Volume 194 Issue 10

Aboriginal and Torres Strait Islander doctors walking in both worlds for the benefit of all Australians In 1983, this country saw a major milestone — for the first time, an Aboriginal Australian graduated from an Australian medical school. This, however, was about 100 years after the graduation of the first Maori, Native American and Aboriginal Canadian medical students.1 In the following decade, only seven other Indigenous Australians would graduate. We have had enormous ground to cover and obstacles and system barriers to overcome in the 28 years since Professor Helen Milroy’s graduation. It is with great pride that I can now say that there are over 150 Aboriginal and Torres Strait Islander medical graduates and almost 170 Aboriginal and Torres Strait Islander medical students.2 There is still much work to be done. With the increasing overall numbers of students entering medical training, we need to ensure that the gap between Aboriginal and Torres Strait Islander students as a proportion of all students and non-Indigenous people undergoing medical education and training narrows, not widens. It is timely that, while the Australian Government’s focus is on the imperative to close the gap in life expectancy between Aboriginal and Torres Strait Islander people and other Australians within a generation, we are beginning to hold in our sights the second generation of Aboriginal and Torres Strait Islander doctors. The Aboriginal and Torres Strait Islander doctor profile is not dissimilar to the Indigenous population profile. There are few medical elders; a limited number of Fellows of Australian medical colleges; most of our doctors are in junior years and training programs; and growing numbers in medical schools. A continuing challenge is to improve school retention rates so that more young Aboriginal and Torres Strait Islander people complete Year 12 and have the prerequisite skills to enter medicine. Work on pathways for our people into medical specialties is also important. Building on the Australian Indigenous Doctors’ Association’s (AIDA’s) successful collaboration with Medical Deans Australia and New Zealand, we now have a set of priority areas for action in cooperation with the Confederation of Postgraduate Medical Education Councils,3 and have also committed to collaborate with the Committee of Presidents of Medical Colleges.3 This level of collaboration along the entire medical and education and training continuum is unprecedented. Further, I am bolstered by the level of concrete action by individual medical colleges. No fewer than nine colleges contributed to the annual AIDA Symposium held in Launceston, Tasmania last year, through provision of sponsorship, information and personnel. This is important both for AIDA members and for the colleges as they seek to improve Aboriginal and Torres Strait Islander health and engage with the Indigenous health workforce. A workshop run by the Royal Australasian College of Surgeons, which included a mobile surgical simulation van that travelled from Sydney, is an exemplar of ways in which colleges might work with AIDA in the future. A large proportion of the current cohort of Indigenous medical students have commenced their studies directly from school, in contrast to many earlier Indigenous doctors who started medical studies after other careers when they already carried responsibilities as parents, community members and leaders. Despite this shift, demands related to family, the Indigenous community and the wider community continue to be disproportionately high for Aboriginal and Torres Strait Islander doctors, and I anticipate that this will be the case for many years to come. There is often an expectation that, when still relatively junior in their clinical and professional lives, these doctors will take up policy, advocacy, representational and community leadership roles. This frequently occurs within the context of their own communities and families living under stress and with extremely poor health, and a congested and changing policy landscape, and while they also need to be servicing their own clinical and professional development requirements. With the expiry of the current National Strategic Framework for Aboriginal and Torres Strait Islander Health in 2013,4 there will be a new Aboriginal and Torres Strait Islander health plan. Aboriginal and Torres Strait Islander doctors will continue to advocate for the plan to be developed and conducted through genuine partnerships between governments and Indigenous organisations, not only because such an approach is consistent with what is contained in the United Nations Declaration on the Rights of Indigenous Peoples,5 but because it makes good sense. It will only be through genuine partnership, including mutual respect, proper negotiation with Aboriginal and Torres Strait Islander people and shared decision making, that collective ownership by all parties will be secured. Health workforce will be an important feature of any new plan. AIDA recognises that having an inadequate workforce to deliver high-quality, sustainable health services for Indigenous people is a real problem, and continues to push for more Aboriginal and Torres Strait Islander health professionals across the board. As Australian political leaders point to a need to support employment,6 it makes economic sense to attract more Indigenous health professionals into the growth area of health care, with multiple flow-on benefits. In some way, every Indigenous doctor is working to improve the health of Indigenous people, whether by leading national policy debates or working at the family or community level. Every contribution is important. The statement “I am an Aboriginal or Torres Strait Islander doctor, not a doctor who is Aboriginal or Torres Strait Islander” holds true for us all; it speaks to the central issue of identity and the primacy of our Indigenous identities being a strength to our practice of medicine. To quote Professor Helen Milroy, now Director and Winthrop Professor at the Centre for Aboriginal Medical and Dental Health, University of Western Australia: Part of the reason why Indigenous doctors are so important is because they can walk in both worlds, bridging an Indigenous knowledge base with a Western one. There is increasing focus on needing more than just an “evidence” base for best practice. Including other knowledge systems and experiences to develop a system of “wise” practice is required in order to close the gap. We are translators, and without translation, we have confusion (personal communication, April 2011). But of course, we need a workforce of Aboriginal and Torres Strait Islander people working in health — not only Aboriginal and Torres Strait Islander health but the whole of the health system — as well as a workforce of all people working specifically to tackle the disparity in outcomes between Indigenous and non-Indigenous Australians. This is where our profession, the community of medicine, can lead the way. The health of Aboriginal and Torres Strait Islander people must be a priority for all doctors — not simply because “close the gap” is a part of the contemporary health lexicon, and a Council of Australian Governments priority, but because of much more. This is about our fundamental roles and responsibilities as doctors — we must advocate to end the glaring inequity and differential health outcomes between our first peoples and other Australians. Having Aboriginal and Torres Strait Islander people practising medicine will benefit all Australians, as a comprehensive approach to patient care is a must for achieving better health outcomes for Aboriginal and Torres Strait Islander people. Such an approach is client- or patient-centred while being strongly guided by the family and community context; it prioritises partnership and joint ownership; and it takes into account cultural, spiritual and clinical aspects of health. We need look no further than the achievement of Aboriginal general practitioner and 2011 Australian of the Year finalist Associate Professor Noel Hayman in establishing the Inala Indigenous Health Service in Brisbane, Queensland, to see the results of such an approach. Over a 15-year period, the service grew from having 12 Indigenous patients to providing comprehensive primary health care and public health programs to over 3000.7 Many of the 150 Aboriginal and Torres Strait Islander community-controlled health services across the country have had similar success. The theme of the AIDA Symposium in Broome in October this year is “Our doctors making a difference”. I hope interested colleagues will be able to join us to hear about the work being undertaken by the current generation of Aboriginal and Torres Strait Islander medical students and doctors. I also hope that our non-Indigenous colleagues will join with us in making a real difference for our people.

Peter O’Mara BMed, FRACGP, FARGP

To what extent should we cushion the realities of remote area living for young people who are seeking challenge and inspiration? There is some evidence that exposure to good learning opportunities in rural and remote areas will influence medical students to more strongly favour rural or remote careers.1-3 Recognising the potential for this outcome, a cadre of academics and rural clinicians began a program of planning and lobbying universities and governments more than two decades ago. As a result, there has been a significant growth in rural and remote teaching facilities, with the development of rural clinical schools (RCSs) and university departments of rural health (UDRHs).4,5 The process of establishing and maintaining facilities for rural and remote medical education has required sustained effort from rural and remote educators, with the political will to undertake the programs often seeming more subject to whimsy than good planning. There have also been numerous practical challenges, some of which are reflected in the adverse student experiences outlined by Patel and colleagues in this issue of the Journal (→ Safeguard or mollycoddle? An exploratory study describing potentially harmful incidents during medical student placements in Aboriginal communities in Central Australia).6 Their findings raise genuine concerns about the adequacy of clinical supervision and organisation for remote area placements, but also provide an opportunity to consider what we expect our students to bring to, and take away from, the remote area experience. Establishing a remote area educational facility requires a holistic approach to the needs of both the student and the community. In large metropolitan centres, universities can concentrate their efforts on delivering quality education to students, while the students bear responsibility for their own domestic needs such as housing, transport, nutrition and socialisation. This is generally not the case for remote units where, as well as considering the quality of education, it is often necessary to make provision for these basic needs. This has created some unforeseen challenges. With housing, for instance, federal grants were used to build new accommodation for the remote units from the late 1990s but, 10 years down the track, it became apparent that there had been no allocation of funds for their upkeep. Communications infrastructure was also in need of upgrading, as internet-based educational resources from the mother universities are not always effective when carried through the old copper wiring on the other side of the black stump. Few vice-chancellors would concern themselves with wondering if their students have access to good sanitation, clean running water, reasonably priced food, and safe areas for social activities, but these have been the day-to-day concerns of the directors of the UDRHs and RCSs. It also seems that many of the students arrive from their mother universities with little warning that, in a remote community, $10 for a head of lettuce can be a bit of a bargain — or of many of the other realities of remote life that await them. Transport is another challenge. While the sandstone universities can reasonably expect their students to avail themselves of the many and varied public transport options to travel from their housing to their place of training, remote area units often have to bear this responsibility and expense themselves. This is in addition to the vast distances that may need to be travelled to reach the remote education centre. For example, the distance from Brisbane to Queensland’s UDRH at Mount Isa is about 1600 km (about the same distance as from Brisbane to Adelaide, or Adelaide to Mount Isa). Once students arrive in Mount Isa, they will then spend some time in one of the outlying centres, which could be Boulia (300 km by road), Mornington Island (460 km by air) or Longreach (660 km by road). Students’ experiences of clinical placements are highly influenced by their teachers and supervisors, as well as the location of the placement.7 In remote areas, teaching and supervision are likely to be delivered by a specific individual. We have managed to acquire gifted teachers in a number of remote areas, and universities have sought to support these teachers, in addition to developing the next generation of teachers, with various graduate certificates and masters degrees now available in medical education. However, putting infrastructure in place, only to have the pivotal individual subsequently leave the area, creates enormous difficulties in placing the student load. Along with these kinds of practicalities, the article by Patel and colleagues raises a philosophical quandary for remote educators and medical schools. To what extent do we wish for the students to experience the joys of remote education without the sorrows of remote area living? We celebrate the courage of folks who try their luck at bungee jumping but, when the rope breaks, we are outraged that the proprietor had the audacity to place patrons at risk. We also forget that bungee jumping did not start as a middle-class pastime, but as a sacred rite of passage for the young men of Pentecost Island.8 The rope was a vine, and it was not purchased and tested by the jump-tower proprietor, but selected, cut and self-attached by the jumper. When a vine snapped and injury or death ensued, there were no lawsuits against the Great Spirit for creating an inferior-quality vine. A rite of passage that has no risk to the initiate is no longer a rite of passage; it is simply an amusement park ride. How much of a genuine disincentive are the risks of the rite of passage to the young person endeavouring to express independence and explore his or her courage and endurance? The primary goal of the UDRHs and RCSs is to increase the rural health workforce. However, there are also benefits for students who choose not to return to the bush. These students will have had their consciousness raised to the idea that working as a rural health practitioner can be a challenging and rewarding career option, and will have acquired a better appreciation of the circumstances and environment in which their rural counterparts need to deliver health care — and of course to where their rural patients will return after receiving tertiary care in the city. Audits such as that done by Patel and colleagues are important tools to improve the quality and safety of students’ experiences in remote communities. But there is a danger that, in focusing only on possible harms, we underestimate the power of difficult circumstances to enhance the very attributes that are required for the long haul in rural and remote practice. When one of us (L G P) worked as a medical educator at the Mount Isa RCS, there was a background assumption that the young people coming to the school were so fickle that allowing them to experience the realities of remote area living would ensure that they never returned. This, however, has not been our anecdotal experience of this generation of caring, compassionate and committed health professionals. Nor is it borne out in the early data from James Cook University School of Medicine, which appear to demonstrate the successful ruralisation of the school’s students, and a larger proportion choosing rural careers.9 Rising to the political and practical challenges of educating medical students in the bush has seemingly been worth the struggle. A lack of trust on the part of older generations in the commitment and good intentions of young people would appear to be as old as the species itself. However, as Edmund Burke noted in a letter to Frances Burney after reading her novel Cecilia, “The arrogance of age must submit to be taught by youth”.10

Louis G Peachey BMed, FACRRM · Kristin E McBain-Rigg BSocSc(Hons)(Anthropology), AAS

Objective: To assess the number and characteristics of potentially harmful incidents occurring during placement of medical students in remote Aboriginal communities in the Northern Territory.Design, participants and setting: A retrospective audit of medical students’ files from Northern Territory General Practice Education placements in Central Australia for the period from January 2006 to December 2007.Main outcome measures: Number and type of potentially harmful incidents.Results: A total of 163 placements were undertaken. Of these, 98 (60%) had adequate documentation to determine whether an incident had occurred. There were 28 cases (17%) where potentially harmful incidents were judged to have occurred. Most incidents fell under several descriptive categories, but clinical supervision, professional practice and administrative issues were most common.Conclusions: One in six students experienced a potentially harmful incident during remote area placement in 2006–2007. While acknowledging the exploratory nature of this investigation and the major educational benefits that clearly arise from these placements, our findings indicate problems with clinical supervision and administration.

Ameeta Patel MB BS(Hons), FRACGP, DRANZCOG · Peter Underwood MD, FRACGP, MRCP · Hung The Nguyen MB BS, FRACGP, MPH · Margaret Vigants RN, BNBAS

Respect, tolerance and trust in Aboriginal and Torres Strait Islander people are needed from government to improve the health and wellbeing of Indigenous Australians Reflecting back over 30 years of working in Indigenous health, I think that it has been a time of change rather than improvement. This is not to say that some improvements have not occurred. No longer do I see children dying of gastroenteritis and pneumonia. Instead, young men are dying of heart disease, diabetes is prevalent, and so many young people are smoking. But even this is not totally bad news; the life-expectancy gap between Indigenous and non-Indigenous Australians narrowed from about 17 years for both males and females between 1996 and 20011 to 11.5 years for males and 9.7 years for females between 2005 and 2007.2 However, we are doing very badly at the level of social determinants — the foundations of how we arrange society, which determines the health and wellbeing of people. Despite commitments from individual bureaucrats and politicians over the years, in the main, both parliamentary parties seem to ignore the fundamental lesson — that social and individual health is founded on wellbeing, and wellbeing is grounded in the respect given to people, and the control afforded to them, in their daily lives.3,4 Two cases illustrate this. In 2007, the Northern Territory Emergency Response (the “Intervention”) was perpetrated on Aboriginal people in the NT, and in doing this the Racial Discrimination Act 1975 (Cwlth) was waived.5 Further, this approach bypassed the Aboriginal leadership, undermining their sense of control over their communities and destiny. It overtook and failed to acknowledge progress that was already being made by Aboriginal health services.6 The psychological and emotional effects of this are not negated by the later increase in consultation and improvements in health service funding that have occurred. The second case is the public “law and order” response to current social disruption in Alice Springs by the dominant section of the town’s society,7 which both ignores the complexities of the situation and reinforces the stereotypes about Aboriginal people to the wider Australian society and to Aboriginal people themselves. In turn, this intolerance fuels more substance misuse and more violence, as the oppressed take out their negative emotions on each other and, where they can, the oppressors.8 I use this blunt language deliberately, to emphasise the nature of the conflicts and the social construction that are the foundational causes of the gap between Indigenous and non-Indigenous Australian health that we are attempting to close. Until, as a nation, we can have the conversation at this level, to understand how the social and political situations of Aboriginal people drive their ill health, we are only tinkering at the clinical level. Clinical services, while essential, are not of themselves sufficient. Dr Richard Denniss, executive director of the Australia Institute, speaking at the Fenner Conference 2010 at the Australian National University, asked the audience to list reasons why Indigenous health is not improving and why governments are not responding to climate change despite the evidence. After a series of expected answers, he responded by postulating that it is actually because governments don’t want to. When you look at the NT Intervention, at gun control measures after the Port Arthur massacre, or at military operations in Iraq and Afghanistan, some of which were unpopular actions, one has to agree that when governments decide to act, they do so. The idea that they don’t act because they don’t want to then carries some weight. However, inaction is not necessarily total. The National Aboriginal Health Strategy in the 1990s is an example. The original strategy required funding in the order of $2.5 billion to implement, but only received around $232 million over 5 years. It looked good. Then, when reviewed, people were amazed that it hadn’t worked.9 I contend that if governments are serious about “closing the gap”, adequate funding is one essential component. The other major component is working with Aboriginal leadership in the spirit of a true partnership. In three decades of working in Indigenous affairs, it is not a lack of willing Indigenous leadership that I have noticed. It is a lack of respect for and trust in that leadership by Australian governments. Respect, tolerance and trust in Aboriginal people has to be led from the top. I am not saying that Indigenous leadership is more capable than non-Indigenous government leadership; but it is not less. I’m not saying that Indigenous people have no responsibility for their own situation, but responsibility is what Indigenous leadership has been demanding — along with the respect and resources to shoulder that responsibility. I’m not saying that Indigenous leadership has all the answers; but nor do Australian governments. But in broad terms, we do know what to do. There are mechanisms in place to face the challenge: for example, the National Congress of Australia’s First Peoples, established in 2010 to be a national representative body for Aboriginal and Torres Strait Islander interests.10 Paul Keating’s 1992 Redfern Speech opened the door;11 Kevin Rudd’s 2008 Parliamentary Apology to the Stolen Generations12 stepped through it. We need to pick up again so that in another two decades we are not reflecting on more change but no real progress. Disclaimer The views represented in this article are not necessarily those of the Central Australian Aboriginal Congress.

Peter W Tait MB BS, FRACGP

Objective: To document rates of serious injuries in relation to government alcohol restrictions in remote Australian Indigenous communities.Design and setting: An ecological study using Royal Flying Doctor Service injury retrieval data, before and after changes in legal access to alcohol in four remote Australian Indigenous communities, Queensland, 1 January 1996 – 31 July 2010.Main outcome measures: Changes in rates of aeromedical retrievals for serious injury, and proportion of retrievals for serious injury, before and after alcohol restrictions.Results: After alcohol restrictions were introduced in 2002–2003, retrieval rates for serious injury dropped initially, and then increased in the 2 years before further restrictions in 2008 (average increase, 2.34 per 1000 per year). This trend reversed in the 2 years after the 2008 restrictions (average decrease, 7.97 per 1000 per year). There was a statistically significant decreasing time trend in serious-injury retrieval rates in each of the four communities for the period 2 years before the 2002–2003 restrictions, 2 years before the 2008 restrictions, and the final 2 years of observations (2009–2010) (P < 0.001 for all four communities combined). Overall, serious-injury retrieval rates dropped from 30 per 1000 in 2008 to 14 per 1000 in 2010, and the proportions of serious-injury retrievals decreased significantly for all four communities.Conclusion: The absolute and the proportional rates of serious-injury retrievals fell significantly as government restrictions on legal access to alcohol increased; they are now at their lowest recorded level in 15 years.

Stephen A Margolis MB BS, MD, FACRRM · Valmae A Ypinazar BEd(Hons), PhD · Reinhold Muller MInf, MS, PhD · Alan Clough PhD

Supply-reduction measures play a vital role in combating the devastating toll of excessive alcohol consumption in Australian Indigenous communities.1 The study by Margolis and colleagues in this issue of the Journal shows an association between increasing alcohol restrictions and falling rates of serious injury in Aboriginal communities in Cape York, Queensland.2 As the authors acknowledge, their study does not address possible unintended consequences, such as substitution of other drugs (especially marijuana) or displacement of drinkers to places where alcohol is available. Nor does it examine the important issue of the degree of local support for the restrictions. The article seems to imply that the restrictions were initiated by local community justice groups and promulgated by various agencies of the Queensland Government. My understanding is that the process was rather different. In 2002, in response to a government-commissioned inquiry into substance misuse and violence in Cape York Indigenous communities, conducted by Justice Tony Fitzgerald, the government committed to introducing restrictions on alcohol availability throughout the Indigenous communities.3 These changes were to be implemented in consultation with communities and, to that extent, the community justice groups and other voices were heeded. But the government insisted from the outset that restrictions of some sort must take effect, and set boundaries defining what it would and would not accept. In doing so, the government was giving effect to an important policy shift with regard to alcohol consumption by Indigenous people, the implications of which are still being worked through today. Put simply, the shift represents an abandonment of a rights-based approach (under which, after decades of prohibition, Indigenous Australians enjoy formal equality with other citizens with respect to alcohol) towards an approach in which governments are increasingly willing to exercise discriminatory powers to restrict Indigenous people’s access to alcohol. This change is in response to confronting evidence of the damage and suffering wrought in Indigenous communities by excessive alcohol consumption. Fitzgerald himself foreshadowed this shift in his 2001 report. In his view, the consequences of alcohol misuse were so pervasive that “despite constitutional obstacles, unless significant improvement is reported within three years consideration should be given to a prohibition on the supply and consumption of alcohol”.4 In adopting this stance, Fitzgerald was influenced by two leading Aboriginal thinkers: Noel Pearson, Director, Cape York Institute for Policy and Leadership; and Marcia Langton, Professor of Anthropology, University of Melbourne, who assisted Fitzgerald in his inquiry. More recently and dramatically, a similar shift informed the Northern Territory Emergency Response (NTER) imposed on NT Indigenous communities in 2007 in the final months of the Howard government, and substantially retained by the Rudd and Gillard governments. The NTER included a blanket ban on possession or consumption of alcohol on all Aboriginal land in the NT. Introducing the measures into parliament, the then Minister for Indigenous Affairs, Mal Brough, was unapologetic about curtailing Aboriginal drinking rights: “When it comes to a choice between a person’s right to drink and a child’s right to be safe, there is no question in my mind which path we must take”.5 As the anthropologist Peter Sutton noted, these policy shifts are part of a broader rethink in Aboriginal policy. The rights-based policy consensus that emerged in the 1970s in the wake of the assimilationist era, with its faith in the transformative powers of self-determination and Indigenous cultures, has been eroded by the sheer weight of evidence of worsening violence, disease and poverty.6 The continuing intensity of debate around Aboriginal policy in general, and the NTER in particular, shows that, to date, no new policy consensus has emerged to take its place. In the meantime, however, pressing questions require answers. An especially relevant one here is: after restrictions on alcohol availability, what next? One of the lessons that emerges, not only from Cape York but from other studies of local alcohol management plans,7,8 is that governments that are willing to change regulations governing the sale of alcohol are much less energetic when it comes to finding the resources for, say, treatment and rehabilitation centres or other interventions. This is hardly surprising: it costs almost nothing to amend regulations, whereas most of the treatment options for alcohol misuse are expensive, difficult to staff (at least, in regional and remote settings) and of dubious effectiveness. Any moves to a more top-down approach also risk trampling on local community-based initiatives unless due recognition is accorded the latter. In short, alcohol restrictions of the type assessed here have an important place in any strategic approach to preventing and managing Indigenous alcohol problems. Such strategies, however, raise at least two further questions. First, what processes will do most to ensure that the restrictions genuinely enhance community capacity to manage alcohol?; and, second, what additional measures, apart from supply reduction, are required?

Peter H N d’Abbs PhD

While it is encouraging to read Margolis and colleagues’ findings in this issue of the Journal that in four Indigenous communities in Cape York, Queensland, there has been a marked reduction in aeromedical retrievals for serious injuries, the extent to which this is an indicator of a reduction in alcohol-related harm is uncertain.1 Robust measurement is crucial in identifying the most effective strategies to reduce alcohol-related harm. Development of aetiological fractions that enable us to measure, with a reasonable degree of accuracy, indicators such as alcohol-caused deaths and hospital admissions, has been a major step in this direction.2,3 However, rates of retrieval for all serious injuries are not among such indicators. No work has been undertaken to identify what proportion of such retrievals are actually alcohol-related, and the validity and reliability of retrieval rates as an indicator of alcohol-related harm have not been demonstrated. However, emergency department presentations provide a rough guide, with Australian research showing that between 22% and 33% of presentations are alcohol-related.4-6 Clearly, the higher levels of hazardous alcohol consumption in Indigenous communities and the different age-structures in the Indigenous and non-Indigenous populations complicate comparisons with data from metropolitan hospitals. Although not available to Margolis et al at the time of writing, aetiological fractions have recently been developed for Australian emergency department presentations.7 In the absence of these, the authors could have obtained a more accurate picture of the impact of alcohol restrictions by using data on ICD-9 and ICD-10 diagnostic coding of injuries, applying hospital aetiological fractions to these, and adjusting the results for age. Discussing their results, the authors state that “Focusing on supply reduction in the absence of demand-reduction strategies may lead to increasing use of other substances (eg, petrol sniffing or marijuana), as the fundamental issue of substance misuse has not been addressed.” This raises two issues. First, there is a view that restricting the availability of alcohol is a stop-gap measure until other strategies are put in place. However, as levels of consumption are a function of both supply and demand, we contend that supply reduction itself (although not sufficient) is addressing the fundamental issue.8 The second issue has to do with substitution. The authors write that there were indications “. . . that some people who consumed alcohol had taken up cannabis use after the first [supply-reduction strategy], some for the first time.” This may be true and we certainly support calls for the provision of a wider range of demand-reduction strategies. However, there is not a simple one-to-one substitutability between drugs.9 Poly-drug use is common in the Indigenous population and, in the face of alcohol restrictions, some people will increase their use of cannabis or other drugs.10 Use of cannabis by Indigenous people, particularly in regional and remote areas, has been increasing — even in areas not subjected to alcohol restrictions.11 Taken together, and in the absence of hard data on the magnitude of any change in these communities, care needs to be exercised in attributing changes to restrictions per se — especially when such attributions may be used by opponents to undermine what has already been shown to be an effective harm-reduction strategy.12 That additional restrictions on alcohol supply have been shown to be effective raises the issue of whether they should be imposed on Indigenous communities. Our response to this is a resounding “No”. For nearly 20 years, Indigenous community organisations, such as those in Tennant Creek and Alice Springs, have been at the forefront of advocating for and implementing additional restrictions on supply. Furthermore, before the Northern Territory Emergency Response (NTER), most remote NT communities had imposed their own bans on alcohol consumption. There is evidence to show that in towns such as Halls Creek and Fitzroy Crossing in Western Australia, where Aboriginal and non-Aboriginal leaders have worked together, restrictions on alcohol sales have benefited these towns significantly.13 Blanket bans such as those imposed on remote communities under the NTER are counterproductive. They take away Indigenous initiative, leading to resentment and exacerbation of existing social problems, both of which undermine willingness to work cooperatively with outsiders to address such problems. Indigenous Australians need support to control their own way out of poverty — including addressing harmful alcohol and other drug use, which are consequences of that poverty.

Dennis A Gray MA, MPH, PhD · Edward T Wilkes BA

In the next Australian Health Survey, Indigenous people under 18 years of age will be excluded from direct clinical measurements and laboratory tests. Indigenous people of all ages were to be excluded from the opportunity, offered to other Australians, to donate blood and urine samples to a national repository. This component has now been abandoned for the whole cohort. This sets perilous precedents of exclusion from opportunities available to all other Australians, and deprives the medical community of information that could inform strategies to improve health profiles and outcomes in this seriously disadvantaged group.

Wendy E Hoy BSc(Med), FRACP, AO

The Australian Health Survey will deliver key health measures for all Australian children and adults, and collect information across Australia. The Australian Bureau of Statistics has consulted widely on the development of the Survey, and has shaped the survey according to strong and consistent advice in relation to Aboriginal and Torres Strait Islander peoples. It is hoped that this approach will maximise survey response rates and place us in good trust to embark on the next survey round.

Paul L Jelfs PhD

Health is dependent on conditions that enable people to live lives they would choose to live Inequalities in health arise from inequalities in society. Small differences in society result in small health inequalities; large differences result in large health inequalities.1 Differences in access to health care matter, as do differences in lifestyle, but the key determinants of social inequalities in health lie in the circumstances in which people are born, grow, live, work, and age. These, in turn, arise from differential access to power and resources. Such was the conclusion of the World Health Organization Commission on Social Determinants of Health (CSDH).2 The CSDH had an optimistic tone. Reviewing evidence from around the world, and reaching judgements on what works, it concluded that it is indeed possible to make great progress in closing health gaps — in a generation. The much-discussed 17-year gap in life expectancy between Indigenous and non-Indigenous Australians bespeaks large social inequalities.3 One can think of two classes of influence to which the remarkably poor health of Australian Aboriginals and Torres Strait Islanders can be ascribed. The first is social disadvantage and the second (common to other Indigenous groups) is the particular relationship of Indigenous Australians to mainstream society. Considering the first class of influence — social disadvantage — the health situation of Indigenous Australians fits with findings from other parts of the world. However, it is necessary to take a more comprehensive approach to social disadvantage than simply attributing it to “poverty”. For example, following the publication of the CSDH Report,2 I was asked by the British government to investigate how the CSDH findings could be applied in one high-income country — England — and the resulting Marmot Review was published as Fair society, healthy lives.4 We made recommendations in six domains, all of which I suggest apply to the health situation of Indigenous Australians. These domains are: early child development; education and skills development; employment and working conditions; minimum income for healthy living; sustainable communities; and a social-determinants approach to prevention. In both the CSDH Report2 and the English review,4 we emphasised the social gradient in health: the lower the social position the worse the health. It might be argued that the subtlety of the social gradient does not apply to the dramatic health disadvantage of Aboriginals and Torres Strait Islanders. I disagree for two reasons. First, in any gradient there will always be people at the most disadvantaged end. Deprivation in relation to the six domains in Fair society, healthy lives4 may be extreme, but these six domains are likely to apply. For example, Coleman and colleagues in this issue of the Journal (page 535) report that a high proportion of the urban Indigenous Australian children for whom child health checks were performed came from households with unemployed parents, single parents, and a history of domestic violence.5 Evidence suggests that the environment in early childhood is key to health status right along the social gradient.2,4 This situation is not so very different in kind from disadvantage found, to varying degrees, elsewhere. The second way in which the social gradient is relevant is that it shows we are not dealing with poverty in the sense of the destitution seen in the poorest countries. Striking among the causes of premature mortality among Indigenous Australians are the high rates of cardiovascular disease, diabetes, kidney disease and cancer — diseases that are closely linked to social causes, which are not well understood by simply grouping them as “poverty”.6 Having the minimum income necessary for a healthy life is, of course, important, but it was only one of six recommendations in the Marmot Review. Action has to be taken on the other five, listed above, at the same time. Early child development, access to education, and then, with the requisite skills, access to jobs will all be important. Note that this approach does not ignore the high rates of drinking and smoking among Indigenous Australians. I have borrowed the phrase “the causes of the causes”.7 It is a reasonable hypothesis that, given good early child development, education, and access to decent work, high rates of smoking and alcohol misuse will be less of a problem. It is difficult to make fundamental changes, but change is possible and it can happen rapidly. Taking the example of educational opportunities, for instance, it took more than 110 years from the establishment of the first Australian university in 1850 until the first Australian Aboriginal, Charles Perkins, graduated in 1966.8 However, less than 30 years later (in 1991), it was estimated that there were more than 3600 Indigenous Australian graduates, and this number had increased to over 20 000 in 2006.9 The second of the classes of influence that help explain the poor health of Indigenous Australians is their marginal position in relation to mainstream society. A fundamental theme of both the CSDH Report2 and the English review4 was the importance of creating the conditions that enable people to take control of their lives. If people were living lives they valued, either in remote rural areas or on the margins of cities, that would be one thing, but if Indigenous Australians do not have the conditions — the six domains — that would allow them to live lives that they would choose to live, ill health is an inevitable result. The challenge now is to apply the findings from research on the social determinants of health that would enable Indigenous Australians to lead more flourishing lives that they would have reason to value.10

Michael Marmot PhD, FRCP, FFPHM

Objective: To evaluate the contribution of non-traditional risk factors to coronary heart disease (CHD) incidence in Indigenous adults.Design, setting and participants: Cohort study of 1706 Aboriginal and Torres Strait Islander adults from 26 remote communities in far north Queensland who were initially free of CHD, with a mean of 7.5 years of follow-up.Main outcome measures: CHD-related deaths and hospitalisations obtained by record matching.Results: CHD incidence was similar in men and women and in Aboriginals and Torres Strait Islanders; overall incidence was 12.1 (95% CI, 10.1–14.1) events per 1000 person-years. At baseline, prevalence of diabetes was 12.4% in Aboriginals and 22.3% in Torres Strait Islanders, prevalence of any albuminuria was similarly high (33.5%) in both groups, and participants with diabetes were 5.5 (95% CI, 4.2–7.3) times more likely to have albuminuria than those without diabetes. At follow-up, adjusted hazard ratios for CHD were 1.7 (95% CI, 1.01–2.8) for obesity based on waist circumference; 1.5 (95% CI, 1.01–2.3) for hypertension; 1.4 (95% CI, 0.9–2.2) for previous or current smoking; 1.9 (95% CI, 1.3–2.7) for elevated triglycerides; 1.3 (95% CI, 0.9–1.9) for low high-density lipoprotein cholesterol; 1.3 (95% CI, 0.8–2.2) for impaired fasting glucose; 2.4 (95% CI, 1.7–3.5) for diabetes; and 4.6 (95% CI, 2.9–7.1) for macroalbuminuria. Baseline albuminuria without diabetes increased risk by 50% (adjusted rate ratio, 1.5 [95% CI, 0.9–2.4]) but diabetes with macroalbuminuria amplified risk sixfold (adjusted rate ratio, 5.9 [95% CI, 3.4–10.1]).Conclusion: High prevalence of glycaemia and albuminuria in this population, especially when combined, account for much of the excess CHD risk beyond the traditional Framingham risk factors. They can be measured simply, lend themselves to cardioprotective interventions, and should be used routinely to estimate risk and monitor effectiveness of treatment.

Robyn A McDermott FAFPHM, PhD · Brad McCulloch BSc, MPH · Ming Li MD, PhD

Objective: To describe the clinical and epidemiological features of sepsis and severe sepsis in the population of the tropical Top End of the Northern Territory of Australia and compare these with published estimates for temperate Australia, the United States and Europe.Design, setting and participants: Prospective cohort study in the major hospital for tropical NT, a region where 27% of the population are Indigenous. We screened all adult (≥ 15 years) acute hospital admissions over a 12-month period (6 May 2007 – 5 May 2008) for sepsis by standard criteria, and collected standardised clinical data.Main outcome measures: Population-based incidence of community-onset sepsis and severe sepsis requiring intensive care unit (ICU) admission; 28-day mortality rate and microbial epidemiology.Results: There were 1191 hospital admissions for sepsis in 1090 patients, of which 604 (50.7%) were Indigenous people; the average age was 46.7 years. The age-adjusted annual population-based incidence of sepsis was 11.8 admissions per 1000 (mortality rate, 5.4%), but for Indigenous people it was 40.8 per 1000 (mortality rate, 5.7%). For severe sepsis requiring ICU admission, the incidence was 1.3 per 1000 per year (mortality rate, 21.5%), with an Indigenous rate of 4.7 per 1000 (mortality rate, 19.3%).Conclusions: The incidence of sepsis in the tropical NT is substantially higher than that for temperate Australia, the United States and Europe, and these differences are mainly accounted for by the high rates of sepsis in Indigenous people. The findings support strategies to improve housing and access to health services, and reduce comorbidities, alcohol and tobacco use in Indigenous Australians. The burden of sepsis in indigenous populations worldwide requires further study to guide appropriate resourcing of health care and preventive strategies.

Joshua S Davis MB BS, FRACP, PhD · Allen C Cheng MB BS, FRACP, PhD · Mark McMillan RN · Alex B Humphrey · Dianne P Stephens MB BS, FCICM, FANCZA · Nicholas M Anstey MB BS, FRACP, PhD

Objective: To describe the epidemiology of infectious syphilis among Aboriginal and Torres Strait Islander (Indigenous) people in Australia.Design and setting: We assessed trends in national infectious syphilis notification rates from 2005 to 2009 using Poisson regression, with a focus on geographic and demographic differences by Indigenous status. We compared Indigenous and non-Indigenous rate ratios over the study period and summarised the annual changes (summary rate ratio).Main outcome measures: Crude notification rates and summary rate ratios by Indigenous status, jurisdiction, sex, age group and area of residence.Results: From 2005 to 2009, in the Indigenous population, there was a substantial decline in the notification rate for infectious syphilis nationally; as well as in the following subgroups: females, 15–29 year olds, and people living in outer regional and remote areas in the Northern Territory and Queensland. In contrast, there was a significant (P < 0.001) upward trend in the notification rate in the non-Indigenous population nationally; as well as in males, in people aged 20 years and over, and in residents of metropolitan and regional areas, New South Wales, Queensland, South Australia, Victoria and Western Australia. The highest summary rate ratios were seen in remote/very remote areas (86.33; 95% CI, 57.45–129.74), in 15–19 year olds (64.65; 95% CI, 51.12–81.78), in females (24.59; 95% CI, 19.73–30.65), and in Western Australia (23.89; 95% CI, 19.82–28.82).Conclusion: These data demonstrate that Australia has two distinct patterns of infectious syphilis: a substantially declining occurrence in Indigenous remote communities and an increasing incidence in males residing in urban and regional areas. Given the decline in notification rates in Indigenous remote communities, now might be the right time to move toward eliminating infectious syphilis from Indigenous communities.

James S Ward BA · Rebecca J Guy BAppSc, MAppEpid, PhD · Snehal P Akre MB BS, MPH · Melanie G Middleton BMedSc, MPH · Carolien M Giele RN, BSc(Hons), MPH · Jiunn Y Su MB, MPH · Craig A Davis MAE, MAppSc, BA · Handan Wand MA, MSc, PhD · Janet B Knox MB BS, MMed(STI/HIV), DTM · Patricia S Fagan MB BS, MPH, FAFPHM · Basil Donovan MD, MB BS · John M Kaldor PhD · Darren B Russell MB BS, FRACGP, DipVen

Australia’s efforts to prevent, diagnose and treat cancer are not as successful for Aboriginal and Torres Strait Islander people as they are for other Australians. There is a need for a nationally coordinated, collaborative, priority-driven research effort to better understand what works, and we need to implement that knowledge. All aspects of the process must involve genuine Indigenous leadership and participation.

Gail Garvey BEd, MEd · Joan Cunningham ScD · Patricia C Valery PhD, MD, MPH · John Condon PhD · David Roder AM, MPH, DDSc · Ross Bailie MB ChB, FAFPHM · Jennifer Martin PhD, FRACP, GAICD · Ian Olver AM, FRACP

With community involvement, research can be a powerful tool for closing the gap in Indigenous health disparity Now, in the first decades of a new millennium, it is exciting and energising to find so many voices and forums converging to provide new perspectives on knowledge. At the Lowitja Institute, Australia’s National Institute for Aboriginal and Torres Strait Islander Health Research, we see this as a unique opportunity to achieve positive, lasting change in the health and wellbeing of Australia’s first peoples. The Lowitja Institute uses research as a powerful tool to generate synergies between the voices and knowledge of Indigenous and non-Indigenous people. To do this effectively, we employ methods and approaches that were first developed at the Cooperative Research Centre (CRC) for Aboriginal and Tropical Health and refined over 15 years through its successor CRCs. Described by some as the newest national community-controlled health organisation in Australia, until 2014, the Lowitja Institute is hosting the CRC for Aboriginal and Torres Strait Islander Health and managing a range of funded projects across Australia. Additionally, the Lowitja Institute has a role and a responsibility to build a national strategic research agenda that incorporates the successes delivered through the CRC model, engages with new partners and clients, and expands our presence across Australia without compromising the quality of research for which the organisation is known. It is both an honour and a challenge to implement this research agenda with Aboriginal and Torres Strait Islander health leaders Dr Lowitja O’Donoghue, Ms Pat Anderson and Professor Ian Anderson. We are supported in this by our 12 national partners, which include community-controlled health services, state, territory and federal government departments, and academic research institutions (see http://www.lowitja.org.au/crcatsih-participants for details). Health professionals are well aware that, despite all the research and the medical interventions spanning decades, improvements — where they occur — are incremental and trend up at a slower rate than for non-Indigenous Australians. For example, while the most recent figures show life expectancy for Aboriginal and Torres Strait Islander peoples is improving, so is the life expectancy of other Australians,1 meaning that the ideal of closing the life expectancy gap within a generation is, in effect, an ever-receding target. Clearly, if it was just a question of implementing effective medical interventions, there would be no life-expectancy gap. Australian health professionals are acknowledged as being among the best in the world and we have, by world standards, a comprehensive, well resourced and well funded public health system. Something else is going on. As Australia’s only Aboriginal and Torres Strait Islander-controlled pure health research organisation, the Lowitja Institute is focused on precisely this conundrum. A growing body of research tells us that, in order to nurture the physical body, we must also bolster the social, emotional and spiritual wellbeing of people who have been adversely affected by over 200 years of colonisation, dispossession and marginalisation.2,3 Other research shows that having Aboriginal and Torres Strait Islander peoples involved in all aspects of research and health infrastructure is crucial to success.4,5 In other words, a doctor can heal broken bones, but Indigenous peoples need to be engaged in creating the diversity of choices and responses to issues affecting their lives; issues that remain well beyond the reach of the surgeon’s scalpel. While the Northern Territory National Emergency Response has highlighted the appalling health and living conditions of Aboriginal people in remote areas, the lack of social capital, amenities and health infrastructure is only part of the story. For even when Aboriginal and Torres Strait Islander peoples live in well resourced urban and regional areas, as most now do, their health and wellbeing is still, on average, substantially worse than that of their non-Indigenous neighbours on the other side of the fence.6 How do we change this? For one thing, we need to respect the information and knowledge systems that Aboriginal and Torres Strait Islander peoples live with, and ensure that we invest in safe spaces where this information and knowledge can be brought to the fore. Using culture-centred research methodologies and strategies is important at the Lowitja Institute, as is building Aboriginal and Torres Strait Islander peoples’ ability to trust and engage with the health system, the higher education system and with society more generally. It is also essential that we continue to bolster Aboriginal and Torres Strait Islander participation at all levels of the health and health research sectors. If we boost the numbers of Aboriginal and Torres Strait Islander health professionals and researchers, and if we facilitate and fund health research that matches the priorities of Australia’s first peoples, we will be in a far better position to shift the fundamentals. These ideals have been at our core from the moment we started our journey back in 1997 as the CRC for Aboriginal and Tropical Health. Like all pioneering ventures we had some false starts, but by the time we won funding for our second iteration as the CRC for Aboriginal Health (CRCAH) in 2003, we had developed a much better idea of what research we wanted to deliver. We had also worked out how best to build the involvement of, and investment from, Aboriginal and Torres Strait Islander peoples in our own health outcomes and in our own health discourses. In particular, we developed a research philosophy we call the Facilitated Development Approach (FDA), in which the CRCAH worked with its partners in the Aboriginal and Torres Strait Islander health sector to identify areas where research could make a real difference, then commissioned that research. Using the FDA, Aboriginal and Torres Strait Islander voices had a strong input at each step of the research process. This contrasts with the conventional way in which research has been carried out, where the researcher identifies the priorities — a “top-down” approach. All too often, this has meant that the interests of researchers do not coincide with the needs of Aboriginal and Torres Strait Islander communities. The underpinning principle of the FDA research model is that the more the users of research — Aboriginal and Torres Strait Islander organisations, individuals, governments and other service providers — are involved from the beginning, the more likely it is that research projects will result in findings being used by the Indigenous health sector. And by increasing the amount of Aboriginal and Torres Strait Islander involvement in research programs at all levels, the FDA increases the amount of directly relevant health knowledge flowing through to communities. This approach has proved highly successful, as shown by the outcomes of research projects that have led to improvements in the way many hospitals liaise with Aboriginal and Torres Strait Islander patients;7,8 improvements in the management of Aboriginal community-controlled health organisations;9 more closely targeted interventions aimed at the underlying causes of ill health, such as scabies infestations and smoking;10,11 and a growing awareness of the inefficiency of current funding arrangements for Aboriginal community-controlled health organisations.12 In fact, this approach has been so successful that the CRCAH is one of only four CRCs ever to succeed in winning a third round of federal funding. This brings us to the here and now, and the future as encapsulated by the Lowitja Institute. The Institute commenced operations in January 2010 and has been established as a not-for-profit company independent of government and other centres of health and policy administration. The principle of strong Aboriginal and Torres Strait Islander leadership at all levels is central to our identity, with a majority presence at Board level and in most executive positions. Our widely admired and respected patron, Dr Lowitja O’Donoghue (AC, CBE, DSG), has not only given the Institute her name but also a clear charter for how she wants the Institute to achieve its aims. It can be summarised as follows: Real Aboriginal and Torres Strait Islander leadership. Full involvement from Aboriginal and Torres Strait Islander individuals and organisations in the initiation, design and implementation of research. Building Aboriginal and Torres Strait Islander participation at all levels of the health system. Mentoring and support for Aboriginal and Torres Strait Islander health workers. Wide dissemination of research findings to all research users. Strong engagement with government and private enterprise, but without compromising core principles. Guided by these principles under the research leadership of Professor Ian Anderson, the Lowitja Institute’s research effort has a tight focus on driving change in areas where, for a relatively small investment, substantial gains can be achieved. The first of our three research program areas is Healthy Start, Healthy Life, which aims to make sure that primary health care and health-related services are able to access and use innovations that will help them provide the best-quality care to Aboriginal and Torres Strait Islander peoples. The research supports the delivery of primary care that encourages a long, healthy life through reducing risk associated with tobacco consumption, obesity and diet; improved early detection and effective management of chronic diseases; and improved maternal and child health outcomes. The second program is Healthy Communities and Settings, which addresses health through a community and family focus and by ensuring that health promotion for Aboriginal and Torres Strait Islander peoples includes innovations at the broader social level. An individual’s health and wellbeing is strongly associated with the wellbeing and resilience of the communities in which they live, and improvements in individual health are more likely to be sustained over the long term when the social and physical environment is positive and supportive. Our third research program area is Enabling Policy and Systems, which examines the fundamental constraints and challenges that contribute to poor performance in Aboriginal and Torres Strait Islander health policy and programs. The research aims to develop knowledge and evaluate tools and resources that will enable research users to reform health system policy and administration, and improve capacity to implement programs effectively. Currently, eight research projects are underway across our three program areas, with many more in the pipeline. The support we provide can include both financial and facilitation assistance, by ensuring a strong Aboriginal and Torres Strait Islander presence in all project leadership teams and that the research is appropriately and widely communicated. Capacity-building initiatives are embedded within all projects, providing support to students and budding researchers through collaborations with some of Australia’s leading educational and training organisations. We also have a strong foundation built on partnerships with other organisations right across the health sector, especially through Congress Lowitja, our principal stakeholder body, which meets biennially (http://www.lowitja.org.au/congress-lowitja). By June 2014, it is our intention to be self-funded so that we can continue our work on a permanent basis without the disruption and uncertainty of relying on short-term grant cycles. This will be no easy task, but we are up for it. In our favour is the ever-strengthening, national, cross-party consensus that closing the gap in Aboriginal and Torres Strait Islander health disadvantage is vital to Australia’s national interest, and will take at least a generation. Wise people know the journey of a thousand miles begins with a single step. At the Lowitja Institute we have taken that step — and we urge all those with a commitment to ensuring the good health and wellbeing of Australia’s first peoples to join us on our journey.

Kerry Arabena BSocWk, PhD · David Moodie BA

To the Editor: The Medicare item for annual child health checks (CHCs) for Aboriginal and Torres Strait Islanders involves taking a comprehensive health-related history from the antenatal period onwards, recording growth parameters, performing a medical examination, identifying new diagnoses and commencing management, which may include advice, referral, vaccinations and treatment. The CHC has had little evaluation as a primary health care tool in the urban setting; indeed, outside remote regions, it has barely been taken out of the toolbox. Although 76% of Aboriginal and Torres Strait Islander people live in urban or regional areas,1 we are unaware of any published research on CHCs outside remote areas. We therefore aimed to evaluate the role of the CHC for 0–14-year-olds at Inala Indigenous Health Service, an urban primary care service in a suburb of Brisbane. Ethics approval was obtained from the University of Queensland’s Behavioural and Social Sciences Ethical Review Committee and Metro South Health Service District Human Research Ethics Committee at the Princess Alexandra Hospital. The local Inala Elders Aboriginal and Torres Strait Islander Corporation supported the project. Descriptive statistical analysis was conducted using Stata, version 10 (StataCorp, College Station, Tex, USA). Of 867 eligible children, we completed 786 CHCs from May 2007 to December 2009. We excluded 245 “subsequent” CHCs (31%) in children who had already had a CHC in the study period, and 109 of the remaining 541 (20%) that were not accompanied by a research consent form, leaving 432 CHCs available for analysis. The children (234 male [54%]) were Aboriginal (394, 91%), Torres Strait Islander (9, 2%) or both (29, 7%). Reported health risk factors included living in households with a smoker (75%), parental unemployment (67%), exposure to domestic violence (29%), never having been breastfed (32%) and not having teeth brushed twice daily (46%), although more than half the children (57%) exercised at least 30 minutes every day. New diagnoses made at the CHC (40%) were primarily dental caries (36%) or conditions involving the skin (18%) or ears (10%). During the CHC, 63% of parents were given health advice, 24% of children were referred for follow-up and 22% were vaccinated (Box). From May 2006 (when CHCs were introduced) to June 2009, 4610 Indigenous CHCs were reported by Australia’s 54 metropolitan Divisions of General Practice, comprising just 4.3% of the eligible population.2 This contrasts with the 14 500 CHCs (89% coverage) completed in prescribed remote areas by the Northern Territory Emergency Response (NTER).3 A recent report highlights the low number of CHCs performed outside the NTER and the lack of timely follow-up within the NTER to address detected health problems. The report concluded: “It’s clearly time to reconsider this failed health policy”.4 However, a distinction should be drawn between the NTER CHCs — usually performed by “fly-in, fly-out” teams who are not in a position to provide ongoing care — and a CHC program embedded in a local clinic as a cornerstone of usual health care. In the wake of the NTER, the then National Aboriginal Community Controlled Health Organisation chairperson, Dr Mick Adams, said, “This is not to say that we do not want more child health checks [but we reject] the present way of doing them”.5 Strengths of our study include the high proportion of our clinic’s eligible population who had CHCs (541/867, 62%). Although our practice comprises only 0.8% of Australia’s urban Indigenous children, our service completed 10% of the CHCs done in Australian metropolitan areas to June 2009.2 Because the study was limited to the day of the CHC, we were unable to evaluate whether referrals resulted in attendances. Further research is required to document the success of follow-up resulting from CHCs, including referral attendance rates. We have found that the Indigenous CHC, performed within the patient’s usual primary care service, provides an important opportunity to make new diagnoses and to identify and initiate management of health risk factors. The CHC is an underused tool worth dusting off in primary care. Health risk factors (reported by parent or carer), new diagnoses and interventions from child health checks of 432 Aboriginal and Torres Strait Islander participants attending Inala Indigenous Health Service, May 2007 – December 2009* Variable No. (%) Variable No. (%) Maternal substance use during pregnancy Adolescent (12–14-year-olds) behaviour (n = 65) Tobacco (n = 432) 156 (36%) Consumes alcohol (n = 54) 5 (9%) Alcohol (n = 432) 70 (16%) Current smoker (n = 54) 4 (7%) Cannabis (n = 431) 36 (8%) Sexually active (n = 51) 3 (6%) Intravenous drugs (n = 431) 16 (4%) New diagnosis resulting from health check Household characteristics Any new diagnosis (n = 432) 174 (40%) Household with a smoker (n = 416) 312 (75%) Dental caries (n = 345) 124 (36%) Unemployed parent (n = 432) 288 (67%) Skin condition, all causes (n = 432) 77 (18%) Single parent caring for child (n = 432) 194 (45%) Ear condition‡ (n = 432) 43 (10%) Stressful event impacting on household (n = 432) 180 (42%) Overweight (n = 332) 83 (25%) Households with six or more residents (range, 6–12) (n = 408) 149 (37%) Obese (n = 332) 36 (11%) History of domestic violence exposure (past or current) (n = 432) 124 (29%) Interventions (n = 432) Perinatal characteristics Any health/lifestyle advice 270 (63%) Premature birth (gestation < 37 weeks) (n = 336) 45 (13%) Nutrition advice 119 (28%) Perinatal complication (n = 432) 170 (39%) Learning/behavioural advice 54 (13%) Never breastfed (n = 339) 110 (32%) Physical activity advice 54 (13%) Childhood health behaviour Smoking cessation advice 42 (10%) Watch electronic media ≥ 60 min/day (n = 237) 183 (77%) Alcohol consumption advice 33 (8%) Teeth not brushed twice daily (n = 360) 165 (46%) Any referral (n = 432) 103 (24%) Suboptimal physical activity† (n = 215) 92 (43%) Paediatrician referral 31 (7%) Parental/carer concerns about child’s behaviour (n = 264) 81 (31%) Dental referral 26 (6%) Parental/carer concerns about child’s learning (n = 276) 82 (30%) Audiology referral 17 (4%) Dietitian referral 13 (3%) Vaccinations given on the day of the check (n = 432) 96 (22%) * Denominators vary because of missing data. † ≤ 30 min/day for < 7 days a week. ‡ Defined as having signs (eg, perforation, bulging) or a diagnosis (eg, otitis media, otitis externa) of ear disease in at least one ear.

Justin J Coleman · Geoffrey K Spurling · Deborah A Askew · Noel E Hayman

To the Editor: Indigenous Australians have a higher risk of vision loss from preventable and treatable causes than non-Indigenous Australians1 and have been reported to attend eye care services at a lower rate than non-Indigenous Australians.2 Here, we report results from the National Indigenous Eye Health Survey1 which indicate that many Indigenous Australians with vision problems have accessed eye care services but not as frequently as recommended by the National Aboriginal Community Controlled Health Organisation (NACCHO) and the National Health and Medical Research Council (NHMRC), particularly for high-risk groups of patients with diabetes.3,4 The survey methods have been reported elsewhere.1 Briefly, 1694 Indigenous children and 1189 Indigenous adults from 30 communities across Australia had a standardised eye examination and completed a questionnaire in 2008. Recruitment rates were 84% for children aged 5–15 years and 72% for adults aged ≥ 40 years, and 96% of responses to questionnaire items were complete. Seventy-nine per cent (936/1189) of Indigenous adults reported vision problems, of whom 83% (778/936) had sought care from an eye care service (Box 1). Similar to previous studies,5 we found use of eye care services increased with increasing age, but being male and having no education were barriers to accessing services. There was a significant association between higher education levels and higher rates of using of eye care services, with the odds for using eye care services being the highest among those with the highest level of education (data not shown). These factors should be considered when designing public health messages on the importance of using eye care services. As elsewhere in Australia, optometric services were the most frequently used facilities (49%, 378/778) across all regions except very remote inland, where primary health care services had the highest reported usage (33%, 49/149). Participants from very remote coastal and very remote inland regions were twice as likely to consult an ophthalmologist compared with the other regions (Box 2). Twenty-three per cent (179/769) of participants with vision problems reported that they had last seen someone about their vision problem within the previous year, 67% (519/769) within the previous 3 years, and for 33% (250/769) it had been ≥ 3 years. Only 20% (87/444) of participants with self-reported diabetes had seen someone about their vision problem within the previous year. NACCHO recommends that Indigenous adults aged ≥ 40 years should be screened for reduced visual acuity at least every 2 years,3 and NHMRC guidelines recommend that Indigenous adults with diabetes have their eyes checked every year.4 Our results show that we are far from reaching these targets. As regular eye examinations have the potential to reduce the incidence of vision loss, this is a matter of great concern. The importance of regular eye examinations and follow-up, particularly for high-risk groups, should be emphasised to health care providers and the community. Reasons given for not seeking eye care were: not enough time (41%, 62/153); condition not severe enough (22%, 33/153); too expensive (17%, 26/153); eye care not available in area (14%, 22/153); decided not to seek care (14%, 22/153); transport or distance issues (10%, 15/153); and waiting time too long (10%, 15/153). The two most common reasons for not seeking care indicate a lack of awareness about the importance of regular eye examinations, possibly because of a lack of culturally appropriate public health messages. 1 Self-reported history of vision problems, facilities used and resolved vision problems for Indigenous adults 2 Indigenous adults with self-reported vision problems, by facility used and region Primary health care (n = 255) Hospital (n = 48) Optometrist (n = 378) Ophthalmologist (n = 91) Not specified (n = 6) No consultation (n = 156) Total χ2 P Major city 34 (31%) 6 (6%) 48 (44%) 7 (6%) 0 13 (12%) 108 22.5 < 0.01 Inner regional 39 (28%) 4 (3%) 71 (52%) 8 (6%) 1 (1%) 14 (10%) 137 17.7 < 0.01 Outer regional 51 (34%) 6 (4%) 56 (37%) 13 (9%) 1 (1%) 25 (16%) 152 18.3 < 0.01 Remote 55 (28%) 9 (5%) 79 (40%) 12 (6%) 2 (1%) 42 (21%) 199 — 0.16* Very remote coastal 27 (14%) 8 (4%) 81 (43%) 30 (16%) 2 (1%) 41 (22%) 189 — 0.87* Very remote inland 49 (33%) 15 (10%) 43 (29%) 21 (14%) 0 21 (14%) 149 12.7 0.03 * Fisher exact test.

Anna-Lena M R Arnold · Lucy Busija · Jill E Keeffe · Hugh R Taylor

Paintings from the Shalom Gamarada Ngiyani Yana Art Exhibition are featured throughout this issue (shown below). The sale of these artworks by acclaimed Aboriginal artists supports the Shalom Gamarada Indigenous Scholarship Program at the University of New South Wales (UNSW), a collaboration between Shalom College (a residential college at the UNSW) and the Muru Marri Indigenous Health Unit, School of Public Health and Community Medicine at UNSW. For more information about the exhibition and sale, and the scholarship program, see the Shalom Gamarada website: http://www.shalomgamarada.org. Artist: Shorty Robertson Artist: Lydia Balbal Artist: Shorty Robertson Artist: Lydia Balbal Artist: Regina Wilson Artist: Lydia Balbal Artist: Gloria Petyarre Artist: Alma Nungarrayi Artist: Elaine Thomas Artist: Judy Napangardi Watson Artist: Shorty Robertson

Alison Dimer is an Aboriginal Health Worker from the goldfields area of Western Australia. In 2008, as part of the Western Desert Kidney Health Project, she worked with Alison Clough (Healthway International Arts Fellow), and this experience sparked an idea. In the year or so that followed, Alison spent evenings and weekends thinking about this idea, and it became the story of Alfie. Continuing her involvement with the Western Desert Kidney Health Project in 2010, Alison worked with animation artist Steve Aiton, local artist and community member Catherine Howard and the children at three local schools to produce an animation — and Alfie the tooth fairy took flight! The complete animation can be viewed below. Alfie is an unwise Tooth Fairy who loves fast food and soft drinks, so he spends his time saving up his money and sneaking away to the burger shop. His unhealthy lifestyle eventually catches up with him and he crashes into a tree because he has become overweight and his eyesight has been affected. Alfie is taken to the Healing Tree where his Black Box is examined and found to be full of sugar — Alfie has developed diabetes. Alfie is taught all about diabetes and its complications, and what he can do to minimise his risk. Alfie becomes a new fairy — health conscious and fit. But this is not just a story about individual redemption — Alfie goes on to educate and motivate his community of Tooth Fairies so they will not fall into the same trap, and so saves his whole community.

Alison Dimer

Remembering that the land is the giver of life to all plants and animals, which we need to fuel our bodies, we have to respect her as a major part of our lives. There is a life force that flows through everything and every one of us. Everything is connected in some form or other, which means we all have a duty of care for each other, regardless of sex, creed or colour. This help might be given in the form of mental, physical or spiritual aid, and this means maintaining our own health so we are strong for others — but, more importantly, we’re also strong in our own body, mind and culture.

Luke B Mallie BA Visual Art(Fine Art)

Hepatitis C is a blood-borne virus, and so in this poster the Aboriginal communities in Victoria are represented as blood cells, holding hands to indicate community strength, and coming together to talk about hepatitis and injecting drug use. Hepatitis C is very much an issue for urban Aboriginal communities in Australia. By coming together we encourage conversations about the more marginalised people in the community who are affected by the virus, and, ultimately, help to prevent and treat this disease. Click here for a larger version of this graphic.

Peter C Waples-Crowe MMS

With permission from my son I am able to tell this story. I have not used his name for privacy reasons. I would like to dedicate this essay to the many Indigenous people who have passed away in psychiatric hospitals and did not make it home to their families and communities. “Historical trauma” is defined as the subjective experiencing and remembering of events in the mind of an individual or the life of a community, passed from adults to children in cyclic processes as “collective emotional and psychological injury . . . over the life span and across generations”.1 I was raised in a foster family from the age of two, in suburban Brisbane, Queensland, with three of my siblings. I am a proud Aboriginal woman with close family ties across south-east Queensland and the north coast of New South Wales. My mother is from the Wakka Wakka clan group in Cherbourg and Brisbane. My father is from the Gumbaynggir and Dunghutti communities of the north-coast region of New South Wales. Recently, I arrived in Canberra from Brisbane with my son to take up a Research Fellowship with the Australian Institute of Aboriginal and Torres Strait Islander Studies. My research is on the question of “Mental health: what treatment options are working for Indigenous peoples?”. I have chosen this topic because of my personal experience as a mother. The day before we left our home in Margate, a suburb in the north of Brisbane on Moreton Bay, to travel to Canberra, we attended my son’s mental health review tribunal hearing, an event that was life-changing for both of us. My son has suffered from a mental illness (schizophrenia) for many years, which saw him hospitalised for ten-and-a-half years. During this time he was on a forensic order as an involuntary patient, because of crimes he had committed while being unwell. I was expecting to be seeking the tribunal’s permission to take my son interstate for the three months that I would be working. Instead, to our surprise, his forensic order was revoked, meaning he was able to leave Queensland and live wherever he wanted. Overwhelmed by the decision, my son kept repeatedly asking the tribunal panel what it meant for him. As a mother I have struggled, mostly because I was only seventeen years old when my son was born. Of course, you can never imagine or prepare yourself for the way life can take such a turn some twenty years later. I had lived with my biological mother on and off since I was fifteen, so she took on significant caring responsibilities for my baby, who was her first grandchild. She was very close to him. My mother had also suffered from “mental illness” as a young woman and had been hospitalised (I don’t know how many times). I remember being told about it in quite a negative way. Mum was admitted to what was the “old” Wolston Park Hospital some forty years ago. This hospital was located on the same grounds as the hospital called The Park, Centre for Mental Health, where my son has spent his years. She had grown up in Cherbourg Aboriginal community in Queensland where she spent some of her childhood in the dormitory while her mother travelled away for work. I know she did not have good memories of the dormitory days, as she later shared some stories with me about the abuse that she witnessed and was subjected to in the dormitory. My mother died at the age of fifty-seven from kidney failure caused by diabetes, when my son was only twelve. What I have read and come to understand about transgenerational trauma within Indigenous communities is that the suffering of individuals and communities from trauma and pain results in many unresolved issues not just for those immediately affected, but for those around them, their families and their descendants, and from what I know about my family history the trauma reaches much further than my mother. Personal experience has left me with no doubt that transgenerational trauma contributed to the mental/spiritual unwellness of both my mother and my son. After my mother’s death our lives changed dramatically. I was in deep grief. It was difficult to “be there” emotionally, or in any other way, for my son. I felt vulnerable and extremely fragile. The grief was unbearable. It took me to a place that I found hard to come back from, to the point where I thought that I would die from it. At the time part of me wanted to. Fortunately, I did come back, just as my son was about to travel down his own road of self-destruction, which began with bizarre behaviour patterns. At about age fourteen, he started to use drugs — first marijuana, then amphetamines, known on the street as speed. This is a parent’s nightmare. Drug taking was not something I had experience with, nor did I expect this to be happening to my child. What followed was years of risky behaviour, crime, eventually juvenile detention and then prison! As a mother, the pain of this is beyond imagination: it reaches into the very core of you. When your child is locked away, you are too. I was overcome with feelings of shame and guilt. I felt emotionally, psychologically and spiritually immobilised and trapped within myself. Of course, eventually it took its toll on my mental and physical health, and I was diagnosed with my own life-threatening illnesses. One of the many challenges was dealing with blame from people who were close to me. Some made conscious and unconscious hurtful comments because of their own pain and lack of understanding of my son’s illness. We also experienced discrimination arising from the general community’s ignorance of mental illness. When going out in public — going shopping, for instance — people would stare, laugh or make comments. The effects of this trauma are still with me today. In prison, my son’s mental illness started to become very obvious, through the signs of self-harm, and symptoms of mental unwellness such as crying and responding to voices. Eventually, he was hospitalised and I visited him regularly, took him on leave many times and had him living with me for short periods. Unfortunately, he was so unwell that he would abscond from the hospital, and would run away from me as well. This caused immense anxiety, not only for me and our family and friends, but also for staff at the hospital who were genuinely concerned about his welfare. My son would go missing for days, sometimes weeks, without his medication. The police were, of course, alerted and it was their responsibility to find him, but I would usually locate him before they did, and would then seek help from the Indigenous workers or nurses to return him safely to hospital. This happened on many occasions. Throughout these years of experience with my son and his illness, there were many moments when I questioned my own thoughts and feelings. I did know, however, that I was experiencing something that was deeply spiritual and unknown. My son’s thin and pale, ghost-like appearance haunted me, and I could feel him detaching from what was real. That is why it was important for me to be around to keep the strong spiritual and emotional bond between us — I knew from a sickening feeling inside me there was a very real risk of losing him through suicide. He was haunted by voices, and would respond by talking to people that he believed were real. Sometimes he was happy and laughing along with them; other times he would be screaming back at them to leave him alone, and would cry in a very mournful way that made me cry as well. I remember all this very vividly, especially the times at night when I would lie awake listening to him talking in another language which I knew to be an Aboriginal language. This did freak me out a little, as he appeared to be having conversations and speaking the language fluently. I thought that I was imagining what I had heard until family members and workers at the hospital told me that they had witnessed him doing the same thing. It was through this experience that I came to know and believe that Indigenous mental illness is also spiritual illness, as it is deeply connected to our spirituality and cultural beliefs. I also believe that this spiritual connection is what helped my son get through his illness to where he is today. A quote from the Schizophrenia Fellowship of NSW newsletter has been helpful in supporting my thoughts around mental–spiritual illness. Wellbeing is an holistic and collective issue, with specific individual health problems being of little relevance if not considered as part of wider social, spiritual and community health . . . Mental illness or disturbance may be seen as a ‘soreness of the spirit’ caused by loss of social and family networks, destruction of kinship and family, dislocation from ancestral lands and the conflict between tradition and the pressures of trying to exist within and alongside European culture.2 On one very memorable visit to the hospital I sat with the treating psychiatrist to discuss my son’s “progress”. She explained to me that there were “two very sick patients in the hospital at the time, [my son] being one of them”, and that “out of the two, he [was] the most unwell”. In a roundabout way, I guess she was trying to tell me that my son was the sickest patient in the hospital at that moment. To this day I don’t remember how I drove myself home. During his long hospital stay of over ten years, my son lost elders and friends, mostly Indigenous patients, who passed away in hospital. He dealt with this in his own way, showing courage and strength. The thought was always at the back of my mind that he himself would not survive. I questioned myself all the time as to whether I was in denial of the possibility that he would be institutionalised forever, but remained convinced that it was important to rise above this thinking, and to try to stay positive, and most of all to believe that things can change and be different. My son is now very well, the best he could possibly be. He lives with me full-time and is actively seeking employment. I have presented at workshops on mental illness in Indigenous communities and received positive responses from people who appreciated honesty and openness in talking about this sensitive area. There is definitely a need for more understanding and education in our communities so people can come together to share and talk openly without any shame or blame. I always tell people that talking about it and seeking help can mean the difference between life or death for a loved one. Through the years, I have always felt very strongly that “someone” was around, guiding me through this time in our lives. I listened to the messages and acted intuitively, particularly when my son was at his most critical times of illness, and the times when he went missing from the hospital. I give many thanks to all the people who were there supporting us on this long journey, such as family, friends, hospital staff and community, who gave us hope and encouragement. If it weren’t for them, I know we would not be here today to tell this story. This story is difficult to tell because I know that I will be revisiting the trauma, reliving the memories of events that took place, and visualising the images that will forever haunt me. With permission from my son, I wanted to document and share this story in the hope that it may give strength and support to some other family who is going through the same or similar circumstances.

Lindy L Moffatt DipCommWelfareWork

A number of inquiries have drawn attention to the unacceptable gap between the physical health status of Aborigines and that of the remainder of the community. The House of Representatives Standing Committee on Aboriginal Affairs report, Aboriginal Health, and the National Trachoma and Eye Health Program of the Royal [Australian] College of Ophthalmologists are recent examples. Comparatively little attention, however, has been given to the mental health needs of Aborigines.1 Health is overratedI arrive at work, sweaty but satisfied, 50 minutes or so after leaving home. “Closing the gap is going to kill me!”, I joke with a colleague as I haul my bicycle up the stairs. My efforts to delay the sprawl of a once moderately shaped midsection mean that I arrive at work at least once but ideally up to three times a week in this manner. As much as my two young boys enjoy using that expanding part of my anatomy as a surrogate trampoline, I felt its recent growth spurt demanded some attention. On reviewing my shape, taunts of my unappreciated high school nickname, “Fat Garvs”, began to revisit my consciousness. This, coupled with an awareness of the high hospitalisation and mortality rates associated with cardiovascular disease for Indigenous men aged 35–44, meant that I was unable to sustain the delusions that my clothes had mysteriously shrunk during winter; that it was OK to be breathing a little heavier from a strenuous round trip to the mail box; and that watching sport burns the same number of calories as doing sport. For the most part, it is easy to be distracted during the morning ride from Fremantle to Bentley. Majestic black swans and other waterbirds meander by along the Derbarl Yerrigan, pausing now and then to graze happily on its banks. By comparison, I imagine cars and other vehicles crawling by on congested roads, pausing now and then to wait impatiently at traffic lights. My laboured breathing belies the fact that I am glad of my choice of transport and the environment through which I propel it. The journey home, however, is another story. There is the “Fremantle Doctor” to contend with — an afternoon sea breeze, often blowing between 15 and 20 knots and penetrating as far as 100 kilometres inland. It provides welcome relief from the heat of the day, but little relief for those attempting to travel against it by bicycle. The potential of this force to both help and hinder isn’t lost on me, but on some days it’s easy to feel ambivalent towards the bloody Doctor! “Yep, closing the gap is going to kill me”, I joke to myself through gritted teeth as I press on, searching for a gear that allows me to keep a steady cadence into the headwind. The ride to and from work oscillates between enjoyment and pain as I negotiate serene distraction and powerful opposition. Maintaining momentum in the face of the latter can be difficult; however, I know that my thoughts about the conditions can mediate their influence on the journey. An unbearable, hopeless, pointless slog is draining, whereas regarding the ride as a challenge invokes (for a competitive person like me) a sense of energy and purpose. Can I turn the pedals five more times at this rate? What about five more? Five becomes ten, and so on, and before long an intermediate goal is reached — a tree 100 metres up the road, another cyclist, a street sign — something to aim for, and a small success to celebrate ... until the next landmark. I find strategies like these give focus and permit completion, while overcoming the struggle provides a sense of achievement likely to prompt another effort tomorrow. This is good, because removing a trampoline isn’t done in a day. The changing nature of workWork is a little different at the moment. It is still at a university — the same one at which I have been employed for close to two decades. In the beginning, I was invited to join the counselling and mental health program being developed at the Centre for Aboriginal Studies (CAS). As a recently graduated psychologist, it was felt that my expertise would be of use to the course and its students — Aboriginal and Torres Strait Islander people from many parts of Australia, diverse yet united in their desire to participate in the restoration and promotion of the social and emotional wellbeing of their families and communities. This meant leaving Cairns and my role in community mental health, but the lure of a new experience and an adventure in the west was too good to miss. “It will only be for two years”, I told myself and others when I departed. Eighteen years later, I am still reminded of this promise during visits home. The program we developed set the benchmark for some time, cresting the wave of an unprecedented focus on Indigenous mental health that was heralded and constructed in such landmark publications and events as the Royal Commission into Aboriginal Deaths in Custody,2 the National Inquiry into the Human Rights of People with Mental Illness,3 the first National Aboriginal Mental Health Conference in Sydney in 1993, the “Ways forward” consultancy report on Aboriginal and Torres Strait Islander mental health,4 and the “Bringing them home” report.5 However, tremors in the Indigenous mental health arena had been felt earlier, along with an attendant frustration at the lack of meaningful response.6 The opening quote of this essay is illustrative of the relative neglect of Indigenous mental health. Perhaps surprisingly, it is not sourced from any recent report but is an observation made 31 years ago in the foreword to a special “mental health” issue of the Aboriginal Health Worker Journal.1 More recently, on the eve of National Close the Gap Day 2011, these old concerns are being echoed.7 While the Close the Gap campaign is commemorating its fifth anniversary of mobilising the current generation’s efforts in Indigenous health, discussion of a mental health gap for Indigenous Australian people was occurring at least a generation earlier. The 1990s also saw a change in the way that my profession sought to engage with Indigenous Australian people — a relational gap of sorts — prompted by the aforementioned documents and at the insistence of a small but active Indigenous membership. In 1995 I was able to observe an interested, ambivalent and curious audience watch the first Aboriginal keynote address to the Australian Psychological Society, delivered by Aboriginal leader and activist Robert Riley. I knew Rob as the man who had taken me, sight unseen, into his home during my initial weeks in Perth. He was a supporter of the CAS, and his offer of accommodation was brokered thanks to his friendship with the then Head of the Centre, Pat Dudgeon. I would argue that Rob’s challenge to the profession to examine its consideration of Indigenous people retains currency within and beyond psychology.8 I would also lament his tragic passing not long after, and question what else I should have done with my supposed expertise to assist him to maintain cadence in the significant headwinds he encountered. Of that period at the CAS, I recall with fondness and frustration the late nights spent preparing student workbooks, the friendships forged and fractured by debates over self-determination and mental health competencies and, of course, how we were meant to assess this stuff in ways demonstrative of student utility, academic rigour and community appropriateness! With our attention well and truly focused on the conceptual and practical requirements of course delivery, I doubt we took the time (or had the time) to consider the symbolic significance of our endeavours — the collaborations, real, messy and imperfect, that arose as we attempted to negotiate and reconcile the kinds of cross-cultural and interpersonal tensions involved in facilitating Indigenous health. It was in many ways a journey into the unknown; an intense and tumultuous time. I remember feeling part of something special, something important, and that we persevered and problem-solved in uncharted territory. I also remember burning out after about two years, to the point where I was unable to recognise the destructive symptoms and had to be told, in no uncertain terms, to take a break. I had tried to keep up with seemingly inexhaustible mentors and a relentless workload; possible for a time, and made easier by the excitement and novelty of the endeavour. Ironically, though, I would fall foul of the very advice we gave our students — to look after themselves in order to avoid such a state of exhaustion, and to be wary of the expectation placed on them to be “superhuman” health workers. The maxim “if you don’t look after yourself, you won’t be of any use to others” rang true as a description of my own debilitated state (one from which I would, thankfully, recover). If there was any consolation, at least I could now use personal experience to illustrate the lesson, and pursue a more sustainable tempo. New landmarksWhile my roles and goals have changed over the years, one constant has remained — an annual ritual of PhD avoidance. A new year’s resolution to enrol would be broken as semester-based demands were allowed to take priority. However, the mantra of “there’s always next year” becomes less reassuring when considered in the context of the gap. Indigenous people get to use the “there’s always next year” excuse some 15–20 fewer times than other Australians, on average, so, statistically at least, now was the time to focus on that next landmark. It should come as no surprise that the research I am pursuing concerns what has been described as “the tensely contested arena” of Indigenous mental health.9 This is motivated by my own questions and experiences of the arena, and by the thousands of conversations over 20 years with people interested in, ambivalent about and curious about the social and emotional wellbeing of Indigenous Australian people. To continue the metaphor, I am not only interested in the tension and conflict apparent on the arena’s floor, but what characterises the hypogeum (Greek for “underground”). In an arena, this refers to a subsurface network of channels and compartments that house combatants, props and other gladiatorial paraphernalia that would eventually be released into the main stage. In terms of my research, it involves an examination of the discursive resources and deeply held myths and metaphors about wellness, relationships and services that have formed Indigenous mental health, and the attendant tense and conflicting responses to it over time. My research is also concerned with bridging and negotiating gaps between people — addressing those enduring dilemmas10 involving the providers, consumers and designers of Indigenous mental health services. My sense is that, until and unless we are willing to consider the role of these less apparent yet influential linguistic and ideational precursors, we will continue to experience conflict in the arena, and the gap-centred litany, such as that in the opening quote, will endure. Moving forwardMy 20 years in health have been characterised by achievements and disappointments, friends made and lost, and lessons often learned the hard way. I maintain a sense of optimism inspired by the Indigenous and non-Indigenous people I’ve met who, despite the challenges, remain committed to Indigenous health. If my time in health and my more recent forays into healthy activity have taught me anything, it is that it is worthwhile setting goals, adopting attitudes and behaving in ways that support a sustainable rhythm over the long term. This is not to say that bursts of energy and enthusiasm aren’t useful or necessary; it is just that shining brightly can often mean shining briefly. My advice to those who choose to engage with the health concerns of Indigenous Australian people or who are about to graduate to such endeavours? Work to maintain a healthy cadence. Negotiate reasonable goals. Develop ways of enduring those inevitable headwinds, and take the time to acknowledge and celebrate landmarks reached. And do be interested in the momentum of others, especially when their tempo is flagging. For me, in addition to a renewed work focus, I have recently been given two beautiful reasons to remain personally and professionally invested in health. If I can build bridges for my sons to negotiate their way with their own “bloody Doctors”, and in any way contribute to their life’s quality as well as its longevity, then the ride will have been worth it. Unfortunately though, while Ollie and Elliot get immeasurable joy from pounding my midsection with their energetic play, I need to say, “Sorry boys, daddy’s trampoline won’t be there much longer. But don’t worry, he’ll be able to get you a real one with the money he saves on new clothes!”

Darren C Garvey BPsych, PostGradCertEd, MHlthProm

Objective: To explore the associations between self-reported racism and health and wellbeing outcomes for young Aboriginal Australian people.Design, setting and participants: A cross-sectional study of 345 Aboriginal Australians aged 16–20 years who, as participants in the prospective Aboriginal Birth Cohort Study, were recruited at birth between 1987 and 1990 and followed up between 2006 and 2008.Main outcome measures: Self-reported social and emotional wellbeing using a questionnaire validated as culturally appropriate for the study’s participants; recorded body mass index and waist-to-hip ratio.Results: Self-reported racism was reported by 32% of study participants. Racism was significantly associated with anxiety (odds ratio [OR], 2.18 [95% CI, 1.37–3.46]); depression (OR, 2.16 [95% CI, 1.33–3.53]); suicide risk (OR, 2.32 [95% CI, 1.25–4.00]); and poor overall mental health (OR, 3.35 [95% CI, 2.04–5.51]). No significant associations were found between self-reported racism and resilience or any anthropometric measures.Conclusions: Self-reported racism was associated with poor social and emotional wellbeing outcomes, including anxiety, depression, suicide risk and poor overall mental health.

Naomi C Priest BAppSci(Hons),PhD · Yin C Paradies MMedStats, MPH, PhD · Wendy Gunthorpe BPsych, PhD · Sheree J Cairney BAppSci, PhD · Sue M Sayers PhD

Objective: To explore attitudes to pregnancy and parenthood among a group of Indigenous young people in Townsville, Australia.Design and participants: Mixed methods and a cross-sectional design involving Indigenous women from a Young Mums Group designing the research instruments and acting as peer interviewers. Data were collected in 2004 from young Indigenous people who had never been pregnant (171 students at three high schools and 15 people at a homeless youth shelter) using a computer-assisted self-administered survey; from 59 of this group who also participated in single sex focus group discussions; and from 10 pregnant and parenting young women in individual semi-structured interviews.Main outcome measure: Self-reported attitudes and behaviour about aspirations, pregnancy and parenthood.Results: Only eight of 186 young Indigenous people who had never been pregnant reported wanting to have a child as a teenager. Large proportions of this group of 186 reported idealised views about pregnancy, particularly young men, with 50.5% reporting that being a parent would always be enjoyable, and 62.6% reporting that being a mother or a father would not change their lives. Idealised views were associated with earlier sexual initiation (P = 0.001). Issues identified in the narratives of young mothers related to difficult backgrounds, pregnancy “just happening” to them, and the transformative impact of having a child on their lives and aspirations.Conclusions: Accurate parenting information may be necessary to address unrealistic views about parenting among Indigenous young people. Young Indigenous parents often come from extremely disadvantaged backgrounds, and becoming a parent may be the impetus for positive change.

Sarah L Larkins MB BS, MPH · R Priscilla Page Cert III Aboriginal Health Work (Clinical) · Kathryn S Panaretto MB BS, MPH, FAFPHM · Melvina Mitchell EN · Valerie Alberts MSocPol, GradCertTeaching, GradCertPHCResearch · Suzanne McGinty DipEd, MA, PhD · P Craig Veitch DipAppSci(RT), BA, PhD

Objective: To describe the trends in maternal smoking and smoking in the household for a cohort of Indigenous women followed from late pregnancy to 7 months postpartum.Design and setting: Prospective cohort study embedded within a randomised controlled trial (RCT) performed in the Northern Territory involving participants recruited between 30 June 2006 and 4 May 2010.Participants: 215 Indigenous women aged 17–39 years who had been recruited into the RCT, 162 of whom had completed their last study visit at 7 months postpartum by 1 June 2010.Main outcome measures: Smoking status of women, and smoking within their households, in their third trimester, and at 1 month, 2 months and 7 months postpartum.Results: There were complete data on women’s smoking status for 121 participants. Among these, the self-reported smoking rate was 45% (95% CI, 36%–55%) during pregnancy, increasing to 63% (95% CI, 54%–71%) at 7 months postpartum. Of the 66 women who were non-smokers at the antenatal visit, 23 (35%; 95% CI, 23%–47%) were smoking by the time their baby reached 7 months of age. Thirty-one per cent (95% CI, 23%–39%) of households included people who smoked inside during the antepartum period, whereas 16% (95% CI, 10%–23%) included people who smoked inside at 7 months postpartum.Conclusions: While an apparent reduction in indoor exposure to tobacco smoke during the postpartum period is encouraging, this is offset by an increase in the proportion of antenatal non-smokers who subsequently reported smoking after the birth of their child. More health care service delivery and research attention needs to be directed to smoking during pregnancy and to postpartum relapse in this population.

Vanessa Johnston MB BS, MPH, PhD · David P Thomas MMedSc, FAFPHM, PhD · Joseph McDonnell MSc, GradDipCompSci · Ross M Andrews MAppEpid, MPH, PhD