Indigenous health

Objective: To assemble what is known about the mental health of Indigenous Australians from community surveys.

Anthony F Jorm PhD, DSc · Sarah J Bourchier BPsych(Hons) · Stefan Cvetkovski MPH · Gavin Stewart BSc(Hons)

Substance misuse and intellectual disability take their toll.

Ernest M Hunter FRANZCP · Bruce D Gynther FRANZCP · Carrick J Anderson MB BS · Leigh-ann L Onnis GradDipPH · Jeffrey R Nelson PhD · Wayne Hall PhD · Bernhard T Baune PhD, MD, FRANZCP · Aaron R Groves FRANZCP

Objective: To document the prevalence of polycystic ovary syndrome (PCOS) and its associated characteristics in a sample of urban Indigenous women.Design: A cross-sectional survey of Indigenous women, including biochemical and anthropometric assessments. PCOS was assessed using the National Institutes of Health 1990 criteria.Setting and participants: Indigenous women, aged 15–44 years, living in a defined area in and around Darwin, Northern Territory, Australia, September 2003 – March 2005.Main outcome measures: Proportion of participants with PCOS overall and measures of obesity.Results: Among 248 women eligible for assessment, the proportion who had PCOS was 15.3% (95% CI, 10.8%–19.8%). The proportion with PCOS was similar across age groups, but was significantly higher (P = 0.001) in women with a body mass index (BMI) of ≥ 30.0 kg/m2 (30.5%) compared with women with a BMI of 25.0–29.9 kg/m2 (8.2%) or a BMI of < 25.0 kg/m2 (7.0%).Conclusions: A high proportion of these Indigenous women had PCOS. The significant relationship with obesity gives a strong rationale for screening for PCOS during routine care of Indigenous women who are obese and of reproductive age.

Jacqueline A Boyle FRANZCOG, MPH · Joan Cunningham ScD · Kerin O'Dea PhD · Terry Dunbar BBus, MProfEdTraining, PhD Candidate · Robert J Norman MD, FRANZCOG, FRCPA

More comprehensive investment is needed to abate the extreme disadvantage experienced in some Aboriginal communities Poor housing, inadequate hygiene practices and household overcrowding directly or indirectly underlie many of the health and social problems present in most remote Aboriginal communities in the Northern Territory. Improving housing and hygiene and reducing household overcrowding are fundamental developmental steps to reduce the extreme disadvantage experienced in remote Aboriginal communities.1-2 These improvements are not only essential to improve health outcomes, but are also a prerequisite for the success of current government efforts to increase participation in the workforce, improve school attendance rates and develop safe communities.3 In this article, I discuss Australian and NT Government policies and programs aimed at Closing the Gap on Indigenous disadvantage in remote Aboriginal community contexts.4 Current initiativesThe Australian Government’s agenda to close the gap on Indigenous disadvantage is driven by three imperatives: to overcome decades of underinvestment in services and infrastructure; to encourage and support personal responsibility as the foundation for healthy, functional families and communities; and to build new understanding and respect between Indigenous and non-Indigenous Australians.4 The policy approach includes the identification of seven key “building blocks” to address specific areas of Indigenous disadvantage — early childhood, schooling, healthy homes, safe communities, economic participation, and governance and leadership. Through the National Partnership Agreement on Remote Indigenous Housing, the Australian Government is investing $5.5 billion nationally over 10 years “to tackle the housing backlog across remote Australia and to help reduce overcrowding in Indigenous communities”.4 Under the Strategic Indigenous Housing and Infrastructure Program (SIHIP), at a cost of $672 million, the Australian and NT governments will build 750 new homes, rebuild 230 existing houses and refurbish 2500 houses across 73 remote Indigenous communities and several community living areas (town camps) in the NT by 2013.5 A new system to manage public housing in remote communities has been introduced. This system includes introduction of tenancy agreements, payment of fair rent, an improved process for repairs and maintenance to homes, and improved tenant support services.6 Influences on the household mixDespite these initiatives, it appears that governments still do not recognise the complex social and cultural issues that underlie housing, health and social issues present in many remote Aboriginal communities in the NT.7,8 Non-Indigenous health workers in remote communities learn about some local practices because they need to be accommodated in the workplace — for example, avoidance relationships that exist between individuals (in some communities, between brother and sister) and protocols concerning “men’s business” or “women’s business”. However, little or nothing is known about how cultural observances shape householders’ day-to-day living practices, especially hygiene behaviour, and how housing infrastructure is perceived and used. Household overcrowding is more complex than a couple and their children living in a house too small for their needs.9 Rather, household membership comprises extended family members, and frequently includes one or more individuals with special needs (eg, frail older people, or people with psychiatric disorders and/or in poor health from chronic diseases). Households experience higher levels of stress when the behaviour of one or more family members is affected by misuse of alcohol, drugs, kava or petrol, or if problem gambling is an issue. More stress is added when a family member is in the court system, imprisoned or in juvenile detention. This household mix presents challenges for those caring for children, and those who wish to maintain good personal and domestic hygiene, and keep their house in a good condition. No quick fixWithout more extensive initiatives, providing a limited number of new, renovated and refurbished houses (compared with the size of the need) will not directly increase employment, improve school attendance, or make remote communities safer. That housing is seen as a quick fix is reflected in three case studies in the Closing the Gap — Prime Minister’s report 2011.4 In these case studies, it is inferred that new housing will enable one tenant to become employed; children will now attend school; and one tenant will now teach his children to keep the house clean. Research has shown that providing infrastructure alone will not resolve the social and cultural factors that shape people’s attitudes and behaviours.10,11 A need for supportIn late January 2011, the Australian Government reported the completion of 179 new houses and 1036 rebuilds or refurbishments in the NT.5 These additional and improved houses meet an urgent need, but it is of concern that very little has occurred to provide tenant support programs, such as life skills or homemaker programs, and improved repairs and maintenance services. Without these programs, any health or social gains as a result of the additional or improved housing are likely to be minimal.10,12 Communities’ desire for such support is evident from a perusal of Local Implementation Plans (plans developed through close consultation between governments and local reference groups that set out the priorities for each community as part of the Working Future program in the NT).13 Of the 11 NT Plans publicly available at the time of writing, eight indicate a desire for programs (eg, life skills and/or improved repairs and maintenance programs) to achieve healthy housing. Addressing key factorsThe size of the housing backlog, the poor state of many existing houses and the level of overcrowding suggest that four key factors need to be addressed in unison to achieve healthy housing in the remote Aboriginal community context: all existing housing stock be maintained in good condition; overcrowding be incrementally reduced by continuing to provide additional housing; appropriate, acceptable programs that are intensive and ongoing be provided to help improve standards of personal, domestic and environmental hygiene; and multifactorial tenant support programs be set up to deal with underlying social and other issues.10,14 Regrettably, there is little or no good-quality evidence available to know what interventions might work in this context. In the past, health promotion and life skill programs have either not been evaluated, or the evaluations have lacked rigour; as a result, the strength of any available evidence is poor.15 Past housing construction and repairs and maintenance programs in remote Aboriginal communities are contentious and generally viewed as failed or failing.16,17 Political imperatives driving the Indigenous health and housing agenda have resulted in a failure to accumulate a knowledge base in these areas. Reviews are conducted to monitor the management of SIHIP,16 but no mechanisms appear to be in place to prevent the unintended negative consequences of past housing policies being repeated. There is a danger that if Closing the Gap programs do not demonstrate progress (especially as this concerns housing), the commitment by governments to deal with the wider social determinants of health will lessen. Instead, narrow lifestyle interventions focusing on personal responsibility and individual behaviours will be introduced. There are examples of this happening already (introduction of tenancy agreements as the primary means to modify tenants’ behaviour;18 income management and the introduction of the BasicsCard;19 withholding the welfare payments to parents whose children do not attend school;20 and fining parents for children’s non-attendance at school21). These measures all reflect a simplified approach to deal with complex problems, and in most cases are not likely to be successful.22,23 More must be doneA recent strategic review of health inequalities in England recommended that to reduce the steepness of the social gradient in health, actions need to be universal, “but with a scale and intensity that is proportionate to the level of disadvantage”.3 The current approach to housing in remote communities falls short both in scale and intensity when compared with the extreme disadvantage experienced in these communities. To achieve major improvements in overall living conditions, and other Closing the Gap programs (especially education, employment and making communities safer), greater investment in a range of social and public health programs needs to accompany the current investment in infrastructure.

Elizabeth L McDonald PhD, MTH, BSc(Nurs)

“Sometimes you go looking for one thing and you find another” — Sancho Panza, in Cervantes’ Don Quixote1 The Arab Spring had been followed by the autumn of the euro. In Lombardy, Italy, at the Rockefeller Foundation Bellagio Center, the season of mists and the gilding of leaves had begun. There I met Paul Pholeros, as he arrived from the celebration of the United Nations World Habitat Day on 3 October this year (Box 1 and Box 2). Pholeros is Managing Director of Healthabitat (http://www.healthabitat.com), working with Dr Paul Torzillo (Medical Director) and Stephan Rainow (Community Director). This private Australian company has won the Building and Social Housing Foundation World Habitat Award for 2011. Established in 1985 as part of the United Nations International Year of Shelter for the Homeless, the World Habitat Awards recognise practical innovations for current housing needs and problems. The citation describes Healthabitat’s Housing for Health program as an initiative to improve the health of Indigenous people in Australia, by ensuring they have access to safe and well functioning housing and an improved living environment. Many Aboriginal and Torres Strait Islander people cannot take safe, functional housing for granted. That inconvenient truth holds now, even though many public health texts, assuming the obvious connection between housing and health, simply focus on emergency shelter.2 What was it about the Healthabitat approach that appealed to the judges ahead of many other projects that might have seemed more exciting? There were about 250 entries from 82 countries, as varied as the GLOBE Community Champions program, from Canada, and a post-earthquake reconstruction and rehabilitation program, from China. The safety and health principles of Healthabitat’s method were first developed in 1985 when a group of Indigenous Australians attempted to improve the health of their communities in a remote desert region of South Australia.2 Housing and the living environment were linked directly to health outcomes. The first priority of the Housing for Health program is safety from electrocution, gas explosion, fire and structural collapse, and the second is the capacity for people to wash. The program systematically works through priorities, house by house, resulting in well documented health improvements.3 “No survey without service” is the starting point, in the tradition of Cochrane and Hollows.4 Instead of vague policy promises on the never-never, Healthabitat’s work in a remote community housing project means immediate, tangible improvements. On the first morning at any house, testing of around 250 aspects of house function begins, with some fixing starting that same day, so that people can live more comfortably. Healthabitat has shown that positive change is possible and sustainable. According to Pholeros, demonstrable health improvement is the essential justification to fix housing problems; building standards alone do not motivate people. The medical and other professions could, similarly, emphasise more often the bottom line of human health in debates about social, environmental or economic improvement. Like the aims of Healthabitat, the Rockefeller Foundation seems to take a long-term view. The Foundation supported the work of Jane Jacobs about what cities should be, half a century ago. Her writing is still much celebrated, as should be the results of Healthabitat projects in coming years. Jacobs talked of urban peace ... kept primarily ... by an intricate, almost unconscious network of voluntary controls and standards among the people themselves, and enforced by the people themselves.5 The Christmas story was set in a “low-rent” district and describes shelter that was apparently adequate for childbirth. Healthabitat represents more good news that all Australians can celebrate, about health and housing, particularly for Indigenous Australians, and shows that change is not too hard or hopeless, and is possible. Before All Souls’ Day, my wife, Hilary, and I visited the Church of San Giacomo in Bellagio, Italy. The Italians proceeded with their religious observances, oblivious to tourists. Hilary lit a candle for my late brother while I searched for the ancient symbols of the evangelists. Luke, patron saint of physicians and artists, is represented by an ox in marble carvings, lost behind plaster for centuries, then found in 1907, and now rightly famous (Box 3). Christian ritual may leave you cold, but the pursuit of peace and shelter as prerequisites for health should at least appeal to those mindful of the Ottawa Charter for Health Promotion.6 The secular stories of Healthabitat remind us how vital these determinants are for improvements in Aboriginal health. 1 Paul Pholeros, Healthabitat Managing Director, with the World Habitat Award 2 Autumn in Bellagio, Italy 3 Ox carving, Church of San Giacomo, Bellagio, Italy

Charles S Guest PhD, FAFPHM

To the Editor: MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes) syndrome has not been reported previously in the Aboriginal Australian population. Here, we describe a patient with MELAS syndrome in this population. A 29-year-old Aboriginal Australian woman presented with a 3-day history of seizures and confusion and a background of cognitive impairment, sensorineural deafness, epilepsy and short stature. On admission, she weighed 29.9 kg and was 1.46 m tall (body mass index, 14 kg/m2). She had myopathic facies, generalised mild motor weakness (4/5) and brisk reflexes (3+). These neurological findings represented a stepwise deterioration from previous assessments. On admission, the patient’s blood count, liver function tests, and serum urea, electrolytes and creatinine levels were normal. Her plasma bicarbonate level, anion gap and thyroid function were also normal. The patient had elevated resting arterial lactate (2.7 mmol/L; reference interval [RI], 0.7–2.5 mmol/L) and pyruvate (98 μmol/L; RI, 30–90 μmol/L) levels. The cerebrospinal fluid (CSF) protein concentration was 820 mg/L (RI, 150–500 mg/L) and the CSF lactate level was 5.4 mmol/L (RI, 0.7–2.5 mmol/L). Magnetic resonance imaging of the patient’s brain demonstrated increased T2 signal involving grey and white matter throughout both cerebral hemispheres, most confluent in the right temporal and parietal lobes (Box 1, A). An electroencephalogram displayed a slow rhythm with epileptic activity in the temporal and centroparietal regions. Histological examination of a biopsy of the gastrocnemius muscle was consistent with MELAS syndrome (Box 1, B). Electron microscopy of a muscle biopsy sample revealed mitochondria with abnormally arranged cristae and abnormal electron densities. Mitochondrial respiratory chain enzyme studies on muscle samples were within normal limits, but the common m.3243A>G mutation in the MTTL1 gene was detected in about 70% of the mitochondrial DNA (mtDNA) in muscle tissue and in 10% of the mtDNA of the peripheral blood. MELAS syndrome is a maternally inherited multisystem disorder resulting from mutations in mtDNA.1 Mitochondrial dysfunction leads to the clinical phenotype and lactic acidosis. Cerebral ischaemia unrelated to vascular territories is suggestive of the diagnosis,2 which is confirmed by genetic studies, enzyme assays and histological examination of affected tissue.3 The patient’s family was of Aboriginal Australian descent and she was not aware of any European ancestry. Further inquiry revealed a family history of deafness, diabetes and epilepsy (Box 2). Consequently, the family were offered genetic counselling. A literature review prompted initiation of arginine and coenzyme Q10 therapy.3 Twelve months later, she had good seizure control and had not been re-hospitalised. The disproportionate differences in health between Indigenous and non-Indigenous Australians are often appropriately ascribed to environmental factors. However, potentially treatable causes should always be considered. 1 Magnetic resonance imaging (MRI) and muscle histological studies A. T1-weighted MRI of the brain showing atrophy and enhancing low attenuation lesions. B. Gomori trichrome stain showing a ragged red fibre (black arrow) and two severely atrophic denervated fibres (white arrow). 2 Pedigree of the family of the patient (arrow)

Luke J Conway · Thomas E Robertson · James J McGill · Josh P Hanson

To the Editor: We read with interest the article by Patel and colleagues,1 which suggests a high rate of critical adverse events occurring for medical students undertaking remote placements in the Northern Territory. We note also that there is significant potential for over- or under-reporting because of the incompleteness of useable documentation in their sample. Regardless, the reported figure of one-sixth of students experiencing a “critical incident” during their placement is concerning. In answer to the question in the title of Patel et al’s article — “Safeguard or mollycoddle?” — the answer is surely neither. There is obvious benefit for students in being removed from their personal, cultural, geographical and clinical comfort zones. After all, challenging and evaluating one’s preconceptions and personal boundaries is essential for personal and professional development. However, it is vital that this is done in a safe and well supported manner, such that both the student and the community into which he or she is placed benefit from the experience. As noted by Patel et al, there is evidence from the United Kingdom that structured placements that are regularly evaluated, adequately planned and firmly grounded in clinical ethics are able to maximise the placement experience for both students and communities.2 In our minds, the key to quality in clinical placements is excellent administrative support and clinical supervision that is appropriate for the level of the student. Recently, there has been a concerted push in medical training to encourage students to gain experience in rural and Aboriginal communities. This is generally well received by Australian medical students. In light of increasing student numbers, it is likely that these alternative clinical training environments will see an increase in student traffic in the coming years. The article by Patel et al1 has highlighted that not all experiences in these settings are positive. Due to persisting rural workforce shortages, we are concerned that students who are unwilling and potentially unsuitable to undertake remote placements may be forced to do so through their medical programs or bonded medical places. We strongly urge the providers of placements and those who fund them to critically evaluate their current practices surrounding clinical placement planning and support. Most importantly, adequate supervision, matched to the individual attributes of the student, should be an absolute requisite for any placement.

Andrew D Webster · Robert D Marshall · Lee J Fairhead · Trent Little · Falk Reinholz

To the Editor: A daunting idea for health care providers is the statistic that, for many medications, only about half of the patients given standard doses will receive the desired therapeutic benefit.1 In the past decade or so, it has been argued that some of this variation in response may be attributed to genetic differences between individuals in mechanisms responsible for the pharmacokinetics and pharmaco-dynamics of many drugs.2 The disparity in health standards among Aboriginal and Torres Strait Islander people compared with non-Indigenous groups is a cause for concern, and requires a concerted political effort to instigate adequate solutions.3,4 Some of the problems include a higher rate of diseases such as hypertension, diabetes, obesity, cardiac disease and depression.3,4 The range of medicines prescribed for these conditions is broad, and some people may not receive the full therapeutic benefit, or may have more severe side effects compared with others. Genetically determined variables contribute to the pharmacokinetics and pharmaco-dynamics of these drugs. Many medications used to treat such diseases are metabolised by the cytochrome P450 (CYP) hepatic enzyme systems, and/or their pharmacokinetics are altered by drug influx and efflux systems. Many of these mechanisms are under genetic control and their efficiency may vary between individuals. Despite this, there are few data on the pharmacogenetics of Indigenous populations generally, and the data on Aboriginal and Torres Strait Islander populations are particularly scant.5 Of the few genetic studies of Indigenous Australians, one found that CYP2C19 and CYP2D6 allele frequencies in a group from remote north-western Australia differed significantly from those for Australians of European ancestry, but were similar to those for East Asian populations.5 An altered CYP2C19 allele could mean alterations in levels of drugs such as phenytoin and clopidogrel, and an altered CYP2D6 allele could mean alterations in levels of drugs such as tricyclic antidepressants, selective serotonin reuptake inhibitors, codeine and tamoxifen. We urgently need to identify clinically relevant issues relating to the capacity of people from these groups to metabolise certain medicines. Screening for genetic variations in drug metabolism and transport mechanisms may highlight significant variations in capacity. This may influence whether people benefit from or are harmed by commonly prescribed medications for hypertension, type 2 diabetes, cardiac disease and depression. The high and increasing prevalence of these diseases among Aboriginal and Torres Strait Islander populations supports a detailed, methodical assessment of the genetics of their drug-metabolising capacity.

Joseph D Tucci

To the Editor: In his thought-provoking editorial in the May issue of the Journal,1 Tait made reference to an apparent recent improvement in the life expectancies of Indigenous Australians by citing a 2010 Australian Bureau of Statistics (ABS) report entitled The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples, Oct 2010.2 In this report, the life expectancy for Indigenous Australians was quoted as 67.2 years for males and 72.9 years for females, compared with 78.7 and 82.6 years for non-Indigenous males and females, leaving a “gap” of 11.5 years and 9.7 years, respectively. These figures are from 2005–2007 (which includes the 2006 Census year), and are quoted again in this year’s update report from the Australian Institute of Health and Welfare.3 At first glance, they appear to be a startling improvement on the figures from 1996–2001, which quote (as late as 2005) Indigenous life expectancies of 59.4 and 64.8 years for males and females respectively, representing a “gap” of about 17 years for both.4 Unfortunately, the apparent improvement represents not a miraculous leap forward in Indigenous health care and outcomes, but rather a change in the methodology used to calculate life expectancies around the time of the 2006 Census. The essence of the change was from an indirect to a direct demographic method of compiling life-expectancy estimates, which entailed correcting Indigenous death registration data before calculating death rates. The ABS anticipated the potential for confusion (not to mention premature celebration), and so included warnings that comparisons should not be made between published estimates of Indigenous life expectancies on their website and in subsequent reports, as well as producing a discussion paper outlining and justifying the changes.5 The October 2010 ABS report explicitly stated that: “Differences should not be interpreted as measuring changes in Aboriginal and Torres Strait Islander life expectancy over time”.2 As with any statistical analysis, the underlying issue is the quality of the data. As we continue to work to narrow the “true” Indigenous life-expectancy gap, we need to be mindful of the importance of accurate record-keeping, including the identification of Indigenous status, if future analysis of mortality statistics is to stand up to scrutiny.

Lachlan J McIver

I was raised by my mother with my two older sisters and attended the local state schools, where I did it all — sport, music, even public speaking competitions. I’m not really that different, although I do remember clearly being told by some of the other kids, “You’re not like other black people”. I find that comments like this are made more commonly than they should be. They are generally unsettling and, ultimately, amusing for a number of reasons. What is it about me that was different to “those other black people” that I would stand out? My education is unexceptional in modern Australia: 12 years of school followed by an undergraduate degree in medical science. I have recently completed the Master of Applied Epidemiology through the Australian National University, which has started me on a career in health research. Why should anyone regard this as “different”? Many times when I was starting out in research I felt a deep sense of obligation to work in Aboriginal and Torres Strait Islander (hereafter respectfully referred to as Indigenous) health. I thought my career would only ever be in Indigenous health or involve Indigenous “issues”, and my growing expertise would only ever be appreciated in that arena. I do feel compelled to be somewhere at the forefront of Indigenous health research trying to rectify the history of colonisation that, let’s face it, is always the crux of our peoples’ issues. Over the past few years I have been involved mainly in cancer research projects. Cancer provides a typical example of the inequity experienced by Indigenous peoples. Compared with non-Indigenous Australians, our cancer incidence rate is similar, if not lower, for all cancers combined,1-3 and yet our mortality rate is estimated to be 50% higher for many cancers.4 Our cancer patients have more comorbid disease;5 their cancer is more advanced when diagnosed3,5,6 and they are less likely to take up and complete treatment.5 These factors contribute to their poorer survival, but they do not fully explain the disparity. This disparity is almost absurd in our modern times but, sadly, is our country’s reality. The most profound moment of my career so far took place in a small remote community. I had the privilege of conducting an interview with an Indigenous cancer patient who was receiving palliative care. I had an almost out-of-body experience as I sat intently listening to this person share her cancer journey. As a researcher and as an Indigenous person I was powerfully moved by her story, her family history and the circumstance of what she and her family were facing. She told me she had to leave her community, on her own, to go to two different cities for chemotherapy and radiotherapy when she was first diagnosed. The doctor at the local hospital in their community “didn’t do that much” even when the patient “knew it came back”. When the doctor did do something, he said, “Don’t like the look of that”. The most heartrending part of our interview was hearing firsthand about the stigmas within that community — “There is no community support, people are scared to visit”. To me, this person embodied the documented literature describing the many barriers that are experienced by Indigenous people in response to their dire health issues: living remotely, having to travel for treatment, and enduring social and even cultural isolation. Until that time, I had thought my obligation towards Indigenous health came from outside pressure and expectations; after that interview, I knew that these feelings were deeply personal. In recent years, our governments have given much greater attention to improving Indigenous health. I believe now is the time to reflect on how we conduct research with Indigenous people, to adapt with changing times and to maximise the application and benefits of research findings across the continuum of health. We can take no more chances with the health of our Indigenous peoples. The right methods, the best practice and the leading researchers and health professionals must be involved in rectifying the health and livelihood of our first nations. We know that the interconnection between health and its social determinants — housing, education, opportunity for employment, socioeconomic status and the like — is central to health improvement. The interconnected web of social habits and social status reflects the health of all people. As a society we seem slow to be shocked by the disparity in health issues, even life expectancy, for Indigenous peoples, and much quicker to blame individuals for not taking responsibility for their own health. While this can be true, it’s not central to the reasons why Indigenous peoples’ health is so poor. We seem to “forget” that there are many social problems that exist that stem from years of oppression, including fear of having to access mainstream health services, low socioeconomic status, disease from poor housing conditions and overcrowding, and lower levels of education that lead to lower rates of employment. We need to reconsider our approach to research to properly account for these factors and not just describe them as a fact that will remain unchanged. Indigenous health research remains Westernised — the “one disease at a time” approach. I believe that, until we move towards the holistic health approach with which Indigenous people identify, we will lessen the impact of current research by underselling the outcomes to government, thereby failing to secure future funding, making research findings non-transferable to policy and practice. This is where the next generation of researchers can take us, to enforce the inclusion of those social determinants and look holistically at research. I don’t know the “ideal” way of performing such research, but I believe there is a tangible method that we can find. In a perfect world, I see great health research being performed with good policy and practice outcomes that directly influence change in other social determinants, such as education. In essence, everything fundamental to my opportunity and progression contributes to “not being like other black people”. Some still consider my opportunity and success in education rare, or against the norm. Statements like this are not only made by non-Indigenous people. In fact, I find the most unsettling and upsetting comments are made by other Indigenous people. It saddens me when I hear them dismiss or denigrate the value of education. As more Indigenous people achieve a level of education equal to other young Australians, these attitudes will change, as they must if all Indigenous Australians are to overcome educational, economic and social disadvantage. We will then no longer be seen as different, but as skilled and educated people who bring a wealth of knowledge and inner culture that only an Indigenous person can have. Our skills will be valued and respected and our contribution will not be considered tokenistic. The achievement of education for Indigenous people and their employment in health-related roles is essential to improving health among the Indigenous population. My primary reason and motivation for working in Indigenous health is because it is the greatest area of need in Australia — it’s morally the right thing to do, regardless of what my cultural heritage is. However, when I reflect on my inner driving force to work in Indigenous health, I believe it comes from an inner obligation of personal connection and contribution. This obligation is not something I have always felt at peace with. I have never wanted to be boxed into thinking that I could or would only work on Indigenous issues, as I am made to feel when I hear other people comment that only Indigenous people should conduct Indigenous research. In some situations, this is very true, appropriate and culturally safe, but in other ways this is a perfect example of resistance to change. We have a long way to go, and I believe that it is a step in the right direction for as many people as possible to come on board and offer their skills. We have a lot to learn, but we also have a lot to teach. I’m sure any other Torres Strait Islander or Aboriginal person can relate to the sense of pride inspired by our community occasions — not pride in oneself, but in our community. What an incredible journey our people have had and are still on; after the years of oppression we can still come together and be proud of what we have achieved together. The list of health problems is long for our Indigenous peoples. They can appear overwhelming and sometimes disheartening to someone working in the health field. However, if any population is resilient enough to overcome these health issues, it certainly is the Indigenous population of Australia. Now we need to use that same sense of community pride and dedication to drive improvements in better health outcomes. I often think about the woman I interviewed a little while ago. Her story alone is a motivator for working in Indigenous health; from diagnosis, to treatment, to palliation, there are improvements to be made. Indigenous health needs commitment. It needs focus and continuous drive. So, where can I be the most useful and make the biggest contribution for Indigenous health? I don’t know the answer yet, but I feel privileged to be part of it. And I will have a story to tell.

Lisa J Whop BMedSc, MAppEpid

To the Editor: In their article on the decline of infectious syphilis in the Australian Indigenous population from 2005 to 2009,1 Ward and colleagues conclude that it “might be the right time to move toward the elimination of infectious syphilis from remote Indigenous communities”. They note that another previously endemic sexually transmitted infection, donovanosis, has almost completely disappeared from Australia as a result of an elimination program.2 I strongly support their call to action and believe that syphilis can, and should, be next. It is likely that, outside of the small number of communities who have been able to implement a coordinated screening program, the decrease in syphilis in remote areas is an unintended benefit of the use of azithromycin for genital chlamydia and trachoma, and amoxicillin for gonorrhoea. Syphilis is only transmissible to sexual partners for a few weeks during the primary phase (when a chancre is present) and during the secondary phase (when mucocutaneous lesions may be present). Although syphilis is highly infectious during these stages, the relatively short duration of infectiousness partly explains why it is less common than other bacterial sexually transmitted infections. Because the painless ulceration of syphilis is easily ignored by men, or may go unnoticed by women with genital lesions, the diagnosis and treatment of latent (ie, subclinical) disease has been the main focus of syphilis control in remote areas. This approach has had only a limited effect on reducing the incidence of infectious syphilis. Indeed, as latent disease detection and treatment improves, there may be a paradoxical increase in the incidence of infectious cases because latently infected individuals become susceptible to new infection again after treatment.3 Therefore, detection and treatment of all cases of early, infectious syphilis must be the aim of an elimination program, but it will be extremely difficult to achieve this in a remote or rural setting using current diagnostic strategies that almost exclusively rely on serological testing. Serology is still the mainstay of syphilis diagnosis, despite the development of sensitive and specific polymerase chain reaction (PCR) tests for Treponema pallidum. Multiplex PCR tests that can also detect herpes simplex and donovanosis have been used to diagnose genital ulcerative disease in remote areas of Australia,4 but not to screen asymptomatic individuals. The validation of a syphilis PCR test that can be used to identify early, infectious syphilis should be a research priority — one that could be carried out as part of an Australian Government-funded, centrally coordinated but locally implemented, targeted syphilis elimination program.

Francis J Bowden

To the Editor: Recently, Professor Hoy argued for the full inclusion of Aboriginal and Torres Strait Islander people in the Australian Health Survey (AHS), including the measurement of clinical variables and the proposed sample repository.1 Although much of the argument is plausible, several points were overlooked that make it untenable overall. First, the current study design arose with input from at least five Indigenous representative bodies, including the National Aboriginal Community Controlled Health Organisation.2 They identified social and cultural issues as priority areas to be addressed — correctly so, as the underlying causes of health disparity are located in these domains, not primarily in the clinical and biomedical aspects of the AHS. The input from these major national bodies cannot be ignored. Second, yes — there are concerns that “the stored samples and their results might be somehow misused”.1 These concerns are legitimate and well founded in historical and contemporary experiences of Indigenous people. The argument for applying “current scientific and epidemiological knowledge, methods and safeguards”1 to the use of information held in the AHS is correct as far as it goes, but ignores equally important Indigenous knowledge and methodologies, Indigenous intellectual property issues, the principles of “ownership, control, access and possession” of Indigenous information,3 and certain aspects of the United Nations Declaration on the Rights of Indigenous Peoples. This position is therefore inconsistent with the National Health and Medical Research Council guidelines on values and ethics in Aboriginal and Torres Strait Islander health research, particularly as they relate to “survival and protection”.4 Third, denying Indigenous people control over how their health information is used by mainstream research institutions prevents accountability of researchers to communities. Using and publishing this information requires review by relevant experts, in this case Aboriginal and Torres Strait Islander community representatives. Biomedical expertise alone is insufficient to enable effective peer review and, at worst, it risks promoting destructive policies that ignore social, cultural and political realities for Aboriginal people and Torres Strait Islanders. Aboriginal people and Torres Strait Islanders rightly feel that they have been one of the most researched groups in history. And yet, even with this background of decades of being constantly studied, researched and examined, it seems that there is still not enough information being collected. Wellbeing is “grounded in the respect given to people, and the control afforded to them, in their daily lives”.5 Sometimes it’s up to Aboriginal and Torres Strait Islander people to identify what is important in Aboriginal and Torres Strait Islander health: it’s our health!

Kevin G Rowley · Alister H Thorpe

In reply: I thank Dr Rowley and Mr Thorpe for their response.1 It is hard to justify exclusion of any Australian from opportunities to participate fully in important initiatives on the recommendation of bodies whose membership sometimes has no direct link to the persons affected. There is no other population group in Australia to whom this applies. Medical and clinical approaches should complement initiatives to address critical social and cultural issues; they are not in competition nor mutually exclusive. The inclusion of health measures in the adult (but not youth) components of the Australian Health Survey (AHS) acknowledges that there is much to be learned and remediated clinically. Any interpretation of the deliberate exclusion of Indigenous youth from the “measures” elements of the survey is unsettling. There is more, not less, to be learned from this group. Their exclusion deprives policymakers of robust evidence that could improve health status. It condemns enquiry to the current sidestream method of short-term research projects on small pockets of people. These sometimes yield results of dubious generalisability and cause ongoing competition for the impossibly stretched research dollar. Alternatively, is it implied that Indigenous parents are less able to make sound decisions on their child’s participation or that the minors are less likely to cooperate? I suggest that the matter of participation in the AHS be aired through general media channels, as well as those with an Indigenous focus, such as “Living Black” (SBS television) and Imparja television, and through local Indigenous radio stations and community networks. With a developed sampling frame for Indigenous people, dialogue about elements of the examination should at least be conducted with the specific individual tribal groups or communities, if not with the targeted individuals (the preferred option). Subsequently, the whole issue of representation to policymakers in Indigenous health matters might be re-examined on a national basis.

Wendy E Hoy

To the Editor: Although Indigenous males are twice as likely and Indigenous females are half as likely to report being diagnosed with osteoporosis compared with their non-Indigenous counterparts,1 data on the interracial differences in osteoporotic risk factors are limited. Our study of 276 patients attending a tertiary hip fracture unit in Western Australia over a 5-year period is the first to report differences in common risk factors for hip fracture between Indigenous and non-Indigenous patients. Our data showed a lower likelihood of vitamin D deficiency and polypharmacy but higher likelihood of diabetes mellitus, renal disease and alcohol use among Indigenous patients with hip fracture compared with non-Indigenous patients. Using the local orthogeriatric database, we identified 46 Indigenous and 230 randomly selected non-Indigenous patients aged ≥ 45 years who were transferred to a hip fracture unit following surgery for a minimal-trauma fracture at Royal Perth Hospital from July 2005 to June 2010. High alcohol use was defined as alcohol intake exceeding guideline recommendations,2 and polypharmacy as the use of more than five medications. We used a laboratory cut-off of 25-hydroxyvitamin D (25-OHD) < 50 nmol/L to indicate a low vitamin D level. Indigenous status was self-reported during admission. We compared data for Indigenous and non-Indigenous patients using the Mann–Whitney U and Pearson χ2 tests. We used logistic regression (SPSS version 17; SPSS Inc, Chicago, Ill, USA) to examine the association between Indigenous status and the predictor variables. Our study was exempted as a quality assurance activity from formal ethics review by the Royal Perth Hospital Ethics Review Committee and the Western Australian Aboriginal Health Information and Ethics Committee. Risk factors among the two groups are shown in the Box. The most common risk factors among Indigenous patients were antihypertensive use, high alcohol use and diabetes. In the final multivariate model, Indigenous patients with hip fracture were significantly more likely to have diabetes and renal disease and to report high alcohol use, but significantly less likely to have a low vitamin D level and polypharmacy, after adjustment for age, sex and rural residency. These well described risk factors contribute to fracture risk through two mechanisms: falls and secondary osteoporosis. Diabetes-related complications such as visual impairment, stroke and peripheral neuropathy can increase fracture risk.3 In renal dysfunction, osteoporosis is related to cortical thinning and uraemic osteodystrophy.4 Excessive alcohol intake at a young age among Indigenous people may affect peak bone mass.5 The effect of alcohol on liver cirrhosis, cognition, falls due to intoxication and peripheral neuropathy may contribute to fracture risk. Risk stratification will be more robust if these results can be cross-validated in other institutions. Associations between hip fracture and risk factors in Indigenous patients compared with non-Indigenous patients at Royal Perth hospital, July 2005 – June 2010 Variable Indigenous (n = 46) Non-Indigenous (n = 230) P* Crude OR Adjusted† OR (95% CI) Continuous (mean [SD]) Age at hip fracture‡ (years) 81.4 (9.1) 82.3 (9.4) 0.58 0.99 1.03 (0.96–1.10) 25-OHD level (nmol/L) 59.9 (30.2) 40.9 (18.6) < 0.001 – – Categorical (no. [%]) Women 29 (63%) 161 (70%) 0.35 1.11 2.52 (0.51–12.31) Non-metropolitan 42 (93.3%) 38 (16.6%) < 0.001 70.37 70.32 (14.43–342.59) Low vitamin D level§ 15 (38.5%) 142 (69.6%) < 0.001 0.27 0.26 (0.07–0.91) Prior fracture 9 (19.6%) 52 (22.6%) 0.65 0.83 0.42 (0.09–1.90) High alcohol use¶ 19 (41.3%) 10 (4.3%) < 0.001 15.5 13.25 (1.89–92.92) Diabetes mellitus 21 (45.7%) 41 (17.8%) < 0.001 3.87 8.19 (2.02–33.18) Renal disease 16 (34.8%) 21 (9.1%) < 0.001 5.31 6.12 (1.29–29.05) Polypharmacy** 18 (39.1%) 137 (59.6%) 0.01 0.44 0.17 (0.04–0.72) Antihypertensive use 26 (56.5%) 118 (51.3%) 0.52 1.23 2.75 (0.70–10.76) 25-OHD = 25-hydroxyvitamin D. OR = odds ratio. * Mann-Whitney U or Pearson χ2 test. Level of significance: P < 0.05. † Multivariate logistic regression. ‡ Minimal-trauma fracture. § 25-OHD level < 50 nmol/L. ¶ Alcohol intake exceeding guideline recommendations.2 ** > 5 drugs.

Michelle M Y Lai · Nicholas G Waldron

Building on a successful program to extend PBS copayment relief to more patients Cost is a well established influence on both access to medicines and medication adherence rates. Prescription fees can lead to patients forgoing essential medications and to a decline in health care status among needy populations,1,2 an observation that is very familiar to Aboriginal community-controlled health services (ACCHSs). While capped patient copayments and the Pharmaceutical Benefits Scheme (PBS) Safety Net minimise the medication cost burden on all Australians, these mechanisms are ineffective for many Aboriginal and Torres Strait Islander peoples. The reasons for this include high rates of unrecorded concession and Safety Net status, disproportionately higher rates of chronic disease and comorbidity, extended social and family obligations, “shame” in accessing prescriptions in culturally alienating settings, high patient mobility, and poor health literacy. PBS utilisation is further reduced in this population by factors that preclude medicines storage and adherence, such as overcrowding, and disease profiles that are inconsistent with medicines listed on the PBS. The Council of Australian Governments (COAG) National Indigenous Reform Agreement of November 2008 led to strategies designed to close the gap in Aboriginal and Torres Strait Islander people’s life expectancy.3 One of these strategies is the $88.7 million “Subsidising PBS Medicine Co-payments” measure,4 which commenced in July 2010 and is predicted to provide financial assistance to “over 70 000 Indigenous people”, to improve their access to PBS medicines.3 This measure was, in fact, built on an existing program — Quality Use of Medicines Maximised for Aboriginal and Torres Strait Islander Peoples (QUMAX)5 — the details and outcomes of which have been kept under wraps until the recent release of the findings of an independent evaluation.6 The QUMAX program, which commenced in November 2008, aimed to overcome a range of known barriers to Aboriginal and Torres Strait Islander peoples’ access to medicines, and was jointly developed and managed by the National Aboriginal Community Controlled Health Organisation and the Pharmacy Guild of Australia, and funded by the Australian Government under the Fourth Community Pharmacy Agreement (2005–2010). Aboriginal and Torres Strait Islander patients could access the QUMAX program through ACCHSs in rural, regional and urban (ie, non-remote) areas. The cost of medicines for eligible needy and disadvantaged patients (as defined in the business rules for the program6) was subsidised through an online system of coordinated, secure and accountable copayment relief arrangements between ACCHSs and participating community pharmacies. The program also supported local quality use of medicines (QUM) initiatives through support pharmacists assigned to each ACCHS, provided QUM education for ACCHS staff, provided dose-administration aids and transport for the delivery of medicines, focused attention on patients’ PBS Safety Net entitlements, and fostered collaboration with community pharmacies — all within the context of culturally appropriate primary health care. Administration of QUMAX was lean, with the majority of the funds appropriately devolved to supplying medicines. The independent evaluation showed almost universal participation by ACCHSs (69 of 70) and involvement of 541 community pharmacies. The capped nature of QUMAX funding to each ACCHS meant that only 20% of the services’ Aboriginal and Torres Strait Islander clients (nearly 34 000 of the 171 094 patients who attended the participating services annually) could receive support for medicines and medication aids. Over 271 000 medicines were dispensed to these patients with the PBS copayment waived.6 Between November 2009 and April 2010, the proportionate increase in the number of PBS medicines dispensed to patients of non-remote ACCHSs was nearly five times greater than the increase in medicines dispensed to all Australians, and exceeded the increase seen in remote areas by a factor of seven. Greater access to medicines for chronic disease (lipid-lowering, antihypertensive and asthma medications) accounted for most of the increase. This increase occurred on a background of substantial inequities in access to medicines. In the 2006–07 financial year, for every dollar per person spent on PBS medicines for non-Indigenous Australians, only 60 cents was spent on Indigenous Australians.7 Among Aboriginal and Torres Strait Islander peoples, geographical disparities in access to medicines had been the reverse of those expected — Aboriginal peoples in non-remote parts of Australia had lower PBS expenditure per person than those in remote locations ($159 in major cities versus $223 in remote and very remote areas).7 This is probably due to the enduring success of another scheme — the special PBS arrangements under section 100 of the National Health Act 1953 for the supply of medicines to remote-area Indigenous health services.8 It is unclear if QUMAX has alleviated the PBS expenditure inequities, but the evaluation report states that, for Aboriginal and Torres Strait Islander peoples, there is “strong evidence that the QUMAX program has helped to overcome the financial barrier to accessing PBS medicines in non-remote areas”.6 In addition to patients of non-remote ACCHSs, the new PBS medicine copayment measure now extends copayment relief to eligible Aboriginal and Torres Strait Islander people who have, or are at risk of, chronic disease and are patients of any private general practice. Although the QUMAX program no longer includes the copayment relief element, it has been extended until 2015 under the Fifth Community Pharmacy Agreement to continue to augment QUM within ACCHSs. PBS listings have also improved, with more medicines now available for conditions that predominate in the Aboriginal and Torres Strait Islander population.9 There is no doubt that ACCHSs have substantially improved access to medicines for their disadvantaged Aboriginal and Torres Strait Islander patients and will continue to do so — to a level likely to eliminate disparity. They are able to do this through multifaceted strategies built on their intense community knowledge and involvement. When gauging the impact of the Subsidising PBS Medicine Co-payments scheme, it will be crucial for data on PBS utilisation by Aboriginal and Torres Strait Islander peoples to be disaggregated by “service type”. While ACCHSs participating in QUMAX have transitioned readily to the new copayment measure, its effectiveness in the private general practice sector now needs to be explicitly understood.10

Sophie Couzos FRACGP, FACRRM, FAFPHM · Vicki Sheedy BA, BEd · Dea Delaney Thiele PGDipHlthMgt

To the Editor: I spent my fifth-year medical student elective at Alice Springs Hospital and a remote Aboriginal settlement in the north-west of South Australia in the early 1980s. I organised this myself and came away with a fairly firm belief that the health of the Indigenous population in remote areas was unlikely to improve. Between 1995 and 2009, I visited remote Aboriginal settlements and hospitals in Darwin and Alice Springs as a specialist physician. Nothing I have seen in that time has changed the view I formed as a student. During my time in these settings, I have seen in the Indigenous population extreme examples of poverty, severe neglect of children and adults with disability, and examples of physical and sexual abuse. On occasions I have been threatened, and at times I have needed to be escorted for my safety. When staying overnight on settlements, I have been provided with secured accommodation. I have walked in fear of feral and diseased camp dogs and have been hurried along in my work to avoid cultural incidents. The article by Patel and colleagues explores some of the issues in this area as they affect medical student training.1 I think it is good that they have done so, but to dress it up with quasi-scientific methodology is unnecessary. My view is that it is not possible to provide or sustain health services of any reasonable standard in small and remote communities that have no economic basis for development and where the population is poor, poorly educated and has little prospect to share in this country’s fortune. There is a reason that we are failing to improve the health of the Indigenous population in remote areas, and that is that we cannot. It is an unrealistic expectation. This needs to be acknowledged, and we all need to move on.

Adrian N Winsor

To the Editor: In their editorial about risks to medical students in rural and remote placements, Peachey and McBain-Rigg stated: 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.1 They referred to such issues as a “philosophical quandary” and went on to use a metaphor about a breaking bungee rope. The editorial conflated two important issues: safety and character-building experiences. The safety of visiting medical students and workers is not a philosophical quandary. Requirements of occupational safety are a practicable matter and a matter of law. Employers are required to assess and manage risks. The editorial’s authors are from Queensland, where the current relevant legislation is the Workplace Health and Safety Act 1995. Assistance is available from state workplace safety bodies, such as Workplace Health and Safety Queensland. Patel and colleagues made a good empirical assessment of adverse events that have happened to medical students in remote areas.2 Such an assessment could contribute to a safety management plan and system. Patel et al stated that “a ‘distressing’ incident does not necessarily lead to an overall negative placement and may in fact be a powerful learning experience”. They gave the example of a female student who was not met when she got off a bus at a remote community at 3 am, which concluded with the student’s words that the placement was a “good placement medically”. A worker might implicitly or explicitly approve of any risk that he or she is exposed to, but this does not relieve the employer of its obligations to the worker’s safety. Inviting readers to look on the bright side of safety shortcomings is not in the best interests of medical students, the permanent workforce or the population of rural and remote areas.

Andrew W Nielsen

In reply: It saddens us that Winsor’s experiences as a remote visiting specialist are so depressingly familiar, but his nihilism is even more disturbing. There has in fact been improvement in the health of the Indigenous population in remote communities; examples of this include the evidence provided by articles in the very same issue of the Journal, by Margolis and colleagues (falling rates of serious injury retrieval) and Ward and colleagues (declining syphilis rates).1,2 An understanding of the social determinants of health is essential to accepting that we can indeed work towards improving health, perhaps not through focusing on specialist medical services but rather in the broader primary health care context. Our students and patients deserve clinicians and mentors who might inspire and look for solutions, rather than retreat into despair. Progress in closing the gap will be far slower than many imagine, but it is not impossible, as we have already seen. We totally refute that we used a “quasi-scientific methodology”. Our study is a simple retrospective audit with not a P value in sight,3 and it has no pretensions to be otherwise. It aims to present a clear story from a defined group, and to add to the many individual anecdotes, such as Winsor’s, that on their own do not gain the attention of employers, policymakers, or government. By building a body of evidence, surely we will be able to more effectively advocate for systemic changes. Collaborating with interested colleagues such as remote area nurses who have published more widely on their own adverse experiences4 is another key strategy in influencing change. We agree wholeheartedly with Nielsen’s viewpoint that obligations to workplace health and safety legislation and to company policy and procedures should be paramount. However, this breaks down when individuals employed or contracted in various capacities are incompetent, ignorant, stupid or just have a sheer disregard for the rules. In addition, there appears to be a lack of scrutiny in remote areas where lower standards are somehow acceptable, and legal frameworks somewhat more fluid. The romanticisation of the bush and the culture of “making do” is partly responsible for the laissez-faire attitude to occupational health and safety. Perhaps our metropolitan colleagues could assist in challenging the status quo and the deeply entrenched beliefs, attitudes and systems that collude in silencing questioners and burnt-out staff.

Ameeta Patel · Margaret Vigants

This article reviews the history of general practice vocational training in Aboriginal and Torres Strait Islander health, identifies current initiatives and recommends future approaches based on recent evidence. General practice vocational training in Aboriginal and Torres Strait Islander health requires ongoing support and investment from governments and training and general practice organisations if the gains made to date are to be consolidated and health outcomes are to improve. In particular, investment in sustained and respectful partnerships with Aboriginal and Torres Strait Islander peoples and organisations will continue to provide the groundwork for effective training of general practitioners in this critical health area, and will also play an important role in capacity-building in Aboriginal and Torres Strait Islander communities.

Mary E Martin · Jennifer S Reath MB BS, FRACGP, MMed

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