Indigenous health

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

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