Indigenous health

To the Editor: We read with interest the article by Kowal about genetic research in Indigenous health.1 As stated, this topic is extremely sensitive, but it is one that we must now tackle. The article raises a related issue that has not received any attention: the provision of genetic health services to Aboriginal and Torres Strait Islander people. We should not presume that Aboriginal and Torres ...

Gail Garvey · Christina M Bernardes

In reply: I thank Hoy, and Garvey and Bernardes, for their responses. Hoy highlights the difficulties her group has experienced in conducting genetic research in an Aboriginal community over two decades. Indeed, this was the project I referred to as losing its ethics approval as a direct result of the Human Genome Diversity Project. She attributes the difficulties she has faced to conflicting views between ...

Emma E Kowal

We describe the first reported cases of phenytoin-related drug-induced hypersensitivity syndrome in unrelated Indigenous Australians with the same HLA-B*56:02 allele. These patients shared common clinical and pathological features, and all three were found to have the otherwise rare HLA-B allele, which might represent a novel genetic susceptibility factor for this syndrome.Clinical recordsPatient 1A 32-year-old Indigenous man from a remote Western Australian community presented with a fever, ...

Damian J Harding MB BS, BSc(Hons), MRCP · Kavitha Subramaniam MB BS, FRACP · Gerry MacQuillan MB BCh, FRACP, PhD · Joshua Davis MB BS, FRACP, PhD · David Nolan MB BS, PhD

Global health is, by definition, an area of great breadth and depth. There is enormous diversity in health systems and health outcomes, with life expectancy at birth varying from 82–84 years in Australia and Japan to less than 55 years in more than 20 African countries. Despite this diversity and difference, communicable diseases such as HIV and severe acute respiratory syndrome, and our more recent understanding of the ...

A Rob Moodie MB BS, MPH

In Cape York Indigenous communities, alcohol restrictions started in 2002–2003, with local prohibition in some communities since 2008. These restrictions may have halved alcohol-related injuries, a historically important change. However, residents of Cape York Indigenous communities suggest that there has been an accompanying rise in cannabis use over this period. During consultations in 2011 for Minister Macklin’s controversial Stronger Futures in ...

Cape York Cannabis Project Team

For many years, the diagnosis of diabetes has been made through the laboratory-based measurement of fasting or random blood glucose levels, or using the oral glucose tolerance test. A glycated haemoglobin (HbA1c) level ≥ 6.5% (48 mmol/mol) is now also acceptable for diagnosing diabetes. Caution is needed in interpreting HbA1c test results in the presence of conditions affecting red blood cells or their survival time, ...

Michael C d’Emden MD, PhD, FRACP · Jonathan E Shaw MD, FRACP, FRCP · Peter G Colman MB BS, FRACP, MD · Stephen Colagiuri MB BS, FRACP · Stephen M Twigg MB BS, PhD, FRACP · Graham R D Jones MB BS, DPhil, FRCPA · Ian Goodall FAACB, FAIMS, FFSC(RCPA) · Hans G Schneider MD, FRCPA, FRACP · N Wah Cheung MB BS, PhD, FRACP

Dennis McDermott argues that educating doctors about the health consequences of everyday racism towards Indigenous Australians challenges all involvedAgenuine engagement with Indigenous health issues challenges medical students and doctors alike. When participants in medical education analyse racism as a social determinant of health, the challenge deepens. The experience can range from disquieting to profoundly disturbing. For educators, the experience can be stressful, even daunting. Analysing racism ...

Dennis R McDermott BEc, BA(Hons)(Psych), MA

Working with Indigenous communities towards research that is relevant, effective and culturally respectful. Writing in the Journal about Indigenous health in 2011, Sir Michael Marmot suggested that the challenge was to conduct research, and to ultimately apply findings from that research, to enable Indigenous Australians to lead more flourishing lives that they would have reason to value. As committed Indigenous health researchers in Australia, we reflect ...

Lisa M Jamieson PhD · Yin C Paradies PhD · Sandra Eades PhD · Alwin Chong MPH · Louise Maple-Brown PhD · Peter Morris PhD · Ross Bailie PhD · Alan Cass PhD · Kaye Roberts-Thomson MPH · Alex Brown PhD

“The girls don’t drink much; ’bout the same as the fellas.” I am an Aboriginal woman, with traditional connections to the Bidjara people from central western Queensland and extensive experience in working with Aboriginal women who consume alcohol during pregnancy. During several decades of working in the health field, I have asked myself and others why Aboriginal people drink alcohol at such dangerous levels. As I have reported ...

Lorian G Hayes MAppEpid, BAppHlthSc(Hons)

To the Editor: It has been estimated that “levelling the playing field” in terms of cardiovascular health alone could narrow the life-expectancy gap between Indigenous and non-Indigenous Australians by 6.5 years.1 While there has been a particular (and important) focus on risk factor modification, and prevention and management of chronic disease, it is worth noting that, compared with other Australians, Aboriginal and Torres Strait Islander people have: three ...

Robert D Grenfell · Vicki Wade · Eleanor Clune · Kelley O’Donohue · Prue Power

The burden of type 2 diabetes mellitus (T2DM) among Indigenous children and adolescents is much greater than in non-Indigenous young people and appears to be rising, although data on epidemiology and complications are limited. Young Indigenous people living in remote areas appear to be at excess risk of T2DM. Most young Indigenous people with T2DM are asymptomatic at diagnosis and typically have a family history ...

Peter Azzopardi MB BS, MEpi, FRACP · Alex D Brown BMed, MPH, PhD · Paul Zimmet MD, PhD, FRACP · Rose E Fahy MB BCh, FRACP, MRCP · Glynis A Dent Grad Cert Diabetes Education, Grad Cert Human Nutrition · Martin J Kelly MB BS, FACRRM, PhD · Kira Kranzusch MB BS, FRACP · Louise J Maple-Brown MB BS, FRACP, PhD · Victor Nossar MB BS, FRACP, FAFPHM · Martin Silink MD, FRACP · Ashim K Sinha MB BS, MD, FRACP · Monique L Stone MB BS, FRACP, MD · Sarah J Wren MHSc (Nursing), Grad Cert Diabetes Education

Objective: To estimate the prevalence of mental disorder in a representative sample of Aboriginal and Torres Strait Islander people in Queensland prisons.Design, setting and participants: Cross-sectional assessment of mental health using the Composite International Diagnostic Interview (CIDI) and clinical interviews, conducted by Indigenous mental health clinicians who undertook specific training for this purpose, with support from forensic psychiatrists when indicated. We ...

Edward B Heffernan MB BS, MPH, FRANZCP · Kimina C Andersen BSW · Abhilash Dev BDS, MPH · Stuart Kinner BA(Hons), PhD

Objective: To determine the effectiveness of an intensive quit-smoking intervention on smoking rates at 36 weeks’ gestation among pregnant Aboriginal and Torres Strait Islander women.Design: Randomised controlled trial.Setting and participants: Pregnant Aboriginal and Torres Strait Islander women (n = 263) attending their first antenatal visit at one of three Aboriginal community-controlled health services between June 2005 and December 2009.Intervention: A general ...

Sandra J Eades BMed, PhD · Rob W Sanson-Fisher PhD, ClinMPsych · Mark Wenitong BMed · Katie Panaretto MB BS · Catherine D’Este BMath, PhD · Conor Gilligan BBiomedSc, PhD · Jessica Stewart BA/LLB, MPP

Objective: To undertake a systematic literature review to determine the scope, rationales, and evaluation foci of indigenous health curricula included in university-based professional training of health care service providers.Study design: Systematic review.Data sources: We searched the Australasian Medical Index, ATSIhealth (Aboriginal and Torres Strait Islander Health Bibliography), CINAHL PLUS, MEDLINE, SCOPUS version 4, and Web of Science databases using relevant keywords. Our ...

Shaun C Ewen BAppSc(Physio), MMIL, DEd · David J Paul MB BS, PhD · Gina L Bloom BA(Hons), MPhil

A group of Indigenous Research Fellows describe the lessons learnt from their involvement in Indigenous health researchWe are a group of Indigenous Research Fellows (IRFs) involved in the Kanyini Qualitative Study (KQS), examining barriers and enablers to chronic disease care for Indigenous Australians. The KQS forms part of the Kanyini Vascular Collaboration (KVC), a health services research program established to reduce the burden and suffering ...

Ricky A Mentha GradCert (RemoteHealthMgmt) · Joanne de Vries DipPHC · Pamela R Simon · Barry N Fewquandie GradCert(PHC) · John Brady BSciApp · Suzanne Ingram BA(Comm), GradCertHealthSciences

Objectives: To identify barriers to and facilitators of colorectal cancer (CRC) screening participation among different cultural subgroups in South Australia, and to describe how these might be shared or be distinct across these groups.Design, participants and setting: Qualitative study using individual interviews in Adelaide, South Australia, between July 2009 and December 2010. ...

Sara Javanparast MD, PhD · Paul R Ward PhD · Stacy M Carter MPH(Hons), PhD · Carlene J Wilson BA(Hons), MBA, PhD

To the Editor: Strongyloidosis in Australia has been reported in Indigenous Australians, war veterans who have served in South-East Asia and travellers and immigrants from regions in which strongyloidosis is endemic.1,2 The condition is caused by ...

Hannah M Soulsby · Saliya Hewagama · Stephen Brady

Gone viral. The germs that share our lives. Frank Bowden. Sydney: University of New South Wales Press, 2011 (216 pp, $32.95). ISBN 978174223273. FRANK BOWDEN tells a good story. As a sexual health physician and professor of medicine at the Australian National University Medical School he is well placed to provide an informative account of 15 “germs that share our life”. The anecdotes from his years of clinical and public health work in Australia make for interesting reading for both health professionals and the public. Fairfield Hospital for Infectious Diseases was, indeed, a “beautiful anachronism” in the 1980s, remembered fondly by generations of Victorian medical students who rotated through there, especially by the registrars who had the good fortune to be mentored in the science and art of general medicine and infectious diseases by Fairfield’s legendary infectious diseases physicians. Bowden provides a poignant account of his training at Fairfield during the early years of the AIDS epidemic: “There were 16 patients with AIDS on Ward 4. They were all men, all homosexual, and they were all dying”. Indigenous health has been an important part of Bowden’s career and many of the organisms he bases his stories on remain major causes of morbidity in Australia’s Indigenous population. Several controversial aspects are raised. The author is for an aggressive approach to screening and treatment of sexually transmitted infections (STIs). He laments that the success of the national donovanosis eradication campaign, which he was centrally involved in, has not been matched with similar results for other STIs, and that historically there has been opposition to the concept of mass treatment as a means to address the high rates of infectious diseases in Indigenous communities. The argument has been that a “sheep-dip approach” fails to address the primary issues of socioeconomic disadvantage, housing, health hardware, and access to health services and education. Nevertheless, the stars may be aligning finally to include the possibility of population-based treatment for infections such as syphilis, scabies, trachoma and chlamydial genitourinary infections in the setting of improved primary health care. Having to reach for the dictionary often when reading can be annoying; or it can be amusing, or even enlightening. Bowden takes the reader along from the role of necromancy in WHO decision making to the adverse impact of HIV misinformation by a pulchritudinous female surgeon. I remain baffled, however, by his allusion to the “metaphorical cojones” of cardiologists!

Bart J Currie

To the Editor: Since the publication of Knight and colleagues’ case report on the topic, five more patients have presented with burns caused by Grevillea pyramidalis ssp. leucadendron, or maangga berry.1 Traditionally, these berries have been used by Aboriginal Australians for tattooing.1 As in the cases described by Knight and colleagues,1 these burns were sustained by Indigenous children aged 8–11 years in northern Western Australia and required specialist burn care. Two patients sustained 1.5% total body surface area, deep partial-thickness burns to their left forearms, which required surgical management. Three patients presented with superficial partial-thickness left forearm burns, which were managed non-operatively via telehealth. Four of the five patients were only referred to the state burns unit 7 days after the initial injury, and one patient was lost to follow-up. Management of these patients’ injuries was limited by compliance issues. Grevillea seeds can be responsible for deeper burns, which require surgical intervention, and superficial burns, which can be treated non-operatively. In this series, the burns occurred in Indigenous children with darker skin, which often has poorer scar outcomes. This demographic, coupled with compliance issues and late referral, make grevillea seed burns a difficult clinical entity to treat. Community education and health staff awareness is imperative in helping us provide optimal treatment in the future.

Joseph Luo · Tania McWilliams · Fiona Wood

Objective: To examine the differential in cancer survival between Indigenous and non-Indigenous people in Queensland in relation to time after diagnosis, remoteness and area-socioeconomic disadvantage.Design, setting and participants: Descriptive study of population-based data on all 150 059 Queensland residents of known Indigenous status aged 15 years and over who were diagnosed with a primary invasive cancer during 1997–2006.Main outcome measures: Hazard ratios for the categories of area-socioeconomic disadvantage, remoteness and Indigenous status, as well as conditional 5-year survival estimates.Results: Five-year survival was lower for Indigenous people diagnosed with cancer (50.3%; 95% CI, 47.8%–52.8%) compared with non-Indigenous people (61.9%; 95% CI, 61.7%–62.2%). There was no evidence that this differential varied by remoteness (P = 0.780) or area-socioeconomic disadvantage (P = 0.845). However, it did vary by time after diagnosis. In a time-varying survival model stratified by age, sex and cancer type, the 50% excess mortality in the first year (adjusted HR, 1.50; 95% CI, 1.38–1.63) reduced to near unity at 2 years after diagnosis (HR, 1.03; 95% CI, 0.78–1.35).Conclusions: After a wide disparity in cancer survival in the first 2 years after diagnosis, Indigenous patients with cancer who survive these 2 years have a similar outlook to non-Indigenous patients. Access to services and socioeconomic factors are unlikely to be the main causes of the early lower Indigenous survival, as patterns were similar across remoteness and area-socioeconomic disadvantage. There is an urgent need to identify the factors leading to poor outcomes early after diagnosis among Indigenous people with cancer.

Susanna M Cramb BAppSc(Med Sci), Grad Cert(Sc), MPH · Gail Garvey BEd, MEd · Patricia C Valery PhD, MD, MPH · John D Williamson BA(Hons), GradCert(PublicHlth), MEpi(Clin Epi) · Peter D Baade BSc, MMedSc, PhD

Dr Hilton Immerman and Dr Josef McDonald (“Macca”) speak of their association as mentor and Indigenous medical student HiltonIn late 2004, Macca successfully completed the bridging course for Indigenous students to gain entry to the University of New South Wales (UNSW). He started the 6-year Medicine degree in March 2005. Since he is from the Newcastle area, he had to find accommodation near campus for his first year-and-a-half. However, he and his family were no longer able to cover the high cost of his accommodation. He had also felt alienated living where he was and was uncomfortable about revealing his Indigenous identity. In 2005, we had just established the Shalom Gamarada Indigenous Scholarship Program, which provides board and lodging, tutoring and other forms of support at Shalom College — the college I have been running since 1989. Macca succeeded in gaining a scholarship in July 2006. He received the Sabina Ross Slater Memorial Medical Scholar-ship, which was provided by Edna Ross in memory of her mother, who had died the year before. I remember interviewing him. He had a sense of humour and a mischievous sparkle in his eyes. I sensed that he might prove a handful as a resident of a UNSW college with an academic culture, accommodating 129 other students. My intuition was proven right. Macca for me exemplified the wonderful Aussie term “larrikin”. In the early years of his studies, he was a bit of a rascal and scallywag — but one with endearing qualities. If ever there were pranks or mischief in college, chances were that Macca was involved! On quite a few occasions, I had to summon him to my office to discuss his youthful indiscretions. As stern as I tried to be, I suspect that I never really succeeded in concealing the fact that I was genuinely fond of and believed in him. In 2007, I was invited to speak about Shalom College’s Indigenous scholarship program to a chapter of Rotary. I proposed that one of our scholarship students would join me and talk about it from his perspective. To be honest, my first choice was a more senior female scholarship holder, but she was not available at the time. So, I decided to take the plunge and ask Macca if he would accompany me. During his talk, to a crowded room, he commented on his former experiences of racism and self-doubt and explained how, ironically, a Jewish college had given him the opportunity to explore and take pride in his Indigenous identity for the first time. At this point, he was so filled with emotions about which he had not previously spoken publicly, that he burst into tears. There were not many dry eyes in the room — mine included! Each year since the scholarship has been running, we have held a Shalom Gamarada Aboriginal Art Exhibition to publicise and raise funds for it. This is an excerpt of what Macca wrote for a display board: “Receiving the Shalom Gamarada Scholarship has been a life-changing experience for me. Apart from the advantages it offers my studies, another great benefit of the program is that it offers a racism-free environment in which Indigenous students can live and discuss Indigenous issues and what it means to be Indigenous. “Without it, [the scholarship] it would be impossible for me to study medicine as there is no way my family could afford for me to live in Sydney.” At the end of 2008, after Macca had successfully completed his 4th Year, he decided to defer his studies in 2009 to support his family over a difficult period. Some had doubts about whether he would return and I confess to sharing their concerns. I endeavoured to keep in touch with him over the course of the year and to involve him in various scholarship-related activities, including the annual art fair. He has always been generous with his time and this was no exception. Macca came back to Shalom College and his studies in 2010. In semester 2 of 2010, he successfully applied to become a college tutor — a role he has ably filled since. He’s been a great mentor and role model to other students, both Indigenous and non-Indigenous. At the recent formal dinner for the new bridging course run by the Nura Gili Indigenous centre at UNSW, Macca was one of four UNSW students interviewed. At the end, he was asked if he had any words of advice for the new students. After deliberating briefly, he said: “If you succeed in getting into medicine and law next year, you’re likely to feel like an imposter. I did. Your peers in the program will be the brightest and most privileged students from around Australia and the world. Many will have come from exclusive, private schools. Most of you come from underprivileged and disadvantaged backgrounds. But, you must never forget that you will have earned your place in your course. You deserve to be there and you owe it to yourselves, your families and your communities to succeed. You can and must!” I feel so much emotion and pride in him when I reflect on how he has grown from being a mischievous adolescent, who was frequently in trouble in college, to a mature and wise adult. On 16 December 2011, I was a member of the academic procession at the UNSW graduation ceremony at which he formally became a doctor.

Hilton Immerman

MaccaMedicine was one of many options that I considered at the end of high school, along with engineering and even astronomy. But my interests in science and social justice drew me to medicine and, in the summer before commencing my studies, I was naively confident and felt as though the world was my oyster. These feelings were short-lived when I moved to Randwick in February 2005 to begin my medical studies at the University of New South Wales. I found the content challenging, and studying occupied most of my time. I also found socialising to be very challenging, as my peers were quite different from those I had spent my time with at home. This caused a feeling of alienation and I succumbed to the “imposter syndrome”, where I felt as though I did not deserve to be in medicine. Everyone appeared to be smarter, better educated, better supported, better travelled and more articulate than me. As a result, I mainly focused on my work and avoided engaging in medicine-related extracurricular activities. I travelled back home to Newcastle every weekend because I was homesick, and this affected my academic performance. Travelling home often reinforced a very poor habit of only studying towards the exam period, which caused lots of anxiety and little sleep, eroding my enthusiasm. My friends and I used humour to maintain a positive mental attitude, often to the delight of spectators. However, despite my best efforts, I was losing stamina quickly and didn’t think I could continue my studies at this rate. I had lost all my pleasurable pastimes — I found little opportunity to go fishing in Sydney. The only thing I seemed to gain during the early years of my medical studies was 15 kg. At 11 o’clock one morning I received a phone call from Professor Lisa Jackson Pulver (Director of the Muru Marri Indigenous Health Unit at the university). She encouraged me to apply for the Shalom Gamarada Indigenous Scholarship Program and, in mid-2006, I was accepted into the program by the Master of Shalom College, Dr Hilton Immerman. Receiving a Shalom Gamarada scholarship was crucial to my personal development and my transformation into a doctor. If it wasn’t for the support of the people on the scholarship program, I doubt that I would have successfully completed medicine. I started to become less homesick, as Shalom College offered a very welcoming, racism-free environment, with fellow students from an Indigenous background. Hilton and the other staff at Shalom should be congratulated for this, as it is only due to ongoing vigilance that a racism-free college can be achieved. I became less homesick and more confident to spend time in Sydney and with my peers, knowing that if I had a bad day, I always had a safe place to return to. My results instantly improved. I started engaging with the material and taking responsibility for my medical career — although not without some bumps along the way. Seeing people like Hilton and Lisa model professional behaviour was another crucial element in my success in the medicine program. I usually saw Hilton in his office, often by his request, to discuss something that happened over the weekend. My friends and I came to dread the 9 am phone call on the Monday after an eventful weekend. Hilton was always fair and this appealed to our sense of justice. I felt comfortable to “pop in” to Hilton’s office to ask him questions about my studies, relationships or personal conduct, and his opinions were always valued. I no longer felt like a rudderless ship. My self-esteem was greatly improved, knowing that I had support and finally had a place in Sydney that I knew I could call home. It was the first time in my life that I felt empowered to achieve anything I set my mind to. It was an indescribable feeling seeing Shalom College and Muru Marri staff at my graduation. What I have achieved still hasn’t sunk in, and I cannot be thankful enough to those who gave me this opportunity. What I do understand very well is that if it had not been for a phone call, the great work of Shalom College, and my very generous benefactor, I could have been in a very different place. Hilton (left) and Macca at Macca's graduation in December 2011. Photograph: Shirli Kirschner

Josef McDonald

Starlight: An Australian Army doctor in Vietnam. Tony White. Brisbane: Copyright Publishing, 2001 (xii + 183 pp: $25.00). ISBN 9871876344689. RETIRED COLONEL Tony White of the Royal Australian Army Medical Corps served in South Vietnam in 1967, and this narrative is largely based on his detailed correspondence with his family at the time. The title, Starlight, refers to the radio call sign for army doctors and medics. Following a move, midway in his medical studies, from the University of Cambridge in the United Kingdom to the University of Sydney in Australia, White accepted an undergraduate scholarship from the Australian Army to complete his studies. After finishing his hospital residency, he was posted as Regimental Medical Officer (RMO) to the newly formed 5th Battalion, Royal Australian Regiment (5RAR). Flying into Saigon’s Tan Son Nhut Airport brought the young 25-year-old RMO to the so-called “Sufferer’s Paradise”. The Vietnam War, in essence a civil war, became the longest and most controversial of Australia’s military conflicts to date. Twelve of the book’s 17 chapters are devoted to White’s wartime experiences with the 5RAR at the Australian base at Nui Dat in Phuoc Tuy Province. The battalion took many casualties during its deployment. February 1967 was the battalion’s critical period, when two tragic episodes beset the unit — White describes them with sensitivity and compassion, but also with a sense of despair. The final segments of the book are devoted to White’s subsequent civilian medical career in dermatology in Sydney. This compact, hardcover book is well illustrated, with several photographs and a map. It contains a handy list of abbreviations and terminologies, as well as a comprehensive index. The text is also supported by appropriate end notes. This moving work is a welcome addition to the few publications of military medical officers’ accounts of their experiences in the Vietnam War. It is recommended to those who partook of that war, to the wider non-military readership who remember the era, as well as to today’s younger generation.

Bruce H Short