Indigenous health

To the Editor: Trachoma control guidelines from the World Health Organization1 and Communicable Diseases Network Australia (CDNA)2 recommend the “SAFE” strategy that includes surgery for trichiasis, antibiotic treatment, facial cleanliness and environmental improvement. Lack of access to antibiotics in isolated areas should not be a major contributor to the persistence of trachoma in Australia because special Pharmaceutical Benefits Scheme arrangements (SPBSA) under section 100 of the National Health Act 1953 for the supply of medicines to remote-area Indigenous health services should enable a ready availability of azithromycin. The 1999–00 to 2001–02 evaluation of the SPBSA suggested that the program had led to major increases in the supply of medicines in remote areas, but that the supply of azithromycin did not change as a result of the introduction of the program.3 We assessed the relationship between reported azithromycin treatment of people with trachoma, their household contacts, and community members; levels of treatment recommended by WHO and CDNA guidelines; and the total number of courses of azithromycin available through the SPBSA. The National Trachoma Surveillance and Reporting Unit (NTSRU) provided 2008 data on treatment with azithromycin and trachoma prevalence in the Northern Territory, South Australia and Western Australia (refer to the report for limitations of the data).4 Data for 2007–08 on the supply of azithromycin to health services under SPBSA were obtained from Medicare Australia. The WHO guidelines recommend treatment of an entire community if the prevalence of active trachoma among children is above 10%.1,5 The CDNA guidelines2 recommend that contacts (> 6 months of age) of infected children within a household be treated. Our estimate of trachoma treatment according to CDNA guidelines is based on multiplying the number of infected children (from the NTSRU data) by the average number of members in remote Indigenous households.5 The impact of shared and multiple residence on estimates of household contacts could not be taken into account. The Box shows the numbers of azithromycin courses available through the SPBSA to remote-area Aboriginal and Torres Strait Islander health services in the three states. In the NT, the reported number of courses given (3069) fell well below the level recommended by both WHO (by 34%) and CDNA (by 41%) guidelines. In SA, reported courses of azithromycin given (7) fell well below the 45 suggested by the CDNA guidelines. The prevalence of trachoma did not exceed 10% in any SA community, so no treatment was required under WHO guidelines. In WA, the reported number of courses given (2917) also fell below recommended levels, although the deficit (WHO, 35%; CDNA, 81%) varied substantially depending on which guidelines were used. Reported treatment with azithromycin was below levels recommended by the CDNA and the WHO despite health services having sufficient courses available to them to mostly meet these targets. All aspects of the SAFE strategy are important in the eradication of trachoma. However, improving the supply and distribution of azithromycin should be relatively easy to implement, fund and monitor. Azithromycin courses* available, 2007–08;† courses given, 2008;‡ and WHO- and CDNA-recommended courses,§ in three Australian states with remote-area Indigenous health services WHO = World Health Organization. CDNA = Communicable Diseases Network Australia. * Azithromycin courses are given to those with active trachoma, their household contacts, and community members. † Under special Pharmaceutical Benefits Scheme arrangements and reported by Medicare Australia. ‡ Reported by the National Trachoma Surveillance and Reporting Unit (NTSRU). § Based on NTSRU data and using community population estimates.

Margaret Kelaher · Angeline S Ferdinand · Hugh R Taylor

To the Editor: Significant morbidity and mortality are associated with excessive alcohol use, which, for Aboriginal Australians, generally occurs within a context of disadvantage. During 2007–2009, we assessed cognitive and psychological factors (using CogState1 and Strong Souls2 [CogState Ltd, Melbourne, Vic]) of 21 men and 11 women on admission to a 2-month Aboriginal residential treatment program in the Northern Territory. Participants’ mean age was 32 years (SD, 8.7 years) and the mean length of time for which they had used alcohol was 13.3 years (SD, 7.7 years). To determine the effect of age, number of years of drinking and other factors on continued alcohol use, we reinterviewed and reassessed participants in their home community with the same cognitive and psychological measures used at the initial assessment after a mean period of 11 months (SD, 4.4 months). At both baseline and follow-up, the number of participants for whom data were available varied for some characteristics. The Human Research Ethics Committee of the Northern Territory Department of Health and Community Services and Menzies School of Health Research (including the Aboriginal Ethics Sub Committee) approved the study. At baseline, 14 of 23 alcohol users reported drinking every day or most days, and 26 of 31 drank more than 10 standard drinks on each occasion. At follow-up in the community, 23 had resumed drinking at the same level, and nine had reduced their use (six had stopped using alcohol, and three had resumed drinking at lower levels). Compared with users who reduced their alcohol intake, users who did not showed poorer paired associate learning at the time of admission for treatment, and poorer performance at follow-up in visual attention, learning and executive function, visual learning and recall, and paired associate learning tasks (Box). This suggests that while subtle cognitive impairment may be a risk factor for continued heavy alcohol use after treatment, heavy alcohol use is also a likely cause of additional cognitive deficits.3 While reduced alcohol use may be associated with improvements in cognitive function, continued use may lead to further cognitive decline. Alcohol users who resumed drinking at the same level were significantly more likely to experience the psychological symptom “worry” after treatment (4/6; Fisher exact test, P < 0.05) than were users who reduced their alcohol use (0/6), which suggests that alcohol may have been used for self-medication or that excessive alcohol use may mask underlying psychological problems. Interestingly, a greater proportion of alcohol users who resumed drinking at the same level (10/16) were also using cannabis at follow-up, compared with those who reduced their use (1/9; Fisher exact test, P < 0.05). Cannabis use has been independently associated with psychological symptoms in other Australian studies, but with no impact on cognition.2,4 Our data indicate that there is a need to treat mental health problems concurrently with alcohol misuse problems among alcohol users undergoing treatment. Alcohol users who resumed drinking at the same level were less likely to return to remote communities with restricted alcohol availability (11/23), compared with those who reduced their alcohol use (9/9; Fisher exact test, P < 0.01), lending some support to the effectiveness of alcohol restrictions. Overall, our data show that cognitive problems and alcohol availability may be underlying factors in ongoing alcohol misuse by Aboriginal Australians. Charactersitics of alcohol users who resumed drinking at the same level and those who reduced their alcohol use after a 2-month residential treatment program, at baseline and at follow-up (n = 32) Characteristic Unchanged alcohol use, median Reduced alcohol use, median Z Significance No. of alcohol users 23 9 Age at baseline, years 31.3 29.0 − 0.15 ns Years of drinking, at baseline 13.0 11.6 − 0.59 ns Visual attention, speed (log transformed)* Baseline 2.81 2.76 − 1.67 ns Follow-up 2.79 2.71 − 2.10 P = 0.04 Working memory, accuracy (arcsine transformed)† Baseline 0.70 0.70 − 0.19 ns Follow-up 0.80 0.74 − 0.53 ns Psychomotor speed, moves per second† Baseline 0.77 0.95 − 0.35 ns Follow-up 1.17 1.37 − 0.75 ns Learning and executive function, moves per second† Baseline 0.44 0.47 − 0.39 ns Follow-up 0.58 0.76 − 2.32 P = 0.02 Visual learning and recall, moves per second† Baseline 0.48 0.46 − 0.21 ns Follow-up 0.73 0.84 − 2.20 P = 0.03 Paired associate learning, duration (seconds)* Baseline 307.81 214.11 − 2.52 P = 0.01 Follow-up 286.51 168.48 − 2.67 P = 0.008 ns = not significant; P > 0.07. * Higher values indicate poorer performance. † Higher values indicate better performance.

Kylie M Dingwall · Paul Maruff · Sheree Cairney

On 8 June 2009, I started work as a locum gastroenterologist on the other side of the world and in a very different environment to the one I was used to. The inspiration for my visit came from an article in the careers supplement to the BMJ.1 A specialist trainee in infectious diseases wrote of his experiences working in Royal Darwin Hospital in the “Top End” of Australia’s Northern Territory. He described the hospital as modern and well equipped, but lacking a full-time gastroenterologist. On an impulse, I offered my services for 3 months, and my offer was accepted. I applied for a 3-month sabbatical — my first sabbatical — from my post of 18 years as a gastroenterologist at the Royal Victoria Hospital, Belfast, and a senior lecturer at Queen’s University Belfast, Northern Ireland, United Kingdom. I must confess that I wasn’t entirely naïve about life and work in Australia. I had previously worked at the Austin and Heidelberg Repatriation hospitals in Melbourne for 18 months in 1990–1991, and I had been back “Down Under” on holiday in 2007, visiting Sydney and Melbourne, as well as Uluru (Ayers Rock) and Port Douglas. Having enjoyed both my previous trips to Australia, I was keen to work there again, especially in the Top End with its particular challenges, not least of which is its remote tropical location, far from Australia’s major cities. After my impulsive decision, I had plenty of time to get used to the idea — negotiating my leave of absence and completing all the necessary paperwork for the Australian authorities took almost 2 years. With Australia’s NT designated as “an area of unmet need”, I was sponsored by the NT Government to obtain an advanced competency registration with the Australian Medical Council and a temporary residency visa for 3 months. I arranged to go during the European summer so that my wife and our two youngest children (who were on school holidays in July and August) could join me for a good part of the time. This also meant we would be in Darwin in the dry, winter season, when the daytime temperature is a comfortable 32°C with moderate humidity, and avoid the very humid wet season. On my first day at the hospital, I was given the role of general physician and put in charge of one of four admission teams, each consisting of a consultant, a registrar and one or two junior doctors. Each team was on duty for 24 hours one weekday per week, and one weekend day for three out of four weekends, and responsible for 15–30 patients at any time, with up to 15 patients admitted on a take-in day. The hospital has an excellent emergency department as well as a rapid assessment planning unit, which was used jointly by physicians and surgeons to assess their patients in the first 24 hours after admission. I soon discovered that there were three main categories of patients at Darwin Hospital: Aboriginal people from the Darwin area and much further afield; other local Darwinians, most of whom had moved to Darwin from other parts of Australia and South East Asia; and older, retired Australian tourists who come to the NT to escape the southern winter (the “grey nomads”). Patients from outside Darwin are brought in by air ambulance. The Royal Flying Doctor Service (RFDS) does not operate in the Top End of the NT, which has its own air ambulance service, but occasionally patients are flown to Darwin by the RFDS from Alice Springs or from areas of Western Australia and Queensland. It is often quicker to fly to Darwin than to one of the other major cities because of the immense distances involved. Although about 30% of the NT population are Aboriginal and Torres Strait Islander people, most living in remote areas, they make up a disproportionate 40%–60% of the patient population at the hospital. This reflects the relatively poor health status of Indigenous Australians compared with the non-Indigenous population. Their high level of diabetes, chronic renal disease, hypertension, heart failure and alcoholism is a disturbing fact, as is their lower life expectancy; the life expectancy gap at birth between Indigenous and non-Indigenous people is 12 years for males and 10 years for females.2 Furthermore, perinatal and infant mortality rates are two to three times non-Indigenous rates.2 My stay helped me to appreciate the complex reasons for this situation, which encompass social and economic as well as educational factors, not to mention the difficulties of delivering health care to remote communities. I greatly enjoyed the challenge of medical practice in a new environment. As well as the usual presentations of patients with neurological, cardiorespiratory and hepatic conditions, we were faced with cases of severe sepsis, tuberculosis, melioidosis (Burkholderia pseudomallei), rheumatic heart disease, severe complications of diabetes, meningitis and infected scabies. The radiological findings discussed at multidisciplinary meetings seemed to have been drawn from a textbook of septic complications. This contrasted with multidisciplinary meetings in the UK, which have been specifically set up to deal with patients with cancer. I rapidly learnt to prescribe ceftriaxone with or without gentamicin as the initial antibiotic regimen, which proved to be life-saving in many situations. My sabbatical coincided with the height of the swine flu outbreak; typically, six or more patients with this condition were admitted each day. The severity ranged from relatively mild to critically ill, with patients in the latter category requiring ventilation and intensive care. Darwin is soon to have its own medical school, but for many years it has functioned as a satellite centre for training students from the medical schools at James Cook University in Townsville, Queensland, and Flinders University in Adelaide, South Australia. I was hugely impressed by the high level of medical care delivered by all the staff in the hospital. Their dedication and professionalism were very evident and, in conversation, I became aware of a strong vocational motivation that elsewhere is becoming lost in an increasingly cynical world. Many of my colleagues relished the challenges of working in Darwin. They were all Australians but, with the exception of the senior physician, Dr Diane Howard, none were originally from Darwin. Their experience of medicine in the major cities in Australia, where they had previously trained and practised, was similar to mine in the UK. They looked upon their time in Darwin as something of an adventure, not dissimilar to my own experience. Of particular value were the hospital’s cultural awareness seminars, which enabled new staff to gain some understanding of the culture of Indigenous people. The key points that I gained from these seminars were an appreciation of the complexity and richness of Aboriginal culture, and the profound personal disruption for Aboriginal people that admission to hospital entails. Hospital admission is traumatic for anyone, but for people who live in small, isolated communities with strong family relationships, it is deeply disturbing and bewildering. First, they have to cope with being unwell, and then with being flown several hundred kilometres to a place which must seem alien in virtually every respect — uncomfortably cold air-conditioning, different food, a different language, and frightening procedures. I learnt that even small things like eye contact, which we regard as a polite courtesy when talking to another person, may be threatening and confrontational to Aboriginal people. Great efforts are made to bridge this cultural gap by providing interpreters and Aboriginal liaison officers, and by encouraging a friend or relative to travel with patients and stay with them at the hospital. These current efforts contrast with some of the misguided government interventions of the past, most notably in relation to the “stolen generation”, when Aboriginal children were removed from their families “for their own good”. I found that these events are still vividly remembered and resented. During my trip, I was fortunate in being able to visit a health clinic in Oenpelli (Gunbalanya), in West Arnhem Land, about 300 km from Darwin. I particularly noticed a mural in the clinic, prominently displaying the word “Reconciliation”. Coming from Belfast and having lived through “the Troubles”, I could not help thinking of the parallels with the situation in Northern Ireland, with our community also struggling with reconciliation — two cultures trying earnestly to understand one another and come to a working arrangement. Health care is often on the frontline of cultural divisions. In Northern Ireland, the health service served both sides faithfully and impartially and was undoubtedly a force for good. I sensed that the health services in the NT are in a similar position. I have now returned to my normal job in Belfast, facing up to old challenges and some new ones. On reflection, I consider myself very fortunate and privileged to have practised medicine in Darwin, to have been accepted so generously by new colleagues, and to have learnt so much from them and from the patients we cared for. I found it refreshing, humbling, often thought-provoking and at times inspiring. It is an experience that I and my family will never forget. Murals promoting Aboriginal health and reconciliation at the Oenpelli (Gunbalanya) Health Clinic, West Arnhem Land, NT (published with permission). I am dwarfed by one of the Northern Territory’s magnetic termite towers, with its accurate north-south alignment to control temperature.

R G Peter Watson MD, FRCP(UK), FRCPI

Objective: To examine cancer incidence and mortality in Indigenous Queenslanders.Design, setting and patients: Assessment of indirectly standardised incidence and mortality ratios for Indigenous Australians in Queensland diagnosed with cancer from 1997 to 2006, compared with the total Queensland population.Main outcome measures: Standardised incidence and mortality ratios.Results: Compared with the total Queensland population, Indigenous Queenslanders had a lower overall incidence of cancer (standardised incidence ratio, 0.79; 95% CI, 0.75–0.82), but a higher incidence of some of the more fatal cancer types. Overall cancer mortality was higher (standardised mortality ratio, 1.36; 95% CI, 1.28–1.45) and similar to rates for Indigenous people in other Australian states.Conclusion: Cancer rates for Indigenous Queenslanders, a mostly urbanised population, are similar to rates for Indigenous Australians mostly living in remote areas.

Suzanne P Moore BHSc(Nursing), MPH, PhD · Peter K O’Rourke BSc(Hons) BA(Hons), PhD · Kylie-Ann Mallitt BSc(Hons) · Gail Garvey BEd, MEd · Adèle C Green MB BS, MSc, PhD · Michael D Coory MB BS, PhD, FAFPHM · Patricia C Valery MD, MPH, PhD

Objectives: To compare the clinical outcomes and mortality rates of Aboriginal and Torres Strait Islander people of Kimberley origin receiving haemodialysis (HD) treatment with other subsets of Aboriginal and Torres Strait Islander HD patients (Northern Territory, Western Australia excluding the Kimberley region, the rest of Australia) and Australian non-Indigenous HD patients.Design, participants and setting: Retrospective identification of Aboriginal and Torres Strait Islander patients of Kimberley origin and analysis of secondary data from the Australia and New Zealand Dialysis and Transplant Registry; this group was compared with other Australian patients receiving HD treatment from 1 January 2003 to 31 December 2007.Main outcome measures: Clinical outcome measures; comorbid conditions; death rates per 100 patient-years, unadjusted and adjusted (for age, sex, comorbid conditions, late referral to nephrologist treatment).Results: Seventy per cent of HD treatments for Aboriginal and Torres Strait Islander patients of Kimberley origin was provided in the Kimberley. They had comparable adjusted mortality rates to non-Indigenous Australian patients (adjusted mortality rate ratio, 0.80; 95% CI, 0.51–1.23).Conclusions: This is the first report showing similar mortality rates for Aboriginal and Torres Strait Islander people exclusively from a remote area of Australia and non-Indigenous Australians receiving HD treatment. HD treatment delivered closer to home can be safe and effective in remote areas.

Julia V Marley PgDipSc, PgDipPolSt, PhD · Hannah K Dent BSc(Hons) · Maree Wearne BNur, CertNephN, CertMid · Cherelle Fitzclarence BMed(Hons), MPHandTM, FRACGP · Carmel Nelson MPHandTM, FACRRM, FRACGP · Karen Siu BN, PGDIPNsg, NephrologyCert · Kevin Warr MB BS, FRACP · David Atkinson MB BS, MPH

The Australian Government has committed to reducing Indigenous disadvantage, including closing the life-expectancy gap within a generation, and to halving the gap in mortality rates for children under 5 years of age within a decade. Sixty per cent of the health gap between Indigenous and non-Indigenous Australians is attributable to the health of Indigenous people living in non-remote areas of Australia. We conducted a brief review of recent Australian original research publications on the health of the 53% of Indigenous people who live in urban areas, and found that data are sparse; there were only 63 studies in the past 5 years (11% of all articles about Indigenous health during this period). Although Indigenous Australians living in remote areas experience greater health disparity, the government will not achieve its aims without paying due attention to the non-remote-living population. More research is required, and particularly research that actually tests the impact of policies and programs.

Sandra J Eades BMed, PhD · Bronwen Taylor BTech, MSc · Sandra Bailey LLB · Anna B Williamson BPsych(Hons), PhD · Jonathan C Craig MB ChB, FRACP, PHD · Sally Redman BA(Hons), PhD

The epidemiology of influenza pandemics demands that Aboriginal and Torres Strait Islander people occupy centrestage in future planning The first wave of pandemic (H1N1) 2009 influenza (pH1N1) broke more heavily on Australia’s Aboriginal and Torres Strait Islander populations than on non-Indigenous Australians. The burden of disease in Aboriginal and Torres Strait Islander people was highlighted by the first Australian death associated with pH1N1 infection: a young Aboriginal man from a remote area of Western Australia who died on 19 June 2009 in an Adelaide hospital.1 The differences between the populations are stark, with Aboriginal and Torres Strait Islander people indisputably over-represented in severe pH1N1 disease. In the Top End of the Northern Territory, pH1N1 rates of notification, hospital admission and intensive care unit (ICU) admission were higher for Aboriginal and Torres Strait Islander people than for the non-Indigenous population (3.5 times, 12 times and 5 times, respectively).2 Similar profound differences have been recorded for Aboriginal communities in New South Wales: Aboriginal people hospitalised with pH1N1 were younger than their non-Aboriginal counterparts (median age of 24.5 years compared with 31.7 years), and the age-standardised rate ratios for Aboriginal to non-Aboriginal admissions to hospital, admissions to ICU and death during the 2009 pandemic wave were 3.2, 4.0 and 4.5, respectively.3 Overall, from May to October 2009 in Australia, Aboriginal and Torres Strait Islander Australians, who comprise 2.5% of the population, accounted for 16.0% of hospitalisations with pH1N1 and 9.7% of pH1N1 admissions to an ICU.4 A fivefold increase in risk of death due to pH1N1 was also reported.5 This experience demands a greater focus on the needs of Aboriginal and Torres Strait Islander communities and their prioritisation in future pandemic planning. We should not have been surprised, as history tragically demonstrates disproportionate morbidity and mortality for Aboriginal and Torres Strait Islander people in previous pandemics.6 It is thus exceedingly disappointing to discover no mention of Aboriginal and Torres Strait Islander Australians in the revised National Action Plan for Human Influenza Pandemic (NAP).7 The 2010 NAP fails to identify Aboriginal and Torres Strait Islander people as a high-risk group during the H1N1 2009 pandemic, although it acknowledges other risk groups that have been recognised internationally and in Australia: severe cases occurred in people with underlying chronic conditions such as respiratory diseases, cardiovascular disease, diabetes, autoimmune disorders and obesity. Pregnant women were also at an increased risk of serious disease.7 It is inexplicable that while Aboriginal and Torres Strait Islander people were identified as a priority group for the rollout of the pH1N1 influenza vaccination — a commendable and necessary preventive strategy — they are overlooked in the NAP.8 Although the Australian Health Management Plan for Pandemic Influenza9 states an equity commitment, and a subsequent appendix10 produced during the “Protect” phase of the 2009 pandemic endorsed the need for partnership between all health care providers in case and contact management among the Aboriginal and Torres Strait Islander population, respectful partnership between governments and Aboriginal and Torres Strait Islander communities to identify culturally appropriate and effective prevention and mitigation strategies enjoys no mention. Given that the NAP is the peak plan for guiding preparations for future pandemics, there is a fundamental need for governments to acknowledge and respond effectively to the specific requirements of Aboriginal and Torres Strait Islander people. Prevention and preparedness must include government support of planning in respectful partnership with Aboriginal and Torres Strait Islander communities, health organisations and representative bodies. Mandating this support and partnership at all levels of government will allow a greater understanding of infection risk and identification of cultural, social, economic and health service factors that may contribute to poor health outcomes, and ensure culturally safe and effective prevention and mitigation strategies. A national project, funded by the National Health and Medical Research Council, working with Aboriginal and Torres Strait Islander communities and health services in NSW, Queensland and Western Australia is learning about feasible and culturally appropriate containment strategies.11 A strong theme emerging from this work is the message to government: “Ask us, listen to us, share with us”. The ability of Aboriginal and Torres Strait Islander communities to develop novel practical mitigation measures has been a particular feature of this respectful engagement that has already informed government strategies in NSW.3 The epidemiology of the current and previous influenza pandemics demands that Aboriginal and Torres Strait Islander people occupy centrestage in future planning. Solutions to limit the burden on Aboriginal and Torres Strait Islander populations exist, but respectful partnership is necessary to unearth them. The partnership must not be a token one, but one developed through engagement with communities, and with the flexibility to be localised to meet the specific needs of diverse urban, rural and remote Aboriginal and Torres Strait Islander communities in all states and territories. Health information delivered with a local flavour is a key message from the project. “Ask us, listen to us, share with us” is a strong message that governments must heed if the impact of pandemic influenza on Aboriginal and Torres Strait Islander communities is to be limited.

on behalf of the Aboriginal and Torres Strait Islander Community Influenza Study Group

Objectives: To examine the determinants of pregnancy within 2 years of a teenager giving birth for the first time (rapid-repeat pregnancy [RRP]) and resumption of sexual intercourse after the birth.Design, setting and participants: Prospective cohort study between June 2004 and September 2006 at the sole tertiary obstetric hospital in Western Australia involving teenagers who gave birth for the first time. Data were collected using questionnaires at recruitment, 6 weeks and 3-monthly intervals for up to 2 years postpartum.Main outcome measures: RRP and time to a return to sexual intercourse after giving birth.Results: Of the 147 participants, 49 (33%) experienced an RRP. Sexual intercourse was independently significantly associated with using an oral contraceptive (odds ratio [OR], 2.83; 95% CI, 1.38–5.82); living with the birth father (OR, 8.43; 95% CI, 5.12–13.86); intending to become pregnant (OR, 3.20; 95% CI, 1.53–6.65); smoking marijuana (OR, 2.60; 95% CI, 1.38–4.79); and using alcohol (OR, 1.93; 95% CI, 1.17–3.20). Use of long-acting contraceptives was associated with reduced odds of RRP (OR, 0.27; 95% CI, 0.12–0.62), while teenagers who used an oral contraceptive had a similar risk of RRP compared with those using barrier methods or no contraception. Other factors predicting RRP were: being sexually active for more than 3 months (OR, 8.96; 95% CI, 1.97–40.74); intending to become pregnant (OR, 2.39; 95% CI, 1.62–4.93); and being an Indigenous Australian (OR, 2.38; 95% CI, 1.38–4.11).Conclusion: There are two options available to health care providers for reducing the rate of RRP: to facilitate teenage mothers’ access to long-acting contraceptives; and to gain clear understanding of their intention with regard to repeat pregnancy and to provide appropriate support.

Lucy N Lewis RM, BSc(Health Sciences), MN · Dorota A Doherty BSc(Hons), PhD(Medical Statistics) · Martha Hickey MB ChB, MD, FRANZCOG · S Rachel Skinner MB BS, PhD, FRACP

Consensus recommendations for managing chronic suppurative lung disease (CSLD) and bronchiectasis, based on systematic reviews, were developed for Australian and New Zealand children and adults during a multidisciplinary workshop. The diagnosis of bronchiectasis requires a high-resolution computed tomography scan of the chest. People with symptoms of bronchiectasis, but non-diagnostic scans, have CSLD, which may progress to radiological bronchiectasis. CSLD/bronchiectasis is suspected when chronic wet cough persists beyond 8 weeks. Initial assessment requires specialist expertise. Specialist referral is also required for children who have either two or more episodes of chronic (> 4 weeks) wet cough per year that respond to antibiotics, or chest radiographic abnormalities persisting for at least 6 weeks after appropriate therapy. Intensive treatment seeks to improve symptom control, reduce frequency of acute pulmonary exacerbations, preserve lung function, and maintain a good quality of life. Antibiotic selection for acute infective episodes is based on results of lower airway culture, local antibiotic susceptibility patterns, clinical severity and patient tolerance. Patients whose condition does not respond promptly or adequately to oral antibiotics are hospitalised for more intensive treatments, including intravenous antibiotics. Ongoing treatment requires regular and coordinated primary health care and specialist review, including monitoring for complications and comorbidities. Chest physiotherapy and regular exercise should be encouraged, nutrition optimised, environmental pollutants (including tobacco smoke) avoided, and vaccines administered according to national immunisation schedules. Individualised long-term use of oral or nebulised antibiotics, corticosteroids, bronchodilators and mucoactive agents may provide a benefit, but are not recommended routinely.

Anne B Chang MPHTM, PhD, FRACP · Scott C Bell MB BS, MD, FRACP · Cass A Byrnes MB ChB, MD, FRACP · Keith Grimwood MB ChB, MD, FRACP · Peter W Holmes MB BS, FCCP, FRACP · Paul T King MB BS, FRACP, PhD · John Kolbe MB BS, FRACP · Louis I Landau MB BS, MD, FRACP · Graeme P Maguire MB BS, FRACP, PhD · Malcolm I McDonald MB BS, FRCPA, PhD · David W Reid MB ChB, MRCP, FRACP · Francis C Thien MB BS, MD, FRACP · Paul J Torzillo MB BS, FRACP, FJFICM

Objective: Design, setting and participants: Descriptive study of alcohol consumption in the NT population, based on sales data and self-report surveys, and alcohol-attributable deaths and hospitalisations among people in the NT in the 2004–05 and 2005–06 financial years using population alcohol-attributable fractions specific to the NT.Main outcome measures: Per capita consumption of pure alcohol, self-reported level of consumption, and age-standardised rates of death and hospitalisation attributable to alcohol.Results: Apparent per capita consumption of pure alcohol for both Aboriginal and non-Aboriginal populations in the NT has been about 14 litres or more per year for many years, about 50% higher than for Australia as a whole. We estimated that there were 120 and 119 alcohol-attributable deaths in the NT in 2004–05 and 2005–06, respectively, at corresponding age-standardised rates of 7.2 and 7.8 per 10 000 adult population. Alcohol-attributable deaths occur in the NT at about 3.5 times the rate they do in Australia generally; rates in non-Aboriginal people were about double the national rate, while they were 9–10 times higher in Aboriginal people. There were 2319 and 2544 alcohol-attributable hospitalisations in the NT in 2004–05 and 2005–06, respectively, at corresponding rates of 146.6 and 157.7 per 10 000 population (more than twice the national rate).Conclusion: In recent years, alcohol consumption and consequent alcohol-attributable deaths and hospitalisations for both Aboriginal and non-Aboriginal people in the NT have occurred at levels far higher than elsewhere in Australia.

Steven J Skov MB BS, FAFPHM, MPH · Tanya N Chikritzhs BA(Hons), PostGradDip(Epi · Shu Q Li BM, BN, MPH · Sabine Pircher BNutrDiet, MPH · Steven Whetton BEc(Hons), MSc(Economics)

To the Editor: National best practice guidelines recognise that accurate data on the health of Indigenous Australians are crucial to improving health service delivery.1 The draft revision of the RACGP Standards for general practices acknowledges the need for improvement and requires that a practice demonstrates how it routinely records, in active patient health records, self-identified Aboriginal and Torres Strait Islander status.2 This is a commendable improvement but should be further strengthened, requiring that Indigenous status be recorded for at least 90% of active patients, the level required for a history of allergies. Improved record keeping in general practice has resulted in the potential to improve Indigenous identification among patients notified with a communicable disease. This enables the documentation of health disadvantage, and allows evaluation of measures aimed at closing the gap in health outcomes between Indigenous and non-Indigenous people. Demographic data in the NSW notifiable diseases database (NDD) were audited for all 258 Hunter New England (HNE) Salmonella infection notifications in 2007 by interviewing patients and their referring general practitioners. Interviews were completed for 83% of patients. Indigenous status was poorly recorded. The NDD listed three patients with salmonellosis as Aboriginal, but showed an unknown status for 87%. Among patients who had attended a GP during their illness (66%), practice records listed two as Aboriginal, but Indigenous status was unknown for 70%. Most GPs (95%) reported using electronic medical records, and 89% completed pathology requests with practice software. Many GPs (60%) requested information on how to appropriately ask about a patient’s Indigenous status. Interviews with patients who had been notified as having had salmonellosis identified 13 as Aboriginal, and no resistance to identification was encountered. The crude salmonellosis notification rates per 100 000 population were 42.2 (95% CI, 19.3–65.1) for Aboriginal HNE residents and 25.5 (95% CI, 21.7–28.6) for non-Aboriginal HNE residents which, while not statistically significant for this small sample, suggests a differential salmonellosis burden, consistent with studies elsewhere.3 The true burden of disease was likely to have been substantially higher, as many infections are not notified.4 The differential burden may also be an underestimate if Aboriginal HNE residents were less likely to be notified than non-Aboriginal residents due to, for example, reduced access to health services. The widespread availability of electronic practice software for generating pathology requests provides a new opportunity to substantially improve Indigenous identification in communicable disease notifications.3 Indigenous status should be routinely recorded by GPs and automatically included on their pathology request forms and subsequent laboratory notifications. There is now a need for a coordinated national approach to ensure consistent inclusion of Indigenous status on all laboratory notification data.

Anthony D Merritt · April R Roberts-Witteveen · David N Durrheim

I was happy in my retirement and living on the old-age pension with my husband when I had a call in early 2009 from Curtin University requesting a meeting to discuss cultural safety in Aboriginal health. You can imagine my surprise! Here I was, a 70-year-old retiree, content in the knowledge that I had worked and studied my way up from being a housewife and mother to being a respected Doctor of Philosophy, writer, and promoter of Aboriginal issues through my writing. I was full of curiosity to know the reason for this out-of-the-blue telephone call. Arrangements were made to meet with Associate Professor (now Professor) Sandra Thompson to discuss her proposition. I was to work as an Associate Professor for Cultural Safety in the Faculty of Health Sciences at Curtin University’s Centre for International Health, which had recently added Indigenous Health to its program. I started work there in April 2009. The cultural safety for indigenous health movement began in New Zealand during the 1980s when a Maori student nurse, Irihapeti Ramsden, queried hospital policy on standard nursing practices by saying “You people talk about legal safety, ethical safety, and safety in clinical practices and a safe knowledge base, but what of cultural safety?”1 Clearly, cultural safety was not on the nursing agenda. Irihapeti Ramsden instigated the cultural safety movement in New Zealand. Although the Treaty of Waitangi recognised the Maori as being the first people of their country, Maori nurses knew that the Treaty was not being honoured in the nursing fraternity.1 Maori nurses and patients were being isolated from mainstream nursing practices and treated as second-class citizens because of their cultural differences. Maori nurses wanted to be acknowledged and treated as equals in the workplace. The Maori nurses and patients had strong cultural ties and began to question why they should maintain nursing practices that were contrary to their own cultural beliefs and customs. Gradually the concerns of Maori nursing staff and patients in hospitals were recognised, and cultural safety is now embedded in most schools of nursing in New Zealand. The Nursing Council of New Zealand has amended its standards for registration to include safe cultural practices.1 Now the concepts of cultural safety, including cultural awareness and cultural competence, are being introduced into the Australian nursing system through the universities. Unfortunately, it is taking longer to change the colonial mentality and inherent racist attitudes towards Aboriginal people in this country than in New Zealand. We have over 200 years of invisibility and exile to overcome before Aboriginal people can attain the ideal status of equality. After joining the Centre for International Health at Curtin University, my interest in cultural safety grew and I realised that it was the solution to many health problems facing Aboriginal people. They needed to feel worthy as individuals and not be denigrated for being Aboriginal, with all the negative connotations that that image conjures up. If medical, nursing and other health organisations could forget the policies of the past and accept Aboriginal people as equals instead of patronising them and treating them as children, the health and hospital systems would have a better chance of reducing morbidity and mortality rates among Aboriginal people. As my own awareness of the cultural safety issues grew, I remembered the past and the government policies I had lived through over the years. Before the 1967 referendum,2 Aboriginal people were wards of the state governments and had no authority over their own lives. They were subject to laws and policies that enabled state governments to monitor their movements and enforce those laws if Aboriginal people dared to show initiative by making their own decisions. They were a subjugated people. However, due to the United Nations policy on indigenous rights, attitudes were slowly changing towards indigenous peoples worldwide. The Universal Declaration of Human Rights was adopted and proclaimed on 10 December 1948 at the General Assembly of the United Nations.3 All countries were to give citizenship to their indigenous people, and Australia was no exception. But the Aboriginal people of Australia did not know about the Declaration, and it was not until almost 20 years later that they were made citizens of this country. The 1967 referendum, in which Australians voted 90.77% in favour of Aboriginal people becoming citizens in their own country,2 was an important landmark for us because it meant we were no longer wards of state governments but were free citizens. Improvements to the living conditions of Aboriginal people living on reserves in Western Australia began by providing the basic necessities of life, such as having easy access to tap water (instead of carrying water in buckets from public taps) and having ablutions blocks with laundry, bathing and toilet facilities. Two-bedroom wooden-slab housing was erected (with no electricity) to replace tin shacks, tents and bough sheds. But no one thought about Aboriginal health except Aboriginal people themselves, when they needed medical and nursing attention. The health and wellbeing of Aboriginal people were in a sorry state. On the positive side, teenage Aboriginal children were being sent to Perth to further their education and obtain training in different careers. I was one of those children. However, it wasn’t until March 1956, when I began training as a nursing aide at Royal Perth Hospital, that the issue of Aboriginal health was brought to my awareness. Training Aboriginal girls as nursing aides (a new program implemented by the state government of Western Australia) had only begun two months previously. But I found that while the hospital system accepted Aboriginal patients, the health personnel were indifferent to Aboriginal needs. In fact, at this time, native hospitals were situated in many country towns, and Aboriginal people with chronic illnesses were mainly admitted to these hospitals. The treatment they received was passable, but there was a definite paternalism that hindered quality patient care. Being an Aboriginal nursing aide in the mainstream hospital system was difficult at times, and I experienced racism from staff and patients. For example, one time when I was working in a country town after completing my training, I needed to have my appendix removed. On the morning of the operation, I had a shower and considered myself clean. But, according to the ward sister, I hadn’t washed the navel area clean enough for her liking, so she sent me back to scrub myself again. What can I say? I was 18 years old and gauche, and arguing with the ward sister was out of the question. In retrospect, I realise that my personal hygiene was being called into question. I felt degraded, because I always showered every morning. Other examples of racism occurred with patients in other hospitals — some didn’t want me to touch them when I had to bed-bathe them or see to their personal needs. When I told the ward sister, she berated these patients, but it was horrible to know that many of these people judged me by the colour of my skin and not my work ethic. These days, racist attitudes have become more covert, and are a subtle mixture of paternalism, arrogance and the assumption of white privilege. But there is an even more serious lack of cultural safety for Aboriginal people when receiving nursing care (as patients) or giving care (as staff). My own cultural upbringing made it very hard for me to tend to the personal needs of Aboriginal men who were hospital patients. I felt uneasy when they needed assistance with their bed-baths or toilet needs. It was embarrassing for both parties because, as a woman, it was culturally taboo for me to be tending to a man’s personal needs. It was a matter of cultural protocols gone awry. Knowing and understanding Aboriginal protocols would be a starting point for many who work in the hospital system. Nevertheless there are many fair-minded Australians who want to improve Aboriginal health and the hospital system through introducing cultural safety to those who have the power to implement change. It needs to be widely recognised that achieving cultural safety in health programs for Aboriginal people will advance good health practices and boost positive health statistics through the acceptance of Aboriginal people for their differences from mainstream Australians. In other words, we are the first peoples in Australia — people in our own right, with our own cultures, customs and protocols. At the Centre for International Health, we intend to implement programs in the curriculum that will include Aboriginal studies and protocols for cultural safety in all schools of health. Talking to Aboriginal students in high school is also on the agenda because it is important for students to think about training for a career in health. Knowing and understanding Aboriginal protocols would be a starting point for many who work in the hospital system. I remember when my father was sick just before he passed away in 1992. The staff at Sir Charles Gairdner Hospital, in Perth, let members of the family visit him regardless of the time limit on hospital visits or the number of family members present. This was at a time when cultural safety was unheard of, but the hospital staff had the common decency to realise that my father had a large family and we all wanted to say goodbye. The human kindness shown by the hospital staff is remembered with gratitude and proves that cultural safety for Aboriginal people can be attained. In this instance, the nursing staff chose to show respect for a grieving family rather than passing negative judgement on us because we were Aboriginal people. The number of workshops and seminars teaching cultural awareness is increasing, but making people aware does not mean they are culturally competent or that they understand cultural safety as a health practice. People working in remote areas generally have more knowledge and acceptance of Aboriginal people than those who live in the cities and suburbs, although there are exceptions, as the above example of my family’s experience shows. Urban and foreign medical and nursing staff working in city and country hospitals should take a crash course in Aboriginal studies and protocols, as many have had no contact with Aboriginal people, let alone experience with treating them as patients. Aboriginal people themselves must change their attitudes to ill health, and understand the necessity of maintaining the treatment that medical and hospital personnel advise. For instance, diabetes sufferers should follow appropriate diets, have regular exercise and remember to take their medication. It is very important that Aboriginal people take responsibility for their own health, provided they are not too old, too young or too infirm to do so. They need to work with medical staff to find mutually acceptable solutions to combat their own or their family’s health problems. Working with medical and nursing practitioners would enhance the practice of cultural safety. Finally, to the question posed in the title of my essay: “Cultural safety in health for Aboriginal people: will it work in Australia?” — I believe it could work. Attitudinal changes of medical and nursing staff will change the status quo of Aboriginal health, and changing antiquated images of a past era is a step in the right direction. We can alter the negativity associated with Aboriginal people and their cultures by recognising their unique value to Australia’s past, present and future. If implementing and maintaining cultural safety for Aboriginal people means improving their wellbeing and survival, then it should be compulsory in all spheres of health practice in this country.

Rosemary van den Berg PhD

Objectives: To describe the health service attendance patterns of urban Aboriginal and Torres Strait Islander (Aboriginal) Australians and make comparisons with those of the general Australian population.Design and setting: General practitioner-completed survey of all attendances over two separate 2-week periods in 2006 at an urban Aboriginal health service in Canberra, which provides services for about 3500 patients per annum.Main outcome measures: Standardised attendance ratios (SARs) for a range of health problems, using patients attending Australian general practice for the same reasons as the reference population.Results: Patients attending the Aboriginal health service were significantly younger than the Australian general practice patient reference population. The most common conditions managed were psychological, encompassing substance misuse; psychological problems accounted for 24% of all attendances. Patients attending the Aboriginal health service had higher rates of attendance for psychological conditions (SAR, 2.14; 95% CI, 2.01–2.28), endocrine conditions (SAR, 2.44; 95% CI, 2.29–2.60) and neurological conditions (SAR, 2.90; 95% CI, 2.71–3.09), as well as for circulatory, digestive and male and female genital conditions, than the reference population. Patients attending the Aboriginal health service had significantly lower attendance rates than the Australian population for respiratory illnesses, and conditions related to eyes or ears.Conclusions: At this urban Aboriginal health service, attendance patterns reflected complex health care needs that are different from those expected of a population of this age. Urban Aboriginal health service attendance appears to reflect significant ill health among the patients, aligning more with Aboriginal health statistics nationally rather than health statistics for urban non-Aboriginal Australians.

Karen M Flegg MB BS(Hons), FRACGP, MIPH · Christine B Phillips MB BS, MPH, FRACGP · Anne L Collins BA, BSc · Peter G Sharp MB BS · Meetali Kanagasundaram BSc(Hons), BBiomedSc, MB BS · Ray W Lovett BN, BHSc, MAppEpi · Marjan Kljakovic MB ChB, FRNZCGP, PhD

Lowering the coffin, feeling its weight on the strap in my hands and glimpsing the darkness waiting at the bottom of the grave, my cheeks were wet with tears. Only later did I realise that those tears came not only from sorrow, but also from pride. Contrary to what Australians have been told about Aboriginal rules against mentioning the names of the deceased, we Noongar people of the south-west of Western Australia use names and images at our funerals. I was crying at the funeral of Lomas Roberts, a man so very important to me in the last decade of his life. In my memory, the photos shown at the funeral service flicker in the dark space into which the body is being lowered, and the old man’s name — the “s” sounds prolonged and blending together — is whispered by the old acacia trees at the cemetery. Kwel ngalak maya wanginy, Uncle Lomas would have said — “the trees are talking to us”. Only a few months previously, driving back from his sister’s funeral, he’d talked of joining her. “Soon”, he said, “not long now”. In fact, he’d missed the burial because I’d had to rush him to the local hospital almost as soon as the eulogy began. He’d had bypass surgery several months before, and the long drive to the funeral probably exacerbated his tension and stress. On the way back to the city, he tilted the car seat so that he could lie almost horizontal. He said it eased the pain in his chest and throat. So his death was really no surprise. When he was drinking, he’d show us the x-rays of his cloudy lungs, but, sober again the next day, he’d say it was all fixed and the cancer was gone because he’d had another visit from that old “bush blackfella” who came and went, as if from nowhere. We’d all nod. Wishing, hoping — none of us liked to see a strong man failing as he was. None of us ever saw this “Mabarn man” (traditional healer). Perhaps he didn’t exist. If he did, his efforts in this instance provided no more healing than the mainstream medical system, although at least the very idea gave Uncle Lomas hope and seemed to make him feel better for a while. Last time I saw Lomas Roberts alive, he was in a hospital bed, his son Geoffrey at his side. Uncle Lomas pulled away his oxygen mask and told us to get a wheelchair and take him home. Then he fell back exhausted, gripping our hands. The nurse adjusted the plastic mask and Uncle Lomas sucked at the oxygen, his eyes wide. He passed away the next day. Edward, a cousin, had taken him home the last time he had discharged himself. Ed said that when the old man got out of the car he thrust out his chest like in the days when he was still boxing, but by the time he got to the front door he was practically crawling. “What can you do?” we asked one another, “he doesn’t like hospital”. He would tell us the doctors were just “kids” — they were white and they were foreign and he couldn’t understand what they were saying. Then, changing the topic, he told us he’d sneaked into the toilets for a cigarette, but when he lit up and blew out that big blue cloud of smoke, the sprinklers on the ceiling came on and he got soaked. “It was a pretty nurse that told me off, too”, he added, enjoying our laughter. Uncle Lomas’s son, Troy, attended the funeral service handcuffed and chained to a prison guard. Wrists lifted in front of him and pulling on the chain, Troy dragged his reluctant, uniformed companion to the microphone. Locked up for years already and with years to go, Troy looked around the crowd that trembled with him, held the silence like a seasoned performer and spoke some of our names: Ed, Geoff, Graeme, Twinny, Iris, Roma ... “Dad loved what you were doing together”, he said, his voice not quite breaking. Troy was referring to a project we were running to retell stories in the old language and revisit the places where those stories belonged. Troy’s words and that project caused my proud tears at the funeral. Perhaps any pride was shameful in the middle of such sorrow and death, but the greatest shame was that we were all so late: the old people were falling away one by one, and Troy was probably not the only one there who understood how it felt to be restrained and isolated. Lomas Roberts, his sisters and some of their surviving cousins were the most important members of a group — an extended clan, a filial community that mostly only got together at funerals — who had gathered in the last couple of years around old pieces of paper returned from the collection of a long-ago linguist. The clash of paperwork and memory ignited stories, not only those carried on the paper, but also of the linguist’s “informants” and other tales they told. There were no welfare narratives in the picture books we developed and took into local schools, and there were no characters to feel sorry for. These stories were peopled by heroes and risk-takers. A few weeks before his death, we’d filmed Uncle Lomas and his remaining sister, Hazel, visiting the old camping grounds and places mentioned in the old stories that were burning within us. At times, on the audio track, you can hear the waves shushing in the background, trees whispering like they did at the cemetery, and even tongues of flame crackling fiercely. It is hard to make out what they might be trying to tell us, and in some of the audio, even the Elders’ voices are unclear because of the sound of the wind in the microphone. It’s as if voices are rushing in, all wanting to speak at once. Uncle Lomas and Aunty Hazel showed us the ruins of the tiny shed where the family had slept when he was a child. They showed us ancient dancing grounds and a whale-dreaming site, and we even went inland to find a granny’s grave not visited by these, her grandchildren, since the eldest was an infant. Uncle Lomas had never been there before. He and his sister thanked the farmer for allowing them on his land. Their respectful courtesy made me uncomfortable because it’s hard for me to reconcile the Elders’ courtesy to the farmer with the historical fact of land stolen from the Aboriginal people. They led us to another property. The farmer was a man with whom I knew Uncle Lomas loved to have a cup of tea and talk about their families. “Not the same today”, they said (as always), shaking their heads as they contemplated the younger generations. “It’s finished”, Uncle Lomas often said when we were talking — an old man feeling his own mortality, frustrated by what he couldn’t remember and what was right there at the tip of his tongue but seemingly unreachable. “All gone now.” Respectfully, I have to disagree. When we left the farmer, Uncle Lomas led us to what seemed to be just a bunch of rocks in a cleared paddock, but when we got up close we saw the circles in the rock of a moon waxing and waning and realised it was the site of one of the stories we’d read in the old paperwork and that Uncle Lomas had already known: an immortality story of how the moon never dies, but diminishes and then builds up again. He took us to another place that, by day, is a dry rock hole and yet, at night, holds the reflections of moon and starlight and cool, dark water. He took us to rocks beside the ocean where you might grind up crabs to lure the groper from his blue depths and then leap and drive your spear deep enough to bring the great fish ashore. Other rocks held the footprints of spirit creatures, creatures you might meet the other side of any tree. Always there is this other world, these other possibilities. So I don’t believe that Noongar heritage is “finished”. It may have diminished, and it’s true that we are a mostly ailing community. Only a minority of my Noongar ancestors survived the first few decades of colonisation, and we’ve had trouble ever since. If you only see skin colour and the like, we’re a truly mixed-up mob these days. We know the health statistics for Indigenous people, the sorry tale the social indicators tell. Very likely, many of you reading this are working yourselves thin and haggard trying to “close the gap” and improve Indigenous wellbeing. We need more efficient health service provision and new technologies, but we need other changes too. Relatively recent historical forces that have shaped Aboriginal heritage have rarely been nurturing, and neither are the ways of talking about that history. I’d like to reject the choice we’re usually offered between narratives simplistically titled either “stolen generations” or “continuity and native title”, because at my old mentor’s funeral I felt the power of some other story. Of course it was an ending. He was finished, he was gone. But my sons were with me, and there were many other young people who mostly only meet each other at funerals. In the tears and hugs, and in gathering around that hollow in the earth there was — there is — an element of “recovery” from grief and illness, and the consolidation of community and belonging. That’s the sort of recovery and consolidation Troy was interested in, and he wants to be part of the recovery and consolidation of old stories and knowledge in a home community. There’s a sense of belonging in that, and pride in one’s resilience, and also a sense of power that comes from sharing one’s Aboriginal heritage with widening circles of people who share the same geographical place. There’s a Noongar word, biirt, meaning “path”, but also “sinew” and “energy”. Biirdiya, from the same word, is most often translated as “boss”, or “leader”, being one who is very familiar with that path and its life-affirming sinews of energy. I don’t suppose such a path of energy can ever be walked in exactly the same way. As such, it’s a little like a river, but you can move along it in such a way as to resonate with that energy and let that life force move in you. I think there’s a many-layered recovery in the return to such old paths, and in the stories and sounds indigenous to that landscape. Many of us who care about social justice have retraced historical paths, noting how decisions were made and how people were forced to enter the unsafe territory they continue to inhabit. These are necessary journeys, but tend to only lead us into the deadends of victimhood and guilt. Biirt is a different kind of path. Some will insist there is no path from a precolonial past to a postmodern future. Indeed, it is often suggested that, in the interests of their own welfare, Aboriginal people must choose between a precolonial “utopian” past and a future as “economic citizens”, or between “assimilation” and “self-determination”. But these are false choices. Recent research suggests that the degree of connection with traditional culture correlates with improved Aboriginal wellbeing.1 If so, consolidating a traditional heritage in home communities is integral to improving Aboriginal health. Uncle Lomas certainly thought so. It made him feel powerful to be helping reconnect younger generations with their heritage, and made us all feel powerful to be sharing it. Closing the gap may require at least some of us to be walking old paths where we focus less on the choice between opposites or between simple alternatives of past and future, and more on where our journey resonates with the energy of a long-abiding culture. In this way, individuals alive to the rhythms of its spirituality may move together towards creating a respectful society in which even the most vulnerable individuals are safe.

Kim J Scott PhD

Incorrect units: In “Impact of income management on store sales in the Northern Territory” in the 17 May 2010 issue of the Journal (Med J Aust 2010; 192: 549-554), there were errors in Box 2 under the column heading “Outcome measures”. The units for “Fruit and vegetable turnover” should have been kg, and the units for “Soft drink turnover” should have been L.

Julie K Brimblecombe · Joseph McDonnell · Adam Barnes · Joanne Garnggulkpuy Dhurrkay · David P Thomas · Ross S Bailie

Time to commit to working in respectful partnerships with Indigenous people On 12 March 2010, the Australian Indigenous Doctors’ Association (AIDA) launched a health impact assessment of the Australian Government’s Northern Territory Emergency Response to protect Aboriginal children. The report of the assessment was developed by AIDA in collaboration with the Centre for Health Equity Training, Research and Evaluation at the University of New South Wales, and with support and financial assistance from the Fred Hollows Foundation. During 2006 and 2007, there was much discussion in the media about child sexual assault in Northern Territory Aboriginal communities. In April 2007, the report of the NT Board of Inquiry into the Protection of Aboriginal Children from Sexual Abuse, entitled Ampe akelyernemane meke mekarle “Little children are sacred”, was presented to the Chief Minister of the NT Government; it was released to the public in June 2007. The report addressed concerns about child sexual abuse and made recommendations that child abuse and child sexual abuse be designated as issues of urgent national significance by both the Australian and NT governments.1 On 21 June 2007, the then Minister for Families, Community Services and Indigenous Affairs, Mal Brough MP, announced, on behalf of the Australian Government, the Northern Territory Emergency Response (NTER) to protect Aboriginal children in the NT.2 The announcement included, among other measures, alcohol restrictions, welfare reform, compulsory income management, compulsory health checks, banning of pornography, scrapping of the permit system for common areas, and improving housing and community living arrangements. Significantly, legislation was passed by the Australian Parliament suspending Part II of the Racial Discrimination Act 1975 (Cwlth), so that the government’s measures could be imposed in prescribed Aboriginal communities in the NT.3 Part II of the Act prohibits racial discrimination in rights to equality before the law; access to places and facilities, land, housing and other accommodation; and provision of goods and services. The introduction of the NTER and, in particular, the lack of community consultation, was a cause for deep concern. In response, AIDA chose to undertake a health impact assessment to give voice to affected communities and, as doctors, to facilitate discussion with policymakers and program leaders on ways to improve the NTER and reduce negative impacts on health and wellbeing. The health impact assessment uses methods endorsed by the World Health Organization.4 It is a predictive tool to assess the potential health impacts of a proposed policy, program or project on the health of a population, and it makes practical recommendations to improve the proposal. It is not an evaluation; rather, by seeking to predict the impacts on the health of affected populations, it has the potential to inform decision making before a proposal is implemented and before negative effects occur. Qualitative and quantitative methods are used to predict the health impact of a given policy on selected health parameters. The health impact assessment of the NTER is underpinned by the Aboriginal understanding of health and wellbeing. It refers to The dance of life model developed by Professor Helen Milroy, Director of the Centre for Aboriginal Medical and Dental Health at the University of Western Australia.5 This model represents an Aboriginal interpretation of health and illustrates health in its five dimensions — cultural, spiritual, social, emotional and physical — within which are a number of layers reflecting historical, traditional and contemporary influences on health. These five dimensions were examined within the health impact assessment framework.5 Evidence for potential impacts was collected in three ways: (a) consultation with four communities; (b) consultation with other stakeholders; and (c) the commissioning of expert appraisal reports. We considered seven components of the NTER: external leadership, governance and control; compulsory income management; alcohol restrictions; prohibited materials; housing; education; and child health checks. The first component, “external leadership, governance and control” was not included explicitly in the conceptualisation of the NTER or in legislation establishing the intervention. However, the evidence gathered from communities, experts and key stakeholders pointed to the need to assess the health impact of the processes and structures of external leadership, governance and control imposed by governments and their agents in introducing and implementing the intervention. In preparing our report, we spoke to more than 250 people affected by the intervention measures. Grandmothers spoke about the humiliation of going “back to the old days” when all decisions were made for them. Mothers spoke about the added burden of trying to buy family groceries using the BasicsCard,6 which can only be used in specified locations. Communities spoke about their hurt when their successful local programs were disregarded by the government. And men everywhere spoke about their despair at being labelled as paedophiles. Bearing in mind the Aboriginal definition of health outlined above, the health impact assessment predicts that the intended health outcomes of the NTER — improved health and wellbeing and, ultimately, longer life expectancy — are unlikely to be fully achieved. The health impact assessment findings speak for themselves and show that the intervention does more harm than good. The report’s disturbing prediction — that the intervention will cause profound long-term damage to our Indigenous communities — should be of concern to all Australians, including medical practitioners. The main findings of the report are that: the intervention could potentially lead to profound long-term damage, with any possible benefits to physical health largely outweighed by negative impacts on psychological health, social health and wellbeing, and cultural integrity; the increasing levels of mistrust caused by the Howard Government’s ill conceived and rushed implementation of the intervention will continue to compromise the Rudd Government’s ability to work in partnership with Aboriginal communities to achieve shared objectives; and the potential negative impacts of the intervention may be minimised, but only if governments commit to working in respectful partnerships with Indigenous people. The Box summarises and rates the potential health impacts of the NTER measures, and outlines the recommendations of the health impact assessment (HIA) report.5 With great generosity of spirit, communities spoke about their willingness to work with governments to show them how to get things right. However, the longer a centralist-style of intervention continues, the more the creeping mistrust of governments will become entrenched. Governments need to act, and they need to act now, before the predictions in this report become a reality. Generally speaking, governments need to think about the ways they can work together with Indigenous people, but, more immediately, AIDA believes that the Racial Discrimination Act must be reinstated and compulsory income management must be overturned. The health impact assessment of the NTER can be viewed online at http://www.aida.org.au/hia.aspx.

Peter O’Mara FRACGP, FARGP, GradDipRural

Objective: To examine the impact of a government income management program on store sales.Design and setting: An interrupted time series analysis of sales data in 10 stores in 10 remote Northern Territory communities during 1 October 2006 to 30 September 2009, which included an 18-month period before income management; a 4–6-month period after the introduction of income management; a 3-month period that coincided with a government stimulus payment; and the remaining income-management period.Main outcome measures: Trends in (i) total store sales; (ii) total food and beverage sales; (iii) fruit and vegetables sales; (iv) soft drink sales; and v) tobacco sales.Results: Modest monthly increases indicative of inflation were found for all outcome measures before the introduction of income management, except for soft drink sales, which remained constant. No change from the increasing rate of monthly sales before income management was seen in the first 4–6 months of income management or for the income-management period thereafter for total store sales, food and beverage sales, fruit and vegetable sales and tobacco sales. The rate of soft drink sales declined significantly with the introduction of income management and then increased significantly thereafter. The 3-month government stimulus payment period (during the period of income management) was associated with a significant increase in the rate of sales for all outcome measures.Conclusion: Income management independent of the government stimulus payment appears to have had no beneficial effect on tobacco and cigarette sales, soft drink or fruit and vegetable sales.

Julie K Brimblecombe BSc, MPH, PhD · Joseph McDonnell BSc(Hons), MSc, GradDipCompSci · Adam Barnes BSc, MSc · Joanne Garnggulkpuy Dhurrkay GradCertEducAdmin · David P Thomas DTM · Ross S Bailie MD(Community Health), FAFPHM, MPhil(MCH)

To the Editor: Australian and international evidence clearly demonstrates that controlling availability is one of the most effective means of reducing alcohol-related harm.1 In recognition of this, additional restrictions on availability have been introduced as part of both the Australian government’s Northern Territory Emergency Response (NTER) and the NT government’s Alcohol Management Plans.2 However, it has been widely asserted in public debate — particularly by those opposed to them — that these restrictions have had the unintended consequence of diverting people in remote communities from alcohol to cannabis consumption and that, as a consequence, there is an epidemic of cannabis use in remote communities.3 Generally, the international evidence is limited but indicates that the substitution of one drug for another is variable and complex, and not a simple one-to-one phenomenon.4 More specifically, there is a paucity of empirical data which could directly verify the assertion that cannabis has been substituted for alcohol as a consequence of the additional alcohol restrictions in the NT. However, while there may well have been some substitution, the increase in cannabis consumption was occurring before the NTER and NT government restrictions. In 2004, Clough and colleagues reported an increase in cannabis use in Arnhem Land (NT).5 Furthermore, in 2006, Putt and Delahunty reported an increase in Queensland, Western Australia and South Australia — jurisdictions that were not later subject to the NT restrictions.6 Thus, while there may have been some substitution of cannabis for alcohol following introduction of the NTER restrictions and Alcohol Management Plans, it seems clear that the increase in use of cannabis cannot be attributed primarily to these interventions. The problem, regardless of the cause, needs to be addressed, but it will not be addressed simply by relaxing alcohol restrictions.

Dennis A Gray

On my first day as an Aboriginal Research Officer, researching the social and emotional wellbeing of Aboriginal children, I was given a report to read as background material for my new role. It evaluated the therapeutic service which had just employed me. I flicked through the report, my eyes alighting on a chart which outlined the types of trauma experienced by the service’s clients, including exposure to family violence and physical assault, such as being hit with objects. (The report referred to all children, not just Aboriginal.) The report went on to list rates of other forms of abuse — emotional abuse, sexual abuse and neglect. I had to think to myself, did I have the inner resources to do this job? In my role, while I would not be interviewing children directly, I would be talking to clinicians, psychiatrists and counsellors, both Aboriginal and non-Aboriginal, who had worked therapeutically with Aboriginal children who had been abused. Would I have the resilience to withstand the vicarious trauma to which I would be exposed? My position was based across a consortium of three organisations, — an Aboriginal childcare agency, a therapeutic service and a university, — so I had a deep pool of knowledge and wisdom to draw upon in developing my report. But what of myself, and my own life experiences; what could I bring to this role? I grew up with my Aboriginal mother and one sister. My non-Aboriginal father was a severe alcoholic, and was absent for most of my childhood. He died from cardiomyopathy when I was nine. There were alcoholic grandparents on both sides of my family, but, fortunately, my mother had escaped that scourge. I suppose I was happy as a child, although we were often living “off the smell of an oily rag”, as my mother would put it, and our small family was quite socially isolated. My mother’s family all lived interstate and we had little association with my father’s family, except at Christmas. But my childhood provided me with lots of freedom: I was surrounded by nature, I had a best friend, I loved reading and I did well academically. By many of the measures I later perused as part of my research, I would have been classified as a resilient child. More to the point, I think I didn’t act up, or act out, or if I did it, it flew beneath the radar. In my teenage years, I experienced my first bout of depression, and it has dogged me my whole life. So how does one undertake research, or work to heal Aboriginal children, when one needs to heal oneself? We Aboriginal workers travel a parallel journey, working to improve our community’s wellbeing, while sometimes struggling with our own. Sometimes I am aware of the irony; in my work I am a strong advocate for increasing the cultural connection of Aboriginal children, believing culture to be healing, especially for those who are in the child protection system and whose access to family and community is nominal. Yet my own cultural connection when I was growing up was very tentative. I always knew I was Aboriginal, I always “felt” it, and yet did not have the bonds with extended family that is so much a part of “being” Aboriginal. There were no other Aboriginal students at my school or in my social milieu. In my childhood I felt quite comfortable telling people of my heritage, but when I reached adulthood, people — white people — would often question my Aboriginality: “How much of you is Aboriginal?” I too began to question my “right” to claim Aboriginal heritage, while still feeling a strong desire to belong, to connect. In my early 30s, being unexpectedly out of work as an advertising copywriter, I came across an ad for a writer/researcher for an Aboriginal theatre company. The project was “The Lost Children”, which later evolved into the play Stolen, themed around the “stolen generations”. I myself was not a member of the Stolen Generation, and neither was my mother, yet I was entrusted to write this important story. It took six years from commission to its stage premiere and, in that time, I read and spoke to as many people as I could. It was an amazing, deep, hands-on education, and yet the most important part of the experience, for me, was finally building some connections. While all along I had doubts about my “entitlement” to belong, I felt (mostly) accepted as an Aboriginal person by the Aboriginal theatre community, and they became my de facto mob. The spotlight is often on the dysfunction of Aboriginal communities, but what of the wider white community? Read the daily papers and note the innumerable examples of binge drinking, stabbings, reckless driving. We are all too aware of the plethora of pornography on the web, high rates of youth suicide and high rates of depression in the general population, but we never classify these as being “white” issues. In contrast, I think a healthy Aboriginal person and community represents “best practice”. They are connected to extended family and community; they participate in community events and have a way of conveying their culture — through art, music, dance, filmmaking, sport and the like. They look out for one another. They have pride in being Aboriginal and can express that, through opportunities such as NAIDOC (the National Aboriginal and Islander Day Observance Committee), but also in myriad everyday ways. Their Aboriginality is a source of strength. Their humour helps them through the tough times, and there is always someone wise to turn to. Although many of these ways of being have been eroded by intergenerational trauma and poor social indicators, the healthy Aboriginal person and community still survives to give us hope. Working in an Aboriginal organisation, you see all around you a dedication to making a contribution, to making a difference for future generations, while many of us at the same time are struggling with our personal demons. One of these can be low self-esteem. Low self-esteem can make us vulnerable to real or perceived slightings or put-downs, or can make us feel undervalued, which can impact on our working lives. One friend told me, after suffering put-downs at work, that she was used to being treated that way — that was how people (Aboriginal or otherwise) had always treated her. “Lateral violence” can be rife: it’s like we feel powerless to assert our rights “out there” in the wider community, so we turn on ourselves and on those closest to us, because it’s there that our anger and sadness and hurt have most traction. Some of us battle addictions, whether it’s alcohol or the pokies. Many of the Aboriginal women I know who are working in the child and family welfare area, me included, are also single mothers, and while that is not a deficit in itself, it is often linked to financial stresses and sometimes means that there is less household support. And yet we, me included, are all striving to be professional (and we are) — striving to have our lived experiences recognised for the insight and wisdom, empathy and compassion they bring to our working lives. In my own journey towards “belonging”, there are gems. Presenting at a recent conference, and introducing myself as having Muruwari heritage, I was later approached by two Elders who had attended the session. One said, “I couldn’t believe it when you said you were Muruwari — we’re Muruwari!” And they were proud of me for presenting at the conference. I felt “claimed” as one of them. I have a photo of myself in between the two Elders, and it is special to me. Travelling up to Bourke and Brewarrina, for the first time, in 2000, and meeting my mum’s cousins and extended family, a young relative greeted me with “G’day cuz”. That was like winning an award for me — priceless. Of course, it’s not only Aboriginal people who have had traumatic life experiences, but on the whole, I reckon we have been subjected to more than most. I’m not going to catalogue mine right here, but they’d make pretty good material for that new genre of literature, “miz lit”, which has been described as a chronicle of a miserable childhood or, in my case, a (partly) miserable adulthood. After reading the statistic on children whose parents had tried to kill them, it was only much later that I recalled that my father had once tried to strangle my sister. Although I didn’t witness it, and was not directly affected, those kinds of episodes permeate the very atmosphere in which you grow up. The crack in the kitchen wall that was never repaired, where he’d punched it in a drunken rage. The shame . . . I was told that I, being the youngest child, had been protected from many of those experiences, but perhaps they cannot help but soak into the core of who you are and how you feel about yourself? As a family we had no professional help, and informal assistance was mainly through my mother’s membership of Al-Anon, a voluntary group that offered support to the families of alcoholics. At this moment in our country, there is a vibrant and exciting conversation happening around healing, with the setting up of the new Aboriginal and Torres Strait Islander Healing Foundation, and many Aboriginal-run healing centres popping up like mushrooms. I try to experience and learn as much as I can about Aboriginal ways of healing, including smoking ceremonies, healing circles, deep listening and narrative ways. I try to increase my understanding of Aboriginal spirituality and how it can be incorporated into a holistic approach to healing. I try to embed all of my learnings into my work with Aboriginal children and communities. For myself, I have found ways to manage my depression, including daily exercise, plenty of omega-3s, good nutrition, managing my physical health, being socially connected, undergoing counselling periodically, involving myself in the arts and having a means of expression through my writing (plays, essays and fiction). My writing helps me to make sense of my world and my experiences, and to learn more about the history of Aboriginal people before and after colonisation. It is a privilege and a responsibility, in equal measure. I believe in the work I do, that it makes a difference in the world, and that, in doing it, I am contributing to something bigger than myself. I try to find time for nature, to learn new things (enrolling in a PhD and having Italian lessons). I have a responsibility to my children, to be a good role model for them, so that they can have a better life than mine, and hopefully one not plagued with many of the issues I’ve had to deal with. For those working with Aboriginal people, we are strong and resilient, but we may also, while doing a fabulous professional job, be subject to strong undercurrents in our lives. Be kind to us, and — for all of us Aboriginal and Torres Strait Islander people who are working for the betterment of our communities, especially our children — be kind to yourselves. You are gold.

Jane Harrison MA

Objective: To compare clinical oral health outcomes between a birth cohort of young Australian Aboriginal adults and age-matched, national-level counterparts.Design, setting and participants: Comparison of outcomes between the dental component of Wave-3 of the Aboriginal Birth Cohort (ABC) study — a cross-sectional study conducted between January 2006 and December 2007, nested within a prospective longitudinal investigation in the Northern Territory’s Top End — and the 2004–06 National Survey of Adult Oral Health (NSAOH), a representative survey of the Australian population. Data were analysed for 442 ABC study participants and 202 NSAOH participants aged 16–20 years.Main outcome measures: Severity and prevalence of clinical oral health outcomes.Results: The mean number of decayed teeth was 8.0 times higher among ABC study participants than NSAOH participants, while the prevalence of untreated decayed teeth was 3.1 times higher. ABC study participants experienced 10.8 times the prevalence of moderate or severe periodontal disease of NSAOH participants, and 1.9, 4.1 and 4.5 times the prevalence of calculus, plaque and gingivitis, respectively.Conclusion: Adverse clinical oral health outcomes were 2–11 times higher in a cohort of young Australian Aboriginal adults than their age-matched, nationally representative counterparts.

Lisa M Jamieson PhD · Susan M Sayers PhD · Kaye F Roberts-Thomson MPH

Objective: To estimate the incidence of type 2 diabetes in two ethnically distinct Indigenous populations in north Queensland, Australia.Design, setting and participants: A community-based follow-up study of 1814 Australian Aboriginal and Torres Strait Islander adults from 1999 to 2007. Participants were initially free of diabetes and lived in 19 remote communities in Far North Queensland.Main outcome measures: Fasting blood glucose level; diagnosis of diabetes; blood lipid levels; weight; waist circumference (WC); and blood pressure.Results: Of the 554 adults who completed the study, 100 developed diabetes over 3412 person-years (py) of follow-up. The incidence of diabetes was similar for Aboriginals (29.7 [95% CI, 20.4–38.4] per 1000 py) and Torres Strait Islanders (29.0 [95% CI, 21.8–38.6] per 1000 py) despite large differences in baseline body mass index (BMI) and WC. The age-standardised incidence for both populations was 30.5 per 1000 py. Obesity defined by WC increased the risk of developing diabetes for Aboriginals (rate ratio [RR], 2.0 [95% CI, 1.1–3.6]) and for Torres Strait Islanders (RR, 6.3 [95% CI, 2.5–16.1]) compared with normal WC. Presence of the metabolic syndrome (MetS) was a strong predictor of incident diabetes (adjusted hazard ratio, 2.4 [95% CI, 1.6–3.7]). For both groups, waist-to-hip ratio and the presence of the MetS better predicted diabetes than WC or BMI.Conclusions: The incidence of diabetes in these Indigenous Australians is nearly four times higher than for the non-Indigenous population and 50% higher than the incidence reported 10 years ago in Australian Aboriginals. Currently used BMI cut-off points are not appropriate for Indigenous Australians to predict diabetes.

Robyn A McDermott FAFPHM, PhD · Ming Li MD, PhD · Sandra K Campbell RN, MAE

To the Editor: Cardiovascular disease (CVD) and mental disorders are the top two contributors to the total burden of disease in Indigenous Australians and make a substantial contribution to the excess morbidity and mortality in this group.1 There is increasing evidence that mental disorders are risk factors for, or consequences of, CVD.2 Awareness and better understanding of the intertwined relationship between mental disorders and CVD in Indigenous populations can provide opportunities for coordinated and seamless management of these conditions in health care systems. We investigated the association between mental disorders due to substance use and CVD in a remote Indigenous community in the Northern Territory. A cohort of 897 Aboriginal adults aged 20–74 years (85% of the community’s total adult population) was established through a population-based renal disease screening program in the community between 1992 and 1995.3 We followed up 784 participants, who were free of CVD at baseline, to 31 May 2005, using hospital and death records. The study was approved by the Behavioural and Social Sciences Ethical Review Committee of the University of Queensland. Substance use-related mental disorders were determined from participants’ hospital records, using International Classification of Diseases, ninth revision (ICD-9) codes 192, 291 and 303–305; and 10th revision (ICD-10) codes F10–F19. Cases of CVD were identified by the first CVD event recorded in participants’ hospital and death records, using ICD-9 codes 390–459 and ICD-10 codes I00–I99. We used the Kaplan–Meier method to calculate cumulative CVD incidence rates for those with and without substance use-related mental disorders. CVD hazard ratios were estimated using Cox proportional hazards models. During a median follow-up period of 10 years, 177 of the 784 participants (23%) had clinically diagnosed mental disorders due to substance use (mainly alcohol: 140 participants), and 243 (31%) developed CVD. Incidence rates of CVD were 71 (95% CI, 58–87) and 27 (95% CI, 23–32) per 1000 person-years for those with and without substance use-related mental disorders, respectively (Box). Participants with substance use-related mental disorders were 2.6 (95% CI, 2.0–3.3) times more likely to develop CVD than those without. After adjusting for CVD risk factors measured at baseline (age, sex, body mass index, smoking status, alcohol use, blood pressure, serum cholesterol level, diabetes and albuminuria status), the association remained statistically significant, with an adjusted hazard ratio of 2.6 (95% CI, 1.9–3.5). Our findings confirm an association between substance use-related mental disorders and CVD in an Indigenous population, after adjusting for potential confounders. Traditional health care systems tend to separate services and treatment for mental disorders from those for physical health problems such as CVD.4 This separation is even more evident in remote Indigenous settings, where primary health care practitioners are already overwhelmed in providing general medical care to community members, with mental health services being delivered infrequently by visiting psychiatrists.5 The observed intertwined relationship between these two common conditions calls for integration of mental health services into routine primary health care, and enhanced collaboration between primary care practitioners, cardiologists and psychiatrists, in an effort to curb the huge burden imposed by these diseases. The emerging Aboriginal mental health worker program in the NT has the potential to be an effective service model to bridge the gap between mental health care and day-to-day primary health care.5 Dedicated financial resources and ongoing support for recruitment, training and retention of Aboriginal mental health workers will be required for sustained integration of mental health care with primary care in Indigenous communities. Kaplan–Meier estimates of cardiovascular disease (CVD) incidence among Aboriginal adults with and without substance use-related mental disorders

Zhiqiang Wang · Damin Si · Wendy E Hoy

Objective: To compare bloodstream infection (BSI) rates, pathogens and mortality among Indigenous and non-Indigenous adults in central Australia.Design, participants and setting: Retrospective study of adult patients (aged ≥ 15 years) admitted to Alice Springs Hospital (ASH) between 1 January 2001 and 31 December 2005. Patients were followed up until 30 June 2008.Main outcome measures: Admission-based and population-based BSI rates and mortality rates for Indigenous and non-Indigenous adults.Results: During the study period, there were 824 BSI episodes (Indigenous, 753; non-Indigenous, 71). The admission-based BSI rate for Indigenous patients was 26.5 (95% CI, 26.4–26.6) per 1000 adult admissions, compared with 5.2 (95% CI, 5.1–5.2) per 1000 adult admissions for non-Indigenous patients (infection rate ratio [IRR], 5.13 [95% CI, 5.10–5.18]). The population-based BSI rate was 1354.7 (95% CI, 1256.3–1460.8) per 100 000 persons per year among Indigenous patients and 69.9 (95% CI, 55.1–88.6) per 100 000 persons per year among non-Indigenous patients (IRR, 19.4 [95% CI, 15.1–24.9]). These differences were not explained by higher comorbidity levels among Indigenous patients. Human T-cell lymphotropic virus type 1 and Strongyloides stercoralis infected 43% and 35%, respectively, of Indigenous patients tested. The risk of death during the follow-up period was 32.1% for Indigenous and 13.4% for non-Indigenous patients (hazard ratio [HR], 2.69 [95% CI, 1.38–5.25]; P = 0.004). Mortality rates were higher among Indigenous patients who had more than a single BSI (HR, 1.86 [95% CI, 1.32–2.62]; P < 0.001). The mean age at death was 48.5 years (SD, 16.2 years) for Indigenous patients and 75.1 years (SD, 18.7 years) for non-Indigenous patients (P < 0.001).Conclusion: Indigenous adults living in central Australia experience BSI rates that are among the highest reported in the world. These are associated with a high risk of death, and are a likely consequence of the poor socioeconomic circumstances of Indigenous people.

Lloyd J Einsiedel PhD, FRACP · Richard J Woodman PhD

Objective: To assess the outcomes of an education intervention for childhood asthma conducted by Australian Indigenous health care workers (IHCWs).Design and setting: Randomised controlled trial in a primary health care setting on Thursday Island and Horn Island, and in Bamaga, Torres Strait region of northern Australia, April 2005 to March 2007.Participants: 88 children, aged 1–17 years, with asthma diagnosed by a respiratory physician (intervention group, 35; control group, 53; 98% Indigenous children).Interventions: Children were randomly allocated to: (i) three additional asthma education sessions with a trained IHCW, or (ii) no additional asthma education. Both groups were re-assessed at 12 months.Main outcome measures: Primary endpoint: number of unscheduled visits to hospital or a doctor caused by asthma exacerbation. Secondary outcomes: measures of quality of life (QoL) and functional severity index; asthma knowledge and understanding of asthma action plans (AAPs); and school days missed because of wheezing.Results: The groups were comparable at baseline (except for asthma severity, which was adjusted for in the analysis). There were no significant differences in the primary outcome (number of unscheduled medical visits for asthma). School children in the intervention group missed fewer school days because of wheezing (100% < 7 days v 21% of those in the control group missed 7–14 days). Significantly more carers in the intervention group could answer questions about asthma medication, knew where their AAP was kept (84% v 56%), and were able to describe the plan (67% v 40%). In both the intervention and control groups (before-and-after comparison), there was a significantly reduced frequency of asthma exacerbations, as well as an improved QoL score and functional severity index, with no significant differences between the groups.Conclusions: A community-based asthma education program conducted by trained IHCWs improves some important asthma outcomes in Indigenous children with asthma.Trial registration: Australian Clinical Trials Registry ACTRN012605000718640.

Patricia C Valery MD, MPH, PhD · Ian B Masters MB BS, FRACP, PhD · Brett Taylor MEd, GradDipExSpSc, BEd(Hons) · Yancy Laifoo IndigCommMgntDev · Peter K O’Rourke BSc(Hons), BA(Hons), PhD · Anne B Chang FRACP, MPHTM, PhD

Objectives: To ascertain whether changing from enhanced to routine surveillance had any deleterious impact on notification rates of acute rheumatic fever (ARF) among Indigenous people in north Queensland; and to determine whether initiatives to raise awareness about ARF among medical practitioners during the routine surveillance period were associated with any changes in the numbers of recurrences of the disease among Indigenous people in the region.Design, participants and setting: Routine surveillance of all cases of ARF, and (to identify unrecognised prior episodes) retrospective checking of the medical records of Indigenous people with notified first cases of ARF from mid 2004 to mid 2009 in north Queensland, which has an estimated resident Indigenous population of about 68 400.Main outcome measures: Rate of notifications of ARF during the routine surveillance period (mid 2004 to mid 2009) compared with that in the previous 5 years of enhanced surveillance; proportion of recurrent episodes of ARF that occurred from mid 2004 to the end of 2006 compared with the proportion in the following 2.5 years.Results: There were 203 notifications of ARF in 194 Indigenous people in north Queensland from mid 2004 to mid 2009, and this was a 23% increase in the average annual incidence compared with that in the preceding 5 years. Of the 54 recurrences, 34 (63%) occurred between mid 2004 and the end of 2006 and 20 occurred between the beginning of 2007 and mid 2009 (P < 0.01). Of the 148 episodes that were not recurrences, 69 (47%) occurred in the first 2.5 years and 79 in the more recent 2.5 years (P > 0.05).Conclusions: Changing from enhanced to routine surveillance in 2004 did not have a negative impact on notifications of ARF. The initiatives to raise awareness about ARF probably contributed to fewer missed cases and therefore to the considerable increase in the number of notifications, and ultimately to fewer recurrences.

Jeffrey N Hanna MPH, FAFPHM · Michele F Clark RN, BNursPrac