Volume 192 Issue 10

On my first day as an Aboriginal Research Officer, researching the social and emotional wellbeing of Aboriginal children, I was given a report to read as background material for my new role. It evaluated the therapeutic service which had just employed me. I flicked through the report, my eyes alighting on a chart which outlined the types of trauma experienced by the service’s clients, including exposure to family violence and physical assault, such as being hit with objects. (The report referred to all children, not just Aboriginal.) The report went on to list rates of other forms of abuse — emotional abuse, sexual abuse and neglect. I had to think to myself, did I have the inner resources to do this job? In my role, while I would not be interviewing children directly, I would be talking to clinicians, psychiatrists and counsellors, both Aboriginal and non-Aboriginal, who had worked therapeutically with Aboriginal children who had been abused. Would I have the resilience to withstand the vicarious trauma to which I would be exposed? My position was based across a consortium of three organisations, — an Aboriginal childcare agency, a therapeutic service and a university, — so I had a deep pool of knowledge and wisdom to draw upon in developing my report. But what of myself, and my own life experiences; what could I bring to this role? I grew up with my Aboriginal mother and one sister. My non-Aboriginal father was a severe alcoholic, and was absent for most of my childhood. He died from cardiomyopathy when I was nine. There were alcoholic grandparents on both sides of my family, but, fortunately, my mother had escaped that scourge. I suppose I was happy as a child, although we were often living “off the smell of an oily rag”, as my mother would put it, and our small family was quite socially isolated. My mother’s family all lived interstate and we had little association with my father’s family, except at Christmas. But my childhood provided me with lots of freedom: I was surrounded by nature, I had a best friend, I loved reading and I did well academically. By many of the measures I later perused as part of my research, I would have been classified as a resilient child. More to the point, I think I didn’t act up, or act out, or if I did it, it flew beneath the radar. In my teenage years, I experienced my first bout of depression, and it has dogged me my whole life. So how does one undertake research, or work to heal Aboriginal children, when one needs to heal oneself? We Aboriginal workers travel a parallel journey, working to improve our community’s wellbeing, while sometimes struggling with our own. Sometimes I am aware of the irony; in my work I am a strong advocate for increasing the cultural connection of Aboriginal children, believing culture to be healing, especially for those who are in the child protection system and whose access to family and community is nominal. Yet my own cultural connection when I was growing up was very tentative. I always knew I was Aboriginal, I always “felt” it, and yet did not have the bonds with extended family that is so much a part of “being” Aboriginal. There were no other Aboriginal students at my school or in my social milieu. In my childhood I felt quite comfortable telling people of my heritage, but when I reached adulthood, people — white people — would often question my Aboriginality: “How much of you is Aboriginal?” I too began to question my “right” to claim Aboriginal heritage, while still feeling a strong desire to belong, to connect. In my early 30s, being unexpectedly out of work as an advertising copywriter, I came across an ad for a writer/researcher for an Aboriginal theatre company. The project was “The Lost Children”, which later evolved into the play Stolen, themed around the “stolen generations”. I myself was not a member of the Stolen Generation, and neither was my mother, yet I was entrusted to write this important story. It took six years from commission to its stage premiere and, in that time, I read and spoke to as many people as I could. It was an amazing, deep, hands-on education, and yet the most important part of the experience, for me, was finally building some connections. While all along I had doubts about my “entitlement” to belong, I felt (mostly) accepted as an Aboriginal person by the Aboriginal theatre community, and they became my de facto mob. The spotlight is often on the dysfunction of Aboriginal communities, but what of the wider white community? Read the daily papers and note the innumerable examples of binge drinking, stabbings, reckless driving. We are all too aware of the plethora of pornography on the web, high rates of youth suicide and high rates of depression in the general population, but we never classify these as being “white” issues. In contrast, I think a healthy Aboriginal person and community represents “best practice”. They are connected to extended family and community; they participate in community events and have a way of conveying their culture — through art, music, dance, filmmaking, sport and the like. They look out for one another. They have pride in being Aboriginal and can express that, through opportunities such as NAIDOC (the National Aboriginal and Islander Day Observance Committee), but also in myriad everyday ways. Their Aboriginality is a source of strength. Their humour helps them through the tough times, and there is always someone wise to turn to. Although many of these ways of being have been eroded by intergenerational trauma and poor social indicators, the healthy Aboriginal person and community still survives to give us hope. Working in an Aboriginal organisation, you see all around you a dedication to making a contribution, to making a difference for future generations, while many of us at the same time are struggling with our personal demons. One of these can be low self-esteem. Low self-esteem can make us vulnerable to real or perceived slightings or put-downs, or can make us feel undervalued, which can impact on our working lives. One friend told me, after suffering put-downs at work, that she was used to being treated that way — that was how people (Aboriginal or otherwise) had always treated her. “Lateral violence” can be rife: it’s like we feel powerless to assert our rights “out there” in the wider community, so we turn on ourselves and on those closest to us, because it’s there that our anger and sadness and hurt have most traction. Some of us battle addictions, whether it’s alcohol or the pokies. Many of the Aboriginal women I know who are working in the child and family welfare area, me included, are also single mothers, and while that is not a deficit in itself, it is often linked to financial stresses and sometimes means that there is less household support. And yet we, me included, are all striving to be professional (and we are) — striving to have our lived experiences recognised for the insight and wisdom, empathy and compassion they bring to our working lives. In my own journey towards “belonging”, there are gems. Presenting at a recent conference, and introducing myself as having Muruwari heritage, I was later approached by two Elders who had attended the session. One said, “I couldn’t believe it when you said you were Muruwari — we’re Muruwari!” And they were proud of me for presenting at the conference. I felt “claimed” as one of them. I have a photo of myself in between the two Elders, and it is special to me. Travelling up to Bourke and Brewarrina, for the first time, in 2000, and meeting my mum’s cousins and extended family, a young relative greeted me with “G’day cuz”. That was like winning an award for me — priceless. Of course, it’s not only Aboriginal people who have had traumatic life experiences, but on the whole, I reckon we have been subjected to more than most. I’m not going to catalogue mine right here, but they’d make pretty good material for that new genre of literature, “miz lit”, which has been described as a chronicle of a miserable childhood or, in my case, a (partly) miserable adulthood. After reading the statistic on children whose parents had tried to kill them, it was only much later that I recalled that my father had once tried to strangle my sister. Although I didn’t witness it, and was not directly affected, those kinds of episodes permeate the very atmosphere in which you grow up. The crack in the kitchen wall that was never repaired, where he’d punched it in a drunken rage. The shame . . . I was told that I, being the youngest child, had been protected from many of those experiences, but perhaps they cannot help but soak into the core of who you are and how you feel about yourself? As a family we had no professional help, and informal assistance was mainly through my mother’s membership of Al-Anon, a voluntary group that offered support to the families of alcoholics. At this moment in our country, there is a vibrant and exciting conversation happening around healing, with the setting up of the new Aboriginal and Torres Strait Islander Healing Foundation, and many Aboriginal-run healing centres popping up like mushrooms. I try to experience and learn as much as I can about Aboriginal ways of healing, including smoking ceremonies, healing circles, deep listening and narrative ways. I try to increase my understanding of Aboriginal spirituality and how it can be incorporated into a holistic approach to healing. I try to embed all of my learnings into my work with Aboriginal children and communities. For myself, I have found ways to manage my depression, including daily exercise, plenty of omega-3s, good nutrition, managing my physical health, being socially connected, undergoing counselling periodically, involving myself in the arts and having a means of expression through my writing (plays, essays and fiction). My writing helps me to make sense of my world and my experiences, and to learn more about the history of Aboriginal people before and after colonisation. It is a privilege and a responsibility, in equal measure. I believe in the work I do, that it makes a difference in the world, and that, in doing it, I am contributing to something bigger than myself. I try to find time for nature, to learn new things (enrolling in a PhD and having Italian lessons). I have a responsibility to my children, to be a good role model for them, so that they can have a better life than mine, and hopefully one not plagued with many of the issues I’ve had to deal with. For those working with Aboriginal people, we are strong and resilient, but we may also, while doing a fabulous professional job, be subject to strong undercurrents in our lives. Be kind to us, and — for all of us Aboriginal and Torres Strait Islander people who are working for the betterment of our communities, especially our children — be kind to yourselves. You are gold.

Jane Harrison MA

Objective: To compare clinical oral health outcomes between a birth cohort of young Australian Aboriginal adults and age-matched, national-level counterparts.Design, setting and participants: Comparison of outcomes between the dental component of Wave-3 of the Aboriginal Birth Cohort (ABC) study — a cross-sectional study conducted between January 2006 and December 2007, nested within a prospective longitudinal investigation in the Northern Territory’s Top End — and the 2004–06 National Survey of Adult Oral Health (NSAOH), a representative survey of the Australian population. Data were analysed for 442 ABC study participants and 202 NSAOH participants aged 16–20 years.Main outcome measures: Severity and prevalence of clinical oral health outcomes.Results: The mean number of decayed teeth was 8.0 times higher among ABC study participants than NSAOH participants, while the prevalence of untreated decayed teeth was 3.1 times higher. ABC study participants experienced 10.8 times the prevalence of moderate or severe periodontal disease of NSAOH participants, and 1.9, 4.1 and 4.5 times the prevalence of calculus, plaque and gingivitis, respectively.Conclusion: Adverse clinical oral health outcomes were 2–11 times higher in a cohort of young Australian Aboriginal adults than their age-matched, nationally representative counterparts.

Lisa M Jamieson PhD · Susan M Sayers PhD · Kaye F Roberts-Thomson MPH

Objective: To estimate the incidence of type 2 diabetes in two ethnically distinct Indigenous populations in north Queensland, Australia.Design, setting and participants: A community-based follow-up study of 1814 Australian Aboriginal and Torres Strait Islander adults from 1999 to 2007. Participants were initially free of diabetes and lived in 19 remote communities in Far North Queensland.Main outcome measures: Fasting blood glucose level; diagnosis of diabetes; blood lipid levels; weight; waist circumference (WC); and blood pressure.Results: Of the 554 adults who completed the study, 100 developed diabetes over 3412 person-years (py) of follow-up. The incidence of diabetes was similar for Aboriginals (29.7 [95% CI, 20.4–38.4] per 1000 py) and Torres Strait Islanders (29.0 [95% CI, 21.8–38.6] per 1000 py) despite large differences in baseline body mass index (BMI) and WC. The age-standardised incidence for both populations was 30.5 per 1000 py. Obesity defined by WC increased the risk of developing diabetes for Aboriginals (rate ratio [RR], 2.0 [95% CI, 1.1–3.6]) and for Torres Strait Islanders (RR, 6.3 [95% CI, 2.5–16.1]) compared with normal WC. Presence of the metabolic syndrome (MetS) was a strong predictor of incident diabetes (adjusted hazard ratio, 2.4 [95% CI, 1.6–3.7]). For both groups, waist-to-hip ratio and the presence of the MetS better predicted diabetes than WC or BMI.Conclusions: The incidence of diabetes in these Indigenous Australians is nearly four times higher than for the non-Indigenous population and 50% higher than the incidence reported 10 years ago in Australian Aboriginals. Currently used BMI cut-off points are not appropriate for Indigenous Australians to predict diabetes.

Robyn A McDermott FAFPHM, PhD · Ming Li MD, PhD · Sandra K Campbell RN, MAE

To the Editor: Cardiovascular disease (CVD) and mental disorders are the top two contributors to the total burden of disease in Indigenous Australians and make a substantial contribution to the excess morbidity and mortality in this group.1 There is increasing evidence that mental disorders are risk factors for, or consequences of, CVD.2 Awareness and better understanding of the intertwined relationship between mental disorders and CVD in Indigenous populations can provide opportunities for coordinated and seamless management of these conditions in health care systems. We investigated the association between mental disorders due to substance use and CVD in a remote Indigenous community in the Northern Territory. A cohort of 897 Aboriginal adults aged 20–74 years (85% of the community’s total adult population) was established through a population-based renal disease screening program in the community between 1992 and 1995.3 We followed up 784 participants, who were free of CVD at baseline, to 31 May 2005, using hospital and death records. The study was approved by the Behavioural and Social Sciences Ethical Review Committee of the University of Queensland. Substance use-related mental disorders were determined from participants’ hospital records, using International Classification of Diseases, ninth revision (ICD-9) codes 192, 291 and 303–305; and 10th revision (ICD-10) codes F10–F19. Cases of CVD were identified by the first CVD event recorded in participants’ hospital and death records, using ICD-9 codes 390–459 and ICD-10 codes I00–I99. We used the Kaplan–Meier method to calculate cumulative CVD incidence rates for those with and without substance use-related mental disorders. CVD hazard ratios were estimated using Cox proportional hazards models. During a median follow-up period of 10 years, 177 of the 784 participants (23%) had clinically diagnosed mental disorders due to substance use (mainly alcohol: 140 participants), and 243 (31%) developed CVD. Incidence rates of CVD were 71 (95% CI, 58–87) and 27 (95% CI, 23–32) per 1000 person-years for those with and without substance use-related mental disorders, respectively (Box). Participants with substance use-related mental disorders were 2.6 (95% CI, 2.0–3.3) times more likely to develop CVD than those without. After adjusting for CVD risk factors measured at baseline (age, sex, body mass index, smoking status, alcohol use, blood pressure, serum cholesterol level, diabetes and albuminuria status), the association remained statistically significant, with an adjusted hazard ratio of 2.6 (95% CI, 1.9–3.5). Our findings confirm an association between substance use-related mental disorders and CVD in an Indigenous population, after adjusting for potential confounders. Traditional health care systems tend to separate services and treatment for mental disorders from those for physical health problems such as CVD.4 This separation is even more evident in remote Indigenous settings, where primary health care practitioners are already overwhelmed in providing general medical care to community members, with mental health services being delivered infrequently by visiting psychiatrists.5 The observed intertwined relationship between these two common conditions calls for integration of mental health services into routine primary health care, and enhanced collaboration between primary care practitioners, cardiologists and psychiatrists, in an effort to curb the huge burden imposed by these diseases. The emerging Aboriginal mental health worker program in the NT has the potential to be an effective service model to bridge the gap between mental health care and day-to-day primary health care.5 Dedicated financial resources and ongoing support for recruitment, training and retention of Aboriginal mental health workers will be required for sustained integration of mental health care with primary care in Indigenous communities. Kaplan–Meier estimates of cardiovascular disease (CVD) incidence among Aboriginal adults with and without substance use-related mental disorders

Zhiqiang Wang · Damin Si · Wendy E Hoy

Objective: To compare bloodstream infection (BSI) rates, pathogens and mortality among Indigenous and non-Indigenous adults in central Australia.Design, participants and setting: Retrospective study of adult patients (aged ≥ 15 years) admitted to Alice Springs Hospital (ASH) between 1 January 2001 and 31 December 2005. Patients were followed up until 30 June 2008.Main outcome measures: Admission-based and population-based BSI rates and mortality rates for Indigenous and non-Indigenous adults.Results: During the study period, there were 824 BSI episodes (Indigenous, 753; non-Indigenous, 71). The admission-based BSI rate for Indigenous patients was 26.5 (95% CI, 26.4–26.6) per 1000 adult admissions, compared with 5.2 (95% CI, 5.1–5.2) per 1000 adult admissions for non-Indigenous patients (infection rate ratio [IRR], 5.13 [95% CI, 5.10–5.18]). The population-based BSI rate was 1354.7 (95% CI, 1256.3–1460.8) per 100 000 persons per year among Indigenous patients and 69.9 (95% CI, 55.1–88.6) per 100 000 persons per year among non-Indigenous patients (IRR, 19.4 [95% CI, 15.1–24.9]). These differences were not explained by higher comorbidity levels among Indigenous patients. Human T-cell lymphotropic virus type 1 and Strongyloides stercoralis infected 43% and 35%, respectively, of Indigenous patients tested. The risk of death during the follow-up period was 32.1% for Indigenous and 13.4% for non-Indigenous patients (hazard ratio [HR], 2.69 [95% CI, 1.38–5.25]; P = 0.004). Mortality rates were higher among Indigenous patients who had more than a single BSI (HR, 1.86 [95% CI, 1.32–2.62]; P < 0.001). The mean age at death was 48.5 years (SD, 16.2 years) for Indigenous patients and 75.1 years (SD, 18.7 years) for non-Indigenous patients (P < 0.001).Conclusion: Indigenous adults living in central Australia experience BSI rates that are among the highest reported in the world. These are associated with a high risk of death, and are a likely consequence of the poor socioeconomic circumstances of Indigenous people.

Lloyd J Einsiedel PhD, FRACP · Richard J Woodman PhD

I have been living at Shalom College for four years. It has been a life-changing experience for me. I have had time to work hard at uni, in a racism-free environment in which Indigenous students can live proudly. Without this scholarship it would be impossible for me to study medicine as there is no way my family could afford for me to live in Sydney.— Josef McDonald, 5th Year Medicine, University of New South Wales, Shalom Gamarada Scholarship Recipient The Shalom Gamarada scholarship program is funded both by the sale of work by Aboriginal artists at the annual, week-long Shalom Gamarada Ngiyani Yana exhibition and by the provision of scholarships by private donors and corporate sponsors. The name of the program comes from the term “gamarada ngiyani yana” in the Eora language and translates to “we walk together as friends.” “Shalom” is a Hebrew word, meaning peace and is part of the name of the Shalom College at the University of NSW. The program was founded in 2005. In 2010, the sixth exhibition and sale will run from 27th June to 4th July. This year's contributors include the internationally renowned contemporary Indigenous artist, Judy Watson. Other artists include Regina Wilson, Weaver Jack, Jan Billycan and Shorty Jangala Robertson. There will be much sought after ceramic works from the Bagu community from Girringun in Queensland. This year, we will be displaying specially commissioned walls which will include works from Utopia and commissioned installations from Yuendumu and Peppimenarti. For the first time, the exhibition will present new work from the community of Martumili from the Pilbara. Exhibition audiences will be offered a unique opportunity to experience an incredible and diverse range of Indigenous art practice from across Australia. Shalom Gamarada will showcase an extensive range of more than 120 stretched artworks hanging and many more unstretched works, some of which can be seen in this issue of the Journal (Box 1, Box 2, Box 3, Box 4, Box 5, Box 6, Box 7, Box 8, Box 9, Box 10), with a total value of over one million dollars. All artworks will be available for purchase, with prices ranging from a modest $150 to more than $25,000. Commissions from all art sales go to residential scholarships for Aboriginal and Torres Strait Islander Medical students at Shalom College. The Shalom Gamarada scholarship program was set up in 2005 to boost the numbers of Aboriginal and Torres Strait Islander medical students attending the University of NSW and runs in partnership with the UNSW’s Shalom College and the Muru Marri Indigenous Health Unit. Since its inception, the Shalom Gamarada Aboriginal art exhibition has been able to assist 24 students to study medicine, optometry and medical science, covering board and lodging expenses so students are able to focus solely on excelling in their studies. Each scholarship is valued at over $15 000 per year for the duration of the degree. We graduated our first Shalom Gamarada doctor in December 2009, Dr Beth Kervan. This year, another scholarship recipient and UNSW’s first Aboriginal optometry student, Jenna Owen — who was the top student in 4th Year Optometry in 2009 — will graduate. Details of the Exhibition and show Open: 11 am to 7 pm each day from 27 June to 4 July Address: Caspary Learning Centre, Shalom College, University of New South Wales, Kensington (enter via Barker St) Admission: Free More information: visit http://www.shalomgamarada.org/ or call Professor Lisa Jackson Pulver on 0404 859 989. Artist: Paddy Sims 1. Artist: Regina Wilson 2. Artist: Shorty Jangala Robertson 3. Artist: Jakayu Biljabu 4. Artist: Collaborative work by Mangkaja Arts, Fitzroy Crossing, WA 5. Artist: Wakartu Cory Surprise 6. Artist: Jimmy McKenzie 7. Artist: Judy Watson 8. Artist: Regina Wilson 9. Artist: Regina Wilson 10. Artist: Kathleen Petyarre The dance of life (cover image) Artist: Helen Milroy The dance of life painting is the last in a series depicting a multidimensional model of health and wellbeing from an Aboriginal perspective. The final painting brings all of the dimensions together to reflect the delicate balance of life within the universe. The dimensions include the biological or physical dimension, the psychological or emotional dimension, the social dimension, the spiritual dimension and finally, but most importantly, the cultural dimension. Within each dimension, there are additional layers to consider, including the historical context, traditional and contemporary views as well as gaps in our knowledge. The potential solutions for healing and restoration of wellbeing come from considering additional factors encompassing issues at the coalface of symptom presentation and service delivery, such as education and training, policy, sociopolitical context and international perspective. As this painting suggests, we can only exist if firmly grounded and supported by our community and spirituality, while always reflecting back on culture in order to hold our heads up high to grow and reach forward to the experiences life has waiting for us. The stories of our ancestors, the collective grief as well as healing, begin from knowing where we have come from and where we are heading. From the Aboriginal perspective, carrying the past with you into the future is as it should be. We are nothing but for those who have been before, and the children of the future will look back and reflect on us today. When we enable a person to restore all of the dimensions of their life, then we have achieved a great deal. When all of the dimensions are in balance within the universe, we can break free of our shackles and truly dance through life.

Lisa R Jackson Pulver

Objective: To assess the outcomes of an education intervention for childhood asthma conducted by Australian Indigenous health care workers (IHCWs).Design and setting: Randomised controlled trial in a primary health care setting on Thursday Island and Horn Island, and in Bamaga, Torres Strait region of northern Australia, April 2005 to March 2007.Participants: 88 children, aged 1–17 years, with asthma diagnosed by a respiratory physician (intervention group, 35; control group, 53; 98% Indigenous children).Interventions: Children were randomly allocated to: (i) three additional asthma education sessions with a trained IHCW, or (ii) no additional asthma education. Both groups were re-assessed at 12 months.Main outcome measures: Primary endpoint: number of unscheduled visits to hospital or a doctor caused by asthma exacerbation. Secondary outcomes: measures of quality of life (QoL) and functional severity index; asthma knowledge and understanding of asthma action plans (AAPs); and school days missed because of wheezing.Results: The groups were comparable at baseline (except for asthma severity, which was adjusted for in the analysis). There were no significant differences in the primary outcome (number of unscheduled medical visits for asthma). School children in the intervention group missed fewer school days because of wheezing (100% < 7 days v 21% of those in the control group missed 7–14 days). Significantly more carers in the intervention group could answer questions about asthma medication, knew where their AAP was kept (84% v 56%), and were able to describe the plan (67% v 40%). In both the intervention and control groups (before-and-after comparison), there was a significantly reduced frequency of asthma exacerbations, as well as an improved QoL score and functional severity index, with no significant differences between the groups.Conclusions: A community-based asthma education program conducted by trained IHCWs improves some important asthma outcomes in Indigenous children with asthma.Trial registration: Australian Clinical Trials Registry ACTRN012605000718640.

Patricia C Valery MD, MPH, PhD · Ian B Masters MB BS, FRACP, PhD · Brett Taylor MEd, GradDipExSpSc, BEd(Hons) · Yancy Laifoo IndigCommMgntDev · Peter K O’Rourke BSc(Hons), BA(Hons), PhD · Anne B Chang FRACP, MPHTM, PhD

Objectives: To ascertain whether changing from enhanced to routine surveillance had any deleterious impact on notification rates of acute rheumatic fever (ARF) among Indigenous people in north Queensland; and to determine whether initiatives to raise awareness about ARF among medical practitioners during the routine surveillance period were associated with any changes in the numbers of recurrences of the disease among Indigenous people in the region.Design, participants and setting: Routine surveillance of all cases of ARF, and (to identify unrecognised prior episodes) retrospective checking of the medical records of Indigenous people with notified first cases of ARF from mid 2004 to mid 2009 in north Queensland, which has an estimated resident Indigenous population of about 68 400.Main outcome measures: Rate of notifications of ARF during the routine surveillance period (mid 2004 to mid 2009) compared with that in the previous 5 years of enhanced surveillance; proportion of recurrent episodes of ARF that occurred from mid 2004 to the end of 2006 compared with the proportion in the following 2.5 years.Results: There were 203 notifications of ARF in 194 Indigenous people in north Queensland from mid 2004 to mid 2009, and this was a 23% increase in the average annual incidence compared with that in the preceding 5 years. Of the 54 recurrences, 34 (63%) occurred between mid 2004 and the end of 2006 and 20 occurred between the beginning of 2007 and mid 2009 (P < 0.01). Of the 148 episodes that were not recurrences, 69 (47%) occurred in the first 2.5 years and 79 in the more recent 2.5 years (P > 0.05).Conclusions: Changing from enhanced to routine surveillance in 2004 did not have a negative impact on notifications of ARF. The initiatives to raise awareness about ARF probably contributed to fewer missed cases and therefore to the considerable increase in the number of notifications, and ultimately to fewer recurrences.

Jeffrey N Hanna MPH, FAFPHM · Michele F Clark RN, BNursPrac

Objective: To describe the epidemiology of acute lower respiratory infection (ALRI) and bronchiectasis in Northern Territory Indigenous infants hospitalised in the first year of life.Design: A historical cohort study constructed from the NT Hospital Discharge Dataset and the NT Immunisation Register.Participants and setting: All NT resident Indigenous infants, born 1 January 1999 to 31 December 2004, admitted to NT public hospitals and followed up to 12 months of age.Main outcome measures: Incidence of ALRI and bronchiectasis (ICD-10-AM codes) and radiologically confirmed pneumonia (World Health Organization protocol).Results: Data on 9295 infants, 8498 child-years of observation and 15 948 hospitalised episodes of care were analysed. ALRI incidence was 426.7 episodes per 1000 child-years (95% CI, 416.2–437.2). Incidence rates were two times higher (relative risk, 2.12; 95% CI, 1.98–2.27) for infants in Central Australia compared with those in the Top End. The median age at first admission for an ALRI was 4.6 months (interquartile range, 2.6–7.3). Bronchiolitis accounted for most of the disease burden, with a rate of 227 per 1000 child-years. The incidence of first diagnosis of bronchiectasis was 1.18 per 1000 child-years (95% CI, 0.60–2.16). One or more key comorbidities were present in 1445 of the 3227 (44.8%) episodes of care for ALRI.Conclusions: Rates of ALRI and bronchiectasis in NT Indigenous infants are excessive, with early onset, frequent repeat episodes, and a high prevalence of comorbidities. These high rates of disease demand urgent attention.

Kerry-Ann F O’Grady GDipPH, MAppEpid, PhD · Paul J Torzillo AM, MB BS, FRACP, FJFICM · Anne B Chang FRACP, MPHTM, PhD

Objective: To determine the burden of hospitalised, radiologically confirmed pneumonia (World Health Organization protocol) in Northern Territory Indigenous children.Design, setting and participants: Historical, observational study of all hospital admissions for any diagnosis of NT resident Indigenous children, aged between ≥ 29 days and < 5 years, 1 April 1997 to 31 March 2005.Intervention: All chest radiographs taken during these admissions, regardless of diagnosis, were assessed for pneumonia in accordance with the WHO protocol.Main outcome measure: The primary outcome was endpoint consolidation (dense fluffy consolidation [alveolar infiltrate] of a portion of a lobe or the entire lung) present on a chest radiograph within 3 days of hospitalisation.Results: We analysed data on 24 115 hospitalised episodes of care for 9492 children and 13 683 chest radiographs. The average annual cumulative incidence of endpoint consolidation was 26.6 per 1000 population per year (95% CI, 25.3–27.9); 57.5 per 1000 per year in infants aged 1–11 months, 38.3 per 1000 per year in those aged 12–23 months, and 13.3 per 1000 per year in those aged 24–59 months. In all age groups, rates of endpoint consolidation in children in the arid southern region of NT were about twice that of children in the tropical northern region.Conclusion: The rates of severe pneumonia in hospitalised NT Indigenous children are among the highest reported in the world. Reducing this unacceptable burden of disease should be a national health priority.

Kerry-Ann F O’Grady GDipPH, MAppEpid, PhD · Debbie M Taylor-Thomson BPharm · Anne B Chang FRACP, MPHTM, PhD · Paul J Torzillo AM, MB BS, FRACP, FJFICM · Peter S Morris MB BS, FRACP, PhD · Grant A Mackenzie MB BS, PhD · Gavin R Wheaton MB BS, FRACP, FCSANZ · Paul A Bauert MB BS, FRACP · Margaret P De Campo FRANZCR, MPH, GDipEpibiostats · John F De Campo FRANZCR, MHA, FRACMA · Alan R Ruben MB BS, MAppEpid

To the Editor: Childhood obesity is a growing concern, with an estimated 22% of Australian children considered to be overweight or obese.1 Overweight and obese Indigenous children are at high risk of developing chronic conditions such as ischaemic heart disease and type 2 diabetes,2 contributing to increased mortality.3 Given the paucity of studies assessing rates of overweight and obesity in Indigenous children in urban areas, we conducted a pilot study to determine whether the Aboriginal and Torres Strait Islander child health check (Medicare item 708) is a useful tool for opportunistically assessing dietary habits, blood pressure and rates of overweight and obesity in children attending the Inala Indigenous Health Service. Data were collected from April 2008 to September 2008, and were compared with the 2006 Healthy Kids Queensland (HKQ) Survey.4 Of the 129 children aged 5–14 years who had health checks during the study period, 50 (39%) participated in our study (25 girls). Of those who participated, 36% (18 of 50) were overweight or obese, compared with 21% (751 of 3561) in the HKQ Survey (χ2 = 6.54; P = 0.01) (Box). Of the 41 participants for whom z scores for waist circumference could be calculated, 19 were ≥ 90th centile. Half of the Inala participants (23 of 46 for whom data were available) consumed takeaway food at least once a week, compared with 33% (1048 of 3185) in the HKQ Survey (χ2 = 5.98; P = 0.01). Non-diet soft drinks were consumed at least once a week by 38% (18 of 47 for whom data were available) of Inala participants, compared with 24% (750 of 3129) of the HKQ population (χ2 = 5.19; P = 0.02). Fewer than two-thirds of Inala participants consumed the minimum recommended amounts of fruit, and fewer than half consumed the minimum recommended amounts of vegetables. Our study demonstrates that the Aboriginal and Torres Strait Islander child health checks are a worthwhile screening tool for overweight and obesity. However, recruitment was slow. Even with practice nurses actively inviting potential participants by telephone, only 5% of school-aged children on the clinic’s register attended during the study period suggesting that most of them were well. Opportunistic recruitment of children attending the clinic to see the doctor was difficult, with only one-third participating. Furthermore, addition of the food frequency questionnaire to the child health check increased consultation length, which was at times frustrating for families and clinic staff. What could we do differently? Promoting child health checks to families through fun campaigns, which aim to educate families on the benefits of preventive health checks, and using a quicker health check tool could boost recruitment. Child health check clinics could be run within schools or as special child-friendly clinics during out-of-school hours or school holidays. Our results, limitations notwithstanding, are alarming for this Indigenous community. The addition of waist circumference and blood pressure measurement (with age-appropriate tables) would enhance an already valuable tool — the Aboriginal and Torres Strait Islander child health check — in the early detection of chronic disease risk factors. Weight categories of children from the Inala Indigenous Health Service study and the Healthy Kids Queensland Survey

Annie R Fonda · Geoffrey K Spurling · Deborah A Askew · Peter S W Davies · Noel E Hayman

To the Editor: Improving access to appropriate, good-quality care in the antenatal and postnatal period is a key part of closing the acknowledged gap between Indigenous and other Australians in perinatal outcomes.1 Previous research in a large Aboriginal medical service in Queensland demonstrated sustained improvements in perinatal outcomes associated with a quality improvement approach.2 Here we describe patterns of the delivery of maternity care and service gaps on a broad scale, using data from baseline clinical audits in 34 Indigenous primary health centres participating in a national quality improvement intervention.3 Participating services were located across the Northern Territory (Top End and Central Australia), North Queensland, Far West New South Wales and Western Australia. Details of the audit methods have been described previously.4 Briefly, a random sample of up to 30 clinical records in each service was assessed to determine the degree of adherence to recommended protocols and procedures in the antenatal and postnatal periods.5 Records of women with an infant aged 2–14 months and who had been resident in the community for at least 6 months of the infant’s gestation were considered eligible for our study. The study was approved by the human research ethics committees in each region, and their Indigenous subcommittees where required. Clinical records of 535 women were assessed. Eighty-nine per cent of the women were Indigenous. However, compared with services in the NT, WA and North Queensland, services in Far West NSW had a higher proportion of non-Indigenous women presenting for antenatal or postnatal care (34% v 0–6%; P < 0.05). Overall, less than half of all women presented for care in the first trimester of pregnancy (Box). Documentation of routine antenatal investigations and brief interventions or advice regarding health behaviour varied, but generally these services appeared to be underutilised. There was relatively good documentation of follow-up of identified problems relating to hypertension or diabetes, with over 70% of identified women being referred to a general practitioner or obstetrician. However, follow-up of other identified problems, such as inadequate rubella immunity, was poor. Although 53% of women had a recorded postnatal visit, documentation of advice regarding health risk factors during the postnatal period was poor. For about half of all women there was documentation about breastfeeding advice and contraception. But advice about smoking, nutrition or mood (depression) was recorded for only 19%–21% of all women, and advice about sudden infant death syndrome prevention, injury prevention or infection/hygiene was recorded for only 4%–5% of all women. The clinical audit data presented here indicate that participating services had both strengths and weaknesses in delivering maternal health care. Nevertheless, improving adherence to recommended screening investigations and brief interventions or advice about health behaviours, particularly smoking cessation, in the antenatal and postnatal period were identified as clear areas for improvement across all services. This information represents baseline data to inform the long-term monitoring of a quality improvement intervention. More broadly, it should be useful for informing local, regional and national efforts to promote and assess the quality of primary maternal health care for Indigenous women, and thus help address the persisting unacceptably high rates of poor Indigenous perinatal outcomes in Australia. Documented pregnancy care across regions Characteristic NT Top End NT Central Australia Far West NSW Western Australia North Queensland Total Number of health centres | number of client records audited 13 | 136 2 | 45 6 | 103 9 | 193 4 | 58 34 | 535 Proportion of women with estimated gestational age < 12 weeks at first antenatal visit 49% 44% 35% 42% 34% 42% Mean number of antenatal visits 9 10 5 6 7 7* Proportion of women with folate prescribed before 20 weeks 29% 49% 3% 33% 24% 27%* Any use of: Cigarettes 41% 40% 39% 42% 55% 43% Alcohol 12% 27% 19% 25% 31% 22%* Illicit drugs 7% 2% 17% 8% 7% 9% Brief interventions or counselling Smoking cessation† 48% 67% 35% 49% 41% 46% Antenatal education 51% 93% 51% 46% 47% 52%* Nutrition 53% 76% 18% 32% 59% 41%* Breastfeeding 21% 51% 17% 25% 19% 24% Alcohol and other substance abuse 37% 56% 12% 39% 34% 34%* Investigations at first antenatal assessment Blood group/Rh 96% 100% 65% 77% 79% 82%* Antibodies 93% 100% 66% 70% 78% 79%* Midstream urine (MSU) 91% 96% 40% 67% 76% 71%* Full blood examination (FBE) 95% 100% 64% 73% 79% 80%* Rubella 92% 100% 61% 70% 78% 77%* Hepatitis B surface antigen 91% 100% 56% 75% 79% 78%* Syphilis serology 94% 100% 58% 55% 81% 72%* HIV 80% 89% 14% 72% 59% 63%* Offered anomaly screening 6% 33% 17% 20% 0% 15%* Other investigations Ultrasound before 16 weeks 32% 49% 38% 39% 24% 36% Ultrasound at 16–20 weeks 47% 69% 31% 41% 34% 42% 50g or 75g glucose challenge test (GCT) or glucose tolerance test (GTT) 78% 49% 33% 38% 66% 51%* FBE (20–28 weeks) 82% 69% 24% 46% 60% 54%* Low vaginal swab for group B streptococcus (34–37 weeks) 49% 62% 31% 29% 10% 35%* Follow-up of abnormal findings Record of abnormal standard GCT 17% (23/136) 22% (10/45) 10% (10/103) 4% (7/193) 17% (10/58) 11% (60/535)* GTT undertaken 87% (20/23) 90% (9/10) 80% (8/10) 43% (3/7) 60% (6/10) 77% (46/60) Anaemia (Hb < 100 g/L) 14% (19/136) 22% (10/45) 11% (11/103) 12% (24/193) 3% (2/58) 12% (66/535)* Iron prescribed 84% (16/19) 100% (10/10) 91% (10/11) 75% (18/24) 50% (1/2) 83% (55/66) Follow-up FBE or Hb test done 42% (8/19) 90% (9/10) 36% (4/11) 46% (11/24) 50% (1/2) 50% (33/66) Nitrites detected by dipstick 21% (28/136) 33% (15/45) 5% (5/103) 24% (46/193) 10% (6/58) 19% (100/535)* Urine sent for culture and sensitivity 96% (27/28) 100% (15/15) 100% (5/5) 93% (43/46) 100% (6/6) 96% (96/100) Oral antibiotic prescribed 93% (26/28) 60% (9/15) 80% (4/5) 37% (17/46) 83% (5/6) 61% (61/100)* Record of a normal follow-up MSU 46% (13/28) 100% (15/15) 40% (2/5) 26% (12/46) 83% (5/6) 47% (47/100)* Rubella antibodies negative or low-titre 35% (47/136) 7% (3/45) 15% (15/103) 15% (28/193) 7% (4/58) 18% (97/535)* Rubella vaccination given postnatally 36% (17/47) 67% (2/3) 13% (2/15) 32% (9/28) 0 (0/4) 31% (30/97) GTT = glucose tolerance test. Hb = haemoglobin. NSW = New South Wales. NT = Northern Territory. * P < 0.05 for comparisons between regions. † Among those who used cigarettes: NT Top End (n = 56), NT Central Australia (n = 18), Far West NSW (n = 40), WA (n = 82), North Queensland (n = 32); total N = 228.

Alice R Rumbold · Ross S Bailie · Damin Si · Michelle C Dowden · Catherine M Kennedy · Rhonda J Cox · Lynette O’Donoghue · Helen E Liddle · Ru K Kwedza · Sandra C Thompson · Hugh P Burke · Alex D Brown · Tarun Weeramanthri · Christine M Connors

Recognising the tensions inherent in all efforts to bring about change in Indigenous health outcomes Health promotion and illness prevention in Aboriginal and Torres Strait Islander communities remain central to closing the gap between Indigenous and non-Indigenous health outcomes. The National Indigenous Health Equality Targets identify the need for effective health promotion activities targeting smoking, alcohol consumption, oral health, chronic disease, nutrition, exercise, mental health, and social and emotional wellbeing.1 An expanding body of research considers the barriers to effective health promotion and illness prevention in Indigenous contexts.2-6 In this issue of the Journal Taylor and colleagues present findings from their study of Indigenous participation in cardiac rehabilitation,7 an important form of secondary prevention. Their study identified many barriers to participation, including the challenges associated with extended family responsibilities, the sociocultural inappropriateness of cardiac rehabilitation programs, and historical barriers to using mainstream services. The barriers they identified are recurring themes in many evaluations of Indigenous health promotion and health care services.2-6 At the heart of these recurring themes are two central tensions of Indigenous development: the tension between cultural difference and statistical equality, and the problem of marginalised identities. For a range of historical, geographical, socioeconomic and cultural reasons, the conditions required for a “healthy life” as defined by Western society (including nutritious food, smoking cessation, and accessing mainstream health services) are found less often in Indigenous than non-Indigenous populations. While many Indigenous communities and individuals see this as a major problem, for others, unhealthy behaviour and conditions are a normal part of life. For some Indigenous people, the environments and behaviour linked to good health are associated with non-Indigenous society and akin to a “foreign” culture. They may even be seen as antithetical to an Indigenous identity. Medical anthropologist Kate Senior’s research at Ngukurr in the Northern Territory provides one example of this. In this Indigenous community, hygiene practices are associated with the missionaries who required mission residents to keep their houses spotless. One older woman told Senior that, “I tell my own daughter how to do it, but all she says is ‘we’re not Munanga [white] — we don’t want to live Munanga way’”.8 Walking for exercise is similarly considered a Munanga behaviour and regarded with amusement. Others have also noted that the approach taken to hygiene interventions in Indigenous communities in the past promoted resistance to, rather than adoption of, health-promoting behaviour.9 Taylor et al suggest that attitudes such as these may be due to social exclusion. As one of the Aboriginal patients in their study commented in regard to health services, the legacy of colonisation and discrimination is that “it remain[s] in the psyche of the Aboriginal people that mainstream services are only there for other people”.7 In addition to social exclusion, others have argued that cultural difference plays a role in the “foreignness” of health services and healthy behaviour. A study of smoking in an Aboriginal community describes how integral the practice is to family interaction and ceremonial exchange, and how refusing to smoke can produce unbearable social isolation and friction — the “passing around and sharing of cigarettes is part of the social fabric of the community”.10 Anthropologist Maggie Brady has shown that alcohol misuse is similarly integrated into Indigenous social practices and identities.11 Such findings imply that calling for health-promoting change may mean changing the “social fabric” of some Indigenous communities. While some working in Indigenous health see this as a necessary and positive change, others are troubled by the thought that certain cultural practices may be compromised in the pursuit of good health. For example, there is debate over the role of “demand sharing”12 (where Indigenous people are obliged to accommodate even unreasonable demands from their kin) in preventing improvements in health behaviour and socioeconomic status. An anthropological study found that some non-Indigenous researchers working in Indigenous health expressed concern that healthy lifestyles may require a rejection of such kinship obligations.13 The overarching tension here is between respecting cultural difference and addressing disadvantage.14 Regardless of whether one believes that aspects of Indigenous culture will be changed by efforts to improve health, many non-Indigenous people working in Indigenous health harbour fears of eroding Indigenous culture and repeating the mistakes of the assimilation era.13 Taylor et al also report that, paradoxically, the widespread dissemination of Indigenous health statistics in the media reduces the likelihood of Indigenous people accessing cardiac rehabilitation services.7 They found that knowledge of the poor health status of the Indigenous population was disempowering and reduced Indigenous people’s motivation to engage with health promotion, an effect also found by others.10 This is one aspect of the broader problem of marginalised identities. When we recognise a distinct and disadvantaged group within the general population, we inadvertently and unavoidably label that population as inherently disadvantaged, even in the act of trying to address this disadvantage.15 The publication of Indigenous health statistics draws attention to health problems and attracts resources to deal with them. However, for Indigenous Australians, it also creates a sense that an Indigenous identity is tied to inevitable ill health, homogenising the varied health and wellbeing of individual Indigenous people. This effect may contribute to the reluctance of Indigenous Australians in the Australian Capital Territory to identify as Indigenous when accessing mainstream health services, as reported by Scotney and colleagues in this issue of the Journal.16 The notion of the statistical “gap” between Indigenous and non-Indigenous health outcomes that forms the centrepiece of current Indigenous policy is an illustrative example. Even when Indigenous health is improving at the same rate as non-Indigenous health, the gap remains constant. In fact, if measured as a relative proportion, the gap will increase as the absolute health of the Indigenous population steadily improves. Recognising these tensions does not mean that we should cease any form of intervention for Indigenous health — which would be unethical — or enter into a state of “paralysis by analysis”. Instead, health practitioners should accept that such tensions are inherent in all efforts to bring about change in Indigenous health contexts. We should be aware of the wider debates concerning cultural difference and statistical equality, and the dilemma of marginalised identities. Such awareness helps us to recognise these issues as they arise across the many diverse contexts of Indigenous affairs. It also makes explicit the ongoing need to manage these tensions in our work with Indigenous people.

Emma E Kowal BA(Hons), MB BS, PhD · Yin C Paradies MMedStats, MPH, PhD

To the Editor: Engaging patients in cardiac rehabilitation (CR), a program of secondary prevention measures, is crucial to improving outcomes after myocardial infarct.1 Rates of participation in CR by Aboriginal and Torres Strait Islander (hereafter Aboriginal) people are extremely low.2,3 We conducted a qualitative study on barriers to CR use from November 2007 to March 2008 with 15 Aboriginal cardiac patients (seven women and eight men, aged 31–74 years) living in Perth, Western Australia. Six had participated in some outpatient CR sessions; nine had not. Participants were interviewed face-to-face using a semistructured interview guide, with questions exploring their views and experiences of CR, barriers to use and suggestions for improvement. Recurring themes included challenges associated with extended family responsibilities and sociocultural inappropriateness of the program. These themes, along with less commonly discussed issues of poor knowledge of CR and the connection between colonialism and health services, reflect findings from previous studies.2,4,5 However, two new themes — media heart health messages and the younger age of the affected Aboriginal population — highlight further factors influencing participation (Box 1). We found that some patients feel constantly reminded of, and therefore come to expect, poor health outcomes, due to dire statistics repeated in the media. While the dominant theme in the Australian media of Aboriginal fatality and futility has been discussed,6 heart health messages are often disempowering, negatively affecting motivation to engage with health programs. This is likely reinforced by regular attendance at funerals for Aboriginal people, who die very prematurely from cardiovascular disease (CVD). This highlights the need for a shift in media and public health campaigns from “shock” headlines and statistics to a focus on strengths and successes, inspiring the groups involved and supporting them to make changes. Younger Aboriginal participants also spoke about feeling isolated in CR sessions among non-Aboriginal people who were 20–30 years older than them. The age demographic of CR program attendees generally reflects CVD epidemiology in the wider community, but the burden of CVD occurs at much younger ages in the Aboriginal population.7 This widening differential7 demands rethinking of how CR should work for this very different demographic group (Box 2). CR programs addressing the needs of younger people may improve receptivity and opportunities for primary prevention in the family and broader community. Although these two themes were reported by a small number of patients, further research into issues for Aboriginal patients with CVD is warranted. Importantly, it will contribute to understanding of how younger Aboriginal people think about their health, and feel motivated and supported by wider society to do something about it. 1 Quotes from Aboriginal cardiac patients reflecting barriers to participating in cardiac rehabilitation (CR) programs ... even with the newspaper, every second page has something to do with the heart ... Turn the radio on, “oh, there’s this new survey about heart conditions”. And I don’t want to know about it! Don’t tell me! ... I don’t want to be told the negatives ... it’s all you used to hear of all the stories regarding the heart. (Aboriginal patient 10) I didn’t like it [the CR program] because everybody else was at least twice my age. I was like the youngest one there and it was just a turn-off for me ... I’d feel more comfortable if people my own age were there for a start, you know? (Aboriginal patient 11) Aboriginal people don’t use [CR and health services] ... as a matter of course because the discrimination that took place in Australia against Aboriginal people ... instead it remained in the psyche of the Aboriginal people that mainstream services are only there for other people. They’re not there for you. (Aboriginal patient 9) 2 Recommendations from Aboriginal patients for improving cardiac rehabilitation (CR) programs Offer CR programs out of working hours Have opportunistic drop-in sessions rather than allocated times Make CR programs more appealing to younger clients Hold CR programs in Aboriginal community health centres Build trust and relationships with patients (the importance of yarning) Develop programs for use at home by the whole family Tailor lifestyle and diet advice to modern Aboriginal family situations Have both male and female Aboriginal health staff delivering CR if possible Target youth with heart health education messages Refocus public health messages away from being negative and fear-based to being positive and strength-based Encourage Aboriginal patients to attend CR sessions together (buddy system)

Kate P Taylor · Julie S Smith · Lyn Dimer · Mohammed Ali · Narelle Wilson · Tyra R Thomas · Sandra C Thompson

Objective: To explore emerging themes related to the mental health of Aboriginal children and adolescents (“young people”) arising from focus groups conducted in Sydney, New South Wales.Design, setting and participants: A qualitative study was conducted between April 2008 and September 2009 in three Aboriginal community-controlled health organisations in Sydney. A semi-structured approach was used in focus groups and small group interviews to elicit the views of 15 Aboriginal parents and 32 Aboriginal workers from a variety of health and social work backgrounds on important factors surrounding the mental health of Aboriginal young people.Results: Major themes identified were the centrality of family and kinship relationships, the importance of identity, confounding factors in the mental health of Aboriginal young people, and issues related to service access and implementation.Conclusion: Clinicians working with Aboriginal young people should be mindful of the critical importance of family and identity issues and should assess possible physical health or social factors that may complicate a diagnosis. Improvements in access to mental health services for Aboriginal families and a more holistic approach to mental health treatment are urgently required.

Anna B Williamson BPsych(Hons), PhD · Beverley Raphael AM, MB BS, MD, FRANZCP · Sally Redman BPsych(Hons), PhD · John Daniels MB BS, FACRRM · Sandra J Eades BMed, PhD · Naomi Mayers

I was asked to review the article below, and found it a compelling read. Zimmet has clearly gone to central Australia with an open heart and mind, and has discovered an intriguing world previously not known to him. He ends his article with a gentle challenge to those of us who have the privilege to work in health care, to consider whether our current methods are best practice, and whether they are best suited to all who seek our help. Having read this article, I found myself with two unanswered questions. First, given that there have now been several generations of Aboriginal people advocating for improvement to the dire circumstances in Aboriginal health, how is it that our young colleagues are still so shocked when they come to our communities? What is it that we (older Aboriginal people) have failed to say to get the attention of our health care providers, and their teachers? Second, how can we see to it that we produce many more graduates of the quality of Zimmet, who see the world with fresh eyes, are not afraid to ask the obvious questions, and are bold enough to tell us all that the Emperor is indeed naked? I strongly recommend that Journal readers take the time to read this article, and spend a moment or two in reflection to examine their own souls, to see if they can rise to this young man’s challenge. Louis G Peachey, BMed, FACRRM, Foundation President, Australian Indigenous Doctors Association, Canberra, ACT. In the Alice Springs paediatric ward, the vast majority of the 20 or so children are Aboriginal. They often have unique first names with an African–American or biblical flavour and distinctive spellings. Some come from town, while others travel from hundreds of kilometres away. Parents often lie with their children on mattresses on the floor, watching Disney DVDs, drawing, and waiting for the sporadic visits of hospital staff. For families, a visit to the ward can mean a period of isolation from their community or time with relatives who live in Alice Springs or who also happen to be in the hospital. It may be an unwanted upheaval from relatively peaceful community life, or an urgent and welcome respite from upheavals at home. What distinguishes the Alice Springs ward most is the type and severity of paediatric health issues. There is a whole other spectrum of health and disease in central Australia — one that challenges the heart and the mind. Labels that don’t stickThe categorisations of disease as I knew them after several years working in Melbourne seemed to collapse when I arrived in Alice Springs. Trying to apply learnt diagnostic and management techniques proved futile in the face of the ostensibly distinct nature of “common” illnesses like gastroenteritis, pneumonia and ear infections in central Australian children, let alone their coexistence with nutritional, social, cultural and historical factors. It is not uncommon to see 4-month-old infants with perforated ear drums. In contrast to coastal city paediatrics, “pink” or “red” tympanic membranes suggesting otitis media do not show up as threats on the diagnostic radar. Ear examination in central Australia is focused on detecting the presence or absence of pus or perforation of the tympanic membrane. Anything less is considered “healthy”. A child presenting with “gastroenteritis” can mean anything from a prolonged cryptosporidium infection to multiple parasitic and worm infestations. Families often refer to these different ailments generically as “guts ache”. Treatment ranges from frequent correction of significant acidoses and hypokalaemia, to using nitazoxanide to treat cryptosporidium. This drug is only available on the special access scheme in Australia, not because it is unsafe, but because so few children need it. The evidence for its use, however, is limited to a few studies, mainly in settings somewhat different to Alice Springs. This is a recurring theme in paediatric medicine here — that evidence from either “first-world” metropolitan research centres or the “third-world” does not necessarily translate to what health workers see in central Australia, a “fourth-world” inside our country. Further, century-old pathological definitions that define disease rather than causation or environmental and social contributors often do not provide us with adequate solutions today. They help us to heal the surface of the skin or lungs, perhaps the lining of the gut, but not always the deeper tissues. The tragically prevalent conditions of chronic suppurative otitis media and chronic suppurative lung disease in children could perhaps be more accurately defined as “chronic exposure to over-crowding, tobacco smoke, inadequate nutrition and bacterial respiratory tract colonisation”. Similarly “failure to thrive” might often be described as “failures of family and community structures, supports and function”. Effects on causesAs paediatric doctors at the hospital, we work closely with families, Aboriginal liaison officers, community organisations and even traditional healers. However, I feel we see the causative cycles of the social determinants of Aboriginal child health, yet cannot always avert the outcomes. Just like someone watching the desert heat evaporate the land’s water over several days, I often feel incapable of doing more than merely waiting for the storm to arrive. Chronic ear infections cause endemic conductive hearing loss. The result for many children is developmental, learning and behavioural issues with profound ramifications for schooling, employment prospects, parenting capabilities, their own future children and their communities. We try to encourage and empower adults to mop their children’s suppurating ears regularly to facilitate healing and help antimicrobial ear drops reach the middle ear, but, often, we don’t properly explain why this is important, or there are no tissues available at home, no refrigerator to safely store the antibiotics, or more urgent daily issues arise. The daunting challenges of social disadvantage, disharmony, and physical distance can cause health practitioners to minimise our efforts. Sometimes optimum care is not provided on the basis of assumptions about what families will do when they leave. Rationalisations such as “they are not going to give the medication so why bother” or “they’ll be back with the same problem in a week” are sometimes heard. This can be a result of us not being able to see the children and families we look after in the foreground, with their own unique strengths and weaknesses, existing within and beyond these pervasive problems. Seeing difference, seeing ways through the gapsOur lack of flexibility and our inability to — accommodate difference can potentially perpetuate the health gaps. There are many situations in which the pressures of the ward have limited my time to be patient with a family, listen carefully, or negotiate a treatment plan meaningfully, in order to understand the family’s perspective better and expedite the child’s recovery. I have also found it extremely important always to look for differences between individual Aboriginal children and families to prevent comical gaffes, therapeutic disasters and the spectre of racism. Aboriginality is not homogenous. Alice Springs and central Australian people have a complexity that is at odds with the predictability of the desert heat. If we accept that a fundamental component of racism is generalisation, then we are all caught in its web more than we would like to admit. This can be as simple as me assuming that a very dark skinned Aboriginal mother could speak an Indigenous language, or that her English would be limited. Neither was true and she spent much time articulating her worries about breastfeeding. Language difficulties play a major role in paediatric health gaps in central Australia. So much still seems to be “lost in translation” in the gap between English and the multitude of local Aboriginal languages, and between differing understandings of symptom durations, rationales for treatment and discharge plans. Translators are not available after hours, when clarity is often critical. There are other dimensions. There are well known and beautiful places near and around Alice Springs called “gaps”, where the mountain ranges part to reveal waterholes and jagged red rock facades. These geographical gaps were given names like Heavitree Gap or Emily’s Gap by Anglo-European explorers. They are important dreaming sites for the local Arrernte people. Heavitree Gap is a place where the local traditional owners would formally welcome and accept visiting people onto their lands. For Arrernte people then, talk of closing “gaps”, may have very different meanings from our own. Dr Patricia Miller, a senior Arrernte woman, recalls another elder fearing that someone would literally close Heavitree Gap, thereby preventing people and transport from entering Alice Springs directly. She could not understand why there not been meetings to explain the closure of such a significant cultural place. “Closing the gap” can also have an array of ramifications for different families. For some, it may mean having to bring their children to clinics for a seemingly endless array of needles, whether for vaccinations, antibiotics or iron supplementation. For others, it is about not having to tell three or four different doctors in one day what has happened to their child after being transferred from a remote area, or not having to explain the same thing repeatedly because community and hospital information systems are in silos. For some Aboriginal people, “closing the gap” may mean doctors learning to “speak” to each other better. For one family, “closing the gap” is a hope for a larger home in which 20 people do not have to share two bedrooms, so their child can get some sleep away from noisy adults. For another family living in town, it may be that “closing the gap” means not having their child’s Aboriginal status questioned because of his or her lighter skin colour and mixed descent. Looking and listeningSome of the health gaps and misunderstandings in health care also relate to how, for many Aboriginal people, conceptions of space and time are significantly different to medical thought. The chain of cause and effect, and the ideas that illnesses have names, time courses and scientific reasons for appearing are often not the main paradigms for our patients in central Australia. A grandmother explained to me, with the assistance of an Aboriginal liaison officer, that the reason why her 18-month-old grand-daughter was not eating or growing properly was not because she was still breastfed by her mother and had trouble eating solids, but because the unborn baby her mother was carrying was playing tricks and interfering with its sibling’s eating habits. A few mothers on the ward told me about the changing winds and misplaced internal rocks that had ravaged their children’s bodies. They had taken their children to see the traditional healers before seeing a doctor. One mother, a painter and former Aboriginal liaison officer, told me she struggled with prioritising one form of healing over the other. This mother and her child are just one example of the astounding resilience of children and families in central Australia. Their ability to remain healthy, keep a sense of humour, stay positive and return to the hospital or clinic for a visit is remarkable. It is even more extraordinary considering the harsh environment and limited resources. This resilience needs to be supported and harnessed at all costs. It is critical that we strengthen Aboriginal families by using their unique structures, dynamics, hopes and needs. The challenge, then, is to balance a paediatric perspective with an Aboriginal one. The two are not mutually exclusive. We have to keep our paediatric medical gaze sharp and unprejudiced. An evidence base should be built for treating the unique conditions that are seen in central Australian children. Concurrently, ensuring that national standards of nutritional and child development health are implemented in the region is paramount, as a matter of health equity and human rights. We need to make sure that what we know as “truth” in paediatric medicine is applied equally to children living in remote areas and, at the same time, keep our eyes, ears and hearts open to the varying strengths and needs of each child, carer, family or community. We should listen to what they tell us and be comfortable with the silences. We need to find ways through the gaps from several vantage points, with Aboriginal people leading the way back to their own health.

Marcel D Zimmet MB BS/BA(Hons)

To the Editor: The Australian Government is seeking to reduce Indigenous disadvantage through its “Closing the Gap” strategy.1 One challenge, however, is incomplete identification of Indigenous status in health and administrative data collections and the necessary caution in interpreting statistics because of such underestimates.2-5 For planning, expenditure, access to and equity of health services, governments need to ensure that Indigenous data collections are accurate. A key area of interest is self-reported Indigenous identification in mainstream general practice settings. Research has focused on general practitioners’ perspectives,6 but not those of Indigenous patients. We conducted a qualitative study that explored the views of Indigenous Australians residing in the Australian Capital Territory who were recruited through a range of Indigenous organisations and differed in age, sex and social background. Participants gave written informed consent to face-to-face interviews, in which they were invited to describe their experiences of being asked their Indigenous status in mainstream general practice settings — including their understanding of why people are asked about their Indigenous identity and views on how they should be asked. Of the 28 participants (age range, 18–78 years), 12 were men, 18 were Aboriginal, five were Torres Strait Islander, and five identified as both Aboriginal and Torres Strait Islander. All had used mainstream general practice services in the ACT. Six reported ever having identified as Indigenous in that setting, although it is unclear how many were asked their Indigenous status. Some reported having been mistaken for being either from another country or non-Indigenous. All stated they would identify as Indigenous if asked, but felt it was essential to be provided with information explaining the rationale for the question — in particular, how it would benefit them if they did identify as such. It was suggested that pamphlets or posters explaining the benefits of identifying could create cultural safety. Participants emphasised the need for appropriate training of practice staff on the rationale for asking the identifier question and how to ask it respectfully. Several themes reflecting issues that would influence an individual’s decision to identify as Indigenous emerged: previous racism in the community; the patient–doctor relationship; the perception that discussing identity would lengthen consultation times; practice staff’s assumed motives for asking; and recognition of the culture and diversity of Indigenous Australians (Box). The principal message was that the process for asking needs to be kept brief and simple. An acceptable form of words was agreed by all participants to be: “For the purpose of providing the best care possible, can you please tell me if you are Aboriginal and/or Torres Strait Islander?” This research highlights the need for GPs to “Just ask!” and to ensure that the Indigenous identifier question and explanation are conveyed consistently and appropriately. Further research in other primary care settings could evaluate the approach that we advocate. Aboriginal medical services provide culturally secure services based on Aboriginal preferences.7 Participants in this study have provided guidance on how similarly culturally secure services could be provided in mainstream general practice. Themes identified from interviews with 28 Indigenous respondents about identifying as Indigenous in mainstream general practice Importance of the patient–doctor relationship “I think it is important to start building relationships between medical professionals and Indigenous people, so that Indigenous people can start becoming more informed about their health and be more proactive in managing it more.” Rationale for asking about Indigenous identity “. . . I can understand why a mainstream service would see if a person wants to identify or not so that they can get those Medicare items. So it needs to be done without someone getting offended. I know that I would be offended if it was done in a mainstream area and a big deal made of just for the money. It’s how you portray it to the Indigenous person so that they don’t get offended.” Creating cultural safety in general practice “When you see posters and pamphlets and information then you think, ‘Oh, so maybe this surgery is OK’. You’re more comfortable in coming back and volunteering information. It is all about creating an environment that enables that.” Mistaken identities of Aboriginal and Torres Strait Islanders “Some of them have asked if I was from PNG [Papua New Guinea], and um [I’m] . . . not really a Torres Strait Islander, I don’t know, it must be my features. They naturally assume that I am from PNG.” Who should ask the question? “I think the doctor. Because then they get an idea of your background and . . . it gives them a good idea of where you come from and what sort of illnesses are around the place.” Just ask! “I love who I am, I don’t mind saying where I’m from.”

Angela Scotney · Jillian A Guthrie · Kamalini Lokuge · Paul M Kelly

New directions and prospects in Aboriginal and Torres Strait Islander health research The NHMRC Road Map II: a strategic framework for improving the health of Aboriginal and Torres Strait Islander People through research (“Road Map II”) will shortly be available from the National Health and Medical Research Council (NHMRC) website and in published form. This editorial outlines new NHMRC activities for research in Aboriginal and Torres Strait Islander health. The NHMRC Road Map: a strategic framework for improving Aboriginal and Torres Strait Islander health through research (“Road Map”) has been the NHMRC’s policy framework for Aboriginal and Torres Strait Islander health, ethics and advice since 2003. During the 2006–2009 triennium, the NHMRC Aboriginal and Torres Strait Islander Health and Research Advisory Committee planned and conducted a national consultation process to evaluate the impact of the Road Map and its accompanying capacity-building activities. The evaluation process included a series of workshops held in Sydney, Melbourne, Perth, Alice Springs and Townsville, a written submission process, and an evaluation of NHMRC 2000–2007 funding data. In response to outcomes from the evaluation, the Aboriginal and Torres Strait Islander Health and Research Advisory Committee recommended that the NHMRC develop an implementation framework and communication strategy for its activities in Aboriginal health. In supporting these recommendations, the NHMRC also supported the Aboriginal and Torres Strait Islander Health and Research Advisory Committee to develop Road Map II. Key features of Road Map IIRoad Map II has seven “action areas” for research, developed in response to the Road Map review and targeted consultation in 2009 with peak national Aboriginal and Torres Strait Islander representative bodies.1 These action areas will be implemented through regular consultation and negotiation with stakeholders, a triennial action plan for NHMRC activities in Aboriginal and Torres Strait Islander health supported in the NHMRC triennial strategic plan, and advice from the NHMRC Aboriginal and Torres Strait Islander Health Advisory Committee. The first action area — improving the participation of Aboriginal and Torres Strait Islander people in NHMRC programs — targets recruitment, participation and retention of Aboriginal and Torres Strait Islander people in all biomedical, clinical, public health, and health services research into Aboriginal and Torres Strait Islander health. The second action area — capacity exchange — increases the focus on evidence translation activities. Avenues for capacity exchange will be identified in the workforce, professional and information capacity-building activities that were strategically successful aspects of the Road Map research framework. The third action area — promotion of the NHMRC’s role in Aboriginal and Torres Strait Islander health — is aimed at research partnerships and collaborations with Aboriginal and Torres Strait Islander communities. The NHMRC is developing a communication strategy for Road Map II research in this action area that will include podcasts and showcasing research and evidence transfer activities. These activities are aimed at supporting the research networks that are integral to the four remaining research action areas: collaborative research to support the Close the Gap campaign activities, evaluation research highlighting clinical outcomes and evidence gaps, intervention research to sustain health gains, and targeted calls for research. The NHMRC’s new peer review policy for Aboriginal and Torres Strait Islander health research is also pivotal. New peer review policy in Aboriginal and Torres Strait Islander health researchIn 2009, the NHMRC introduced a new policy for peer review in Aboriginal and Torres Strait Islander health research. The new policy takes account of all research-related activities that an Aboriginal or Torres Strait Islander funding applicant has been involved in, and includes these as part of that applicant’s research “track record”. The new policy is intended to facilitate research opportunities for applicants with high levels of experience or long-standing involvement in Aboriginal and Torres Strait Islander health fields. It is aimed at supporting capacity exchange and capacity building in Aboriginal and Torres Strait Islander health research. Other NHMRC supportIn 2009–2012, the NHMRC will also support a study exchange program for established researchers in Aboriginal and Torres Strait Islander health. Activities supported may include participation in clinical exchanges and placements, and speaking at international events. Priority will continue to be given to research projects about interdisciplinary intervention, social interactions, role conflicts, social control, life stress, social integration, family interactions, and institutional settings that have relevance to clinical, public and health services. The NHMRC, Health Research Council of New Zealand and Canadian Institutes of Health Research have formed the International Collaborative Indigenous Health Research Partnership. In 2009, Partnership grants supported projects investigating health literacy among Indigenous people living with cardiovascular disease, and their families and health care providers; reduction of chronic dental disease in early childhood; and how professional health education can reduce disparities in chronic disease care.2 In all funded research, the NHMRC document Values and ethics — guidelines for ethical conduct in Aboriginal and Torres Strait Islander health research3 continues to have a major influence on national and international collaborations with researchers in Indigenous health. Evidence that can be translated into policy and practice is in short supply in this area, and research must be appropriate for use in Indigenous communities. Finally, evidence and evaluation of experience and outcomes with current government interventions need to be linked, so that policy and practice continue to improve. Prospects for Aboriginal and Torres Strait Islander health researchAboriginal and Torres Strait Islander researchers and communities have made significant investments in NHMRC research and research-related resources. In the Road Map II research framework, prospects for Aboriginal and Torres Strait Islander researchers are linked to the NHMRC’s success in engaging with Aboriginal and Torres Strait Islander communities. In turn, health gain in communities is linked to effective research. These relationships have been highlighted for many years and, in highlighting them again now, people working in the NHMRC, research communities and the broader health sector are urged to participate in mentoring affiliations that support Aboriginal and Torres Strait Islander health researchers. We continue to support the capacity-building activities and new peer review processes that are working well for Aboriginal and Torres Strait Islander researchers, and it is our sincere aim that, with support from all stakeholders, Road Map II and its accompanying capacity-building activities will lead to health gain in Aboriginal and Torres Strait Islander communities.

Warwick P Anderson AM

Objective: To identify policy strategies that are perceived by researchers active in Aboriginal and Torres Strait Islander health as effective in increasing the amount of high-quality intervention research undertaken in this field.Design and setting: A cross-sectional study using a web-based survey was emailed to researchers based in clinical, public health and other academic institutions.Participants: Researchers who had published more than once in Aboriginal health between 1 January 2005 and 1 August 2009, based on a MEDLINE search.Main outcome measures: Participants selected and weighted 17 strategies that were, in their opinion, important for increasing the amount of high-quality intervention research being conducted in Aboriginal health.Results: We invited 157 researchers to complete the survey, and received 74 completed surveys. The most highly weighted strategies were: for research funding bodies to give funding priority to intervention research proposals that target Aboriginal populations (median weighted score,15%); for peak bodies representing Aboriginal communities to clearly specify intervention research priorities in a national Aboriginal health research agenda (median weighted score, 10%); for research funding bodies to fund research to develop reliable measures of health for Aboriginal people (median weighted score, 9.5%); for health care organisations to participate more in intervention research targeting Aboriginal populations (median, 8.5%); and for research review panels to accept intervention research designs other than the randomised controlled trial (median weighted score, 8%).Conclusions: Researchers who are active in Aboriginal health research perceive that improvements in funding mechanisms, priority setting and research systems are required to increase the amount of high-quality intervention research being conducted in this field. A national intervention research agenda that encourages multidisciplinary research teams and community partnerships may offer a solution.

Jessica M Stewart BA/LLB, MPS · Rob W Sanson-Fisher PhD · Sandra J Eades MB, PhD · Nicole M Mealing BSc(Adv Maths)

Objective: To describe the impact of pandemic (H1N1) 2009 influenza (nH1N1) on Indigenous people in the Top End of the Northern Territory at community, hospital and intensive care unit (ICU) levels. Design, setting and participants: We analysed influenza notifications for the Top End from 1 June to 31 August 2009, as well as data on patients admitted through Top End emergency departments with an influenza-like illness. In addition, data on patients with nH1N1 who were admitted to Royal Darwin Hospital (RDH) and the RDH ICU were prospectively collected and analysed.Main outcome measures: Age-adjusted notification rates for nH1N1 cases, Top End hospital admission rates for patients with nH1N1 and RDH ICU admission rates for patients with nH1N1, stratified by Indigenous status.Results: There were 918 nH1N1 notifications during the study period. The age-adjusted hospital admission rate for nH1N1 was 82 per 100 000 (95% CI, 68–95) estimated resident population (ERP) overall, with a markedly higher rate in the Indigenous population compared with the non-Indigenous population (269 per 100 000 versus 29 per 100 000 ERP; adjusted incidence rate ratio, 12 [95% CI, 7.8–18]). Independent predictors of ICU admission compared with hospitalisation were hypoxia (adjusted odds ratio [aOR], 4.5; CI, 1.5–13.1) and chest x-ray infiltrates (aOR, 4.3; CI, 1.5–12.6) on hospital admission.Conclusions: Pandemic (H1N1) 2009 influenza had a disproportionate impact on Indigenous Australians in the Top End, with hospitalisation rates higher than those reported elsewhere in Australia and overseas. These findings have implications for planning hospital and ICU capacity during an influenza pandemic in regions with large Indigenous populations. They also confirm the need to improve health and living circumstances and to prioritise vaccination in this population.

Shaun M Flint MB BS, BSc, FRACP · Joshua S Davis MB BS, DTM · Jiunn-Yih Su MB, MPH · Erin P Oliver-Landry MB BS, BSc · Benjamin A Rogers MB BS, FRACP · Aaron Goldstein MB BS · Jane H Thomas BN, GradDipPH · Uma Parameswaran MB BS · Colin Bigham MB BS, MRCP, FRCA · Kevin Freeman BSc · Paul Goldrick FCICM, FANZCA, FFARCSI · Steven Y C Tong MB BS, FRACP

To the Editor: Aboriginal and Torres Strait Islander people were more at risk of hospitalisation, admission to intensive care units and death during the 2009 influenza A pandemic than non-Indigenous Australians.1 We conducted a descriptive analysis of our response to the pandemic at Winnunga Nimmityjah Aboriginal Health Service (Winnunga) — an Aboriginal community controlled health service in Canberra, Australian Capital Territory, which provides comprehensive primary health care to more than 3500 patients per year. Data were sourced from the Winnunga electronic patient record system, pathology laboratories and ACT Health. The Winnunga Board approved this analysis and report for publication. In May 2009, we implemented the pre-existing Winnunga influenza pandemic plan, working closely with ACT Health and the ACT Division of General Practice. We enhanced infection control, implemented influenza testing procedures, initiated electronic data collection and obtained oseltamivir from the ACT stockpile to dispense on site. We adapted ACT Health pandemic protocols to create a flow chart appropriate for Winnunga, with approval from the ACT Chief Health Officer. This involved using clinical discretion to decide whether to dispense oseltamivir to Aboriginal and Torres Strait Islander people with mild illness, and included the provision to supply prophylactic oseltamivir to high-risk household contacts, especially in overcrowded households. A plan was made to open an on-site influenza clinic, but this was not necessary. Increased testing for influenza commenced in late May. The first patient with pandemic (H1N1) 2009 influenza was identified on 1 July (Box). Of the 168 nasal swabs tested for influenza by polymerase chain reaction analysis, 52 (31%) were positive for pandemic (H1N1) 2009 influenza. In addition, six Winnunga patients tested positive at other locations. In late July, testing guidelines changed and laboratory testing was no longer recommended for most patients with influenza-like illness.2 Consequently, we did not identify test-positive cases past the beginning of August. The actual number of cases of pandemic influenza that occurred in Winnunga patients is unknown. Of the 58 patients who tested positive, 54 were Aboriginal and/or Torres Strait Islander, 28 were male, and 47 were ACT residents. The mean age was 22 years (range, 0–62 years), 31 patients were aged under 20 years and four patients were pregnant. There was one overnight hospitalisation. During July, Winnunga accounted for 8% (44/551) of all notified pandemic influenza cases in the ACT — more than expected based on patient numbers alone. However, more testing may have been done at Winnunga than at other organisations because of our high-risk population. In July and August, 13% (204/1604) of all presenting patients at Winnunga had an influenza-like illness. There were 229 recorded episodes of influenza-like illness between May and November with a sharp peak in July and a smaller peak in August (Box). Oseltamivir dispensing commenced 1 week before identification of the first patient who tested positive, and corresponded with episodes of influenza-like illness (Box). A total of 107 courses of oseltamivir were dispensed to 33 children and 74 adults. Clinical risk factors other than Aboriginal and Torres Strait Islander status were recorded for 47 of these patients. Oseltamivir dispensed to Winnunga patients at other locations was not included in our analysis. We do not know whether oseltamivir made a difference in reducing severity of disease or preventing hospitalisations in our patients. During July and August 2009, pandemic influenza created an increased workload at Winnunga. Although there were some staff absences due to pandemic influenza, these were short and did not significantly affect clinical functions. Pandemic influenza in patients was also not as severe as planned for. A more severe pandemic would place a significant burden on our already busy Aboriginal medical service. A pre-existing influenza pandemic plan, internal public health capacity, good working relationships with local health agencies, on-site dispensing and service-specific protocols were important features of our response to the 2009 pandemic. Vaccination for influenza is being strongly promoted at Winnunga in 2010. Influenza-like illness, influenza testing, tests positive for pandemic (H1N1) 2009 influenza, and courses of oseltamivir dispensed at Winnunga Nimmityjah Aboriginal Health Service, May to November 2009

Ana Herceg · Peter G Sharp · Christine G Arthur · Julie A Tongs

The politics of suffering. Indigenous Australia and the end of liberal consensus. Peter Sutton. Melbourne: Melbourne University Press, 2009 (xii + 268 pp). ISBN 978 0 522 85636 1. Have you spent a day or three in a sweltering clinic in a remote Aboriginal community in northern Australia? No? Then read this book, for you will learn why the appalling state of Aboriginal health heads the list of national moral and political challenges. It may encourage you to fill the second gap, that between rhetoric and action, needed to “close the gap” (in health and life expectancy between Indigenous and non-Indigenous Australians). Sutton’s polemic is a cri de coeur from a true warrior. From the early 1970s, his academic interest in Indigenous language and sacred art led to a life-long deep engagement with the Wik people, and to a role in negotiations that have led to landmark political achievements. In the first chapters, he urges a critical re-analysis of causality beyond that of systematic oppression. He argues that more recent dislocations have stressed beyond tolerance the tension between the conflicting imperatives towards modernity versus traditional social values, and that these are relevant in accounting for the endemic domestic violence, alcohol abuse, and ill-health in remote communities. Halfway through the tone mellows, and the reader is treated to a series of charming vignettes of “Unusual Couples”; stories of deep black–white friendships in the landscape of Indigenous history. These lead into his final chapter, “On feeling reconciled”, where we are challenged to confront our own moral thought patterns: Is collective reconciliation about the politics of appeasement? Are our notions of apology and reconciliation, based on European moral and intellectual traditions, compatible with an Aboriginal morality forged over 60 000 years in this land? Sutton navigates us through this moral maze to the conclusion that reconciliation is a personal experience. This fits with what an Aboriginal writer told me in my own searching: “You change one heart at a time.” Sutton’s book should open many hearts to being changed, one at a time.

John Boulton