Indigenous health

Objective: To describe the epidemiology of acute lower respiratory infection (ALRI) and bronchiectasis in Northern Territory Indigenous infants hospitalised in the first year of life.Design: A historical cohort study constructed from the NT Hospital Discharge Dataset and the NT Immunisation Register.Participants and setting: All NT resident Indigenous infants, born 1 January 1999 to 31 December 2004, admitted to NT public hospitals and followed up to 12 months of age.Main outcome measures: Incidence of ALRI and bronchiectasis (ICD-10-AM codes) and radiologically confirmed pneumonia (World Health Organization protocol).Results: Data on 9295 infants, 8498 child-years of observation and 15 948 hospitalised episodes of care were analysed. ALRI incidence was 426.7 episodes per 1000 child-years (95% CI, 416.2–437.2). Incidence rates were two times higher (relative risk, 2.12; 95% CI, 1.98–2.27) for infants in Central Australia compared with those in the Top End. The median age at first admission for an ALRI was 4.6 months (interquartile range, 2.6–7.3). Bronchiolitis accounted for most of the disease burden, with a rate of 227 per 1000 child-years. The incidence of first diagnosis of bronchiectasis was 1.18 per 1000 child-years (95% CI, 0.60–2.16). One or more key comorbidities were present in 1445 of the 3227 (44.8%) episodes of care for ALRI.Conclusions: Rates of ALRI and bronchiectasis in NT Indigenous infants are excessive, with early onset, frequent repeat episodes, and a high prevalence of comorbidities. These high rates of disease demand urgent attention.

Kerry-Ann F O’Grady GDipPH, MAppEpid, PhD · Paul J Torzillo AM, MB BS, FRACP, FJFICM · Anne B Chang FRACP, MPHTM, PhD

Objective: To determine the burden of hospitalised, radiologically confirmed pneumonia (World Health Organization protocol) in Northern Territory Indigenous children.Design, setting and participants: Historical, observational study of all hospital admissions for any diagnosis of NT resident Indigenous children, aged between ≥ 29 days and < 5 years, 1 April 1997 to 31 March 2005.Intervention: All chest radiographs taken during these admissions, regardless of diagnosis, were assessed for pneumonia in accordance with the WHO protocol.Main outcome measure: The primary outcome was endpoint consolidation (dense fluffy consolidation [alveolar infiltrate] of a portion of a lobe or the entire lung) present on a chest radiograph within 3 days of hospitalisation.Results: We analysed data on 24 115 hospitalised episodes of care for 9492 children and 13 683 chest radiographs. The average annual cumulative incidence of endpoint consolidation was 26.6 per 1000 population per year (95% CI, 25.3–27.9); 57.5 per 1000 per year in infants aged 1–11 months, 38.3 per 1000 per year in those aged 12–23 months, and 13.3 per 1000 per year in those aged 24–59 months. In all age groups, rates of endpoint consolidation in children in the arid southern region of NT were about twice that of children in the tropical northern region.Conclusion: The rates of severe pneumonia in hospitalised NT Indigenous children are among the highest reported in the world. Reducing this unacceptable burden of disease should be a national health priority.

Kerry-Ann F O’Grady GDipPH, MAppEpid, PhD · Debbie M Taylor-Thomson BPharm · Anne B Chang FRACP, MPHTM, PhD · Paul J Torzillo AM, MB BS, FRACP, FJFICM · Peter S Morris MB BS, FRACP, PhD · Grant A Mackenzie MB BS, PhD · Gavin R Wheaton MB BS, FRACP, FCSANZ · Paul A Bauert MB BS, FRACP · Margaret P De Campo FRANZCR, MPH, GDipEpibiostats · John F De Campo FRANZCR, MHA, FRACMA · Alan R Ruben MB BS, MAppEpid

To the Editor: Childhood obesity is a growing concern, with an estimated 22% of Australian children considered to be overweight or obese.1 Overweight and obese Indigenous children are at high risk of developing chronic conditions such as ischaemic heart disease and type 2 diabetes,2 contributing to increased mortality.3 Given the paucity of studies assessing rates of overweight and obesity in Indigenous children in urban areas, we conducted a pilot study to determine whether the Aboriginal and Torres Strait Islander child health check (Medicare item 708) is a useful tool for opportunistically assessing dietary habits, blood pressure and rates of overweight and obesity in children attending the Inala Indigenous Health Service. Data were collected from April 2008 to September 2008, and were compared with the 2006 Healthy Kids Queensland (HKQ) Survey.4 Of the 129 children aged 5–14 years who had health checks during the study period, 50 (39%) participated in our study (25 girls). Of those who participated, 36% (18 of 50) were overweight or obese, compared with 21% (751 of 3561) in the HKQ Survey (χ2 = 6.54; P = 0.01) (Box). Of the 41 participants for whom z scores for waist circumference could be calculated, 19 were ≥ 90th centile. Half of the Inala participants (23 of 46 for whom data were available) consumed takeaway food at least once a week, compared with 33% (1048 of 3185) in the HKQ Survey (χ2 = 5.98; P = 0.01). Non-diet soft drinks were consumed at least once a week by 38% (18 of 47 for whom data were available) of Inala participants, compared with 24% (750 of 3129) of the HKQ population (χ2 = 5.19; P = 0.02). Fewer than two-thirds of Inala participants consumed the minimum recommended amounts of fruit, and fewer than half consumed the minimum recommended amounts of vegetables. Our study demonstrates that the Aboriginal and Torres Strait Islander child health checks are a worthwhile screening tool for overweight and obesity. However, recruitment was slow. Even with practice nurses actively inviting potential participants by telephone, only 5% of school-aged children on the clinic’s register attended during the study period suggesting that most of them were well. Opportunistic recruitment of children attending the clinic to see the doctor was difficult, with only one-third participating. Furthermore, addition of the food frequency questionnaire to the child health check increased consultation length, which was at times frustrating for families and clinic staff. What could we do differently? Promoting child health checks to families through fun campaigns, which aim to educate families on the benefits of preventive health checks, and using a quicker health check tool could boost recruitment. Child health check clinics could be run within schools or as special child-friendly clinics during out-of-school hours or school holidays. Our results, limitations notwithstanding, are alarming for this Indigenous community. The addition of waist circumference and blood pressure measurement (with age-appropriate tables) would enhance an already valuable tool — the Aboriginal and Torres Strait Islander child health check — in the early detection of chronic disease risk factors. Weight categories of children from the Inala Indigenous Health Service study and the Healthy Kids Queensland Survey

Annie R Fonda · Geoffrey K Spurling · Deborah A Askew · Peter S W Davies · Noel E Hayman

To the Editor: Improving access to appropriate, good-quality care in the antenatal and postnatal period is a key part of closing the acknowledged gap between Indigenous and other Australians in perinatal outcomes.1 Previous research in a large Aboriginal medical service in Queensland demonstrated sustained improvements in perinatal outcomes associated with a quality improvement approach.2 Here we describe patterns of the delivery of maternity care and service gaps on a broad scale, using data from baseline clinical audits in 34 Indigenous primary health centres participating in a national quality improvement intervention.3 Participating services were located across the Northern Territory (Top End and Central Australia), North Queensland, Far West New South Wales and Western Australia. Details of the audit methods have been described previously.4 Briefly, a random sample of up to 30 clinical records in each service was assessed to determine the degree of adherence to recommended protocols and procedures in the antenatal and postnatal periods.5 Records of women with an infant aged 2–14 months and who had been resident in the community for at least 6 months of the infant’s gestation were considered eligible for our study. The study was approved by the human research ethics committees in each region, and their Indigenous subcommittees where required. Clinical records of 535 women were assessed. Eighty-nine per cent of the women were Indigenous. However, compared with services in the NT, WA and North Queensland, services in Far West NSW had a higher proportion of non-Indigenous women presenting for antenatal or postnatal care (34% v 0–6%; P < 0.05). Overall, less than half of all women presented for care in the first trimester of pregnancy (Box). Documentation of routine antenatal investigations and brief interventions or advice regarding health behaviour varied, but generally these services appeared to be underutilised. There was relatively good documentation of follow-up of identified problems relating to hypertension or diabetes, with over 70% of identified women being referred to a general practitioner or obstetrician. However, follow-up of other identified problems, such as inadequate rubella immunity, was poor. Although 53% of women had a recorded postnatal visit, documentation of advice regarding health risk factors during the postnatal period was poor. For about half of all women there was documentation about breastfeeding advice and contraception. But advice about smoking, nutrition or mood (depression) was recorded for only 19%–21% of all women, and advice about sudden infant death syndrome prevention, injury prevention or infection/hygiene was recorded for only 4%–5% of all women. The clinical audit data presented here indicate that participating services had both strengths and weaknesses in delivering maternal health care. Nevertheless, improving adherence to recommended screening investigations and brief interventions or advice about health behaviours, particularly smoking cessation, in the antenatal and postnatal period were identified as clear areas for improvement across all services. This information represents baseline data to inform the long-term monitoring of a quality improvement intervention. More broadly, it should be useful for informing local, regional and national efforts to promote and assess the quality of primary maternal health care for Indigenous women, and thus help address the persisting unacceptably high rates of poor Indigenous perinatal outcomes in Australia. Documented pregnancy care across regions Characteristic NT Top End NT Central Australia Far West NSW Western Australia North Queensland Total Number of health centres | number of client records audited 13 | 136 2 | 45 6 | 103 9 | 193 4 | 58 34 | 535 Proportion of women with estimated gestational age < 12 weeks at first antenatal visit 49% 44% 35% 42% 34% 42% Mean number of antenatal visits 9 10 5 6 7 7* Proportion of women with folate prescribed before 20 weeks 29% 49% 3% 33% 24% 27%* Any use of: Cigarettes 41% 40% 39% 42% 55% 43% Alcohol 12% 27% 19% 25% 31% 22%* Illicit drugs 7% 2% 17% 8% 7% 9% Brief interventions or counselling Smoking cessation† 48% 67% 35% 49% 41% 46% Antenatal education 51% 93% 51% 46% 47% 52%* Nutrition 53% 76% 18% 32% 59% 41%* Breastfeeding 21% 51% 17% 25% 19% 24% Alcohol and other substance abuse 37% 56% 12% 39% 34% 34%* Investigations at first antenatal assessment Blood group/Rh 96% 100% 65% 77% 79% 82%* Antibodies 93% 100% 66% 70% 78% 79%* Midstream urine (MSU) 91% 96% 40% 67% 76% 71%* Full blood examination (FBE) 95% 100% 64% 73% 79% 80%* Rubella 92% 100% 61% 70% 78% 77%* Hepatitis B surface antigen 91% 100% 56% 75% 79% 78%* Syphilis serology 94% 100% 58% 55% 81% 72%* HIV 80% 89% 14% 72% 59% 63%* Offered anomaly screening 6% 33% 17% 20% 0% 15%* Other investigations Ultrasound before 16 weeks 32% 49% 38% 39% 24% 36% Ultrasound at 16–20 weeks 47% 69% 31% 41% 34% 42% 50g or 75g glucose challenge test (GCT) or glucose tolerance test (GTT) 78% 49% 33% 38% 66% 51%* FBE (20–28 weeks) 82% 69% 24% 46% 60% 54%* Low vaginal swab for group B streptococcus (34–37 weeks) 49% 62% 31% 29% 10% 35%* Follow-up of abnormal findings Record of abnormal standard GCT 17% (23/136) 22% (10/45) 10% (10/103) 4% (7/193) 17% (10/58) 11% (60/535)* GTT undertaken 87% (20/23) 90% (9/10) 80% (8/10) 43% (3/7) 60% (6/10) 77% (46/60) Anaemia (Hb < 100 g/L) 14% (19/136) 22% (10/45) 11% (11/103) 12% (24/193) 3% (2/58) 12% (66/535)* Iron prescribed 84% (16/19) 100% (10/10) 91% (10/11) 75% (18/24) 50% (1/2) 83% (55/66) Follow-up FBE or Hb test done 42% (8/19) 90% (9/10) 36% (4/11) 46% (11/24) 50% (1/2) 50% (33/66) Nitrites detected by dipstick 21% (28/136) 33% (15/45) 5% (5/103) 24% (46/193) 10% (6/58) 19% (100/535)* Urine sent for culture and sensitivity 96% (27/28) 100% (15/15) 100% (5/5) 93% (43/46) 100% (6/6) 96% (96/100) Oral antibiotic prescribed 93% (26/28) 60% (9/15) 80% (4/5) 37% (17/46) 83% (5/6) 61% (61/100)* Record of a normal follow-up MSU 46% (13/28) 100% (15/15) 40% (2/5) 26% (12/46) 83% (5/6) 47% (47/100)* Rubella antibodies negative or low-titre 35% (47/136) 7% (3/45) 15% (15/103) 15% (28/193) 7% (4/58) 18% (97/535)* Rubella vaccination given postnatally 36% (17/47) 67% (2/3) 13% (2/15) 32% (9/28) 0 (0/4) 31% (30/97) GTT = glucose tolerance test. Hb = haemoglobin. NSW = New South Wales. NT = Northern Territory. * P < 0.05 for comparisons between regions. † Among those who used cigarettes: NT Top End (n = 56), NT Central Australia (n = 18), Far West NSW (n = 40), WA (n = 82), North Queensland (n = 32); total N = 228.

Alice R Rumbold · Ross S Bailie · Damin Si · Michelle C Dowden · Catherine M Kennedy · Rhonda J Cox · Lynette O’Donoghue · Helen E Liddle · Ru K Kwedza · Sandra C Thompson · Hugh P Burke · Alex D Brown · Tarun Weeramanthri · Christine M Connors

Recognising the tensions inherent in all efforts to bring about change in Indigenous health outcomes Health promotion and illness prevention in Aboriginal and Torres Strait Islander communities remain central to closing the gap between Indigenous and non-Indigenous health outcomes. The National Indigenous Health Equality Targets identify the need for effective health promotion activities targeting smoking, alcohol consumption, oral health, chronic disease, nutrition, exercise, mental health, and social and emotional wellbeing.1 An expanding body of research considers the barriers to effective health promotion and illness prevention in Indigenous contexts.2-6 In this issue of the Journal Taylor and colleagues present findings from their study of Indigenous participation in cardiac rehabilitation,7 an important form of secondary prevention. Their study identified many barriers to participation, including the challenges associated with extended family responsibilities, the sociocultural inappropriateness of cardiac rehabilitation programs, and historical barriers to using mainstream services. The barriers they identified are recurring themes in many evaluations of Indigenous health promotion and health care services.2-6 At the heart of these recurring themes are two central tensions of Indigenous development: the tension between cultural difference and statistical equality, and the problem of marginalised identities. For a range of historical, geographical, socioeconomic and cultural reasons, the conditions required for a “healthy life” as defined by Western society (including nutritious food, smoking cessation, and accessing mainstream health services) are found less often in Indigenous than non-Indigenous populations. While many Indigenous communities and individuals see this as a major problem, for others, unhealthy behaviour and conditions are a normal part of life. For some Indigenous people, the environments and behaviour linked to good health are associated with non-Indigenous society and akin to a “foreign” culture. They may even be seen as antithetical to an Indigenous identity. Medical anthropologist Kate Senior’s research at Ngukurr in the Northern Territory provides one example of this. In this Indigenous community, hygiene practices are associated with the missionaries who required mission residents to keep their houses spotless. One older woman told Senior that, “I tell my own daughter how to do it, but all she says is ‘we’re not Munanga [white] — we don’t want to live Munanga way’”.8 Walking for exercise is similarly considered a Munanga behaviour and regarded with amusement. Others have also noted that the approach taken to hygiene interventions in Indigenous communities in the past promoted resistance to, rather than adoption of, health-promoting behaviour.9 Taylor et al suggest that attitudes such as these may be due to social exclusion. As one of the Aboriginal patients in their study commented in regard to health services, the legacy of colonisation and discrimination is that “it remain[s] in the psyche of the Aboriginal people that mainstream services are only there for other people”.7 In addition to social exclusion, others have argued that cultural difference plays a role in the “foreignness” of health services and healthy behaviour. A study of smoking in an Aboriginal community describes how integral the practice is to family interaction and ceremonial exchange, and how refusing to smoke can produce unbearable social isolation and friction — the “passing around and sharing of cigarettes is part of the social fabric of the community”.10 Anthropologist Maggie Brady has shown that alcohol misuse is similarly integrated into Indigenous social practices and identities.11 Such findings imply that calling for health-promoting change may mean changing the “social fabric” of some Indigenous communities. While some working in Indigenous health see this as a necessary and positive change, others are troubled by the thought that certain cultural practices may be compromised in the pursuit of good health. For example, there is debate over the role of “demand sharing”12 (where Indigenous people are obliged to accommodate even unreasonable demands from their kin) in preventing improvements in health behaviour and socioeconomic status. An anthropological study found that some non-Indigenous researchers working in Indigenous health expressed concern that healthy lifestyles may require a rejection of such kinship obligations.13 The overarching tension here is between respecting cultural difference and addressing disadvantage.14 Regardless of whether one believes that aspects of Indigenous culture will be changed by efforts to improve health, many non-Indigenous people working in Indigenous health harbour fears of eroding Indigenous culture and repeating the mistakes of the assimilation era.13 Taylor et al also report that, paradoxically, the widespread dissemination of Indigenous health statistics in the media reduces the likelihood of Indigenous people accessing cardiac rehabilitation services.7 They found that knowledge of the poor health status of the Indigenous population was disempowering and reduced Indigenous people’s motivation to engage with health promotion, an effect also found by others.10 This is one aspect of the broader problem of marginalised identities. When we recognise a distinct and disadvantaged group within the general population, we inadvertently and unavoidably label that population as inherently disadvantaged, even in the act of trying to address this disadvantage.15 The publication of Indigenous health statistics draws attention to health problems and attracts resources to deal with them. However, for Indigenous Australians, it also creates a sense that an Indigenous identity is tied to inevitable ill health, homogenising the varied health and wellbeing of individual Indigenous people. This effect may contribute to the reluctance of Indigenous Australians in the Australian Capital Territory to identify as Indigenous when accessing mainstream health services, as reported by Scotney and colleagues in this issue of the Journal.16 The notion of the statistical “gap” between Indigenous and non-Indigenous health outcomes that forms the centrepiece of current Indigenous policy is an illustrative example. Even when Indigenous health is improving at the same rate as non-Indigenous health, the gap remains constant. In fact, if measured as a relative proportion, the gap will increase as the absolute health of the Indigenous population steadily improves. Recognising these tensions does not mean that we should cease any form of intervention for Indigenous health — which would be unethical — or enter into a state of “paralysis by analysis”. Instead, health practitioners should accept that such tensions are inherent in all efforts to bring about change in Indigenous health contexts. We should be aware of the wider debates concerning cultural difference and statistical equality, and the dilemma of marginalised identities. Such awareness helps us to recognise these issues as they arise across the many diverse contexts of Indigenous affairs. It also makes explicit the ongoing need to manage these tensions in our work with Indigenous people.

Emma E Kowal BA(Hons), MB BS, PhD · Yin C Paradies MMedStats, MPH, PhD

To the Editor: Engaging patients in cardiac rehabilitation (CR), a program of secondary prevention measures, is crucial to improving outcomes after myocardial infarct.1 Rates of participation in CR by Aboriginal and Torres Strait Islander (hereafter Aboriginal) people are extremely low.2,3 We conducted a qualitative study on barriers to CR use from November 2007 to March 2008 with 15 Aboriginal cardiac patients (seven women and eight men, aged 31–74 years) living in Perth, Western Australia. Six had participated in some outpatient CR sessions; nine had not. Participants were interviewed face-to-face using a semistructured interview guide, with questions exploring their views and experiences of CR, barriers to use and suggestions for improvement. Recurring themes included challenges associated with extended family responsibilities and sociocultural inappropriateness of the program. These themes, along with less commonly discussed issues of poor knowledge of CR and the connection between colonialism and health services, reflect findings from previous studies.2,4,5 However, two new themes — media heart health messages and the younger age of the affected Aboriginal population — highlight further factors influencing participation (Box 1). We found that some patients feel constantly reminded of, and therefore come to expect, poor health outcomes, due to dire statistics repeated in the media. While the dominant theme in the Australian media of Aboriginal fatality and futility has been discussed,6 heart health messages are often disempowering, negatively affecting motivation to engage with health programs. This is likely reinforced by regular attendance at funerals for Aboriginal people, who die very prematurely from cardiovascular disease (CVD). This highlights the need for a shift in media and public health campaigns from “shock” headlines and statistics to a focus on strengths and successes, inspiring the groups involved and supporting them to make changes. Younger Aboriginal participants also spoke about feeling isolated in CR sessions among non-Aboriginal people who were 20–30 years older than them. The age demographic of CR program attendees generally reflects CVD epidemiology in the wider community, but the burden of CVD occurs at much younger ages in the Aboriginal population.7 This widening differential7 demands rethinking of how CR should work for this very different demographic group (Box 2). CR programs addressing the needs of younger people may improve receptivity and opportunities for primary prevention in the family and broader community. Although these two themes were reported by a small number of patients, further research into issues for Aboriginal patients with CVD is warranted. Importantly, it will contribute to understanding of how younger Aboriginal people think about their health, and feel motivated and supported by wider society to do something about it. 1 Quotes from Aboriginal cardiac patients reflecting barriers to participating in cardiac rehabilitation (CR) programs ... even with the newspaper, every second page has something to do with the heart ... Turn the radio on, “oh, there’s this new survey about heart conditions”. And I don’t want to know about it! Don’t tell me! ... I don’t want to be told the negatives ... it’s all you used to hear of all the stories regarding the heart. (Aboriginal patient 10) I didn’t like it [the CR program] because everybody else was at least twice my age. I was like the youngest one there and it was just a turn-off for me ... I’d feel more comfortable if people my own age were there for a start, you know? (Aboriginal patient 11) Aboriginal people don’t use [CR and health services] ... as a matter of course because the discrimination that took place in Australia against Aboriginal people ... instead it remained in the psyche of the Aboriginal people that mainstream services are only there for other people. They’re not there for you. (Aboriginal patient 9) 2 Recommendations from Aboriginal patients for improving cardiac rehabilitation (CR) programs Offer CR programs out of working hours Have opportunistic drop-in sessions rather than allocated times Make CR programs more appealing to younger clients Hold CR programs in Aboriginal community health centres Build trust and relationships with patients (the importance of yarning) Develop programs for use at home by the whole family Tailor lifestyle and diet advice to modern Aboriginal family situations Have both male and female Aboriginal health staff delivering CR if possible Target youth with heart health education messages Refocus public health messages away from being negative and fear-based to being positive and strength-based Encourage Aboriginal patients to attend CR sessions together (buddy system)

Kate P Taylor · Julie S Smith · Lyn Dimer · Mohammed Ali · Narelle Wilson · Tyra R Thomas · Sandra C Thompson

Objective: To explore emerging themes related to the mental health of Aboriginal children and adolescents (“young people”) arising from focus groups conducted in Sydney, New South Wales.Design, setting and participants: A qualitative study was conducted between April 2008 and September 2009 in three Aboriginal community-controlled health organisations in Sydney. A semi-structured approach was used in focus groups and small group interviews to elicit the views of 15 Aboriginal parents and 32 Aboriginal workers from a variety of health and social work backgrounds on important factors surrounding the mental health of Aboriginal young people.Results: Major themes identified were the centrality of family and kinship relationships, the importance of identity, confounding factors in the mental health of Aboriginal young people, and issues related to service access and implementation.Conclusion: Clinicians working with Aboriginal young people should be mindful of the critical importance of family and identity issues and should assess possible physical health or social factors that may complicate a diagnosis. Improvements in access to mental health services for Aboriginal families and a more holistic approach to mental health treatment are urgently required.

Anna B Williamson BPsych(Hons), PhD · Beverley Raphael AM, MB BS, MD, FRANZCP · Sally Redman BPsych(Hons), PhD · John Daniels MB BS, FACRRM · Sandra J Eades BMed, PhD · Naomi Mayers

I was asked to review the article below, and found it a compelling read. Zimmet has clearly gone to central Australia with an open heart and mind, and has discovered an intriguing world previously not known to him. He ends his article with a gentle challenge to those of us who have the privilege to work in health care, to consider whether our current methods are best practice, and whether they are best suited to all who seek our help. Having read this article, I found myself with two unanswered questions. First, given that there have now been several generations of Aboriginal people advocating for improvement to the dire circumstances in Aboriginal health, how is it that our young colleagues are still so shocked when they come to our communities? What is it that we (older Aboriginal people) have failed to say to get the attention of our health care providers, and their teachers? Second, how can we see to it that we produce many more graduates of the quality of Zimmet, who see the world with fresh eyes, are not afraid to ask the obvious questions, and are bold enough to tell us all that the Emperor is indeed naked? I strongly recommend that Journal readers take the time to read this article, and spend a moment or two in reflection to examine their own souls, to see if they can rise to this young man’s challenge. Louis G Peachey, BMed, FACRRM, Foundation President, Australian Indigenous Doctors Association, Canberra, ACT. In the Alice Springs paediatric ward, the vast majority of the 20 or so children are Aboriginal. They often have unique first names with an African–American or biblical flavour and distinctive spellings. Some come from town, while others travel from hundreds of kilometres away. Parents often lie with their children on mattresses on the floor, watching Disney DVDs, drawing, and waiting for the sporadic visits of hospital staff. For families, a visit to the ward can mean a period of isolation from their community or time with relatives who live in Alice Springs or who also happen to be in the hospital. It may be an unwanted upheaval from relatively peaceful community life, or an urgent and welcome respite from upheavals at home. What distinguishes the Alice Springs ward most is the type and severity of paediatric health issues. There is a whole other spectrum of health and disease in central Australia — one that challenges the heart and the mind. Labels that don’t stickThe categorisations of disease as I knew them after several years working in Melbourne seemed to collapse when I arrived in Alice Springs. Trying to apply learnt diagnostic and management techniques proved futile in the face of the ostensibly distinct nature of “common” illnesses like gastroenteritis, pneumonia and ear infections in central Australian children, let alone their coexistence with nutritional, social, cultural and historical factors. It is not uncommon to see 4-month-old infants with perforated ear drums. In contrast to coastal city paediatrics, “pink” or “red” tympanic membranes suggesting otitis media do not show up as threats on the diagnostic radar. Ear examination in central Australia is focused on detecting the presence or absence of pus or perforation of the tympanic membrane. Anything less is considered “healthy”. A child presenting with “gastroenteritis” can mean anything from a prolonged cryptosporidium infection to multiple parasitic and worm infestations. Families often refer to these different ailments generically as “guts ache”. Treatment ranges from frequent correction of significant acidoses and hypokalaemia, to using nitazoxanide to treat cryptosporidium. This drug is only available on the special access scheme in Australia, not because it is unsafe, but because so few children need it. The evidence for its use, however, is limited to a few studies, mainly in settings somewhat different to Alice Springs. This is a recurring theme in paediatric medicine here — that evidence from either “first-world” metropolitan research centres or the “third-world” does not necessarily translate to what health workers see in central Australia, a “fourth-world” inside our country. Further, century-old pathological definitions that define disease rather than causation or environmental and social contributors often do not provide us with adequate solutions today. They help us to heal the surface of the skin or lungs, perhaps the lining of the gut, but not always the deeper tissues. The tragically prevalent conditions of chronic suppurative otitis media and chronic suppurative lung disease in children could perhaps be more accurately defined as “chronic exposure to over-crowding, tobacco smoke, inadequate nutrition and bacterial respiratory tract colonisation”. Similarly “failure to thrive” might often be described as “failures of family and community structures, supports and function”. Effects on causesAs paediatric doctors at the hospital, we work closely with families, Aboriginal liaison officers, community organisations and even traditional healers. However, I feel we see the causative cycles of the social determinants of Aboriginal child health, yet cannot always avert the outcomes. Just like someone watching the desert heat evaporate the land’s water over several days, I often feel incapable of doing more than merely waiting for the storm to arrive. Chronic ear infections cause endemic conductive hearing loss. The result for many children is developmental, learning and behavioural issues with profound ramifications for schooling, employment prospects, parenting capabilities, their own future children and their communities. We try to encourage and empower adults to mop their children’s suppurating ears regularly to facilitate healing and help antimicrobial ear drops reach the middle ear, but, often, we don’t properly explain why this is important, or there are no tissues available at home, no refrigerator to safely store the antibiotics, or more urgent daily issues arise. The daunting challenges of social disadvantage, disharmony, and physical distance can cause health practitioners to minimise our efforts. Sometimes optimum care is not provided on the basis of assumptions about what families will do when they leave. Rationalisations such as “they are not going to give the medication so why bother” or “they’ll be back with the same problem in a week” are sometimes heard. This can be a result of us not being able to see the children and families we look after in the foreground, with their own unique strengths and weaknesses, existing within and beyond these pervasive problems. Seeing difference, seeing ways through the gapsOur lack of flexibility and our inability to — accommodate difference can potentially perpetuate the health gaps. There are many situations in which the pressures of the ward have limited my time to be patient with a family, listen carefully, or negotiate a treatment plan meaningfully, in order to understand the family’s perspective better and expedite the child’s recovery. I have also found it extremely important always to look for differences between individual Aboriginal children and families to prevent comical gaffes, therapeutic disasters and the spectre of racism. Aboriginality is not homogenous. Alice Springs and central Australian people have a complexity that is at odds with the predictability of the desert heat. If we accept that a fundamental component of racism is generalisation, then we are all caught in its web more than we would like to admit. This can be as simple as me assuming that a very dark skinned Aboriginal mother could speak an Indigenous language, or that her English would be limited. Neither was true and she spent much time articulating her worries about breastfeeding. Language difficulties play a major role in paediatric health gaps in central Australia. So much still seems to be “lost in translation” in the gap between English and the multitude of local Aboriginal languages, and between differing understandings of symptom durations, rationales for treatment and discharge plans. Translators are not available after hours, when clarity is often critical. There are other dimensions. There are well known and beautiful places near and around Alice Springs called “gaps”, where the mountain ranges part to reveal waterholes and jagged red rock facades. These geographical gaps were given names like Heavitree Gap or Emily’s Gap by Anglo-European explorers. They are important dreaming sites for the local Arrernte people. Heavitree Gap is a place where the local traditional owners would formally welcome and accept visiting people onto their lands. For Arrernte people then, talk of closing “gaps”, may have very different meanings from our own. Dr Patricia Miller, a senior Arrernte woman, recalls another elder fearing that someone would literally close Heavitree Gap, thereby preventing people and transport from entering Alice Springs directly. She could not understand why there not been meetings to explain the closure of such a significant cultural place. “Closing the gap” can also have an array of ramifications for different families. For some, it may mean having to bring their children to clinics for a seemingly endless array of needles, whether for vaccinations, antibiotics or iron supplementation. For others, it is about not having to tell three or four different doctors in one day what has happened to their child after being transferred from a remote area, or not having to explain the same thing repeatedly because community and hospital information systems are in silos. For some Aboriginal people, “closing the gap” may mean doctors learning to “speak” to each other better. For one family, “closing the gap” is a hope for a larger home in which 20 people do not have to share two bedrooms, so their child can get some sleep away from noisy adults. For another family living in town, it may be that “closing the gap” means not having their child’s Aboriginal status questioned because of his or her lighter skin colour and mixed descent. Looking and listeningSome of the health gaps and misunderstandings in health care also relate to how, for many Aboriginal people, conceptions of space and time are significantly different to medical thought. The chain of cause and effect, and the ideas that illnesses have names, time courses and scientific reasons for appearing are often not the main paradigms for our patients in central Australia. A grandmother explained to me, with the assistance of an Aboriginal liaison officer, that the reason why her 18-month-old grand-daughter was not eating or growing properly was not because she was still breastfed by her mother and had trouble eating solids, but because the unborn baby her mother was carrying was playing tricks and interfering with its sibling’s eating habits. A few mothers on the ward told me about the changing winds and misplaced internal rocks that had ravaged their children’s bodies. They had taken their children to see the traditional healers before seeing a doctor. One mother, a painter and former Aboriginal liaison officer, told me she struggled with prioritising one form of healing over the other. This mother and her child are just one example of the astounding resilience of children and families in central Australia. Their ability to remain healthy, keep a sense of humour, stay positive and return to the hospital or clinic for a visit is remarkable. It is even more extraordinary considering the harsh environment and limited resources. This resilience needs to be supported and harnessed at all costs. It is critical that we strengthen Aboriginal families by using their unique structures, dynamics, hopes and needs. The challenge, then, is to balance a paediatric perspective with an Aboriginal one. The two are not mutually exclusive. We have to keep our paediatric medical gaze sharp and unprejudiced. An evidence base should be built for treating the unique conditions that are seen in central Australian children. Concurrently, ensuring that national standards of nutritional and child development health are implemented in the region is paramount, as a matter of health equity and human rights. We need to make sure that what we know as “truth” in paediatric medicine is applied equally to children living in remote areas and, at the same time, keep our eyes, ears and hearts open to the varying strengths and needs of each child, carer, family or community. We should listen to what they tell us and be comfortable with the silences. We need to find ways through the gaps from several vantage points, with Aboriginal people leading the way back to their own health.

Marcel D Zimmet MB BS/BA(Hons)

To the Editor: The Australian Government is seeking to reduce Indigenous disadvantage through its “Closing the Gap” strategy.1 One challenge, however, is incomplete identification of Indigenous status in health and administrative data collections and the necessary caution in interpreting statistics because of such underestimates.2-5 For planning, expenditure, access to and equity of health services, governments need to ensure that Indigenous data collections are accurate. A key area of interest is self-reported Indigenous identification in mainstream general practice settings. Research has focused on general practitioners’ perspectives,6 but not those of Indigenous patients. We conducted a qualitative study that explored the views of Indigenous Australians residing in the Australian Capital Territory who were recruited through a range of Indigenous organisations and differed in age, sex and social background. Participants gave written informed consent to face-to-face interviews, in which they were invited to describe their experiences of being asked their Indigenous status in mainstream general practice settings — including their understanding of why people are asked about their Indigenous identity and views on how they should be asked. Of the 28 participants (age range, 18–78 years), 12 were men, 18 were Aboriginal, five were Torres Strait Islander, and five identified as both Aboriginal and Torres Strait Islander. All had used mainstream general practice services in the ACT. Six reported ever having identified as Indigenous in that setting, although it is unclear how many were asked their Indigenous status. Some reported having been mistaken for being either from another country or non-Indigenous. All stated they would identify as Indigenous if asked, but felt it was essential to be provided with information explaining the rationale for the question — in particular, how it would benefit them if they did identify as such. It was suggested that pamphlets or posters explaining the benefits of identifying could create cultural safety. Participants emphasised the need for appropriate training of practice staff on the rationale for asking the identifier question and how to ask it respectfully. Several themes reflecting issues that would influence an individual’s decision to identify as Indigenous emerged: previous racism in the community; the patient–doctor relationship; the perception that discussing identity would lengthen consultation times; practice staff’s assumed motives for asking; and recognition of the culture and diversity of Indigenous Australians (Box). The principal message was that the process for asking needs to be kept brief and simple. An acceptable form of words was agreed by all participants to be: “For the purpose of providing the best care possible, can you please tell me if you are Aboriginal and/or Torres Strait Islander?” This research highlights the need for GPs to “Just ask!” and to ensure that the Indigenous identifier question and explanation are conveyed consistently and appropriately. Further research in other primary care settings could evaluate the approach that we advocate. Aboriginal medical services provide culturally secure services based on Aboriginal preferences.7 Participants in this study have provided guidance on how similarly culturally secure services could be provided in mainstream general practice. Themes identified from interviews with 28 Indigenous respondents about identifying as Indigenous in mainstream general practice Importance of the patient–doctor relationship “I think it is important to start building relationships between medical professionals and Indigenous people, so that Indigenous people can start becoming more informed about their health and be more proactive in managing it more.” Rationale for asking about Indigenous identity “. . . I can understand why a mainstream service would see if a person wants to identify or not so that they can get those Medicare items. So it needs to be done without someone getting offended. I know that I would be offended if it was done in a mainstream area and a big deal made of just for the money. It’s how you portray it to the Indigenous person so that they don’t get offended.” Creating cultural safety in general practice “When you see posters and pamphlets and information then you think, ‘Oh, so maybe this surgery is OK’. You’re more comfortable in coming back and volunteering information. It is all about creating an environment that enables that.” Mistaken identities of Aboriginal and Torres Strait Islanders “Some of them have asked if I was from PNG [Papua New Guinea], and um [I’m] . . . not really a Torres Strait Islander, I don’t know, it must be my features. They naturally assume that I am from PNG.” Who should ask the question? “I think the doctor. Because then they get an idea of your background and . . . it gives them a good idea of where you come from and what sort of illnesses are around the place.” Just ask! “I love who I am, I don’t mind saying where I’m from.”

Angela Scotney · Jillian A Guthrie · Kamalini Lokuge · Paul M Kelly

New directions and prospects in Aboriginal and Torres Strait Islander health research The NHMRC Road Map II: a strategic framework for improving the health of Aboriginal and Torres Strait Islander People through research (“Road Map II”) will shortly be available from the National Health and Medical Research Council (NHMRC) website and in published form. This editorial outlines new NHMRC activities for research in Aboriginal and Torres Strait Islander health. The NHMRC Road Map: a strategic framework for improving Aboriginal and Torres Strait Islander health through research (“Road Map”) has been the NHMRC’s policy framework for Aboriginal and Torres Strait Islander health, ethics and advice since 2003. During the 2006–2009 triennium, the NHMRC Aboriginal and Torres Strait Islander Health and Research Advisory Committee planned and conducted a national consultation process to evaluate the impact of the Road Map and its accompanying capacity-building activities. The evaluation process included a series of workshops held in Sydney, Melbourne, Perth, Alice Springs and Townsville, a written submission process, and an evaluation of NHMRC 2000–2007 funding data. In response to outcomes from the evaluation, the Aboriginal and Torres Strait Islander Health and Research Advisory Committee recommended that the NHMRC develop an implementation framework and communication strategy for its activities in Aboriginal health. In supporting these recommendations, the NHMRC also supported the Aboriginal and Torres Strait Islander Health and Research Advisory Committee to develop Road Map II. Key features of Road Map IIRoad Map II has seven “action areas” for research, developed in response to the Road Map review and targeted consultation in 2009 with peak national Aboriginal and Torres Strait Islander representative bodies.1 These action areas will be implemented through regular consultation and negotiation with stakeholders, a triennial action plan for NHMRC activities in Aboriginal and Torres Strait Islander health supported in the NHMRC triennial strategic plan, and advice from the NHMRC Aboriginal and Torres Strait Islander Health Advisory Committee. The first action area — improving the participation of Aboriginal and Torres Strait Islander people in NHMRC programs — targets recruitment, participation and retention of Aboriginal and Torres Strait Islander people in all biomedical, clinical, public health, and health services research into Aboriginal and Torres Strait Islander health. The second action area — capacity exchange — increases the focus on evidence translation activities. Avenues for capacity exchange will be identified in the workforce, professional and information capacity-building activities that were strategically successful aspects of the Road Map research framework. The third action area — promotion of the NHMRC’s role in Aboriginal and Torres Strait Islander health — is aimed at research partnerships and collaborations with Aboriginal and Torres Strait Islander communities. The NHMRC is developing a communication strategy for Road Map II research in this action area that will include podcasts and showcasing research and evidence transfer activities. These activities are aimed at supporting the research networks that are integral to the four remaining research action areas: collaborative research to support the Close the Gap campaign activities, evaluation research highlighting clinical outcomes and evidence gaps, intervention research to sustain health gains, and targeted calls for research. The NHMRC’s new peer review policy for Aboriginal and Torres Strait Islander health research is also pivotal. New peer review policy in Aboriginal and Torres Strait Islander health researchIn 2009, the NHMRC introduced a new policy for peer review in Aboriginal and Torres Strait Islander health research. The new policy takes account of all research-related activities that an Aboriginal or Torres Strait Islander funding applicant has been involved in, and includes these as part of that applicant’s research “track record”. The new policy is intended to facilitate research opportunities for applicants with high levels of experience or long-standing involvement in Aboriginal and Torres Strait Islander health fields. It is aimed at supporting capacity exchange and capacity building in Aboriginal and Torres Strait Islander health research. Other NHMRC supportIn 2009–2012, the NHMRC will also support a study exchange program for established researchers in Aboriginal and Torres Strait Islander health. Activities supported may include participation in clinical exchanges and placements, and speaking at international events. Priority will continue to be given to research projects about interdisciplinary intervention, social interactions, role conflicts, social control, life stress, social integration, family interactions, and institutional settings that have relevance to clinical, public and health services. The NHMRC, Health Research Council of New Zealand and Canadian Institutes of Health Research have formed the International Collaborative Indigenous Health Research Partnership. In 2009, Partnership grants supported projects investigating health literacy among Indigenous people living with cardiovascular disease, and their families and health care providers; reduction of chronic dental disease in early childhood; and how professional health education can reduce disparities in chronic disease care.2 In all funded research, the NHMRC document Values and ethics — guidelines for ethical conduct in Aboriginal and Torres Strait Islander health research3 continues to have a major influence on national and international collaborations with researchers in Indigenous health. Evidence that can be translated into policy and practice is in short supply in this area, and research must be appropriate for use in Indigenous communities. Finally, evidence and evaluation of experience and outcomes with current government interventions need to be linked, so that policy and practice continue to improve. Prospects for Aboriginal and Torres Strait Islander health researchAboriginal and Torres Strait Islander researchers and communities have made significant investments in NHMRC research and research-related resources. In the Road Map II research framework, prospects for Aboriginal and Torres Strait Islander researchers are linked to the NHMRC’s success in engaging with Aboriginal and Torres Strait Islander communities. In turn, health gain in communities is linked to effective research. These relationships have been highlighted for many years and, in highlighting them again now, people working in the NHMRC, research communities and the broader health sector are urged to participate in mentoring affiliations that support Aboriginal and Torres Strait Islander health researchers. We continue to support the capacity-building activities and new peer review processes that are working well for Aboriginal and Torres Strait Islander researchers, and it is our sincere aim that, with support from all stakeholders, Road Map II and its accompanying capacity-building activities will lead to health gain in Aboriginal and Torres Strait Islander communities.

Warwick P Anderson AM

Objective: To identify policy strategies that are perceived by researchers active in Aboriginal and Torres Strait Islander health as effective in increasing the amount of high-quality intervention research undertaken in this field.Design and setting: A cross-sectional study using a web-based survey was emailed to researchers based in clinical, public health and other academic institutions.Participants: Researchers who had published more than once in Aboriginal health between 1 January 2005 and 1 August 2009, based on a MEDLINE search.Main outcome measures: Participants selected and weighted 17 strategies that were, in their opinion, important for increasing the amount of high-quality intervention research being conducted in Aboriginal health.Results: We invited 157 researchers to complete the survey, and received 74 completed surveys. The most highly weighted strategies were: for research funding bodies to give funding priority to intervention research proposals that target Aboriginal populations (median weighted score,15%); for peak bodies representing Aboriginal communities to clearly specify intervention research priorities in a national Aboriginal health research agenda (median weighted score, 10%); for research funding bodies to fund research to develop reliable measures of health for Aboriginal people (median weighted score, 9.5%); for health care organisations to participate more in intervention research targeting Aboriginal populations (median, 8.5%); and for research review panels to accept intervention research designs other than the randomised controlled trial (median weighted score, 8%).Conclusions: Researchers who are active in Aboriginal health research perceive that improvements in funding mechanisms, priority setting and research systems are required to increase the amount of high-quality intervention research being conducted in this field. A national intervention research agenda that encourages multidisciplinary research teams and community partnerships may offer a solution.

Jessica M Stewart BA/LLB, MPS · Rob W Sanson-Fisher PhD · Sandra J Eades MB, PhD · Nicole M Mealing BSc(Adv Maths)

Objective: To describe the impact of pandemic (H1N1) 2009 influenza (nH1N1) on Indigenous people in the Top End of the Northern Territory at community, hospital and intensive care unit (ICU) levels. Design, setting and participants: We analysed influenza notifications for the Top End from 1 June to 31 August 2009, as well as data on patients admitted through Top End emergency departments with an influenza-like illness. In addition, data on patients with nH1N1 who were admitted to Royal Darwin Hospital (RDH) and the RDH ICU were prospectively collected and analysed.Main outcome measures: Age-adjusted notification rates for nH1N1 cases, Top End hospital admission rates for patients with nH1N1 and RDH ICU admission rates for patients with nH1N1, stratified by Indigenous status.Results: There were 918 nH1N1 notifications during the study period. The age-adjusted hospital admission rate for nH1N1 was 82 per 100 000 (95% CI, 68–95) estimated resident population (ERP) overall, with a markedly higher rate in the Indigenous population compared with the non-Indigenous population (269 per 100 000 versus 29 per 100 000 ERP; adjusted incidence rate ratio, 12 [95% CI, 7.8–18]). Independent predictors of ICU admission compared with hospitalisation were hypoxia (adjusted odds ratio [aOR], 4.5; CI, 1.5–13.1) and chest x-ray infiltrates (aOR, 4.3; CI, 1.5–12.6) on hospital admission.Conclusions: Pandemic (H1N1) 2009 influenza had a disproportionate impact on Indigenous Australians in the Top End, with hospitalisation rates higher than those reported elsewhere in Australia and overseas. These findings have implications for planning hospital and ICU capacity during an influenza pandemic in regions with large Indigenous populations. They also confirm the need to improve health and living circumstances and to prioritise vaccination in this population.

Shaun M Flint MB BS, BSc, FRACP · Joshua S Davis MB BS, DTM · Jiunn-Yih Su MB, MPH · Erin P Oliver-Landry MB BS, BSc · Benjamin A Rogers MB BS, FRACP · Aaron Goldstein MB BS · Jane H Thomas BN, GradDipPH · Uma Parameswaran MB BS · Colin Bigham MB BS, MRCP, FRCA · Kevin Freeman BSc · Paul Goldrick FCICM, FANZCA, FFARCSI · Steven Y C Tong MB BS, FRACP

To the Editor: Aboriginal and Torres Strait Islander people were more at risk of hospitalisation, admission to intensive care units and death during the 2009 influenza A pandemic than non-Indigenous Australians.1 We conducted a descriptive analysis of our response to the pandemic at Winnunga Nimmityjah Aboriginal Health Service (Winnunga) — an Aboriginal community controlled health service in Canberra, Australian Capital Territory, which provides comprehensive primary health care to more than 3500 patients per year. Data were sourced from the Winnunga electronic patient record system, pathology laboratories and ACT Health. The Winnunga Board approved this analysis and report for publication. In May 2009, we implemented the pre-existing Winnunga influenza pandemic plan, working closely with ACT Health and the ACT Division of General Practice. We enhanced infection control, implemented influenza testing procedures, initiated electronic data collection and obtained oseltamivir from the ACT stockpile to dispense on site. We adapted ACT Health pandemic protocols to create a flow chart appropriate for Winnunga, with approval from the ACT Chief Health Officer. This involved using clinical discretion to decide whether to dispense oseltamivir to Aboriginal and Torres Strait Islander people with mild illness, and included the provision to supply prophylactic oseltamivir to high-risk household contacts, especially in overcrowded households. A plan was made to open an on-site influenza clinic, but this was not necessary. Increased testing for influenza commenced in late May. The first patient with pandemic (H1N1) 2009 influenza was identified on 1 July (Box). Of the 168 nasal swabs tested for influenza by polymerase chain reaction analysis, 52 (31%) were positive for pandemic (H1N1) 2009 influenza. In addition, six Winnunga patients tested positive at other locations. In late July, testing guidelines changed and laboratory testing was no longer recommended for most patients with influenza-like illness.2 Consequently, we did not identify test-positive cases past the beginning of August. The actual number of cases of pandemic influenza that occurred in Winnunga patients is unknown. Of the 58 patients who tested positive, 54 were Aboriginal and/or Torres Strait Islander, 28 were male, and 47 were ACT residents. The mean age was 22 years (range, 0–62 years), 31 patients were aged under 20 years and four patients were pregnant. There was one overnight hospitalisation. During July, Winnunga accounted for 8% (44/551) of all notified pandemic influenza cases in the ACT — more than expected based on patient numbers alone. However, more testing may have been done at Winnunga than at other organisations because of our high-risk population. In July and August, 13% (204/1604) of all presenting patients at Winnunga had an influenza-like illness. There were 229 recorded episodes of influenza-like illness between May and November with a sharp peak in July and a smaller peak in August (Box). Oseltamivir dispensing commenced 1 week before identification of the first patient who tested positive, and corresponded with episodes of influenza-like illness (Box). A total of 107 courses of oseltamivir were dispensed to 33 children and 74 adults. Clinical risk factors other than Aboriginal and Torres Strait Islander status were recorded for 47 of these patients. Oseltamivir dispensed to Winnunga patients at other locations was not included in our analysis. We do not know whether oseltamivir made a difference in reducing severity of disease or preventing hospitalisations in our patients. During July and August 2009, pandemic influenza created an increased workload at Winnunga. Although there were some staff absences due to pandemic influenza, these were short and did not significantly affect clinical functions. Pandemic influenza in patients was also not as severe as planned for. A more severe pandemic would place a significant burden on our already busy Aboriginal medical service. A pre-existing influenza pandemic plan, internal public health capacity, good working relationships with local health agencies, on-site dispensing and service-specific protocols were important features of our response to the 2009 pandemic. Vaccination for influenza is being strongly promoted at Winnunga in 2010. Influenza-like illness, influenza testing, tests positive for pandemic (H1N1) 2009 influenza, and courses of oseltamivir dispensed at Winnunga Nimmityjah Aboriginal Health Service, May to November 2009

Ana Herceg · Peter G Sharp · Christine G Arthur · Julie A Tongs

The politics of suffering. Indigenous Australia and the end of liberal consensus. Peter Sutton. Melbourne: Melbourne University Press, 2009 (xii + 268 pp). ISBN 978 0 522 85636 1. Have you spent a day or three in a sweltering clinic in a remote Aboriginal community in northern Australia? No? Then read this book, for you will learn why the appalling state of Aboriginal health heads the list of national moral and political challenges. It may encourage you to fill the second gap, that between rhetoric and action, needed to “close the gap” (in health and life expectancy between Indigenous and non-Indigenous Australians). Sutton’s polemic is a cri de coeur from a true warrior. From the early 1970s, his academic interest in Indigenous language and sacred art led to a life-long deep engagement with the Wik people, and to a role in negotiations that have led to landmark political achievements. In the first chapters, he urges a critical re-analysis of causality beyond that of systematic oppression. He argues that more recent dislocations have stressed beyond tolerance the tension between the conflicting imperatives towards modernity versus traditional social values, and that these are relevant in accounting for the endemic domestic violence, alcohol abuse, and ill-health in remote communities. Halfway through the tone mellows, and the reader is treated to a series of charming vignettes of “Unusual Couples”; stories of deep black–white friendships in the landscape of Indigenous history. These lead into his final chapter, “On feeling reconciled”, where we are challenged to confront our own moral thought patterns: Is collective reconciliation about the politics of appeasement? Are our notions of apology and reconciliation, based on European moral and intellectual traditions, compatible with an Aboriginal morality forged over 60 000 years in this land? Sutton navigates us through this moral maze to the conclusion that reconciliation is a personal experience. This fits with what an Aboriginal writer told me in my own searching: “You change one heart at a time.” Sutton’s book should open many hearts to being changed, one at a time.

John Boulton

To the Editor: The recent article by Davis and colleagues reported that the SMART-COP score underestimates the severity of pneumonia in tropical northern Australia, but can be improved by using locally relevant additions.1 The authors’ revised scoring system, SMARTACOP, increased the score for an albumin level < 35 g/L and added Aboriginal or Torres Strait Islander status as a variable. While these additions are useful, the reason for adding ethnicity was not fully clarified. A factor overlooked was low serum 25-hydroxyvitamin D [25(OH)D] levels among dark-skinned Australians.2 Smoking, identified as a marginally insignificant risk factor,1 is also associated with lower serum 25(OH)D levels.3 Vitamin D enhances the innate immune system through induction by 1,25-dihydroxyvitamin D of cathelicidin and defensins, which combat several types of bacterial and viral infections including upper respiratory tract infections.4 In the 1918–1919 influenza pandemic in the United States, many deaths were due to pneumonia that occurred as a complication of influenza infection. An ecological study found that indices for levels of vitamin D production from solar ultraviolet-B irradiance explained 50% of the variance in pandemic case-fatality rates among 12 communities.5 The mechanisms proposed for the beneficial effect of vitamin D were reduced proinflammatory cytokine production, which would reduce damage to the epithelial lining of the lungs, and induction of cathelicidin and defensins to fight the secondary bacterial pneumonia infection. If sera are available for those included in the Australian SMART-COP study,1 they could be analysed for 25(OH)D levels to test this hypothesis.

William B Grant

In reply: We thank Grant for his interest in our study on pneumonia severity assessment in tropical Australia. Our revised scoring system included increased weighting for hypoalbuminaemia, as well as adding a point for Indigenous status, because these two factors had the strongest association with the need for intensive respiratory or vasopressor support on univariate analysis.1 Unlike vitamin D status, these and the other factors included in the scoring system are readily available measures that can be used in the clinical setting to rapidly predict the need for intensive support. The scoring system was not intended to identify underlying aetiology or risk factors for severe pneumonia. For example, Indigenous status is likely to be a surrogate measure for undiagnosed comorbidities, lack of access to health care, and socioeconomic disadvantage. We agree that vitamin D is important in immune function and that the levels of insufficiency that result in impaired resistance to infection are not well defined.2 Most data on vitamin D deficiency in dark-skinned populations in Australia come from temperate areas,3,4 and the reference offered by Grant to support the concern about vitamin D deficiency does not cite any data from Australian populations north of southern Queensland.5 Further studies are needed on the prevalence of vitamin D deficiency in Indigenous Australians in tropical areas, and the additional contribution of vitamin D deficiency independent of known risk factors of severity and outcome.

Joshua S Davis · Allen C Cheng · Bart J Currie · Nicholas M Anstey

To the Editor: There is generally a high level of awareness about the burden of disease associated with diabetes and its complications in Indigenous Australians.1 While high rates of renal failure, retinopathy and cardiovascular disease in Indigenous people are frequently emphasised, diabetes-related foot complications receive relatively little attention. As part of the Western Australian Department of Health’s Cardiovascular Health Network initiative (http://www.healthnetworks.health.wa.gov.au/network/cardio.cfm), we reviewed the trends in amputations for arterial disease or diabetes-related complications in Western Australia for the period 2000–2008. Discharges from hospital for any lower-limb amputations were identified using the relevant International Classification of Diseases, 10th revision, Australian modification, codes.2 Each individual was included only once, regardless of whether they had a further amputation. Age-standardised rates were calculated for Indigenous and non-Indigenous people residing in Western Australia, with and without diabetes. Toe or foot amputations were defined as “minor”, and amputations below or above the knee as “major”. Among those aged 25–49 years with diabetes, minor amputations were 27 times more likely, and major amputations 38 times more likely, in Indigenous people (Box). These data have not been validated by chart review, but there is no reason to suspect systematic bias. Nearly all (98%) of the amputations in Indigenous people were associated with diabetes. Although it is difficult to estimate the role of macrovascular arterial disease using administrative data, the literature suggests that peripheral neuropathy, ulceration and sepsis are important causal factors in these amputations.3 There is ample evidence that simple interventions such as foot screening, education and appropriate footwear are cost-effective measures to reduce amputations in patients with diabetes.4 Although there are some excellent programs and services for Indigenous people with diabetic foot problems throughout Australia, they are few in number, often fragmented and generally poorly resourced. Multidisciplinary foot clinics — considered international best practice5 — typically remain centred in capital city tertiary hospitals, requiring Indigenous people from rural and remote areas to travel long distances onto someone else’s land, with unfamiliar surroundings and devoid of family support. Although further research is required to better understand the underlying reasons for this disparity in amputation rates, there is a more urgent need to implement culturally appropriate versions of simple interventions among Indigenous people and ensure foot care is a standard component of comprehensive, multidisciplinary diabetes management. Age-standardised amputation rate* (crude number) by age group, 2000–2008 Minor amputations† Major amputations‡ 25–49 years ≥ 50 years 25–49 years ≥ 50 years Indigenous with diabetes 46.4 (93) 185.0 (118) 15.0 (30) 76.8 (49) Non-Indigenous with diabetes 1.7 (108) 28.9 (1408) 0.4 (26) 13.1 (638) Indigenous without diabetes 0.0 (0) 4.7 (3) 1.0 (2) 3.1 (2) Non-Indigenous without diabetes 0.3 (21) 6.5 (317) 0.3 (17) 12.8 (628) * Per 100 000 Indigenous and non-Indigenous people (irrespective of diabetic status) using the 2001 Census as the standard population. † Toe or foot amputations. ‡ Amputations below or above the knee.

Paul E Norman · Deborah E Schoen · Joel M Gurr · Marlene L Kolybaba

Aim: To determine the prevalence and causes of vision loss in Indigenous Australians.Design, setting and participants: A national, stratified, random cluster sample was drawn from 30 communities across Australia that each included about 300 Indigenous people of all ages. A sample of non-Indigenous adults aged ≥ 40 years was also tested at several remote sites for comparison. Participants were examined using a standardised protocol that included a questionnaire (self-administered or completed with the help of field staff), visual acuity (VA) testing on presentation and after correction, visual field testing, trachoma grading, and fundus and lens photography. The data were collected in 2008.Main outcome measures: VA; prevalence of low vision and blindness; causes of vision loss; rates of vision loss in Indigenous compared with non-Indigenous adults.Results: 1694 Indigenous children and 1189 Indigenous adults were examined, representing recruitment rates of 84% for children aged 5–15 years and 72% for adults aged ≥ 40 years. Rates of low vision (VA < 6/12 to ≥ 6/60) were 1.5% (95% CI, 0.9%–2.1%) in children and 9.4% (95% CI, 7.8%–11.1%) in adults. Rates of blindness (VA < 6/60) were 0.2% (95% CI, 0.04%–0.5%) in children and 1.9% (95% CI, 1.1%–2.6%) in adults. The principal cause of low vision in both adults and children was refractive error. The principal causes of blindness in adults were cataract, refractive error and optic atrophy. Relative risks (RRs) of vision loss and blindness in Indigenous adults compared with adults in the mainstream Australian population were 2.8 and 6.2, respectively. By contrast, RRs of vision loss and blindness in Indigenous children compared with mainstream children were 0.2 and 0.6, respectively.Conclusion: Many causes of vision loss in our sample were readily avoidable. Better allocation of services and resources is required to give all Australians equal access to eye health services.

Hugh R Taylor AC,MD, FRANZCO · Jing Xie PhD · Sarah Fox BA · Ross A Dunn BAppSc(AppChem), GradDipBIT · Anna-Lena Arnold BSc · Jill E Keeffe OAM, PhD

To the Editor: In their article, Couzos and Delaney Thiele raise many good points with respect to Medicare Australia’s Practice Incentives Program (PIP) Indigenous health incentive.1 The funds in question are part of the “closing the gap” spending by the Rudd government. However, the central question is whether spending many millions of dollars of this allocation to add to the income of general practitioners (through a patient enrolment program and the generation of “care plans”) will in fact convert into greater access to, and greater utilisation of, health services by the Aboriginal and Torres Strait Islander population (hereafter referred to as the “Aboriginal” population). The authors correctly point out that most practices in Australia do not treat Aboriginal patients, and that the uptake of targeted, extended-primary-care items by Aboriginal people is much lower than in the general population.1 In most areas, apart from the most remote, the problem is not a lack of services, but the red tape that blocks Aboriginal patients from taking advantage of health services. Adding further layers of red tape, such as patient enrolment, care plans, and health assessments, will only make it harder for Aboriginal patients to access extra health care. For example, an allied health service, normally accessed by walking in off the street, requires a care plan plus a team care plan. Such red tape only adds to the burden of compliance — the problem that lies at the heart of the reason why so many Aboriginal patients fail to meet basic health outcomes. From an economic viewpoint, one needs to ask what could be done with the money that will go to the health provider for administration, rather than for actual clinical care. For example, paying a GP $500 to enrol a patient could instead pay for a significant amount of dental work, speech pathology, diabetes education or physiotherapy. The Department of Veterans’ Affairs (DVA) Gold Card offers an efficient, simple and highly efficacious model that would serve the Aboriginal population a lot better.2 Under the DVA model, doctors are paid a modestly higher rebate for treating veterans (or their families). However, the real benefit for DVA Gold Card holders lies in their ability to access an expanded pharmaceuticals scheme, a comprehensive range of allied health and medical equipment, free patient transport, and private hospital care. Under the DVA, such benefits are accessed with minimal paperwork for the referring doctors and patients. Therefore, the DVA model, in contrast to the PIP Indigenous health incentive model, better targets funds towards service delivery. It is time for politicians and the Department of Health and Ageing to adopt a DVA-style model for the Aboriginal population.

Aniello Iannuzzi

Objective: To determine the prevalence of trachoma among Indigenous Australians.Design, setting and participants: A national, stratified, random cluster sample survey of Indigenous children (5–15 years) and adults (≥ 40 years) in 30 communities across Australia. Data collection was undertaken in 2008.Main outcome measures: Results based on a standardised protocol that included trachoma grading and double grading of photographs of the tarsus.Results: 1694 Indigenous children and 1189 Indigenous adults were examined. Recruitment rates were 84% for children and 72% for adults. The overall rate of follicular trachomatous inflammation among children was 3.8%, ranging from 0.6% in major cities to 7.3% in very remote areas; 50% of communities in very remote areas had endemic rates (> 5%). Trachomatous scarring (TS) occurred among 15.7% of adults, trachomatous trichiasis (TT) among 1.4% and corneal opacity (CO) among 0.3%. TS was found in all regions and TT in all except major cities and inner regional areas. The highest community rates for TS were 58.3%; for TT, 14.6%; and for CO, 3.3%.Conclusion: Blinding endemic trachoma remains a major public health problem in many Aboriginal and Torres Strait Islander communities. Although active trachoma is predominantly seen in very remote communities, scarring and blinding sequelae occur among Indigenous people across the country. The Australian Government’s recent commitment to eliminate blinding trachoma is welcomed and much needed.

Hugh R Taylor AC, MD, FRANZCO · Sarah S Fox BA · Jing Xie PhD · Ross A Dunn BAppSci(App Chem), GradDip(BIT) · Anna-Lena M R Arnold BSc · Jill E Keeffe OAM, PhD

Researchers have longstanding concerns about the logistical and administrative burdens posed by ethics review of multisite studies involving human participants. Centralised ethics review, in which approval by one committee has authority across multiple sites, is widely touted as a strategy for streamlining the process. The Harmonisation of Multi-centre Ethical Review (HoMER) project is currently developing such a system for Australia. It is unclear how centralised review will work for multisite Indigenous health research, where the views of local stakeholders are important and community consultation is mandatory. Our recent experience in conducting the National Indigenous Eye Health Survey (NIEHS) shows how elaborate the current ethics approval and community consultation processes can be, and points to several lessons and ideas to guide pending reforms.

David M Studdert LLB, ScD, MPH · Tamara M Vu LLB · Sarah S Fox BA · Ian P Anderson MB BS, PhD · Jill E Keeffe PhD · Hugh R Taylor MB BS, MD

To the Editor: The recent letter by Cox, about transfer of pregnant women from remote communities to Cairns for birthing,1 mirrored my experiences while working in general practice and psychiatric community outreach in rural Australia for many years. The removal of people from their familiar surroundings (especially for extended periods) in itself exacerbates health problems, even more so when they are already hindered by impaired socioeconomic status or ethnic disadvantage. Almost always, the security of their attachment and capacity to maintain resilience are strained. Furthermore, this displacement often occurs in emotionally charged or threatening health situations, where it is likely to be most damaging: childbirth, treatment of life-threatening disease caused by malignant neoplasm or cardiovascular disease, and management of mental disorders or substance misuse. The increasing concentration of “expert” treatment centres in fewer and fewer (usually metropolitan) centres, together with the degradation and de-skilling of rural and remote services that I have observed for the nearly 30 years I have worked in Australia, are sad. However, even worse is the failure of government to do anything to reverse the trend, despite repeated hand-wringing and talking about the rural health “problem”.

Robert D Craig

Objective: To examine the performance in tropical northern Australia of SMART-COP, a simple scoring system developed in temperate Australia to predict the need for intensive respiratory or vasopressor support (IRVS) in pneumonia patients.Design, setting and patients: A prospective observational study of patients admitted to Royal Darwin Hospital in the Northern Territory with sepsis between August 2007 and May 2008. Chest x-rays were reviewed to confirm pneumonia, and each patient’s SMART-COP score was assessed against the need for IRVS.Results: Of 206 patients presenting with radiologically confirmed pneumonia, 184 were eligible for inclusion. The mean age of patients was 50.1 years, 65% were Indigenous and 56% were men. Overall, 38 patients (21%) required IRVS, and 18 patients (10%) died by Day 30. A SMART-COP score of ≥ 3 had a sensitivity of only 71% for predicting the need for IRVS and 67% for 30-day mortality. As the variables most strongly associated with IRVS were serum albumin level < 35 g/L (odds ratio, 6.8) and Indigenous status (odds ratio, 2.3), we tested a modified scoring system (SMARTACOP) that used a higher weighting for albumin and included Indigenous status. A SMARTACOP score of ≥ 3 had a sensitivity of 97% for IRVS and 100% for 30-day mortality.Conclusions: The SMART-COP score underestimates the severity of pneumonia in tropical northern Australia, but can be improved by using locally relevant additions.

Joshua S Davis MB BS, DTM · Gail B Cross BSc, MB BS · Patrick G P Charles MB BS, FRACP, PhD · Bart J Currie MB BS, FAFPHM, FRACP · Nicholas M Anstey MB BS, FRACP, PhD · Allen C Cheng MB BS, FRACP, PhD

Paying incentives above the baseline Medicare Benefits Schedule to health services for the additional work required to meet the health needs of Aboriginal people or Torres Strait Islanders might mitigate inequalities of care, but evidence supporting this is lacking. The proposed “Indigenous health” incentive payment to reduce Aboriginal health disadvantage, which is largely aimed at increasing the responsiveness of mainstream general practices, provides an opportunity to examine the assumptions behind this and other recent health reform bids. Contentious implementation issues include: the ineligibility of several Aboriginal community controlled health services (ACCHSs) to receive this payment; determining Aboriginality and the potential for misappropriation of payments; the difficulty accounting for practice population diversity and patient mobility; and concerns about the benefits or otherwise to the Aboriginal community. Evaluation of the measure will present problems: to attribute outcomes, an evaluation must disaggregate outcomes by type of service provider (general practice or ACCHS). If these challenges are not addressed, this initiative may end up merely funding coordination of care for those Aboriginal people and Torres Strait Islanders who are already regular users of the health system.

Sophie Couzos FRACGP, FACRRM, FAFPHM · Dea Delaney Thiele PGDipHlthMgt

Objectives: To describe associations between birthweight and infant, child and early adult mortality from natural causes in a remote Australian Aboriginal community against a background of rapidly changing mortality due to better health services.Design, participants and setting: Cohort study of 995 people with recorded birthweights who were born between 1956 and 1985 to an Aboriginal mother in a remote Australian Aboriginal community. Participants were followed through to the end of 2006.Main outcome measures: Rates of natural deaths of infants (aged 0 to < 1 year), children (aged 1 to < 15 years) and adults (aged 15 to < 37 years), compared by birth intervals (1956–1965, 1966–1975 and 1976–1985 for infants and children, and 1956–1962 and 1963–1969 for adults) and by birthweight.Results: Birthweights were low, but increased over time. Deaths among infants and children decreased dramatically over time, but deaths among adults did not. Lower birthweights were associated with higher mortality. Adjusted for birth interval, hazard ratios for deaths among infants, children and adults born at weights below their group birthweight medians were 2.30 (95% CI, 1.13–4.70), 1.78 (95% CI, 1.03–3.07) and 3.49 (95% CI, 1.50–8.09), respectively. The associations were significant individually for deaths associated with diarrhoea in infants, with cardiovascular and renal disease in adults, and marginally significant for deaths from pulmonary causes in children and adults.Conclusion: The striking improvements in infant and child survival over time must be applauded. We confirmed a predisposing effect of lower birthweights on deaths in infants and children, and showed, for the first time, an association between lower birthweights and deaths in adults. Together, these factors are probably contributing to the current epidemic of chronic disease in Aboriginal people, an effect that will persist for decades. Similar phenomena are probably operating in developing countries.

Wendy E Hoy FRACP · Jennifer L Nicol BSc(Hons), MSc(Stats)