Indigenous health

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

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

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

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

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

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

I have been living at Shalom College for four years. It has been a life-changing experience for me. I have had time to work hard at uni, in a racism-free environment in which Indigenous students can live proudly. Without this scholarship it would be impossible for me to study medicine as there is no way my family could afford for me to live in Sydney.— Josef McDonald, 5th Year Medicine, University of New South Wales, Shalom Gamarada Scholarship Recipient The Shalom Gamarada scholarship program is funded both by the sale of work by Aboriginal artists at the annual, week-long Shalom Gamarada Ngiyani Yana exhibition and by the provision of scholarships by private donors and corporate sponsors. The name of the program comes from the term “gamarada ngiyani yana” in the Eora language and translates to “we walk together as friends.” “Shalom” is a Hebrew word, meaning peace and is part of the name of the Shalom College at the University of NSW. The program was founded in 2005. In 2010, the sixth exhibition and sale will run from 27th June to 4th July. This year's contributors include the internationally renowned contemporary Indigenous artist, Judy Watson. Other artists include Regina Wilson, Weaver Jack, Jan Billycan and Shorty Jangala Robertson. There will be much sought after ceramic works from the Bagu community from Girringun in Queensland. This year, we will be displaying specially commissioned walls which will include works from Utopia and commissioned installations from Yuendumu and Peppimenarti. For the first time, the exhibition will present new work from the community of Martumili from the Pilbara. Exhibition audiences will be offered a unique opportunity to experience an incredible and diverse range of Indigenous art practice from across Australia. Shalom Gamarada will showcase an extensive range of more than 120 stretched artworks hanging and many more unstretched works, some of which can be seen in this issue of the Journal (Box 1, Box 2, Box 3, Box 4, Box 5, Box 6, Box 7, Box 8, Box 9, Box 10), with a total value of over one million dollars. All artworks will be available for purchase, with prices ranging from a modest $150 to more than $25,000. Commissions from all art sales go to residential scholarships for Aboriginal and Torres Strait Islander Medical students at Shalom College. The Shalom Gamarada scholarship program was set up in 2005 to boost the numbers of Aboriginal and Torres Strait Islander medical students attending the University of NSW and runs in partnership with the UNSW’s Shalom College and the Muru Marri Indigenous Health Unit. Since its inception, the Shalom Gamarada Aboriginal art exhibition has been able to assist 24 students to study medicine, optometry and medical science, covering board and lodging expenses so students are able to focus solely on excelling in their studies. Each scholarship is valued at over $15 000 per year for the duration of the degree. We graduated our first Shalom Gamarada doctor in December 2009, Dr Beth Kervan. This year, another scholarship recipient and UNSW’s first Aboriginal optometry student, Jenna Owen — who was the top student in 4th Year Optometry in 2009 — will graduate. Details of the Exhibition and show Open: 11 am to 7 pm each day from 27 June to 4 July Address: Caspary Learning Centre, Shalom College, University of New South Wales, Kensington (enter via Barker St) Admission: Free More information: visit http://www.shalomgamarada.org/ or call Professor Lisa Jackson Pulver on 0404 859 989. Artist: Paddy Sims 1. Artist: Regina Wilson 2. Artist: Shorty Jangala Robertson 3. Artist: Jakayu Biljabu 4. Artist: Collaborative work by Mangkaja Arts, Fitzroy Crossing, WA 5. Artist: Wakartu Cory Surprise 6. Artist: Jimmy McKenzie 7. Artist: Judy Watson 8. Artist: Regina Wilson 9. Artist: Regina Wilson 10. Artist: Kathleen Petyarre The dance of life (cover image) Artist: Helen Milroy The dance of life painting is the last in a series depicting a multidimensional model of health and wellbeing from an Aboriginal perspective. The final painting brings all of the dimensions together to reflect the delicate balance of life within the universe. The dimensions include the biological or physical dimension, the psychological or emotional dimension, the social dimension, the spiritual dimension and finally, but most importantly, the cultural dimension. Within each dimension, there are additional layers to consider, including the historical context, traditional and contemporary views as well as gaps in our knowledge. The potential solutions for healing and restoration of wellbeing come from considering additional factors encompassing issues at the coalface of symptom presentation and service delivery, such as education and training, policy, sociopolitical context and international perspective. As this painting suggests, we can only exist if firmly grounded and supported by our community and spirituality, while always reflecting back on culture in order to hold our heads up high to grow and reach forward to the experiences life has waiting for us. The stories of our ancestors, the collective grief as well as healing, begin from knowing where we have come from and where we are heading. From the Aboriginal perspective, carrying the past with you into the future is as it should be. We are nothing but for those who have been before, and the children of the future will look back and reflect on us today. When we enable a person to restore all of the dimensions of their life, then we have achieved a great deal. When all of the dimensions are in balance within the universe, we can break free of our shackles and truly dance through life.

Lisa R Jackson Pulver

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

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

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

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

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

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

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

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

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

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