Indigenous health

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)

Objective: To compare the clinical effectiveness of single-dose azithromycin treatment with 7 days of amoxycillin treatment among Aboriginal children with acute otitis media (AOM) in rural and remote communities in the Northern Territory. Design, setting and participants: Aboriginal children aged 6 months to 6 years living in 16 rural and remote communities were screened for AOM. Those diagnosed with AOM were randomly allocated to receive either azithromycin (30 mg/kg as a single dose) or amoxycillin (50mg/kg/day in two divided doses for a minimum of 7 days). We used a double-dummy method to ensure blinding. Our study was conducted from 24 March 2003 to 20 July 2005. Main outcome measures: Failure to cure AOM by the end of therapy; nasal carriage of Streptococcus pneumoniae and non-capsular Haemophilus influenzae (NCHi). Results: We followed 306 of 320 children (96%) allocated to the treatment groups. Single-dose azithromycin did not reduce (or increase) the risk of clinical failure (50% failure rate [82/165]) compared with amoxycillin (54% failure rate [83/155]) (risk difference [RD], – 4% [95% CI, – 15% to 7%]; P = 0.504). Compared with amoxycillin, azithromycin significantly reduced the proportion of children with nasal carriage of S. pneumoniae (27% v 63%; RD, – 36% [95% CI, – 47% to – 26%]; P < 0.001) and NCHi (55% v 85%; RD, – 30% [95% CI, – 40% to – 21%]; P < 0.001). Nasal carriage of S. pneumoniae with intermediate or full resistance to penicillin was lower (but not significantly so) in the azithromycin group (10% v 16%), but this group had significantly increased carriage of azithromycin-resistant S. pneumoniae (10% v 3%; RD, 7% [95% CI, 0.1% to 12%]; P = 0.001). Carriage of β-lactamase-producing NCHi was about 5% in both groups. Conclusion: Although azithromycin reduced nasal carriage of S. pneumoniae and NCHi, clinical failure was high in both treatment groups. The possibility of weekly azithromycin treatment in children with persistent AOM should be evaluated. Trial registration: Australian Clinical Trials Registry ACTRN 12609000691246.

Peter S Morris MB BS, PhD, FRACP · Gaudencio Gadil MD · Gabrielle B McCallum BNurs, MPH · Cate A Wilson EN, BPsych(Hons) · Heidi C Smith-Vaughan BAppSci, PhD · Paul Torzillo MB BS, FRACP, JFICM · Amanda J Leach BAgSc(Hons), MAgSc, PhD

Conference delegates workshopped a realistically staged disaster scenario in which they were completely isolated from outside resources If you have to have a disaster, Broome, on the remote Kimberley coast of Western Australia, seems a good place to be; that is, until you take a closer look at what it would be like at the centre of the action. And this is exactly what delegates did during the inaugural conference on Tropical, Emergency and Disaster Medicine (TED-MED), held in Broome on 22–24 May 2009. The conference was attended by 81 delegates, including 28 general practitioners, eight tropical medicine specialists, six emergency medicine specialists and five disaster medicine specialists, plus representatives of government agencies, rural and remote nurse paramedics, clinical laboratory scientists and environmental health and industry participants. In this conference, we used the scenario of a tropical cyclone to move conference attendees outside their comfort zones and draw them into the reality of health crisis management in regional Australia. As it happened, Broome turned out to be an excellent location for the TED-MED conference because of a series of recent events, including the explosion of a refugee boat off the north-west coast of Australia and a tourist vehicle rollover on the Mitchell Plateau to the north-east. To add further realism to the program, there was severe wind damage caused by storms hitting Perth the day before visiting speakers flew into Broome, and the nation was on the verge of moving from the “Delay” phase to the “Contain” phase of the response to pandemic (H1N1) 2009 influenza. There were two triggers for a broad-based conference such as this. One was a renewed emphasis on regional development, particularly in WA’s north-west, where the expansion of the Ord River Irrigation Scheme, mining and petrochemical industries, and tourism are expected to drive a threefold to fourfold expansion of the regional population over the next decade. The second trigger was the Government of WA’s Royalties for Regions policy, under which some of the revenue generated by the mining and resources industry is returned to regional WA in the form of infrastructure funding, and is expected to add impetus to the population growth in the north of the state. In his opening address, WA Director General of Health Peter Flett emphasised the challenges of providing health care to such a thinly spread population in a tropical environment. He said that there was an urgent need to tackle the declining professional population as the baby boomer generation goes into retirement. David Atkinson, from the Kimberley Aboriginal Medical Service Council, compared his extensive experience in remote Aboriginal communities with indigenous communities in remote Canada. The extremes of hot and cold were explored further by retired remote and rural general surgeon Val Lishman AM, who spoke on his work in northern Australia and as an Australasian Antarctic Expedition doctor. Val’s moving snapshot of wilderness medicine in extreme environments was a profound reminder of the importance of resourcefulness and unquenchable optimism in the face of adversity. At the centre of the conference program was a carefully researched disaster scenario (Cyclone TED). Delegates prepared for an extended problem-solving activity through a series of lectures. Major-General Paul Alexander (Australian Defence Force [ADF] Surgeon General) gave the initial plenary session on ADF health capability, reflecting on the role Defence personnel often play in disaster response. He usefully clarified what the Defence Force can do and under what circumstances they would be tasked to assist. Highlights of subsequent parallel sessions were a vivid description by plastic surgeon Fiona Wood of the management of patients with burns who were injured in the Bali bombing, the challenges to medical evacuation from a combat zone by David Werda (former ADF paramedic during United Nations deployment to Somalia), and tag-team presentations on snakebite and emergency resuscitation by George Jelinek and Steve Dunjey (both from the Emergency Department at Sir Charles Gairdner Hospital). Steve’s recent high-profile resuscitation success in outback WA led him to comment that medicine is full of surprises. “You can see unexpected survival in patients under 50 after over 20 minutes’ resuscitation.” The closing straight was led by a relay team of experts. Juliet Hubbard, speaking for Indigenous communities, advocated much wider training of health professionals in cultural safety, particularly in managing major community crises. Alison McMillan (Department of Human Services, Victoria), speaking on the Victorian bushfire disaster, reminded us how quickly local emergency services can be overwhelmed. She gave delegates a sense of the confusion that arises as responding agencies piece together a picture of a disaster. Finally, Brad Santos, a severe-weather expert from the Bureau of Meteorology, left the storm damage in Perth behind him and showed how cyclones behave, with specific reference to their severity and time course. Having given us a taste of what to expect, he introduced the disaster scenario with a scene-setting severe-weather warning. Unlike in many tabletop exercises that aim to advertise the capabilities of host agencies, the details of the scenario were not disclosed to participating agencies. Michael Watson (Clinical Microbiologist, Perth), who led the team of scenario writers, said that he wanted a realistic challenge. As it happened, the date of the conference coincided with peak high tides, enabling Michael and his team to design a realistic scenario in which cyclonic winds caused a storm surge and significant flooding. They envisaged power, telecommunications, the airport, and road links being out of action for 48 hours. To the frustration of health administrators, there was no phone-a-friend-in-Perth option. Police, fire and emergency services, ambulance services, the Royal Flying Doctor Service, the Water Corporation, the Department of Housing and the Department for Child Protection (which is responsible for resettling displaced people) had to rely on what was available locally. There was a lot of tension in the room in the early stages of the disaster scenario as participants grappled with conflicting priorities. In the wrap-up session, table after table recounted tales of resources they discovered when they started to reach out to other groups. Some discovered leadership skills they didn’t know they had. Others showed a natural talent for critical thinking under pressure. One of the conference highlights was a vivid description by Phil Kuhne (Department for Child Protection) of what it would be like in an overcrowded cyclone shelter, and why there wouldn’t be any cyclone parties on his watch. Adding a little realism to the scenario, television crews from two competing channels arrived to interview organisers and speakers just after the scenario started, diverting critical expertise when it was most needed. Cyclone TED was full-on; a draining experience for all those involved. However, there was little rest for the delegates. While the lessons of the disaster scenario were still fresh in their minds, participants split into three parallel skills-development workshops on practical aspects of disaster response, life support with particular emphasis on failed intubation drills, and deployable molecular diagnostic laboratories. Ronan Murray brought the more esoteric aspects of laboratory diagnostic support down to earth by reminding participants of the potential role of the molecular diagnostics laboratory in assisting with front-line clinical decision making in remote or rural regions. The Australasian College of Tropical Medicine took the opportunity to consult on the practical needs of health practitioners in tropical Australia, convening a small group to write up the lessons learned and condense them into a regional development framework — as one delegate put it, the “where we are, where we need to be and how we’re going to get there” of health care in tropical Australia. This process generated the action statement that was presented at the conclusion of the conference. The document, known as the Broome Declaration (Box), captured the spirit of the meeting and provided a sense of direction. In the final discussion of the conference, converting the Declaration into action was debated. There was uncertainty over where resources could be found for infrastructure development, and some scepticism over anything resembling a centrally driven capital project, but there was considerable enthusiasm for local ownership of the process from local delegates. The TED-MED Conference demonstrated that there are people who work at the hot and dusty end of health care who are willing to provide professional leadership. The Broome Declaration represents a benchmark for health development in tropical and regional Australia. It remains to be seen whether there is a substantive political commitment to support front-line health care professionals in developing health capability for regional Australia. The Broome Declaration 1. On this day, 24th May 2009, in Broome, Western Australia, we, the participants in the first consultative tropical medicine summit convened under the auspices of the Australasian College of Tropical Medicine, hereby recognise that the following 10 themes are essential to the development of tropical health: holistic, one health;* collaborative intersectoral partnership; primacy of prevention, early intervention; cultural safety;† subsidiarity;‡ leadership development; proximity of services; immediate availability; effective communication; and strategic urgency. 2. Recognising the current shortfall in health capability in this region as typical of many parts of the tropics, we commit to: establishing tropical health development priorities based on the above themes; informing health authorities of our conclusions; and working toward practical development outcomes within our immediate areas of professional influence. 3. We therefore propose the following specific priorities for north-west Australia: developing a remote access tropical medicine training program; establishing a regional development centre for all stakeholder groups in the Kimberley and the rest of the north-west; and forming a steering group to identify governance and resource support for these outcomes. * A reference to the concept of health as a state of physical, mental and social wellbeing, rather than an absence of disease, first articulated in the Declaration of Alma-Ata.1 † Achieved in a health care setting when carers and providers are attuned to the cultural context of the individuals and communities, and are sensitive to culture-specific vulnerability. ‡ The principle of devolving responsibility for decision making to as close as possible to the level of community at which action is taken.

Timothy J J Inglis DM, FRCPA, FACTM · Ronan J Murray FRCPA, FRACP, FACTM · Michael Watson FRCPA, FRACP, FACTM

A child is born to be cared for, loved and nurtured. However, the hope that birth brings is not to be taken for granted. Where, and in what circumstances, the new life takes hold is a lottery that some win and others lose. I have worked for some years in both East Timor and Central Australia. I find the burden of despondency and disease heavier in my own country than in East Timor. Non-Aboriginal Australia is tired of hearing of the problems of Aboriginal Australia. A culture, they say, of handouts and victimisation — why can’t they just get over it like every other ravaged and decimated people? The domino effect is in play — one generation is knocked out and the effects are felt in subsequent generations. Try to imagine losing your land, your language, your way of life, your mother and father. I reflected on all of this when I went out to a mission settlement, Kumanjai Creek (near Tennant Creek, in the Barkly region of the Northern Territory), with three sisters, Connie, Joyce and Theresa. We stood on slabs of cement as the women explained: This was the “half-caste” dormitory; this was the kitchen; this is where we were locked in; this is where the boys slept. We had to carry out toilet buckets past the boys in the mornings and they mocked us. The old women swept away the dirt to reveal a date — 1945 — that they knew was scrawled in the cement. We sat around a camp fire under an ancient gum tree, which stood as a silent witness to past events, and ate kangaroo tails, witchetty grubs and seeds the women had collected. They told stories of the day Joyce was taken away. I tried to imagine: being a child who had to run away with my family for hundreds of kilometres because a white man was killed and I might be killed in retaliation; landing at a mission, being locked in at night, being beaten, eating only flour, rice and goats milk, eating no fruits or bush tucker, and little meat or vegetables; being that “half-caste” child separated from those I loved and locked up with others of lighter skin in a separate dormitory; being sent away because of my colour, while those who remained banged their heads with rocks as if in mourning for the dead. In the last century, a large percentage of the women’s kinsmen were killed or displaced. The old people had mastery of the language of the land, but it was hard to regroup in a new and alien world. They were powerless, landless and their ancient skills were not valued. The keepers and owners of country became outcasts and margin dwellers. They knew each plant, animal and water soakage. They knew medicinal bark, the goanna holes, bush raisins and tomatoes, and the roots that harbour witchetty grubs. They survived in one of the harshest environments in the world. They are resilient people whose roots tap deep into the red soil. The old people of Central Australia still remember how to survive. They also remember what happened to their people. The wheel keeps turning. Now the old people can’t sleep at night because younger people are drinking too much alcohol. What can be done? They don’t know; no one knows. They care for others’ children because part of a generation is lost. What will happen when they are gone? A 3-week-old baby, his mother, father and sister, his grandmother and 89-year-old great-grandmother live in a tin shed without power, water or sanitation. That newborn doesn’t have a fair chance. Too many children in Central Australia struggle as no child should have to. A child has a right not to be blighted with fetal alcohol syndrome, not to have rheumatic fever, not to have kidneys destroyed by glomerulonephritis, not to suffer intractable otitis media, not to have scabies so badly that to walk or make a fist is nearly impossible. Children deserve to hear, to be sent to school and to live in safe and clean environments. A young woman is angry because she needs to nurture her child, and yet her future is uncertain — like many others, she has end-stage renal failure. In her early twenties, she is facing a long period of exile in Alice Springs (the nearest major town to Tennant Creek about 500 km away) because of a shortage of dialysis beds where she lives. In our town, you often see wheelchairs used by people missing limbs because of diabetes, or by children with congenital abnormalities. There is a high rate of substance misuse, with all its consequences for the individual and their family. We hope there will be funding for ear, nose and throat surgeons to visit regularly so that the hundreds of children of the Barkly needing surgery will be spared the long waiting lists and midnight bus trips to Alice Springs. We hope for more dialysis beds so that the incoming wave of patients with renal failure will not be faced with the choice between exile in Alice Springs or death. We hope for more public health staff to tackle scabies, strongyloidiasis, alcoholism, diabetes and the other medical curses of the inland. We hope for more social workers and child protection officers to help and follow up children at risk. I have worked in East Timor,1 where, despite enormous poverty, the people are rebuilding their communities after a long period of destruction (related to the Indonesian occupation and resulting civil conflict). They have regained their sovereignty, and preserved their language and beliefs. They retain their hope while many of our own people do not. In East Timor, the thread of culture is not broken. The spirit and structure of society survives. The indigenous people still plant their corn, tend their caribou and thatch their houses as before. There are changes at the margin but the fabric of their society is not torn asunder. Many towns in East Timor now have “sister cities” in Australia. There is contact and connection between East Timorese and Australian communities. What stops similar connections being forged within Australia itself, between coastal communities and the outback? Should we not face our history a little more squarely and admit that the atrocities were real, and not a delusion perpetuated by the “black-armband set”? Could a new understanding be reached between Aboriginal and non-Aboriginal Australians, who for too long have sat in opposing camps? The welfare of the people of Central Australia has been thought of as a “government issue” that the ordinary citizen, business sectors and non-government organisations have stayed out of, but this is changing. No one knows the way forward. It is a way we need to forge together. There is anger and suspicion to overcome; people have been hurt and damaged. Nothing will be easy. The problems of the outback are social, but the consequences are medical. People need suitable housing, but ideally they should be involved in their design and construction and so have pride and personal investment in the buildings. They need support to maintain their buildings. Education is offered as a way out of the poverty trap of “sit-down money”, but still many children attend school irregularly and leave as soon as they can. Traineeships and apprenticeships are few, and work in general is scarce. Poor physical health is a symptom of a deeper illness at the heart of Australia. Change will take a long time, but a groundswell of support and small projects may do more than top-down intervention. To paraphrase Marcus Aurelius: to work for change and stay on our feet, we don’t need the fancy footwork of the dancer, but the determination of the wrestler. If enough people, both Aboriginal and non-Aboriginal, stay engaged, we can work together towards healing. Then, perhaps, love will be reborn in the heart of our country. “They told stories of the day Joyce was taken away.” “Children deserve to hear, to be sent to school and to live in safe and clean environments.” “They are resillent people whose roots tap deep into the red soil.” Indigenous women, Kumanjai Creek, NT Tilling the field, East Timor School children, East Timor

Colette L Livermore MB BS(Hons), FRACGP, MPH

We were cruising at 5000 feet, enjoying beautifully clear winter weather, just south of Tennant Creek in the Northern Territory. My friend Don and I were flying in his Cessna 182 and about to turn east and follow the Barkly Highway to a large cattle property known as “Avon Downs”. We were planning to visit an old patient — let’s call her Claire. Originally from England, she was working for the South Australian Government in the NT looking after Aboriginal children in a kindergarten. The story began when a letter arrived from Claire asking if I would make a flying visit to her “back country” village. She heard that I had taken up private flying and had an interest in visiting the bush. My friend Don was a novice private pilot like myself, and we were both very keen to take the opportunity to test our wings on a long flight to the country. Claire lived alone in a large caravan that could accommodate four adults. It was grouped in a large, protected area with three other similar caravans: one served as the ablution block for the children, another was for their changing and rest rooms, and the third was a large classroom where lessons were conducted. Claire was endeavouring to help with training in health and education for young Indigenous children from deprived areas. The excitement was immense as we landed in a cloud of dust on the bush airstrip. We taxied up to Claire, who was surrounded by dancing and shouting children. It was not long before we were chatting about bygone years and about how Claire was coping with the various demands while attempting to introduce Western culture into the Aboriginal community. Claire described her disappointment with the lives of some of her former pupils — for example, girls aged 10 or 12 who, on returning to their Aboriginal communities, were allocated as wives to elders of the tribe. She was anxious to visit some of these older children, who now lived on the coast at Borroloola, about 500 km north of Avon Downs. Why not make a flying visit to Borroloola? It was soon decided that we should. We quickly cleared the aircraft of unwanted gear so that Claire would be able to join us on the flight. We took off early the next morning and arrived at Borroloola after about two and a half hours. Claire was very excited to see her former pupils and learn about their lifestyle and activities in the years since leaving school at Avon Downs. We spent a happy day meeting all the young mothers and their children, and the time passed very quickly. Then we suddenly remembered that the airstrip at Avon Downs did not have landing lights! We realised we had to leave quickly because the calculated flying time would only just allow us to arrive home before last light. When I turned to walk to our aircraft, I met the anxious gaze of the hospital matron: “Could you possibly help with a desperately ill little Aboriginal baby? The Flying Doctor can’t come till tomorrow and this wee child is seriously distressed and unfortunately the hospital sisters can’t help.” I looked across to Don and Claire as I followed the matron running to the sick child’s bedside. He was seriously ill from dehydration after protracted vomiting and diarrhoea and needed an intravenous saline drip. So a small baby with collapsed veins set the challenge for time and urgency. Naturally, my flying companions were a bit anxious about the prospect of delaying our departure. However, the nursing staff were all very grateful for my help. After some effort, the needle entered the vein of this brave little boy, who began to improve with the added fluid. I stood back with relief, which was shared by us all. After a quick farewell we went out to the aircraft. We checked the seatbelts, oil and fuel, then warmed up the engine and leapt into the air on track for Avon Downs. We checked our calculation on the time for last light for Avon Downs with a radio call to Mt Isa traffic control. Our calculations were correct — we would be 25 minutes late for last light on arrival! There were no options at this stage, so we pressed on, hoping the last light of the sunset on the flat landscape would give us sufficient vision. But look! What was that unusual glow ahead on the track near the horizon? That must be close to the Avon Downs airstrip! As we flew nearer to this bright area, while the natural light was failing rapidly, we saw we were being welcomed by numerous cars that had their headlights lighting up the airstrip to guide our return. It seemed the hospital staff from Borroloola had called the folk at Avon Downs and told them about our problem and why we had a delayed departure. Claire was sad to say goodbye to us but, happily, she wrote to say what fun our visit had been and that the little boy had recovered and was doing well. North-eastern region of the Northern Territory

Anthony H T Hodgkinson FRCS, FRACS, FAOrthA

Objectives: To examine patterns of nicotine dependence, the value of the Fagerström Test for Nicotine Dependence (FTND) and its correlation with self-reported tobacco use and urinary cotinine concentrations among pregnant Indigenous women in Townsville.Design, participants and setting: Cross-sectional study of 201 consecutive women who self-reported tobacco use at their first antenatal visit to Townsville Aboriginal and Islander Health Service (TAIHS) between 1 November 2005 and 31 October 2007. All smokers were to be assessed by FTND, and 108 women participating in the Tilly’s Tracks project (a randomised trial of an intervention to reduce smoking in pregnant Aboriginal and Torres Strait Islander women) were to have a comprehensive smoking history taken and urinary cotinine samples collected.Main outcome measures: Self-reported smoking status, FTND scores and urinary cotinine concentrations.Results: Of 302 Indigenous women presenting to TAIHS, 201 (66.6%) identified as current tobacco users at their first antenatal visit; this proportion rose to 79.6% in women aged < 20 years. An FTND was completed for 152 women (75.6%), with a median score of 4, and 40.1% scoring 3 or less, indicating low levels of nicotine dependence. There were significant correlations between the FTND and number of cigarettes smoked (ρ = 0.56; P < 0.001) and urinary cotinine concentrations (ρ = 0.25; P = 0.030). Of those who provided comprehensive smoking histories, the median age of starting smoking was 15 years, with a median of two previous quit attempts; 71.4% reported partners who smoked and 27.3% reported smoking occurred inside the house.Conclusion: The use of the FTND in Indigenous pregnant women may assess physical nicotine dependence, thus providing information that will help in preparing quit-smoking plans, including tailoring of pharmacological support to individual need. Quit-smoking programs that better address the behavioural and psychological aspects of smoking within the Indigenous community in Australia are needed.

Kathryn S Panaretto MB BS, FAFPHM · Melvina R Mitchell EN · Lynette Anderson EN · Conor Gilligan BPsych, PhD · Petra Buettner PhD · Sarah L Larkins MB BS, MPH · Sandra Eades MB BS, PhD

To the Editor: Bronchiolitis, most often associated with respiratory syncytial virus (RSV), is a major cause of hospitalisation in young children. Those with chronic lung and congenital heart disease (the latter affecting about 192 births annually in Western Australia) are at particularly high risk.2 Immunoprophylaxis with the RSV monoclonal antibody palivizumab is effective in reducing severe RSV-related hospitalisations, and monthly immunoprophylaxis is recommended in high-risk children.2,3 Monthly immunoprophylaxis is costly; therefore, the most cost-effective schedule follows the times of peak RSV activity4 — usually the winter months, May to October. Using the Western Australian Data Linkage System,5 we investigated the seasonality of bronchiolitis hospitalisations (International Classification of Diseases-10 code J21) from 1996 to 2005 as a proxy for RSV-related illness. Data specifically for RSV-related illness were considered unreliable because some children may not have been tested for RSV, test results may not have been documented on hospital discharge notes, or RSV immunofluorescence tests may have given false negative results. Furthermore, RSV codes (B97.4, J12.1, J20.5, J21.0) were not used by hospitals in WA until July 1999. We identified 11 988 hospitalisations for bronchiolitis throughout WA among 245 249 births. Most bronchiolitis admissions (81%) were in children younger than 12 months. In the Perth metropolitan region, there was a clear winter seasonal pattern, with hospitalisations peaking in July. However, in the Kimberley region in northern WA, there was a sustained bimodal seasonality, with a peak in April and second peak in August (Box). Moreover, only 51.5% (469) of bronchiolitis admissions in the Kimberley and 61.5% (444) in the Pilbara–Gascoyne (located in mid-north WA) occurred between May and October, as opposed to 84.3% (6354) in the metropolitan region. These data support an earlier implementation and longer dosing schedule with palivizumab for high-risk children in the Kimberley and Pilbara–Gascoyne than for those in Perth. Our study has some limitations. Not all bronchiolitis hospitalisations may be caused by RSV. However, when we investigated only those hospitalisations with a specific RSV code, the monthly distribution showed a similar pattern. Additionally, timing of RSV activity, and therefore bronchiolitis, may vary from year to year. Although the numbers were too small to allow separate analysis by calendar year, bronchiolitis hospitalisations in the Kimberley showed extended seasons in 8 of the 10 years. Our findings support the need for each jurisdiction to know its seasonal pattern of bronchiolitis and RSV hospitalisations, and to implement recommended palivizumab schedules accordingly. Such use of extended prophylactic regimens may well require its cost-effectiveness to be reconsidered. Our analysis highlights the relevance of population-based data linkage studies to clinical care policy. Monthly distribution of bronchiolitis hospitalisations by region of child’s birth, 1996–2005

Hannah C Moore · Anthony D Keil · Peter C Richmond · Deborah Lehmann

To the Editor: More than 30 years ago, I was employed by the Commonwealth Government’s Maternal Mortality Committee to identify and evaluate factors contributing to maternal and infant mortality among Aboriginal Queenslanders. At that time, government policy was to transfer all pregnant Aboriginal women from their rural communities or missions to Cairns Base Hospital at 32 weeks’ gestation until 7–10 days after birth. Findings I presented in a report to Queensland Health in 19771 and at the Australian College of Paediatrics Annual Meeting in 19792 included: Babies of women who were compulsorily transferred at 32 weeks’ gestation to Cairns Hospital had lower neonatal death rates. It was assumed that — as Aboriginal women had unreliable gestational age assessments, antenatal care was irregular, and birthweights were lower than for other races3 — the risk of premature deliveries could be avoided by early transfer. There was a lower rate of breastfeeding among mothers transferred to Cairns, largely because if they opted to bottle-feed they could return home after 3–4 days (rather than waiting 7–10 days in Cairns to ensure breastfeeding was established).1 Growth failure was common in the month after weaning.4 Bottle-fed babies experienced slower weight gain and higher rates of illness.5 Suboptimal growth in bottle-fed babies during the early postnatal months predisposed babies to poor growth patterns during infancy6 and increased death rates.7 Women returning to their communities took with them infections acquired during the hospital stay in Cairns. Separation anxiety or maternal deprivation was common among children left in their communities. There was decreased family bonding (eg, between the father and the new child) and sibling resentment at maternal separation. There was unquantifiable resentment at having babies born away from the ancestral lands. Women delayed admitting their pregnancies in an attempt to remain in their communities, resulting in fewer antenatal visits. The antenatal transfer policy has been in effect for 30 years, despite conflict between those who were predominantly concerned with maternal and perinatal mortality (who favoured compulsory delivery in Cairns Base Hospital), and those (myself included) who were concerned about the effects on children’s growth and development. During this time, I have observed weakening family and community bonds, increasing alcohol and substance misuse and sexual abuse, low school attendance, poor employment records and domestic violence. My studies of Aboriginal and non-Aboriginal children born in Cunnamulla in western Queensland followed the same cohort of children from birth8 for 20 years.9 The presence of a father who was employed at the time of the child’s birth acted as a role model for the future and was more effective than all other social interventions with respect to the child’s successful education or employment 20 years later, irrespective of race or subsequent social support or interventions offered to the child during school years.9,10 Arnold and colleagues’ recent article in the Journal records a situation almost unchanged from 30 years ago, with the exception that antenatal ultrasounds have allowed transfer to occur at 36 weeks’ instead of 32 weeks’ gestation.11 Enormous resources of goodwill, effort and money have been spent in these communities over 30 years, yet the family disruption, unemployment and abuse statistics remain at variance with the Queensland norm. Perhaps the time has come to allow low-risk births to occur in selected towns, where the mother can be surrounded by her friends and relations, and be in closer contact with her ancestral land. I endorse the article by Arnold et al and hope they are more successful in implementing change than I have been.

John W Cox

To the Editor: A letter by Scrimgeour1 in the 18 May 2009 issue of the Journal praised an earlier study by Andreasyan and Hoy2 for adding to the evidence that Indigenous people living in small communities (known as “outstations” or “homelands”) in very remote areas are healthier than those living in larger settlements. I believe this was an error. The study found that mortality was lower in both outer regional areas and very remote areas than in remote areas.2 But, unfortunately, this tells us nothing about outstations. The Accessibility/Remoteness Index of Australia (ARIA) classification used by the authors groups larger remote communities and their outstations together — categorising both as “very remote”. Scrimgeour is not alone in overstating the evidence for better health among Indigenous people living in smaller communities. The possible health benefits associated with living in outstations has become a major argument against the Australian Government’s plan to create 26 remote “hubs” that will receive improved services (to the likely detriment of smaller communities)3 and the related plan of the Northern Territory Government to develop 20 larger remote communities.4 For example, Tom Calma, Aboriginal and Torres Strait Islander Commissioner at the Australian Human Rights Commission, was reported as saying that there was “a strong body of research showing that people on homelands lived longer, healthier lives”.5 Calma seriously overstated the evidence we have to date, which consists of two studies from Utopia in central Australia and one study of land management practices in an Arnhem Land community.6-8 Although this research is encouraging, we are a long way from determining the causes of better health among sections of those two communities, and whether residence at outstations/homelands or land management practices are associated with better health in other communities as well. There are many reasons for supporting the growth of outstations, and health may be one of them, but it is crucial that those in the field of Indigenous health get this right. Rather than jumping the gun, we need more research into the effects of outstation life on health and wellbeing.

Emma E Kowal

To the Editor: In an article about Indigenous mortality in the Northern Territory, Andreasyan and Hoy1 concluded that Indigenous residents in very remote areas (VRAs) had a better health status than those in remote areas (RAs) and outer regional areas (ORAs). This result is inconsistent with previous reports and prompted us to examine the authors’ outcome. A central problem with the authors’ analysis lies in the identification of “usual residence” for death registration. The usual residence is defined by the Australian Bureau of Statistics as the dwelling at which a person spends or intends to spend 6 months or more in the year in which the question is asked.2 This definition limits its usefulness for the authors’ purpose, but is further compromised by the common practice by certifying doctors of simply using the last known address as a proxy for usual residence. In either case, the address recorded at death registration may differ from the location where a person lived for the majority of his or her life. The latter is the location more closely associated with health risks, particularly for chronic disease. As a test, we investigated changes of residence for all NT public hospital inpatients who died within a 7-year period by linking multiple hospitalisations between 1 January 2001 and 31 December 2007. We found that 26% of inpatients classified as residents of RAs at the time of death were previously usual residents of VRAs. This “unhealthy migrant” effect can be readily recognised as people relocate due to illness from VRAs, which have limited health services, to RAs or ORAs to access secondary and tertiary health care. The likelihood of inconsistent classification of usual residence in mortality data can also be tested demographically. Assuming the authors’ mortality ratios were correct for a stable population, we estimate that the Indigenous life expectancy at birth in VRAs would be 72.3 years, or 23 years longer than the life expectancy at birth in RAs (49.1 years). Such a large discrepancy is implausible. The age structure of a stable population is determined by fertility and mortality,3 and reported NT Indigenous fertility rates show a lack of substantial variation across regions.4 If the life expectancy at birth in VRAs was significantly longer than the life expectancy in RAs, VRAs would have about five times more elderly people (aged over 75 years) than the current estimates.5 The mobility of residence shown by hospital data and the absence of a substantial elderly population in VRAs suggest that the reported differential mortality rates between VRAs and RAs are the result of misidentification of “usual residence”.

Yuejen Zhao · Steve Guthridge · Shu Q Li · Christine Connors

In reply: We thank Zhao and colleagues for their interest in our study.1 The main issue they raise is misclassification of deaths by remoteness of residence. In our article, we acknowledged the role of migration to larger urban centres to access health services and raised the issue of unhealthy lifestyle and its flow-on effects on mortality. If we were to assume that 26% of deaths in hospital in remote areas were deaths of people who previously lived in very remote areas (as Zhao and colleagues suggest), regional variation in the disparity between Indigenous and total Australian all-cause mortality would narrow but would still remain. A re-analysis of our data based on this assumption1 shows that standardised mortality ratios in remote areas would drop from 875% (95% CI, 799%–956%) to 646% (95% CI, 582%–717%) in 1998–2000 and from 731% (95% CI, 665%–801%) to 540% (95% CI, 484%–601%) in 2001–2003. In very remote areas, the standardised mortality ratios would increase from 214% (95% CI, 193%–236%) to 281% (95% CI, 258%–306%) in 1998–2000 and from 208% (95% CI, 189%–228%) to 264% (95% CI, 242%–286%) in 2001–2003. Furthermore, in our article we stressed the importance of examining Indigenous migration to enable more accurate interpretation of our findings and called for future studies to “clarify the reasons for these differences in mortality by remoteness, with a particular focus on migration”. Our studies of Queensland data and national data (unpublished) have shown a similar pattern of higher Indigenous mortality in remote areas than in very remote areas, but the difference in mortality rates between these areas is highest in the Northern Territory. Thus, the phenomenon of the “methodological” error applies to all of these studies. We propose to undertake a prospective study of Indigenous mortality that will overcome some study design problems inherent in a cross-sectional study.

Karen Andreasyan · Wendy E Hoy

To the Editor: We commend the Indigenous Health issue of the Journal (18 May 2009). Its editorial emphasis — that partnerships with and continued leadership by Aboriginal and Torres Strait Islander peoples will be key to closing the gap between Indigenous and non-Indigenous Australians1 — is supported by preliminary, unpublished findings from our research into improving mainstream general practice care of Indigenous patients. Couzos and Thiele emphasised that closing the gap in health and life expectancy between Indigenous and non-Indigenous Australians depends on Aboriginal community controlled health services (ACCHSs).2 By virtue of their governance structure and focus, these services deliver culturally safe and appropriate primary health care to Indigenous Australians, while addressing issues of Indigenous autonomy and other social determinants of health.2 However, although not all general practices see Indigenous patients, 0.9% of general practice encounters (range, 0.7%–1.6%) are with Indigenous patients, equating to about one million consultations a year. Indigenous Australians present to general practitioners with essentially the same range of clinical conditions as do non-Indigenous Australians, although consultation rates for diabetes and circulatory conditions are higher for Indigenous patients.3 Most Indigenous Australians (76%) live in urban and regional areas, and are widely spread through the general population. They are likely to need mainstream services including general practice and primary care services, at least some of the time and for the foreseeable future. There is clearly a need for initiatives beyond support for ACCHSs, Indigenous workers and communities, to improve mainstream services for Indigenous Australians in a culturally sensitive and appropriate manner.4 Better sociocultural education for health care providers, trainees and students is required to close the gap that exists in mainstream understanding and acceptance of Indigenous cultures and aspirations. The Inala Indigenous Health Service in Brisbane is an example of a mainstream practice successfully developing into an accessible service.5 Our research aims to improve mainstream general practice care for Indigenous Australians with diabetes who live in urban areas of Victoria. As the following statement made by Indigenous participants in focus groups for our research indicated, health services must be patient-centred: We need to hold the health system — and that includes GPs — accountable for delivering help to Aboriginal people. The best one to do that is the consumer. Focus group participants also highlighted the importance of working together: I think we need to take some responsibility ourselves as (Indigenous) workers in organisations and go to these mainstream services. Whether it’s diabetes or drugs and alcohol, we need to say look, you get funded to look after everybody, and we want to come here and tell you how to look after our people when they come to your centres.

Siaw-Teng Liaw

In reply: It is unclear how many mainstream general practice consultations involve Aboriginal and Torres Strait Islander patients. Of 485 300 patient encounters attributed to general practices in the BEACH study (2003–2008), 7292 were with Indigenous patients, but 2906 of these encounters took place in Aboriginal community controlled health services (ACCHSs) rather than in general practices.1 If funding to close the gap in Aboriginal disadvantage is being channelled to general practice and the Divisions of General Practice (through recent measures of the Council of Australian Governments), then the Indigenous health outcomes of mainstream services must be carefully attributed.2 The ACCHS sector agrees there is a need to make general practices culturally secure for Indigenous Australians. For example, the Aboriginal Health Council of Western Australia has developed modules for cultural safety training, which are accredited by the Royal Australian College of General Practitioners for GPs’ professional development.3 The National Health and Hospitals Reform Commission report recommends that health services be required, by accreditation processes, to meet specific standards of cultural safety for Indigenous patients to ensure high-quality care.4 Within a quality assurance framework, systematic reforms such as these can potentially improve mainstream services, while supporting Indigenous workers who face unrealistic pressures to improve their local services. As Liaw points out, these initiatives are in addition to the vital role of ACCHSs in closing the health disparity gap.

Sophie Couzos · Dea D Thiele

Incorrect graph and wording: In “Avoidable hospitalisation in Aboriginal and non-Aboriginal people in the Northern Territory” in the 18 May 2009 issue of the Journal (Med J Aust 2009; 190: 532-536), there was an error in Box 4 (Li et al). In the panels headed “25–44 years” and “45 years and over”, the lines representing Aboriginal and non-Aboriginal rates were transposed. The correct version of Box 4 appears here. In addition, in the second paragraph of the results section, the wording was potentially misleading. The paragraph should have read: “Although total average avoidable hospitalisation rates were higher in Aboriginal than non-Aboriginal people in the NT, the largest differences were observed in the age groups 25–44 and 45–64 years (Box 1).” 4 Trends in age-adjusted, avoidable hospitalisation rates by Aboriginality and age group, Northern Territory, 1998–99 to 2005–06

Shu Q Li MPH, MB, BNursing · Natalie J Gray MIPH(Hons), MB BS(Hons), BSc/LLB(Hons) · Steve L Guthridge MB BS, MPH, FAFPHM · Sabine L M Pircher MPH, BNutrDiet

Otitis media in Australia, particularly among Indigenous children, has not received the attention that other less common but more emotive diseases attract. However, this condition, with its significant impact on hearing, language development and learning in the vulnerable early childhood years, has been commented on since early European settlement in Australia.1 The end result of recurrent acute otitis media — chronic suppurative otitis media — is uncommon in most developed countries, but Indigenous Australian children account for the highest prevalence of chronic suppurative otitis media in the world (70% in some remote communities). The World Health Organization regards a prevalence of chronic suppurative otitis media of over 4% in a defined population of children as a massive public health problem requiring urgent attention.2 John Ah Kit, Minister for Community Development from the Northern Territory, described the situation of Indigenous children as A spiral of being ill before birth, of being poorly fed in childhood, of being deaf at school. Of a life without work that would be cut short by a litany of disease and violence.3 What has happened in the 13 intervening years since the last Medical Journal of Australia supplement on otitis media was published?4 In some areas (described further in this supplement), our understanding of pathogenesis, new concepts of biofilm and intracellular infection, and the importance of nasopharyngeal carriage, we have progressed significantly. Likewise, new research — into the genetics of recurrent acute otitis media, the immunological responses of children to these infections, and the impact of antibacterial vaccines — is contributing to our knowledge about this condition. New social and medical interventions, such as the swimming pool project,5 building new housing, and the controversial Northern Territory Intervention, with new guidelines on the use of antibiotics in otitis media and its sequelae in children, have been partially successful in ameliorating the burden of otitis media in Indigenous (and non-Indigenous) children.6 Yet, in this time of financial constraint, the necessary programs to implement change in the fundamental and underlying causes of otitis media and its complications are not being provided. Chronic suppurative otitis media is a disease of poverty, and without actions to lessen overcrowding and provide appropriate housing and water supply, education of parents and adequate access to medical care, progress to improvement will be slow.7 In addition, throughout urban, rural and remote Australia, we must increase awareness about otitis media, and the ramifications of neglect of this silent epidemic, among parents, teachers, community leaders, and health workers. We must train more Aboriginal health workers specialising in ear conditions (and possibly also eye conditions and dental health), perhaps with support from ear nurse specialists (this has been very successful in the government-funded Variety Club ear buses program in New Zealand), and ensure there is an adequate workforce of audiologists, speech pathologists and teachers of the deaf to provide the necessary ancillary support services for children with impaired hearing and speech delays. The recent publication The cost burden of otitis media in Australia brings to light the pervasive nature and community costs of otitis media and its sequelae. Admission for insertion of grommets is the second major cause of surgical admission to hospital in Australia for children. Over 650 000 Australians had otitis media in 2008; 9.9% of these were Indigenous. For 2008, the estimated health system costs of otitis media range from $85.6 million to $163.2 million, and the net cost of lost wellbeing due to otitis media is estimated at between $1.05 billion and $2.6 billion.8 So where to next? Governments must advocate for otitis media prevention programs, improve living standards for socially disadvantaged families, ensure adequate medical and paramedical resources, and continue to fund basic and outcomes-based research into otitis media. As otitis media is, in part, a vaccine-preventable disease, attention to considering the newer vaccines available for invasive and otitis media infections in children for the immunisation schedule should be a priority.

Harvey L C Coates AO, MS, FRACS

Otitis media remains a major health problem in Australia, with an unacceptably great dichotomy of incidence and severity of otitis media and its complications between Indigenous and non-Indigenous Australians. Among most children with acute otitis media, infection resolves rapidly with or without antibiotics, with ongoing middle ear effusion the only sequela. Overcrowding, poor living conditions, exposure to cigarette smoke, and lack of access to medical care are all major risk factors for otitis media. Estimates of the number of cases of otitis media in 2008 vary between 992 000 and 2 430 000 Australians, with a total estimated cost of $100 – $400 million.

Kelvin Kong BSc, MB BS, FRACS · Harvey L C Coates AO, MS, FRACS

Otitis media typically presents as either acute otitis media (AOM), with symptoms including fever, otalgia, otorrhoea or irritability and short duration; or as otitis media with effusion (OME), which is often asymptomatic and characterised by accumulation of fluid in the middle ear. Diagnostic certainty of otitis media is challenging, given the young age of patients and variability of symptoms. Otitis media predominantly occurs as coincident to viral upper respiratory tract infections and/or bacterial infections. Common viruses that cause upper respiratory tract infection are frequently associated with AOM and new-onset OME. These include respiratory syncytial virus, rhinovirus, adenovirus, parainfluenza and coronavirus. Predominant bacteria that cause otitis media are Streptococcus pneumoniae, Moraxella catarrhalis, and non-typeable Haemophilus influenzae. Antibiotic therapy does not significantly benefit most patients with AOM, but long-term prophylactic antibiotic therapy can reduce the risk of otitis media recurrence among children at high risk. In Australia, 84% of AOM is treated with antibiotic therapy, which contributes to development of antibiotic resistance. Vaccine development is a key future direction for reducing the world burden of otitis media, but requires polymicrobial formulation and ongoing monitoring and modification to ensure sustained reduction in disease burden.

Helen M Massa PhD · Allan W Cripps PhD · Deborah Lehmann MB BS, MSc