Indigenous health

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

Peter H N d’Abbs PhD

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

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

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

Wendy E Hoy BSc(Med), FRACP, AO

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

Michael Marmot PhD, FRCP, FFPHM

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

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

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

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

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

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

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

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

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

Kerry Arabena BSocWk, PhD · David Moodie BA

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

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

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

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

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

Alison Dimer

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

Luke B Mallie BA Visual Art(Fine Art)

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

Lindy L Moffatt DipCommWelfareWork

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

Darren C Garvey BPsych, PostGradCertEd, MHlthProm

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

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

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

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

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

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

I have been living at Shalom College for four years. It has been a life-changing experience for me. I have had time to work hard at uni, in a racism-free environment in which Indigenous students can live proudly. Without this 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.— Josef McDonald, 5th Year Medicine, University of New South Wales, Shalom Gamarada Scholarship Recipient The Shalom Gamarada scholarship program is funded both by the sale of work by Aboriginal artists at the annual, week-long Shalom Gamarada Ngiyani Yana exhibition and by the provision of scholarships by private donors and corporate sponsors. The name of the program comes from the term “gamarada ngiyani yana” in the Eora language and translates to “we walk together as friends.” “Shalom” is a Hebrew word, meaning peace and is part of the name of the Shalom College at the University of NSW. The program was founded in 2005. In 2010, the sixth exhibition and sale will run from 27th June to 4th July. This year's contributors include the internationally renowned contemporary Indigenous artist, Judy Watson. Other artists include Regina Wilson, Weaver Jack, Jan Billycan and Shorty Jangala Robertson. There will be much sought after ceramic works from the Bagu community from Girringun in Queensland. This year, we will be displaying specially commissioned walls which will include works from Utopia and commissioned installations from Yuendumu and Peppimenarti. For the first time, the exhibition will present new work from the community of Martumili from the Pilbara. Exhibition audiences will be offered a unique opportunity to experience an incredible and diverse range of Indigenous art practice from across Australia. Shalom Gamarada will showcase an extensive range of more than 120 stretched artworks hanging and many more unstretched works, some of which can be seen in this issue of the Journal (Box 1, Box 2, Box 3, Box 4, Box 5, Box 6, Box 7, Box 8, Box 9, Box 10), with a total value of over one million dollars. All artworks will be available for purchase, with prices ranging from a modest $150 to more than $25,000. Commissions from all art sales go to residential scholarships for Aboriginal and Torres Strait Islander Medical students at Shalom College. The Shalom Gamarada scholarship program was set up in 2005 to boost the numbers of Aboriginal and Torres Strait Islander medical students attending the University of NSW and runs in partnership with the UNSW’s Shalom College and the Muru Marri Indigenous Health Unit. Since its inception, the Shalom Gamarada Aboriginal art exhibition has been able to assist 24 students to study medicine, optometry and medical science, covering board and lodging expenses so students are able to focus solely on excelling in their studies. Each scholarship is valued at over $15 000 per year for the duration of the degree. We graduated our first Shalom Gamarada doctor in December 2009, Dr Beth Kervan. This year, another scholarship recipient and UNSW’s first Aboriginal optometry student, Jenna Owen — who was the top student in 4th Year Optometry in 2009 — will graduate. Details of the Exhibition and show Open: 11 am to 7 pm each day from 27 June to 4 July Address: Caspary Learning Centre, Shalom College, University of New South Wales, Kensington (enter via Barker St) Admission: Free More information: visit http://www.shalomgamarada.org/ or call Professor Lisa Jackson Pulver on 0404 859 989. Artist: Paddy Sims 1. Artist: Regina Wilson 2. Artist: Shorty Jangala Robertson 3. Artist: Jakayu Biljabu 4. Artist: Collaborative work by Mangkaja Arts, Fitzroy Crossing, WA 5. Artist: Wakartu Cory Surprise 6. Artist: Jimmy McKenzie 7. Artist: Judy Watson 8. Artist: Regina Wilson 9. Artist: Regina Wilson 10. Artist: Kathleen Petyarre The dance of life (cover image) Artist: Helen Milroy The dance of life painting is the last in a series depicting a multidimensional model of health and wellbeing from an Aboriginal perspective. The final painting brings all of the dimensions together to reflect the delicate balance of life within the universe. The dimensions include the biological or physical dimension, the psychological or emotional dimension, the social dimension, the spiritual dimension and finally, but most importantly, the cultural dimension. Within each dimension, there are additional layers to consider, including the historical context, traditional and contemporary views as well as gaps in our knowledge. The potential solutions for healing and restoration of wellbeing come from considering additional factors encompassing issues at the coalface of symptom presentation and service delivery, such as education and training, policy, sociopolitical context and international perspective. As this painting suggests, we can only exist if firmly grounded and supported by our community and spirituality, while always reflecting back on culture in order to hold our heads up high to grow and reach forward to the experiences life has waiting for us. The stories of our ancestors, the collective grief as well as healing, begin from knowing where we have come from and where we are heading. From the Aboriginal perspective, carrying the past with you into the future is as it should be. We are nothing but for those who have been before, and the children of the future will look back and reflect on us today. When we enable a person to restore all of the dimensions of their life, then we have achieved a great deal. When all of the dimensions are in balance within the universe, we can break free of our shackles and truly dance through life.

Lisa R Jackson Pulver

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

To the Editor: Eades and colleagues identify the scarcity of data on the health and health care needs of Aboriginal Australians.1 This is particularly so for Aboriginal children in urban settings. The Gudaga Study2 has actively worked to redress this shortcoming. The Gudaga Study (Gudaga being an Aboriginal word meaning healthy baby) is a longitudinal study of a birth cohort of Aboriginal infants born at a large outer urban hospital.2 Gudaga staff use methods that respect the values and beliefs of Aboriginal Australians3 to systematically collect information on the health, development, and service use of study participants at 6-monthly intervals. The Gudaga research team is working with the stakeholders in Aboriginal health in the region to discuss the implications of the information for policy and practice. A number of scientific articles are currently being prepared for publication. These include articles on birth outcomes, breastfeeding, universal health home visiting, health status and service use, development, and vaccination. Information collected by the Gudaga Study is contributing to the development of services for Aboriginal families in the region, and is changing the ways that service providers think about the health and service needs of Aboriginal families in the region. For example, the lack of data created difficulty in securing funding for services for pregnant Aboriginal women. Enumeration of the high rates of sudden infant death syndrome (3/149) and the removal of children by the Department of Community Services among participating infants (11/149 over 4 years) as a part of the Gudaga Study had two important effects. It influenced the public health service response to close the gap on Aboriginal disadvantage and influenced the decision to reorient child and family services and establish the Bulundidi Gudaga program with ongoing funding. The Bulundidi Gudaga program provides sustained home visiting of pregnant Aboriginal women and their infants by nurses, commencing during pregnancy and continuing until the infant is aged 2 years.4 This research developed over several years. It began during discussions with the Aboriginal community at Tharawal Aboriginal Corporation, Campbelltown, who raised concerns about the health of their children, difficulties in securing funding for an Aboriginal infant and maternal home visiting service that commenced 1999, the lack of relevant data on the needs of Aboriginal children, and receipt of National Health and Medical Research Council funding in 2003. The Gudaga Study commenced in 2005, and the first of the participating children are turning 5 years of age. The research is now part of a strong research program at the University of New South Wales into the health and development of Aboriginal children in urban settings.

Elizabeth J Comino · Lisa R Jackson Pulver · Jenny A Knight

To the Editor: Following the 1918 influenza pandemic, during which an estimated 50 million people died,1 the relationship between influenza and secondary bacterial infections such as Streptococcus pneumoniae (pneumococcus) became recognised as an area of considerable scientific importance. It has been shown that influenza infection results in epithelial damage, up-regulation and exposure of respiratory tract receptors, alterations in the immune response and increased adherence of pneumococcus.2 The most severe form of pneumococcal infection, invasive pneumococcal disease (IPD), has a mortality of 7%–9%.3 It occurs frequently in the Indigenous population of the Northern Territory, with an incidence of 70.5 per 100 000, compared with 7 per 100 000 in Australia overall.3 In population studies, 11%–20% of seasonal increases in IPD have been attributed to influenza.4,5 During the increase in influenza notifications in 2009 in the NT, as a result of pandemic H1N1 (2009) influenza, a concurrent increase in IPD notifications was also recorded. Our study aimed to investigate whether there was a relationship between influenza and subsequent IPD. We calculated the relative risk of IPD in the 4 weeks after laboratory-confirmed influenza compared with the background risk. Cases were defined as patients who were diagnosed with IPD within 4 weeks of laboratory-confirmed influenza being diagnosed. Data concerning cases of influenza and IPD between 2005 and 2009 were extracted from the NT Notifiable Diseases System and merged by date of birth using Stata, version 11 (StataCorp, College Station, Texas, USA), leading to 75 matches. The 75 matched records were checked individually to determine whether they met the case definition, resulting in eight potential cases. Demographic characteristics (name, sex, Indigenous status and address) were then checked to confirm the match. One case was excluded, leaving seven cases eligible for analysis. We identified 2567 cases of influenza and 346 cases of IPD in the study period. The risk of IPD within 4 weeks of influenza was calculated as 7/2567 (2.7 × 10-3). To calculate the background risk of IPD in a 4-week period, we first calculated the annual risk of IPD occurring without previous influenza (339/1 076 470 person-years) and divided this by the number of 4-week periods in a year (13). This gave a background risk of 2.42 × 10-5 and a relative risk of 112.5 (95% CI, 48.9–224.8; χ2 = 758.3; P < 0.001). This analysis is based on population surveillance data, and is therefore limited by the possibility of ascertainment bias due to variations in influenza testing. Nevertheless, our study provides additional evidence that IPD is an important complication of influenza, and reinforces the need for clinicians to promote influenza vaccination in high-risk individuals and to be aware of complications which may occur in the weeks after the initial viral infection. Additionally, achieving high coverage of pneumococcal vaccination in at-risk groups will reduce the impact of influenza.

Laura J Edwards · Peter G Markey · Heather M Cook · James M Trauer · Vicki L Krause

Objective: To determine the iodine status of participants in the Aboriginal Birth Cohort Study who resided in the Darwin Health Region (DHR) in the “Top End” of the Northern Territory prior to the introduction of mandatory iodine fortification of bread.Design, setting and participants: Participants in our study had been recruited at birth and were followed up at a mean age of 17.8 years. Spot urine samples were collected and assessed for iodine concentration at a reference laboratory. The median urinary iodine concentration (MUIC) of residents of the DHR was calculated and compared with international criteria for iodine status. Analyses were conducted for subgroups living in urban areas (Darwin–Palmerston) and remote communities (rural with an Aboriginal council). We collected a repeat sample in a subset of participants to explore the impact of within-person variation on the results.Main outcome measure: MUIC for residents of the DHR.Results: Urine specimens were provided by 376 participants in the DHR. Overall MUIC was 58 μg/L when weighted to the 2006 Census population. Urban boys had higher values (MUIC = 77 μg/L) than urban and remote-dwelling non-pregnant girls (MUIC = 55 μg/L), but all these groups were classified as mildly iodine deficient. Remote-dwelling boys had the lowest MUIC (47 μg/L, moderate deficiency). Pregnant girls and those with infants aged less than 6 months also had insufficient iodine status. Correction for within-person variation reduced the spread of the population distribution.Conclusions: Previously, iodine deficiency was thought to occur only in the south-eastern states of Australia. This is the first report of iodine deficiency occurring in residents of the NT. It is also the first study of iodine status in a defined Indigenous population. Future follow-up will reassess iodine status in this group after the introduction of iodine fortification of bread.

Dorothy E M Mackerras MPH, PhD · Gurmeet R Singh MPH · Creswell J Eastman MD, FRACP, FRCPA

Objective: To investigate the adequacy of vitamin D status in a South Australian Aboriginal population, and to examine the relationship between serum 25-hydroxyvitamin D (25-OHD) levels and biochemical variables of calcium and bone mineral homeostasis, as well as other factors which may influence vitamin D synthesis, storage and metabolism.Design, setting and participants: A single-visit, observational study of 58 adults from two Aboriginal community-controlled health services in Adelaide and Yalata, South Australia. Participants were recruited between May 2008 and December 2009.Main outcome measures: Serum levels of 25-OHD, parathyroid hormone (PTH), fasting glucose and fasting C-terminal telopeptides of type I collagen (β-CTx).Results: Serum 25-OHD levels showed clear seasonal variation, being higher in summer (P < 0.001). The overall mean level was 56.8 nmol/L (SD, 22.1), which is below the recommended target level of 60 nmol/L. Serum 25-OHD levels correlated significantly with β-CTx (P = 0.03), but not with age, body mass index (BMI), PTH levels or levels of fasting glucose. A significant association was found between BMI and PTH levels (P = 0.001). A significant inverse association between serum 25-OHD levels and BMI, observed in other studies, was not found in our study.Conclusions: Vitamin D insufficiency is highly prevalent in this population of adult Aboriginal Australians, with low mean values found in all seasons other than summer.

Simon J Vanlint MB BS, FRACGP · Howard A Morris PhD, FAACB, ARCPA · Jonathan W Newbury MD · Alan J Crockett MPH, PhD, FANZSRS