Global health

To the Editor: We refer to Liaw and colleagues’1 recently published study in the Journal. We acknowledge the positive intentions and rigour of this trial, and empathically concur with Thompson and Thackrah’s2 comment that the results of this research “[do] not mean that efforts to improve cultural competence in health care settings should be abandoned”. To the contrary, this study demonstrates the urgent need for more research to improve cultural competence in the health care setting; in particular, the use of culturally safe research methods that truly benefit Aboriginal and Torres Strait Islander peoples and communities.3 Like Thompson and Thackrah,2 we question the authors’ choice of the cultural quotient questionnaire.4 This generic tool is not designed for assessing cultural competence of health professionals when working with Aboriginal and Torres Strait Islander peoples in Australia. Importantly, it lacks recognition of the unique colonial experiences of Aboriginal and Torres Strait Islander peoples and, therefore, it cannot measure health professionals’ understandings or attitudes about such a key part of any cultural training, where we would hope to see change. We suggest the use of a scale that has been designed and validated by Aboriginal and Torres Strait Islander peoples, such as the Cultural Capability Measurement Tool.5 We fear that, if not carefully interpreted, the study findings have the potential to further complicate and undermine the substantial work — endorsed by the National Aboriginal Community Controlled Health Organisation and the Department of Health — being undertaken to develop the cultural safety of Australia’s health system.6 It is crucial that in all areas of Australia’s health system, including Aboriginal and Torres Strait Islander health, we present a reliable, strategically aligned approach consistent with the vision of an Australian health system free of racism and inequality.6 It is important that we continue to work together to harness the energy and commitment of the workforce towards our shared goals. We look forward to the qualitative findings of the research study.

Sophie Hickey · Roianne West

In reply

Siaw‐Teng Liaw · Vicki Wade

To the Editor: In the recently published article by Morgan and colleagues1 and associated podcast, the authors raised the issue of future research into the outcomes of identification of Aboriginal and Torres Strait Islander peoples in hospital. The implementation of a visual identification methodology has previously been described2 and was put in place in partnership with the hospital department of Aboriginal health. The purpose of this identification initiative was to encourage all medical professionals who care for Aboriginal and Torres Strait Islander patients to question what they can do to assist them while they are in hospital. We describe here the positive outcomes of this process. In addition to hospital pharmacists,2 the visual alert system is also used by other departments and professionals within the hospital, such as cardiothoracic care, the emergency department (ED), Aboriginal health, and speech pathology, as well as ward‐based nursing and medical staff. The Aboriginal and Torres Strait Islander patients’ identification system is used by health care providers within the hospital to easily identify the patients they need to visit, to provide culturally appropriate resources and services and links to other services, and to enhance the care patients receive and enable them to remain in a caring hospital environment. At ward level, nursing and medical staff use the identification system to highlight the referral process needed to link with Aboriginal health workers — connecting the right resources to the right people. Because of the visual alert,2 staff feel more aware of the cultural needs of the patient before they meet them. Specifically in the ED, there is a system‐wide approach that firstly identifies Aboriginal and Torres Strait Islander patients presenting to the ED using the visual alert at triage, and then implementing initiatives that aim to reduce the level of “did not wait for treatment” episodes. The Heart and Lung Stream at St Vincent's Hospital uses the system to identify Aboriginal and Torres Strait Islander patients early during their admission in order to provide culturally specific education, resources and follow‐up after hospital discharge. We encourage others to explore this initiative in their hospital, together with cultural responsiveness training, to enhance the care of Aboriginal and Torres Strait Islander peoples during and after their hospital visit.

Susan A Welch · Sonia Robinson · Tamra Langley · Pauline Deweerd

In reply

David JR Morgan · Martin Whitely · Tania Harris

Tensions and traumas in health law

Andrew Alston

Textbook of global health, 4th edition

Mieke L van Driel

The rates of RHD are among the highest in the world, particularly in girls and young women

Kimberly Davis · Bo Remenyi · Anthony DK Draper · Januario Dos Santos · Noel Bayley · Elizabeth Paratz · Benjamin Reeves · Alan Appelbe · Andrew Cochrane · Timothy D Johnson · Laura M Korte · Ivonia M Do Rosario · Inez T Da Silva Almeida · Kathryn V Roberts · Jonathan R Carapetis · Joshua R Francis

To the Editor:I thank Byard and colleagues1 for their review of risks of herbal products to the Australian community, which highlighted the high rates of use in younger women with a tertiary education and in patients with chronic diseases or comorbidities. Refugee and migrant women represent a group with potentially high rates of use of herbal products as well as other traditional practices, particularly during pregnancy. Ethnobotany surveys found that 90% of women in eastern Ivory Coast and 80% of women in Mali used medicinal plants during pregnancy.2 A prospective cohort study found that 45% of women in China consumed Chinese herbal medicine during pregnancy and the postpartum period.3 The ingestion of soil, clay or chalk has been observed in up to 84% of pregnant women in African countries, and may be complicated by hypokalaemic paralysis, iron and zinc deficiency, lead poisoning, intestinal obstruction and parasitic infestation.4,5 It is commonly reported that migrant women transfer cultural practices to their new country. In the United Kingdom, geophagia is associated with immigrants from South Asia and West Africa.6 Likewise, Congolese and Zimbabwean women commonly consume clay during pregnancy after migrating to Cape Town.7 In addition, the use of skin lightening creams has been reported in 69% of pregnant women on their third-trimester attending a standard maternal centre in Dakar, which may result in maternal Cushing’s syndrome and adrenal insufficiency and in fetal intrauterine growth restriction. Most case reports in the literature describing Cushing’s syndrome due to skin lightening creams have been on African women who had migrated to Australia, the United States or Europe.8 Skin lightening creams may also contain mercury, with the risk of birth defects and irreversible neurological damage to the child. These products are usually obtained over the counter in African shops, and thus are not subject to any form of safety regulation. A further difficulty is that migrant women may not disclose their use of herbal medicines or other traditional products, even when questioned specifically. Therefore, health professionals in Australia should be aware of the risk of use of herbal and other natural products and practices by migrant women, particularly during pregnancy. Engagement with matriarchal figures, nurses and doulas within migrant communities may be valuable in identifying the extent of these practices.

Adam Morton