginal Deaths in Custody research officer. He has spent most of the past 40 years working and living with Aboriginal people, particularly in the Western Desert where much of this book was researched. The author addresses one of the salient issues missing in the discussion on the poor health of Aboriginal men: an approach that acknowledges the relevance of culture and accurately reflects the current health status of Aboriginal men within a broader social sphere. He begins with a relatively dry academic style that becomes quite poignant as the nature of his research is developed. He locates his personal frame of reference, builds on his own relationships with Aboriginal people, then examines the past and recent, relevant history of the Western Desert. From there the book delves deeper, into the nature of Aboriginal male relationships and how these have been affected and what the impact has been, in terms of broad health and social and emotional wellbeing. For those of us who work with Aboriginal people, this is an important book, and for those who don’t, and want to have a deeper intellectual understanding of Aboriginal issues, it’s a good read.

Mark Wenitong