Indigenous health

Otitis media is a common childhood illness associated with hearing loss, social disadvantage and medical costs. Prevalence and severity are high among Indigenous children. Respiratory bacterial and viral pathogens ascend the eustachian tube from the nasopharynx to the middle ear, causing inflammation, fluid accumulation, and bulging of the tympanic membrane, with or without pain. Among Australian Indigenous children, ear disease commences earlier in life, and involves multiple strains of bacterial pathogens at high density that persist longer. Persistent nasal discharge, overcrowded living conditions (particularly exposure to many children) and poor facilities for washing children perpetuate a vicious cycle of transmission and infection. Risk factors include environmental tobacco smoke, season, lack of breastfeeding, younger age and immature immune system, and possibly genetic factors. The innate immune system is a critical first response to infection, particularly as passive maternal antibodies decline and during the maturation of the infant adaptive immune response. The relative contributions of innate factors to protection from otitis media are currently not well understood. A diversity of antibodies that target strain-specific and conserved antigens are generated in response to natural exposure to otitis media pathogens (or to vaccines). Deficiencies in these antibodies may explain susceptibility to recurrent infections. Incremental contributions from all these elements are likely to be important in otitis media susceptibility versus protection. Effective medical and social strategies to prevent early age of onset are urgently needed.

Selma P Wiertsema PhD · Amanda J Leach PhD

Acute otitis media (AOM) is diagnosed on the basis of acute onset of pain and fever; a red, bulging tympanic membrane; and middle ear effusion. AOM is managed with analgesia (paracetamol or non-steroidal anti-inflammatory drugs). Antibiotic therapy is minimally effective for most patients; it is most effective for children < 2 years with bilateral otitis media and for children with discharging ears. National guidelines recommend antibiotic therapy for Indigenous children with AOM. Evidence for corticosteroids, topical analgesia and xylitol are scant. Otitis media with effusion (OME) is diagnosed as the presence of middle ear effusion (type B tympanogram or immobile tympanic membrane on pneumatic otoscopy) without AOM criteria. Well children with OME with no speech and language delays can be observed for the first 3 months; perform audiological evaluation and refer to an ear, nose and throat (ENT) specialist if they have bilateral hearing impairment > 30 dB or persistent effusion. Children with effusions persisting longer than 3 months can benefit from a 2–4-week course of amoxycillin. Chronic suppurative otitis media is a chronic discharge through a tympanic membrane perforation. It is managed with regular ear cleaning (dry mopping or povidone–iodine [Betadine] washouts) until discharge resolves; topical ear drops (eg, ciprofloxacin); audiological evaluation; and ENT review.

Hasantha Gunasekera DCH, FRACP, MIPH(Hons) · Tony E O’Connor AFRCSI, FRCS(ORL-HNS) · Shyan Vijayasekaran MB BS, FRACS · Christopher B Del Mar MD, FRACGP

In Australia, three to five children die each year because of otitis media complications, and 15 children will suffer permanent hearing loss each year as a result of otitis media. Extracranial complications occur most commonly, and include mastoiditis, cholesteatoma and otitis media with perforation. Intracranial complications are less common, and include meningitis, brain abscess and lateral sinus thrombosis. In Australia, approximately 60% of extracranial and intracranial complications of otitis media occur in children. The contrasting rates of childhood otitis media among Indigenous and non-Indigenous children have implications for the frequency and types of complications occurring in both groups. Otitis media with effusion and acute otitis media predominate among non-Indigenous children, whereas chronic suppurative otitis media (CSOM) occurs most commonly among Indigenous children. The incidence of mastoiditis in Australia is low by international standards (2/100 000 children), but cholesteatoma rates among Indigenous children in Australia are higher than previously estimated (up to 10% in CSOM). A high rate of chronic tympanic membrane perforation occurs among Indigenous children, estimated to be as high as 80%. Intracranial complications of otitis media are uncommon, but are potentially life-threatening and are more likely to occur among Indigenous than non-Indigenous children. Reduced access to medical care, lower socioeconomic status and remote living conditions mean that levels of early childhood hearing loss among Indigenous children are likely to be underestimated. This has implications for early childhood speech and language development and education.

Tony E O’Connor AFRCSI, FRCS(ORL-HNS) · Christopher F Perry MB BS, DTM · Francis J Lannigan MD, FRCS(ORL)(Ed), FRACS

Otitis media with effusion and recurrent acute otitis media are ubiquitous among Indigenous children. Otitis media causes conductive hearing loss that may persist throughout early childhood and adversely affect social interactions, language acquisition and learning. Control of otitis media usually restores hearing to adequate levels. Surgery is to be considered when otitis media has not responded to medical treatment. In non-Indigenous populations, tympanostomy tubes (“grommets”), with or without adenoidectomy, can control otitis media; how these findings relate to Indigenous Australians is not known. Tympanic membrane perforation is a frequent sequela of early childhood otitis media among Indigenous children. It occurs as early as 12 months of age and causes conductive hearing loss. Perforation is associated with recurrent aural discharge, particularly in the tropics and in desert regions. Medical and public health management is required until a child is old enough to undergo surgical closure of the perforation, usually by an age of 7–10 years. Surgical closure of the tympanic membrane stops the aural discharge and improves the hearing sufficiently to avoid the need for hearing aids in most cases. The success rate of surgery conducted in rural and remote Australia is below urban benchmarks; improving this will probably require funding for community-based follow-up.

Stephen J O’Leary BMedSc, PhD, FRACS · Ross D Triolo BSc(MedSci), MB BS

Otitis media is a common disease in childhood that can adversely affect cognitive and educational outcomes. The literature in this area is equivocal, and findings may be influenced by research design. The impact of otitis media on individual children’s development appears to depend on the inter-relationship between several factors. Children who have early-onset otitis media (under 12 months) are at high risk of developing long-term speech and language problems. Otitis media has been found to interact negatively with pre-existing cognitive or language problems. For biological or environmental reasons, some populations have a pattern of early onset, higher prevalence and episodes of longer duration; this pattern leads to a higher risk of long-term speech and language problems. These factors suggest that Indigenous children may be at higher risk of cognitive and educational sequelae than non-Indigenous children.

Corinne J Williams PhD · Ann M Jacobs BAppSc(Speech and Hearing)

Objective: To identify individual and household factors associated with violence among Australian Indigenous women with dependent children.Design and participants: Univariate and multivariable analysis of data from the 2002 National Aboriginal and Torres Strait Islander Social Survey, stratified by area.Main outcome measure: Self-reported experience of being a victim of violence in the previous year.Results: One in four Indigenous women living with dependent children younger than 15 years reported being victims of violence in the previous year; this corresponds to an estimated 24 221 Indigenous mothers (95% CI, 21 507–26 935) nationwide. Violence was more prevalent in regional areas and cities than remote areas. In remote areas, mothers who had been removed from their natural families during childhood had nearly threefold greater odds of being victims of violence (odds ratio [OR], 2.90; 95% CI, 1.82–4.61); in non-remote areas, the odds were 72% greater (OR, 1.72; 95% CI, 1.23–2.39). Older maternal age (≥ 45 years) was associated with lower odds of experiencing violence in both non-remote areas (OR, 0.39; 95% CI, 0.25–0.60) and remote areas (OR, 0.46; 95% CI, 0.30–0.70). Women with partners residing in the household faced lower odds of violence in both non-remote areas (OR, 0.54; 95% CI, 0.41–0.72) and remote areas (OR, 0.46; 95% CI, 0.32–0.67).Conclusions: The prevalence of violence against Indigenous mothers with young children is alarmingly high across remote and non-remote areas. This study identified distinctive characteristics of victims, but further research is needed to assess potential risk factors, such as history of removal from natural family.

Kyllie Cripps BA(Hons), PhD · Catherine M Bennett PhD, MAppEpid · Lyle C Gurrin PhD · David M Studdert LLB, ScD

Otitis media affects nearly all children worldwide. Despite an enormous amount of research, our understanding of this common condition continues to be challenged. New pathogens involved in otitis media are still being identified. The importance of interactions between viral and bacterial infection and the role of new vaccines need to be clarified. The proposal that bacteria can become more resistant to therapy through biofilm formation and intracellular infection could have important implications for treatment. The most important clinical research findings have been summarised in systematic reviews. In developed countries, research supporting “watchful waiting” of otitis media with effusion and acute otitis media have had most impact on evidence-based clinical practice guidelines. Indigenous Australian children remain at risk of more severe otitis media. Research programs targeting this population have been well supported. Unfortunately, interventions that can dramatically improve outcomes have remained elusive. For children at high risk of otitis media, health care services should concentrate on accurate diagnosis, antibiotic treatment of suppurative infections, and scheduled follow-up of affected children. Despite the lack of recent studies, strategies to minimise the impact the hearing loss associated with otitis media are important. Improvements in education, hygiene practices, and living conditions are likely to reduce the incidence and severity of otitis media. Studies of these types of interventions are needed.

Peter S Morris MB BS, FRACP, PhD · Peter Richmond MB BS, FRACP · Deborah Lehmann MB BS, MSc · Amanda J Leach MAgSci, PhD · Hasantha Gunasekera DCH, FRACP, MIPH(Hons) · Harvey L C Coates AO, MS, FRACS

Objective: To describe a prolonged outbreak of mumps in the Kimberley region of Western Australia in 2007–2008.Design: Descriptive analysis of all mumps cases notified to the WA Notifiable Infectious Diseases Database for the period 1 July 2007 to 30 June 2008.Main outcome measures: Notified cases of mumps by patients’ place of residence, age, Indigenous or non-Indigenous ethnicity, vaccination status and method of diagnosis.Results: 84% (153/183) of mumps notifications in WA over the study period occurred in the Kimberley region or were directly linked to Kimberley cases. Median age of patients was 18 years (range, 2–63 years), and 54% of patients were aged less than 20 years. Almost all (92%) were Australian Aboriginal people; 67% (102/153) had received at least one dose of mumps vaccine, and 52% had received two doses. The highest notification rate (1816 cases per 100 000 population) was in the Aboriginal 15–19-years age group, and 92% of these patients had received at least one dose of mumps vaccine. Almost all outbreak cases (94%) were laboratory confirmed. Genotyping was performed on 20 mumps virus isolates: all were genotype J.Conclusion: A prolonged outbreak of mumps occurred in a well defined, highly vaccinated, predominantly young Aboriginal population in the remote Kimberley region of WA. This outbreak raises questions about the effectiveness and scheduling of the current vaccine (which is genotype A-derived), especially for Aboriginal people. Surveillance of circulating mumps virus genotypes and neutralisation studies will help in evaluating the protection provided by the current vaccine against genotypically different strains.

Revle D Bangor-Jones MB BCh, MRCGP, MPH · Gary K Dowse BMedSc(Hons), MSc, FAFPHM · Carolien M Giele BSc(Hons), MPH, GradDipClinEpi · Paul G van Buynder MB BS, MPH, FAFPHM · Meredith M Hodge MB BS, MPHTM, FRACP · Mary M Whitty RN, RM, ChildHlthCert

I am an Aboriginal Kuku Yalanjii and Birri Gubba man. My Yalanjii people are from north of Mareeba, near Cairns, and my Birri Gubba connection is in Proserpine, right next to the beautiful Whitsunday Islands. My family grew up in Inala, on the outskirts of Brisbane, where we have lived for over 25 years. I come from a family of eight children. My mother is from Woorabinda and my father is from Proserpine and they are both Aboriginal. I have always heard about Aboriginal and Torres Strait Islander men having heart attacks at a young age and in higher proportions than non-Indigenous men. I have lost a number of uncles from heart disease, through not eating right, hereditary factors, high alcohol consumption and lack of exercise. In terms of my own health, I thought I was fine because I was always physically active, playing rugby league and touch football and being very involved in the community. I would never have believed it possible that at 34 years of age I could suffer a heart attack. I am sharing this story with other Aboriginal and Torres Strait Islander people around Australia in the hope that it will make some kind of impact on their lives. My story demonstrates how working in the Aboriginal and Torres Strait Islander community can have both a positive and a negative impact on yourself, your family and your community. I started working in the Inala Indigenous Health Service in 2001 as a research assistant and then moved to the role of community health worker. Before this, I’d had no experience in the areas of health or education. The main experience I’d had in community work was as a youth worker with the Queensland Department of Family, Youth and Community Care and as a teacher aide at the Glenala State High School. I’d also had experience as a volunteer coach of a Junior Rugby League side at Inala that has a high proportion of young Aboriginal and Torres Strait Islander people, parents and families involved. Working in the service gave me valuable experience under the guidance of our Aboriginal doctor Noel Hayman and Aboriginal nurse manager Nola White. Together, they gave me the confidence to undertake a Bachelor of Applied Health Science in Indigenous Primary Health Care at the University of Queensland in Brisbane. It took me 5 years to complete the course, while simultaneously juggling commitments to my family, community and employer. All I ever wanted to do was give back to the community that I grew up in, and working at the Inala Indigenous Health Service has given me that opportunity. In the 8 years I have worked at the Health Service, I have been involved in all areas of Indigenous health, including hearing health; drugs and alcohol; health status research; mental health; nutrition; counselling; transport; Indigenous leadership; youth issues; youth and adults incarceration; and health promotion. A major role I shared with my mentor Matilda Bani (Indigenous Service Officer with Centrelink) was coordination of the Inala Aboriginal and Torres Strait Islander Interagency Forum. This forum, which has been going for over 12 years, promotes information-sharing between departments and other agencies working with the Inala Aboriginal and Torres Strait Islander community. Shared Responsibility Agreement: making a differencePerhaps one of the biggest achievements in my life (besides having children) was being involved in establishing a Shared Responsibility Agreement (SRA) between my community and the federal government in 2006 (Box 1). The central aim of the SRA was to improve the health and wellbeing of Aboriginal and Torres Strait Islander men in our community via their engagement in rugby league. Rugby league has been an institution within our community, particularly among Aboriginal and Islander boys and men. For 5 years prior to the SRA, there was no opportunity for men in Inala to play rugby league, due to a lack of activities and sporting programs for Aboriginal and Torres Strait Islander men, and few Aboriginal and Torres Strait Islander men were likely to go outside the community to play rugby league. Without football in the community, few men played sport, and this contributed to many problems such as boredom, poor health, low self-esteem, and high intake of drugs and alcohol — all of which can lead to incarceration. Through conversations with the federal government, I developed a proposal to get a group of respected Aboriginal and Torres Strait Islander men to look at ways of getting our brothers involved in sport, employment and healthy living for themselves and their families. The federal government agreed to fund two open rugby league sides at Inala, on the condition that men in the community participated in health, employment, education and mentoring opportunities within the community. My role as the Community Health Worker was to encourage Aboriginal and Torres Strait Islander men to come to the Inala Indigenous Health Service for adult health assessments, and to participate in other health promotion activities such as the Inala Indigenous Health Calendar (Box 2) and workshops on nutrition and physical activity. The men were also enlisted to participate in mentoring activities, such as coaching, refereeing, volunteering with junior teams, participating in local training and employment initiatives (if they were unemployed), promoting healthy lifestyles, and demonstrating positive behaviour on the sporting field and in the community. Through this process, many local men also participated in training that saw them become qualified referees, coaches and first aid officers. Since being involved with the SRA in Inala, I have seen some great success stories. Seeing other young Aboriginal and Torres Strait Islander men putting their hand up to be involved in rugby league as coaches, referees, first aid officers and volunteers at the club has really built the self-confidence of men in our community. The pressures of community work, family and volunteering: my healthDuring this time, I was so passionate about my work that I forgot who I was. I was doing this as part of my role as Community Health Worker, but was also a volunteer. I was so busy taking care of everyone else that I forgot to take care of myself. I was at the club nearly 7 days a week with the junior and senior teams, feeling constantly stressed, spending a lot of time away from my family, and not taking time out for myself. Because I was always on the go, I was not eating healthily. I just wanted the SRA to succeed and be sustainable, so that Inala Aboriginal and Torres Strait Islander men could be strong, self-reliant, and able to source other avenues such as sponsorship and fundraising. I was also a rugby league player at the time, so I was heavily involved in the game, both on and off the field. Rugby league has always been my passion and, although I would go to games to help with strapping and make sure everything was taken care of, I would often jump on the field and play if the team were short of players. It was towards the end of the 2008 season that I put on the jersey for Inala, like so many times before. But during this particular game, I started experiencing dizziness, came off the field and collapsed. Although I didn’t know it at the time, I had just had a heart attack. Fortunately, the coach of the team (one of my closest friends and a participant in a first aid course delivered under the SRA) and the registered first aid officer kept me alive until an ambulance arrived. It was only their quick actions that saved my life. All I remember is drinking a sports drink and then waking up in the ambulance. When I asked the ambulance officer if I had been knocked out on the field, he told me I’d had a cardiac arrest and said that, if it wasn’t for the coach and first aid officer, I wouldn’t be alive. Since then, I have had three operations on my heart and am now fitted with a defibrillator in my chest in case a similar episode happens again. At 34 years of age, I am very lucky to be alive, and to this day I feel enormous gratitude to the coach and first aid officer to whom I owe my life. There is an irony in the fact that the very thing that caused so much stress in my life was also the very thing that led to my life being saved. My illness also made a big impact on the Inala Aboriginal and Torres Strait Islander community in the south of Brisbane. There has been an increase in the number of people attending the Inala Indigenous Health Service, and the number of health checks has doubled. Many Aboriginal and Torres Strait Islander people aged 35 years and over are now attending the health service. I’m glad that some good has come out of my heart attack, not only for me and my family, but also for the community as a whole. It has changed my life dramatically — I thought I was OK, and then all of a sudden my whole life was turned upside down. Lessons I have learntAfter having all the operations and undergoing mainstream cardiac rehabilitation at a hospital in Brisbane, I started to get my confidence up with doing exercise such as walking and playing tennis and doing things around the house with my family. Back at work a month after having surgery, I am slowly easing my way back into work, eating more healthily, and getting lectures from family and community members about taking it easy in the community. I am doing OK now and just taking life one day at a time. I am grateful to everyone for their support — my family, my work colleagues and my community. There is much good that is happening, and Inala is continuing to grow and develop into a really great community. After all the operations and cardiac rehabilitation, I decided to get married to my lovely partner of many years. I put the pain behind me to set up a new chapter in the lives of me and my family. At times I don’t think about the heart attack, I just think every day what I can do to get my kids out of the house and do something active. My family is my life, my community is my strength, and my work keeps me active. I share my story with people who are reluctant to go for a heart operation and encourage them to have it done so they will be able to live longer and see their children and grandchildren grow up. Today I am enrolled in a Master of Philosophy by research at the University of Queensland, while working as a research fellow with the Inala Indigenous Health Service and at the George Institute for International Health in Sydney. This will broaden my role in my line of work and will enhance my capacity to be a good role model and mentor for my community. I feel very passionate about working in Indigenous health, especially in the field of heart disease, kidney disease and diabetes, with the support of the Inala Indigenous Health Service and the George Institute’s Kanyini program. Rugby league is continuing to thrive in Inala with the keen involvement of other Aboriginal and Torres Strait Islander men in the community. They have been playing the game for 3 years now without any funding assistance from the federal government. They won a grand final in 2007, were runners-up in 2008 (Box 3), and are very actively involved in community events and the junior club. I am slowly working my way back into the community, having learnt some valuable lessons from this journey — in particular, the need to balance my family commitments, work and volunteering. I have taken a big step back from being involved in the community in a voluntary capacity. Inala is going forward in a very positive way, and members of the next generation are putting up their hand to give back to the community that has supported them. 1 Some of the people involved in our Shared Responsibility Agreement Left to right: John Brady, Tricia Button (State Manager, Indigenous Coordination Centre), Mal Brough (former Minister for Families, Community Services and Indigenous Affairs), Robert Duncan (Junior Club President). 2 Health messages from the Inala Indigenous Health Calendar 3 Inala rugby league team members and young supporters

John P Brady BAppHlthSc

To the Editor: Roe and McDermott recently noted that the health benefits of swimming pools demonstrated by Silva and colleagues1 may be more modest than reported.2 Our initial observations from a remote South Australian Aboriginal community support this observation, but there are also many difficulties with study implementation that may introduce biases. A swimming pool was constructed during 2007 as a result of a community-led initiative. With ethics approval, trachoma screening was performed before the pool opening (November 2007) and 6 and 18 months after the pool was opened. Rates of middle ear infections, skin infections and antibiotic prescriptions among children aged 1–15 years were assessed using a retrospective analysis of clinic records between May 2007 and April 2009. A questionnaire regarding the benefits of and barriers to swimming pool use in the community was administered to key persons, such as community health workers and school teachers in April 2009. We aimed to examine every child in the community aged 1–10 years; 45/56 (80%), 46/62 (74%) and 59/64 (92%) children were examined at each of the three visits. The proportion of children with follicular trachomatous inflammation remained low and unchanged at the three time points (7%, 7% and 8%). The clinic records of 166 children showed a trend of increasing rates of infection and antibiotic prescriptions for the period. With hypoendemic rates of trachoma and possible confounding factors, including a small sample size, population mobility, reporting bias and a high turnover of health personnel, we were unable to demonstrate health benefits of pool usage. Our findings highlight the importance of avoiding complacency once a single intervention, such as a swimming pool, has been put in place. Long-term maintenance and supervision are needed to ensure efficacy of a pool. Aspects such as housing, sanitation, nutrition, education and substance misuse should also be high priorities when trying to address health conditions for which low socioeconomic conditions are major risks.3,4 Although we found no specific health benefits of having a pool, interviewees reported that the pool benefited the community in other ways, including providing an opportunity for exercise and recreational activity for otherwise unoccupied children, and creating an incentive to attend school, owing to a “no school, no pool” policy. The pool is a “public good”2 that cannot be denied based on lack of health benefits. Ongoing investigation is planned to monitor the effects of the pool in this community, and it may be too early to draw final conclusions concerning the health benefits of swimming pool use.

Anu A Mathew · Collin J McDonnell · Jill Benson · Hugh R Taylor

To the Editor: Li and colleagues analysed avoidable hospitalisation rates for Aboriginal and non-Aboriginal people in the Northern Territory, examined trends over time, and assessed “the implications for future primary care interventions”.1 Their study results confirmed that Aboriginal Australians in the NT experience significantly higher rates of avoidable hospitalisations than non-Aboriginal people. They also report a widening gap between avoidable hospitalisation rates of Aboriginal and non-Aboriginal people during the study period, 1998–99 to 2005–06. Avoidable hospitalisation rates are used nationally and internationally as an indicator of primary health care effectiveness and accessibility. However, debate continues about which conditions to include as “avoidable”, and the potential for errors in allocating and coding the primary diagnosis. Furthermore, serious methodological issues remain regarding the use of avoidable hospitalisation rates as an indicator of primary health care effectiveness and accessibility. The outcome measure “avoidable hospitalisation” is affected by more than just primary health care. This is acknowledged by Li et al,1 who identify other factors that affect hospitalisation, including disease prevalence and severity, and geographical remoteness.2 If these factors are not controlled for, it is not possible to attribute differences in hospital admissions to differences in quality of primary care. This would only be possible if Indigenous and non-Indigenous populations were similar in health status and residential location (and other important respects). Aboriginal people in the NT experience far higher rates of diabetes than non-Aboriginal Australians and the age of onset is far younger. For example, there is a 10% prevalence of diabetes in Aboriginal people aged 25–34 years residing in remote areas of the NT. This is 19.5 times the rate of diabetes in a sample of the Australian population of the same age (which will be close to the non-Indigenous rate in the NT), using data from the AusDiab study.3 This young Aboriginal population is also 18 times more likely to have multiple chronic conditions than the AusDiab group of the same age.3 Hospitalisation rates of a population with this health profile should be high, particularly if the primary care system is performing well. Even though Li and colleagues recognise the complexity of measuring primary health care effectiveness and access,1 they still attribute higher rates of avoidable hospitalisations to Aboriginal people’s lack of access to effective primary care. This simply cannot be deduced from their analysis, as it fails to adjust for the high and increasing incidence, prevalence and severity of chronic diseases in the NT Aboriginal population compared with the non-Aboriginal population. This type of misinterpretation of data is serious, given the potential policy implications. We agree that the research question is important, but it warrants a sophisticated analysis that properly adjusts for the most important confounders.

Odette R Gibson · Leonie Segal

In reply: The national and international use of avoidable hospitalisations as an indicator of accessibility and overall effectiveness of primary care1 has included reporting differences in hospital admissions for different ethnic populations and across different geographical regions to highlight inequities in access to primary care. Avoidable hospitalisation rates are also routinely reported for the Aboriginal and Torres Strait Islander population.2 Currently, there is no “gold standard”, but compared with other indicators, such as self-reported data from population surveys, avoidable hospitalisation rates are regarded as an objective and robust measure of primary care.3 Despite the established use, there are well recognised limitations in the interpretation of avoidable hospitalisations, which are outlined in our article,4 and also raised in the letter by Gibson and Segal. What our article highlights, using well identified data sources, is the difference in avoidable hospitalisation rates between the Northern Territory Aboriginal and non-Aboriginal populations, as well as the very different trends. There are expectations that current reforms in the delivery of primary care for Aboriginal Australians can be directly monitored by improvements in avoidable hospitalisation rates. Our results highlight the need for caution in interpreting changes in these rates, and the substantial risks associated with unrealistic performance benchmarks.

Shu Q Li · Natalie J Gray · Steve L Guthridge · Sabine L M Pircher

Objective: To describe cardiovascular disease (CVD) risk management in Indigenous primary health care.Design, setting and participants: Review of 1165 randomly selected case records of Indigenous Australian adults, aged ≥ 18 years, regularly attending eight health services in diverse settings in New South Wales, Queensland and Central Australia, October 2007 – May 2008.Main outcome measure: Adherence to CVD risk screening and management guidelines, especially with respect to overall or absolute CVD risk.Results: More than half the people in the sample (53%) were not adequately screened for CVD risk according to national recommendations. Underscreening was significantly associated with younger age, less frequent attendance, and lower uptake of the Medicare Health Assessment. Of the sample, 9% had established CVD, and 29% of those aged ≥ 30 years were classified as high risk according to the 2004 National Heart Foundation of Australia (NHFA) adjusted Framingham equation. Of those with CVD, 40% (95% CI, 30%–50%) were not prescribed a combination of blood pressure (BP) medicines, statins and antiplatelet agents, and 56% (95% CI, 49%–62%) of high-risk individuals without CVD were not prescribed BP medicines and statins. For high-risk individuals not prescribed BP medicines or statins, 74% (95% CI, 64%–84%) and 30% (95% CI, 23%–39%) respectively, did not meet 2004 NHFA criteria for prescribing of these medications, and of those already prescribed BP medicines or statins, 41% (95% CI, 36%–47%) and 59% (95% CI, 52%–66%) did not meet respective guideline targets.Conclusions: These management gaps are similar to those found in non-Indigenous health care settings, suggesting deficiencies across the health system. Prescribing guidelines which exclude many high-risk individuals contribute to suboptimal management. Guideline reform and improved health service capacity could substantially improve Indigenous vascular health.

David P Peiris MB BS, FRACGP, MIPH · Anushka A Patel MB BS, PhD, FRACP · Alan Cass MB BS, FRACP, PhD · Michael P Howard RN, MHN, MPH · Maria L Tchan BN, MPH · John P Brady BScApp · Joanne De Vries DipPHC · Bernadette A Rickards RN, MPH · Della J Yarnold MB · Noel E Hayman MB BS, MPH, FAFPHM · Alex D Brown BMed, MPH, FCSANZ

To the Editor: In March 2008, nicotine patches (15 mg per 16 hours) were authority-listed for Aboriginal and Torres Strait Islander people by the Pharmaceutical Benefits Advisory Committee (PBAC) as part of efforts to improve access to medications.1,2 Although timely and welcome, the decision to list only 15 mg patches should be revisited, as it is not consistent with current smoking cessation clinical guidelines.3-5 Neither is it consistent with evidence from a 2008 tobacco survey that we conducted in remote Aboriginal communities in Arnhem Land, Northern Territory. Clinical guidelines advise that smokers will require more intensive support to quit smoking if they: (i) demonstrate a high level of dependency; (ii) have had more than one short quit attempt; (iii) still smoke or experience cravings when using nicotine replacement therapy (NRT); and/or (iv) are frequently exposed to other smokers.3,4 This support includes appropriate medication and counselling, which are more effective in combination.5 Under-dosing is a common problem, given that NRT products deliver nicotine plasma levels well below that delivered by a cigarette.3 Higher-dose NRT products (eg, 4 mg gum) or combination nicotine therapies (eg, patches with gums) are effective for highly dependent smokers.3,5 In the Arnhem Land survey, we interviewed 397 people (aged ≥ 16 years) about tobacco. Of these, 77% were current smokers. Among the current smokers, 17% were attempting to quit or had tried to quit, and 58% were contemplating quitting. Dependency was common, with 55% of smokers reporting they smoked first thing in the morning or during the night. With many dependent smokers, high rates of smoking and widespread “cue” exposure, there is a high need for intensive quit support. We also interviewed 24 smokers interested in quitting who were offered 21 mg patches, and 4 mg and 2 mg gums and lozenges. All used the gums; four combined gum with 21 mg patches, with one of these initially trying lozenges. Modest increases in periods of abstinence and reduction in daily consumption were documented in the 11 participants followed up so far. This evidence, albeit limited, challenges the PBAC rationale for listing patches but not gums for Aboriginal and Torres Strait Islander people, namely: “this population eschews oral aids for smoking cessation”.1 Some Aboriginal and Torres Strait Islander smokers wanting to quit may benefit from combination NRT or gums alone. A wider range of NRT products including gums should therefore be considered by the PBAC.

Jan A Robertson · David J MacLaren · Alan R Clough

Aboriginal protocol usually links the right to tell a story with a declaration of involvement or connection to the story.1 Iam Aboriginal . . . I am a woman, daughter, sister, aunty and wife. I am also a mother to three beautiful children aged 6, 4 and 2 years. To my children at this point in their lives, I am their provider, nurturer, teacher, cook, taxi driver, mediator, stylist, Elder, slave, and expert on all there is to know in the world. Being the centre of the universe to three impressionable young minds is a role that I cherish deeply, and I take the responsibilities of it very seriously. I love the job of parenting. As any parent would agree, it is the most challenging and difficult job of all, but the opportunity to bring a life into the world and shape and mould a little person into a big person brings rewards that no career can. The story I share here is of a professional journey I travelled within my own community in coordinating an Indigenous early years intervention. I simply cannot tell this story without acknowledging and declaring my connections as a mother first. It is through my identities as a mother and an Aboriginal person that this journey was experienced, and therefore it is through these eyes that this story is told. An Indigenous early years interventionAfter the birth of my third child, I returned to the workforce in a part-time capacity with the Inala Indigenous Health Service. Through a partnership with Mission Australia’s Communities for Children initiative (funded by the Australian Government Department of Families, Housing, Community Services and Indigenous Affairs Stronger Families and Communities Strategy), I was given the brief to develop an intervention that would improve the lives of Indigenous children aged 5 years and under and their families in the Inala to Goodna region. In recent times, the term “intervention” seems to have become a kind of dirty word within Indigenous communities. Within the context of Indigenous social policy, intervention seems to imply swift action and necessary interference. However, for a number of Indigenous communities (and many Indigenous parents) in the Northern Territory and Far North Queensland, the idea of intervention has meant forced, punitive social controls and surveillance over everyday living and family decision making. These interventions are justified through the premise that Indigenous parents in these communities just don’t have the capacity or desire to raise their children right. For some people, the policy of intervention in Indigenous communities invokes imagery of incompetent parents; for others, it invokes images of incompetent politicians and policymakers. I recognise that I have no first-hand involvement with or connection to the intervention experience in the NT or the family income management schemes in Cape York. But the common experience I share with the parents in these places (and all parents, for that matter) is the desire to raise happy, healthy children who will grow to be physically strong, culturally wise and always walk with their heads held high. The community that my children call home and the site of this intervention is an outer-western suburb of Brisbane called Inala. It is home to one of the largest Indigenous communities in south-eastern Queensland, and has a high density of public housing.2 Every socioeconomic indicator strongly suggests that Inala is a disadvantaged community, which commonly implies that Inala must be a “bad” community. “Bad” communities, of course, are composed of “bad” families, as evidenced by a statement from the Queensland Government Family Responsibilities Commissioner, David Glasgow, in which he suggested extending the Cape York welfare reforms to “places like Inala, Redbank and places of that nature where children are not looked after properly”.3 As parents (who happen to be Aboriginal), my husband and I know that we are far from perfect. Inasmuch as we love our children, we are just as convinced that we will make mistakes — that is part of life, no doubt. Yet, the challenges of parenthood are made more difficult by the stigmas attached to parents who happen to be Aboriginal or younger than average, or who reside in disadvantaged neighbourhoods. When my husband and I venture out with our children into the predominantly white spaces of neighbouring suburbs, we cannot help but notice how people are “reading” us. As Aboriginal parents, we are aware that the public gaze is transfixed on the horrors of physical and sexual abuse and neglect of Indigenous children and families, to the extent that it makes it difficult for some people to see us beyond those depictions. I can attest that the stigma of stereotyping is a heavy burden to shoulder, and is one that we are loath for our children to inherit. Given these experiences, I was determined that this intervention would not be grounded in those kind of assumptions. Of course, there are Aboriginal parents who are abusive and neglectful of their duties. However, it would be unthinkable to allow the worst cases of parental abuse and neglect within the non-Indigenous community to be used as the yardstick for driving family and social policy for the rest of Australian society. So my starting point for the Indigenous Early Years Intervention in Inala was the premise that all parents love their children and only want what’s best for them. Therefore, our intervention would not necessitate forced or punitive controls and surveillance to effect positive social change. I believe it is for precisely this reason that this initiative achieved a wide range of positive outcomes for Indigenous families in our community. Within just 12 months, the Indigenous Early Years Intervention was successful in developing local Indigenous health promotion resources, establishing an Indigenous playgroup within the community, and improved literacy awareness among Indigenous parents and carers, as well as providing opportunities for skill development for local Indigenous parents and workers. The intervention also focused on building the capacity of the Indigenous sector to support Indigenous children and their families beyond the lifespan of the project. The Box lists some of our major accomplishments. It is kind of ironic that these kinds of outputs could be achieved, given what we supposedly know about Indigenous parents and “places like Inala”. The critical success factors for this intervention don’t lie in romanticised assumptions about families in Inala or Aboriginality. The success achieved is a product of age-old processes that our mob has used in the doing of our everyday business. The failure to recognise the strengths of Indigenous parents in Indigenous social policy is simply reflective of a broader failure to recognise the strengths of Aboriginal culture, processes and protocols. As a health professional working in Indigenous communities, I’ve always been guided by the principles I’ve been taught as an Aboriginal person. Mapping country — seeing strengthFor many Aboriginal people, the importance of knowing one’s country is inherent to our sense of Aboriginality and sense of wellbeing. This requires an intimate knowledge of traditional lands and the dreaming stories contained within. These lands are identified by geographical boundaries, and landmarks such as lakes, rivers, mountains, trees and rocks. Tom Dystra articulates this distinct relationship: We cultivated our land, but in a different way from the white man. We endeavoured to live with the land; they seemed to live off it. I was taught to preserve, never to destroy.4 As an Aboriginal person working within my own community, it is imperative that I know my country too. I must know the landmarks and identifiers of the country and community that I live in and call home. However, the landmarks that I’m looking for here are not so much about the physical landscape, but instead are features of the social landscape. Mapping country is about taking the time to explore and identify the existing energies, strengths, and skills of the community, its members and the service sector. Importantly, our attention here is drawn to what is already present in a community and not in what is lacking. White fellas call this process “asset mapping” — we call it mapping country. Recognising a community’s strengths or assets sets the platform for possibilities. Charting a community’s deficits only seems to deepen the despair. Admittedly, some strengths may be small — they may be only seeds that have just been planted. But that is our role as custodians of our land, community and culture — to nurture and grow, and preserve, not destroy. Perhaps that is what is so offensive about the other intervention experiences inflicted upon Aboriginal people. Before the circus of armies, institutes, researchers and bureaucrats rolled into town, not one person cared to take the time to look and see what was already there. Yarning up — hearing hopeOur Aboriginal culture is steeped in oral tradition. Consequently, the act of yarning and storytelling is one of utmost importance. As a child, and the youngest of four, the rules of narrating and witnessing stories were impressed upon me from early on. My father always would remind me as a child to “know my place” and the importance of being quiet and listening. Working within a community, the task of respecting the knowledge and wisdom of those who have gone before you is another fundamental. In developing this intervention, the obvious next step was to listen and learn from our community. White fellas call this consultation — we call it yarning. There are several important points to this yarning process that are integral to its effectiveness in informing community practice within an Indigenous context. Firstly, we yarned with people about what they thought was necessary to make their community better. The question wasn’t “what is wrong with your family and community?” Instead we asked, “how can the community better support you and your family?” This is important, because our communities have become so accustomed to recounting stories of dysfunction and horror, it can be far too easy to be drawn back to community weakness and need. The yarning process must be empowering. When we talked to people, we spoke with both big fellas and little fellas because Eldership and leadership are not determined solely by the number of breaths one has taken. We went to our mob — we didn’t expect them to come to us. We went to sporting festivals and community gatherings, and engaged in conversations wherever they could be had. As a result, we yarned with over 100 people. The development of this intervention grew out of the dialogue between the service sector and the community in question, and not external spectators, voyeurs, commentators and public opinion. It seems glaringly obvious that community ownership and control is the perfect antidote to passivity and dependency, but such ownership can only be facilitated by engaging our mob in the yarning process from the very beginning. Creating new dreaming storiesThese processes must culminate in a “joining of the dots”, so to speak. Through mapping the landscape and collecting knowledge stories, a new dreaming can be found. For our intervention, this meaning-making occurred through a collaborative process between our community workers and organisations. What emerged through the efforts of the Indigenous Early Years Partnership Group was a 12-month plan of possibility and opportunity. It was precisely because the initiatives stemmed from community strengths, knowledge and desires that very little investment was required to engage Indigenous parents in the activities and opportunities created. Not one person had to be transported to an activity or initiative; food and gifts were not brandished in the faces of parents to entice their interest; and, most importantly, no one’s welfare payments were threatened in order to enlist collaboration or compliance. We shifted ideologically in our thinking of our community, from negative assumptions to endless opportunities. We refrained from drawing assumptions around notions of “good” and “bad” communities or families — we simply started from strengths. We did not assume that nothing was being done in our community — we simply asked “what can we do better?” Through this process, we uncovered endless examples of Indigenous workers, organisations, parents and children embracing opportunities to grow stronger. Unless and until current Indigenous social policy and interventions are premised upon the possibility that Indigenous parents, families and communities possess strength and capabilities, there will never be the opportunity for our children, families, community and culture to grow stronger. Indigenous Early Years Intervention — highlights Consultations undertaken with over 100 local Indigenous community members. More than 10 local community organisations and government agencies involved in steering the initiative via the Indigenous Early Years Partnership Group (met bimonthly). The development of an Indigenous child health promotion resource, in partnership with eight local agencies and 90 community members and children, with a distribution of 16 000 units within our community and across the state. The establishment of an Indigenous playgroup in partnership with six local agencies, attracting over 133 children, 75 parents and carers, and 56 volunteers within a 7-month period. The delivery of Let’s Read resources to more than 70 Indigenous children and their families. Support provided to four local Indigenous community festivals to become more child-friendly (involving reviewing site layout, provision of infrastructure and activities for children under 5 years of age). Engaged over 80 volunteers. Supported 50 people to participate in early years training opportunities within our community. Supported over 20 organisations and initiatives with resource support (eg, grant-writing support, health resources and information, health promotion stalls and activities, committee membership, in-service training to early years sector).

Chelsea Bond PhD

Indigenous and non-Indigenous Australians need to work together to restore balance Healing is part of life and continues through death and into life again. It occurs throughout a person’s life journey as well as across generations. It can be experienced in many forms such as mending a wound or recovery from illness. Mostly, however, it is about renewal. Leaving behind those things that have wounded us and caused us pain. Moving forward in our journey with hope for the future, with renewed energy, strength and enthusiasm for life. Healing gives us back to ourselves. Not to hide or fight anymore. But to sit still, calm our minds, listen to the universe and allow our spirits to dance on the wind. It lets us enjoy the sunshine and be bathed by the golden glow of the moon as we drift into our dreamtime. Healing ultimately gives us back to our country. To stand once again in our rightful place, eternal and generational. Healing is not just about recovering what has been lost or repairing what has been broken. It is about embracing our life force to create a new and vibrant fabric that keeps us grounded and connected, wraps us in warmth and love and gives us the joy of seeing what we have created. Healing keeps us strong and gentle at the same time. It gives us balance and harmony, a place of triumph and sanctuary for evermore. Associate Professor Helen Milroy, Aboriginal Child Psychiatrist and Australia’s first Aboriginal doctor, 2009. The Apology by the Prime Minister to Aboriginal and Torres Strait Islander peoples of Australia in February 2008 was the first step in a significant healing journey. Importantly, it was the commencement of a healing process rather than an end in itself. The Apology created a climate of hope and a sense that the government may be open to taking a different approach to Indigenous health and Indigenous affairs generally. This year, the Prime Minister marked the first anniversary of the Apology by announcing the establishment of a Healing Foundation to address trauma and healing in Indigenous communities.1 It is therefore timely to generate wide-ranging discourse about healing and what it means for Aboriginal and Torres Strait Islander health. A healing journey will not only deliver better lives for Aboriginal and Torres Strait Islander peoples, but is essential for the wellbeing of Australia as a nation. Healing means different things to different people. Within medical science, healing has specific meanings related to the pathophysiology of wound closure, organ repair and system function. The process of cell turnover occurs in the body to ensure health through the renewing of red blood cells, the sloughing and replacement of various epithelia, and bone remodelling. Throughout our daily work as doctors, we see the body’s “enthusiasm for life”. For Aboriginal and Torres Strait Islander doctors, healing goes beyond treating the disease. It is about working towards reclaiming a sense of balance and harmony in the physical, psychological, social, cultural and spiritual lives of our people, and practising our profession in a manner that upholds these multiple dimensions of Indigenous health. In essence, it is “Moving forward in our journey with hope for the future, with renewed energy, strength and enthusiasm for life”. Specific and holistic concepts of healing are not dissimilar, however, particularly if the foundational concept is that of “renewal”. Healing needs to occur at various levels — from cells, organs and systems to individuals, families and communities. A number of different modalities may be used to ensure healing is meaningful to different people and different communities. For example, this could mean Western-trained doctors working alongside Ngangkaris (traditional healers from Central Australia) to deliver an optimal health service that facilitates physical repair, psychological buffering, social nurturing, cultural reclamation and spiritual maintenance. Indigenous healing services need to be culturally meaningful and must focus on why people are at risk of succumbing to physical disease and to using drugs and alcohol, as well as the ways in which restoring cultural norms and repairing the social fabric can mitigate these negative disruptions. Health professionals must be culturally competent and need to understand the cultural and spiritual elements of health. The national effort to improve the health of Indigenous Australians is vital and must continue apace, with the driving principle of a holistic view of Indigenous health as being: Not just the physical well-being of the individual but the social, emotional, and cultural well-being of the whole community. This is a whole-of-life view and it also includes the cyclical concept of life–death–life.2 Having a state of health (however defined) assumes an individual has access to all levels of health care services and is able to negotiate the health system successfully. It also assumes access to nutritious food; the ability to have a good night’s sleep and feel safe; the capacity for motivation and the facility to undertake regular exercise or recreation; and the presence of sound relationships with family, community and society. It assumes that an individual is protected by reasonable health infrastructure. Many of these issues have been tackled in recent health reviews and initiatives, Council of Australian Governments announcements, and the national effort to “close the gap” in life expectancy. These initiatives are to be applauded, although they are well overdue. If implemented effectively, they can go some way towards healing. These efforts need to occur in parallel with a national discussion on the issues that are a little more confronting and yet are known to have an impact on health, such as the effects of cultural dislocation, dispossession,3 loss of autonomy,4 social exclusion, racism, and marginalisation.5 Unless Aboriginal and Torres Strait Islander peoples are able to take action to restore balance to their lives and to experience the strength that comes from regaining that balance — and unless the rest of society facilitates, supports and nurtures this action — we will be forever addressing the symptoms rather than the root causes. Until these issues can be resolved, healing cannot occur at a community level or at a national level. How can the medical profession further contribute to Australia becoming a healed nation? As a collective, we can promote understanding of the multiple determinants of Indigenous health — the physical, psychological, social, cultural and spiritual aspects of wellbeing; ensure this understanding informs clinical interactions as well as policy and resource allocation; advocate for and practise culturally appropriate health service provision across the care spectrum; encourage sectors such as housing, education and justice to work with the health sector to create reform; and advance an appreciation of the healing strengths of reconnecting with family, culture and Country. Clearly healing is a complex issue, and I hope this article raises questions and possibilities as to how healing might occur, and helps to explore the frameworks within which it can occur. The fundamental aim of healing is to provide a better future for our children and to create a world in which Aboriginal and Torres Strait Islander peoples and culture thrive. As a profession working towards this end, we can truly show leadership in guiding change and generating a sustainable vision of health for all Australians into the future.

Tamara Mackean BSc(Med), MB BS

In 2006, with outstanding cooperation from Department of Corrective Services staff at Cessnock Correctional Centre, two Justice Health staff made a huge step in walking together in the constant fight for Aboriginal health. In a mere six and a half hours, 88 Aboriginal offenders — 100% of the Aboriginal population in that centre — were screened for markers of kidney disease. We had been fighting for years to get renal screening into the jails. Finally it happened! A special renal screening research project funded by the Hunter New England Area Health Service was to be carried out in three facilities in the Hunter Valley and northern New South Wales: Cessnock, St Heliers (Muswellbrook) and Tamworth. We were offered five days to do three jails. If anyone could pull it off, I reckoned I could. I’ve been an Aboriginal Health Worker in the system since 1985, longer than most of the “lifers” — but they let me out from time to time, I like to remind everyone. I did some serious thinking and strategic planning on just how to pull this off at the Cessnock site. I had 66 Aboriginal patients spread over five wings and various other locations, and no nurse or place to do the screening. A well-meaning officer jokingly said to me on hearing about it, “How many you wanting to do?” “Sixty-six, officer — the lot”, I answered. He laughed and retorted, “Impossible, you’ll never do it . . . I’d say 30, tops . . . and three days. It’s a bet”. They were fighting words. “You’re on.” That was how this story started. What I first needed was a nurse and a place to do it. I fronted the clinic and did some passionate Aboriginal-kidney-health-at-an-all-time-low talking to the Justice Health Nursing Unit Manager. She was already four nurses down that day, but after some drastic roster raping and creative roster placing, I got my Aboriginal male nurse for the project. We needed a toilet for collection of specimens. Urine testing is not the easiest thing to do in a hurry. Next we needed to give the patients-to-be an incentive. I headed into the prison-yards — “Calling all Kooris!” I’d kick that Koori grapevine into gear fast to get the word out. The bait was a Koori-coloured red, yellow and black water bottle. One each. It wasn’t much, but then most of these guys have almost nothing. To make sure everyone knew what was happening and how important it was to get 66 permission forms signed beforehand, we arranged afternoon tea for the next day. Hot buttered damper with syrup and billy tea were promised. That hit the spot. Full turn-up next day and 66 names and forms were signed and collected, with spares kept at the ready for any new arrivals. The officer’s challenge was taken by all offenders with wry grins and much laughing as hot buttered damper with syrup was consumed with lots of lip-smacking and licking of fingers and enthusiastic agreement as we planned D-Day down to the minute. The jobs of rounding everyone up and getting them from point A to point B were allocated. Twelve patients at a time was agreed — ready to roll out, bladders brimming, as others returned. They were ready — all they needed was complete cooperation from all officers concerned on the day. D-Day arrived. By 7.30 am I was already in the yards as the wings were emptying for breakfast. We rallied the Kooris to win the bet as soon as methadone parade was over. We had 66 for sure, and others signing on, as the transports arrived with more offenders. It was shaping up well. By mid morning, the Aboriginal Delegate (the community leader of all Aboriginal offenders of the centre) had 22 more signed permissions: 100% of the Aboriginal population in the Cessnock facility, now 88 in total. All in. “Bring it on Aunt, we’re ready for them!” The war cry went up. Something was about to break the boredom that day. Everybody knew it and was ready to play a part — not just the Kooris. The operation was fully planned for speed. As each patient arrived in the allotted clinic area, I would give him a specimen cup to write his name and ID number on; record his height and weight; then send him on to the nurse to have his specimen tested and blood pressure taken. Each patient was warned — any abnormality and he would be listed to see the doctor. After receiving their water bottles, each group returned to the yards to spread the word of encouragement and help rally the rest. When the queue got down to five, the Aboriginal Delegate and I would take off down the “avenue” to gather the next 12. This is where the story gets humorous. Some of the old laggers who were taking it easy, sitting in the sun on the walls along the avenue and generally bored silly with the monotonous routine of their surroundings, started to take a keen interest in the comings and goings and the unusual enthusiasm of the Koori lads that morning. At this point they decided to get in on the act too. As they spied them striding fast (you don’t run inside jails) towards the avenue gates, the laggers would call out, “Come on you Koori lads, Aunt is coming for you, boots and all”. Fact is, Kooris never hurry for anyone or anything, it’s kind of a principle — but when they heard that call, “there was movement in the yards, for the word had passed around, that Aunt was coming fast and the boots were gaining ground”, they were gathering and forming up already in lines. The old laggers sitting on the walls were well into the game by now and sent out a new call to the avenue rover: “Hey chief, they’re on their way back now . . . big bunch of ’em coming up fast”. This alerted the rover to open up each of the three security gates promptly for us to pass through. On the third trip down, the old laggers called out in jovial fashion, “Go Aunt, go! We’re taking book on this, you know”. That called for some laughter and cheering as the patients passed each time. The applause and calls of encouragement from the crowd, which had now swelled considerably, added a definite flavour to the day. Our project had become a talking point. Some officers remarked later that the Aboriginal health exercise lifted morale that week for the whole jail. It had been all good. By lunchtime, we were out of resources. Hunter Area Health had only sent 50 packs. We’d ordered more, but were still waiting for them. I phoned again — they were on their way. We still had two wings and the work crews to get through. Cuppa was in order, but then word came — “The parcels are here and on their way down!” Yes! The officers were met halfway. They had two big bags of water bottles and the testing gear. Cheers rang out from the avenue throng and the officers were heroes for a minute or so. Because of the tight security in the next areas (Maximum), it took a little longer, but we finished by 2.30 pm, still with time to catch the Aboriginal lads returning from work in their assigned prison duties for the day. Because of prison staff shortages, early lockdown in Maximum meant they had to be escorted individually down two flights of stairs to take part. With great officer cooperation, it happened. We needed to complete the project before total jail lockdown at 4.00 pm, and we did. Hoping we’d managed to test everyone, the pair of us wearily trudged back through the long jail yards past all five wings to the clinic. Our step lightened as we heard the inmates calling to us, “Good on you fellas, did you get them all? . . . Deadly job you two, a great day!” Everyone wanted to know if they had reached the goal, headed by the officer who’d bet we couldn’t do it. With a grin on his face he asked if we’d done all 66 prisoners, looking very confident we hadn’t. I was happy to bring him up to date. Count done: 100% of current Aboriginal offenders had participated and all had been tested. By the clock, we had done 88 patients in six and a half hours! The officer was astounded: “That was some feat you two pulled off . . . I can’t believe it . . . glad I didn’t put money on it!” The serious side of the screening research project showed itself in the results. Of the 88 Aboriginal offenders, 14 screened positive for microalbuminuria and many more were positive for other high-risk chronic illnesses such as hypertension and diabetes. The next two jails visited were St Heliers and Tamworth. At St Heliers, all 37 Aboriginal offenders were screened. Of these, 13 tested positive, and again many were referred for other high-risk illnesses. At Tamworth, 42 Aboriginal people were screened (one refusing), with 14 being positive and one dangerously positive. In all, over the three sites, 167 renal screenings were carried out, resulting in 42 abnormal kidney readings. As a result of this successful renal screening project, one new Aboriginal position has been created for the area: the Coordinator Aboriginal Renal/Health Promotion will be working with the Aboriginal Health team for two years within the existing 16 Aboriginal Chronic Care Program sites. The Program gives us vital information on the cardiovascular health of Aboriginal offenders well in advance of onset of cardiovascular disease. The renal health component is a nice addition to the Program. Aboriginal people normally don’t access the mainstream Justice Health centres in the jails because Aboriginal staff from many external Aboriginal Medical Services can’t regularly visit the centres any more due to a lack of staff and funding. This is why we need Aboriginal Health Workers in every jail, especially in those with a high percentage of identified Aboriginal offenders. Change — stalled a decade ago — is slowly starting to happen again. Twenty per cent of the male client base and 31% of the female client base in NSW prisons are Aboriginal people, with levels as high as 50% in younger offenders. Despite the Royal Commission into Aboriginal Deaths in Custody1 20 years ago, which recommended that culturally appropriate medical care be provided to offenders, with access to Aboriginal Health Workers wherever possible, and despite what you read in annual reports since then, Justice Health 10 years ago adopted an unofficial policy of mainstreamed take-it-or-leave-it medical service to Aboriginal offenders. It is now slowly moving away from this stance by employing its own Aboriginal Health Workers as part of the health centre staffing profile, beginning with one of the newer facilities at Wellington in midwestern NSW. Visiting Aboriginal Medical Services staff should be welcome to work with members of their community who are in jail, but clearly, Aboriginal Health Workers are needed within the system itself, trained to go into the yards with the Aboriginal Delegates to encourage the brothers to access and be tested at the Health Centre. The hardest part of the process is moving the prisoners within the jail. Locked gates, classification, segregation, non-association, constant lockdowns, inter-jail transfers without notice, request forms denied or simply lost — all add to the burden of self-destructive thinking that offenders bring into jail with them. Even knowing of a serious medical problem, they will often give up and cease to care. Aboriginal people in general, and prisoners in particular, are also dealing (or not dealing, as the case may be) with the blight of long-term systemic racism. A popular notion (unfortunately given scientific credibility by Charles Darwin) is that they are the lowest form of human life — one step above the apes: [H]ow little can the hard-worked wife of a degraded Australian savage, who uses hardly any abstract words and cannot count above four, exert her self-consciousness, or reflect on the nature of her own existence? [quoting Büchner] . . . At some future period . . . the civilised races of man will almost certainly exterminate and replace throughout the world the savage races.2 I commend you instead to the words of Kevin Gilbert — a self-educated Wiradjuri man and former offender — writing 100 years later, after doing 15 years for murder: As Aborigines began to sicken physically and psychologically, they were hit by the full blight of an alien way of thinking. They were hit by the intolerance and uncomprehending barbarism of a people intent only on progress in material terms, a people who never comprehended there could be cathedrals of the spirit as well as of stone. Their view of Aborigines as the most miserable people on earth was seared into Aboriginal thinking because they now controlled the provisions that allowed blacks to continue to exist at all. Independence from them was not possible. White people’s devaluation of Aboriginal life, religion, culture, and personality caused the thinking about self and race that I believe is the key to modern Aboriginal thinking. As Robert Kantilla said, “Suffering is that the white people class them as the lowest person on earth”. My thesis is that Aboriginal Australia underwent a rape of the soul so profound that the blight continues in the minds of most blacks today. This psychological blight, more than anything else, causes the conditions we see in reserves and missions today and is repeated down the generations . . . [T]hey have been patterned into that stereotype, and they do live it.3 No more is needed to explain the present and ongoing over-representation of Aboriginal people in the prison population, or their generally poor health. And the solution? Kevin Gilbert goes on to say that it starts with your education, and I agree. But it’s a special education. It’s a pity I don’t have room to quote him more, because he just blows Charles Darwin away. And healthwise, whether you’ve been injured by a truck or by generations of white racism, it’s the same solution, believe it or not — education. Kooris, Gooris, Murris and all Aboriginal people, your health education can start right here, with you learning these principles: Recovery and ongoing maintenance of your good health starts, first and foremost, with a free decision by you to take primary personal responsibility for it. Yes, you can do it, and yes, you are worth it. You need education — information, strategies, and especially role models. Find them, and stick with the strength, or else . . . For the many Aboriginal people locked in prison — especially those also locked in their self-destructive rituals of negativity, resentment and blame — experience shows that the process of health education in prison is only likely to start when they are targeted, brought together and encouraged into the caring hands of Justice Health’s wonderful Health Centres, with their specially trained and enthusiastic Aboriginal Health Workers.

Beverley F Spiers BEd(Aboriginal Adult Ed), GradDipAdultEd

I don’t know where I would be — six years’ study is a long time — and the fact that I have had a home, with meals, on campus lets me do the job I have to do to pass my exams. I have been here for four years now, and I have had the time to work hard at uni, and work out where I want to go when I graduate. The scholarship — without question — has allowed me to stay at uni and get on with my dream of becoming a doctor. I really want to go into public health when I finish — and make a difference to my people. — Josef McDonald, fifth year medical student Josef is one of 22 Aboriginal students enrolled in medicine at the University of New South Wales (UNSW), and one of 10 students who hold a Shalom Gamarada Ngiyani Yana residential scholarship. There are many reasons why Indigenous health professionals are part of the critical path to wellness for Indigenous Australians. Indigenous health professionals can provide a shared understanding of the circumstances of other Aboriginal and Torres Strait Islander people who enter the health system, and bring a diversity of understandings and views around health that enrich the academy initially and the profession over time. Like so many Indigenous students, Josef is one of the few in his extended family who have been able to finish high school and enter university. Josef’s sister, 9 years his senior and herself a success story, is an engineer. While at university, she worked every night to support herself — an experience familiar to many students. There are few scholarships and awards that can help Indigenous students pursue their dreams of becoming health professionals — Josef and his college cohort are certainly aware of this and of the role they each play in providing encouragement to others from their families and communities who also wish to enter tertiary education in the future. “I’m the same as anybody that has a dream. The only difference is that I’ve been given the opportunity to achieve mine,” says Jenna Owen, the first Aboriginal student at UNSW to study optometry. Jenna will be one of only two Aboriginal optometrists when she graduates, and is the first person in her large extended family to attend university. Each residential scholarship is valued at $15 000 per year and covers tuition and full board at Shalom College on the university’s Kensington campus. Each student awarded a scholarship has tenure until they complete their degree. These scholarships are funded mainly from the proceeds of the annual Shalom Gamarada Ngiyani Yana Art Exhibition and show (http://www.shalomgamarada.org/). The art show is run in partnership with Shalom College, and two distinct Aboriginal units on campus, the Muru Marri Indigenous Health Unit and the Nura Gili Indigenous Programs at UNSW. The first exhibition was held in 2005, and it has run annually since. This year, as in the past, the artists themselves, through their agency as the creators of the artworks, make a deliberate contribution to improving Aboriginal health outcomes. This year, the show will focus on two distinct areas —the Yuendumu community in the Western Desert region of the Northern Territory and the artists of Bidyadanga in northern Western Australia. All of our works are sourced from community art centres and we expect to have about 130 pieces on display this year, some of which can be seen in this issue of the Journal (see below), with prices ranging from $150 to $50 000 or more. The opening ceremony will be held at 5pm on Sunday 19 July, with guest artist Daniel Walbidi from Broome, and Yuendumu art centre coordinator Cecilia Alfonso as guest speakers. Shalom Gamarada allows the public to see a broad range of current contemporary and traditional art. People can meet representative community members and artists and learn about collecting art and hear about the current thinking in health, and all proceeds go to help grow more Indigenous health professionals — all of this makes this particular week-long event unique. Details of the Exhibition and show Open: 10am to 6.30pm each day from 19 July to 26 July Address: Eric Caspary Learning Centre, Shalom College, University of New South Wales, Kensington (enter via Barker St) Art Panel: art centre managers from Peppimenarti, Yuendumu and Bidyadanga, 3pm Sunday 19 July 2009 Health Forum: 3pm Sunday 26 July 2009 More information: visit http://www.shalomgamarada.org/ or call Professor Lisa Jackson Pulver on 02 9385 1769. Artist: Liddy Napanangka Walker Artist: Shorty Jangala Robertson Artist: Jan Billycan Artist: Jan Billycan Artist: Weaver Jack Artist: Jan Billycan Artist: Joanne Currie Nalingu Artist: Shorty Jangala Robertson

Lisa R Jackson Pulver

Indigenous Australians die of asthma at more than three times the rate of the rest of the nation The recently released Australian Centre for Asthma Monitoring (ACAM) report Asthma in Australia 2008 focuses attention on several important and novel findings about asthma among Indigenous Australians (see Box).1 This is the third report in the 2-yearly series from ACAM, and brings together analyses of routinely collected national data, including data from Australian Bureau of Statistics national health surveys, and current information from published articles. Asthma is clearly identified in the report as a prevalent health problem in the Indigenous population. It is one of the two most common causes of hospitalisation of Indigenous Australians, second only to renal dialysis.2 It is also the second most common self-reported long-term illness among Indigenous Australians, and the mortality rate due to asthma among Indigenous Australians is 3.2 times that of other Australians.1 However, in contrast to the attention given to other medical conditions over-represented among Indigenous Australians, such as cardiovascular disease and diabetes mellitus, disproportionately little attention is given to respiratory disease, including asthma. In contrast to lower prevalence rates reported in the past,3,4 the prevalence of asthma among Indigenous Australians (16.5%) is now higher than among other Australians (10.2%), particularly in adults older than 35 years and those living in urban locations.1 Furthermore, the report shows that the prevalence of asthma in Indigenous adults older than 55 years is higher than the prevalence seen in children. This is in stark contrast to the data for other Australians and from other countries, which show the prevalence of asthma to be higher in children than in adults. We can only speculate about the reasons, but these may include the cumulative effects of three factors: life-long exposure to pulmonary toxicants, such as tobacco smoke and infections; uncertainty among Indigenous Australians about the nature of the disease and of the diagnosis (probably a very significant factor, particularly in the very young and the elderly); and long-term undertreatment of asthma. Uncertainty about the diagnosis is an issue as most of the prevalence data are based on self-reported questionnaire data from the National Aboriginal and Torres Strait Islander Health Survey 2004–05,5 and are not confirmed by clinical examination. Although this survey was conducted on a representative sample of Indigenous people (respondents totalled 10 439), with oversampling in remote communities, there remains a need for well conducted epidemiological studies of asthma and wheezing illness in urban, rural and remote Aboriginal populations that include objective measures, such as results of lung function and airway hyper-responsiveness tests. The problems of smoking and poor access to high-quality health care for Indigenous Australians are well known and similar to those affecting minority groups in many other affluent countries.6 Indigenous Australians have very high rates of smoking, a particular concern in relation to asthma. Intrauterine and postnatal exposure to environmental tobacco smoke has serious implications for lung health in young children, especially the many who suffer frequent wheezing illness and persistent lower respiratory tract symptoms. Concurrent smoking and asthma are associated with accelerated lung function decline, and the report highlights the very serious lung-health consequences of the high smoking rates in Indigenous Australians, for children and adults. Chronic obstructive pulmonary disease (COPD) and lung cancer are other important adverse lung outcomes largely attributable to smoking. Hospitalisation rates for asthma are disproportionately high among Indigenous Australians, as are rates of absences from work or school because of asthma. This occurs despite rates of possession of asthma action plans among Indigenous patients (24.9%) being similar to those among other Australians (22.5%).1 A possible explanation is the underuse of appropriate medications and devices. Indigenous Australians are less likely to use inhaled preventer medications for asthma. Studies in different regions of Australia, from the Australian Capital Territory to northern Queensland, have confirmed high levels of parent-reported asthma and symptoms such as wheeze in Indigenous children compared with other children, and relative underuse of preventive treatments for asthma.7,8 However, Indigenous adults, especially those older than 55 years, have high overall usage of medications for airway disease.1 Indigenous people with asthma also have a high prevalence of comorbid conditions that may complicate the management of asthma; in particular, comorbid heart disease, cerebrovascular disease and diabetes mellitus are likely to affect asthma management.1 Furthermore, Indigenous Australians report poorer quality of life than other Australians with asthma, suggesting asthma has a more serious impact in the Indigenous community than in the non-Indigenous community.1 These data and other findings described in Asthma in Australia 2008 have important implications for setting priorities and selecting initiatives to promote lung health in Indigenous communities. A start should be made with research into and implementation of more effective and tailored interventions to minimise tobacco use, particularly in settings where high levels of exposure have such deleterious consequences for healthy lung growth, and aggravating effects on respiratory symptoms in children with wheezing illness. Once symptoms are present, further attention is required to ensure that Indigenous Australians receive optimal care for their asthma, particularly to improve inhaler use and maintenance of long-term medication regimens. There are difficulties in accurately diagnosing the cause of airway symptoms such as cough and wheeze in young children. As diagnosis drives the management of asthma, it is important to conduct research into and promote accurate diagnosis of asthma and related conditions, such as chronic suppurative lung disease and bronchiolitis and, in older people, COPD. In remote Indigenous communities, asthma-like symptoms may be the presenting features of these other respiratory conditions in both children and adults.9 Reasons for the high prevalence and morbidity of wheezing illness and asthma, particularly in the very young (younger than 1 year of age) and older Indigenous people, are not known, and require research and clinical attention. The high rate of hospitalisations for asthma, more than twice that of other Australians, suggests there is a need for careful and systematic investigation to develop interventions most likely to benefit the Indigenous community. These are needed to help improve the quality of medical care and preventive strategies for children and adults at risk of asthma exacerbations and hospital admission. Attention to the presence of comorbidities is advocated both clinically and at a health service policy level. This may include health practitioners incorporating asthma management into cardiovascular and diabetes care plans and vice versa. To rectify the disparity in asthma and asthma-related outcomes in the Indigenous population, a complex multilevel framework10 is likely to be required, firstly to understand the reasons for this disparity, and then to develop the most appropriate strategies to overcome it. Opportunities need to be taken to significantly improve the quality of asthma-related care using culturally appropriate programs when they become available. Urgent research into and policy development for the “how to” and “what” of these programs are required. Recent data have shown the efficacy of culture-specific asthma programs compared with “usual care”.11 The Thoracic Society of Australia and New Zealand and the Australasian Sleep Association are about to release a report entitled Respiratory and sleep health in Indigenous Australians,12 and the major respiratory advocacy organisations are planning an Indigenous Lung Health Summit to consider the areas most in need of action and to prioritise new initiatives. The initiatives we have recommended here, if undertaken, would be small but important steps in reducing the health gap between Indigenous and other Australians. Asthma in Australia 2008: major findings1 Prevalence of asthma is higher among Indigenous Australians (16.5%) than it is among other Australians (10.2%). Indigenous Australians are twice as likely to be hospitalised for asthma and three times as likely to die of asthma as other Australians. Among adults, 48.2% of Indigenous Australians with asthma smoke, compared with 23.8% of other Australians with asthma. Indigenous Australians with asthma are three times as likely to have diabetes mellitus as other Australians with asthma.

Christine R Jenkins AM, MD, FRACP · Anne B Chang MPHTM, PhD, FRACP · Leanne M Poulos BMedSc(Hons), MPH(Hons) · Guy B Marks PhD, FRACP, FAFPHM

Objectives: To analyse rates of avoidable hospitalisations in Aboriginal and non-Aboriginal residents of the Northern Territory, 1998–99 to 2005–06, and to consider the implications for primary care interventions.Design and setting: Retrospective descriptive analysis of inpatient discharge data from NT public hospitals.Main outcome measures: Avoidable hospitalisations by age, sex, Aboriginality and condition, with annual time trends.Results: Between 1998–99 and 2005–06, Aboriginal people in the NT had an avoidable hospitalisation rate of 11 090 per 100 000 population, nearly four times higher than the Australian rate of 2848 per 100 000. The rate for non-Aboriginal NT residents was 2779 per 100 000. During this period, the average annual increase in avoidable hospitalisations was 11.6% (95% CI, 11.0%–12.1%) in the NT Aboriginal population and 3.9% (95% CI, 3.3%–4.5%) in the non-Aboriginal population. The greatest increase occurred in those aged ≥ 45 years, and was primarily attributable to diabetes complications.Conclusions: The significantly higher rates of avoidable hospitalisations in NT Aboriginal people reflect the emerging epidemic of chronic disease in this population, highlight barriers to Aboriginal people accessing effective primary care, and emphasise the extent of potential health gains with appropriate interventions.

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

Objectives: To determine whether teenage pregnancy and Indigenous status are associated with increased risk of adverse pregnancy outcomes.Design, setting and participants: A cross-sectional descriptive analysis of nulliparous women with singleton pregnancies who delivered at the sole tertiary obstetric hospital in Western Australia between June 2004 and September 2006, using data obtained from computerised midwifery records.Main outcome measures: Maternal risk factors, pregnancy characteristics, and obstetric and perinatal outcomes for teenage and adult pregnancies.Results: Of the 4896 births reviewed, 560 (11%) were to teenage mothers. Teenagers were more likely to be Indigenous and to experience maternal risk factors such as anaemia and smoking. Indigenous women were more likely than non-Indigenous women to be smokers, with young Indigenous teenagers (aged 12–16 years) being most likely to smoke (odds ratio [OR], 6.29; 95% CI, 3.99–9.92). Perinatal outcomes for teenage and adult births were similar, while adjustment for smoking and Indigenous status changed the observed association for the Indigenous population of preterm delivery < 37 weeks’ gestation (OR, 1.31; 95% CI, 1.01–1.71), admission to special care nursery (OR, 1.41; 95% CI, 1.10–1.81) and low birthweight (OR, 1.43; 95% CI, 1.10–1.87). However, older teenagers (aged 17–18 years) were the group at highest risk of stillbirth (OR, 1.99; 95% CI, 1.03–3.76).Conclusions: These results improve our understanding of the obstetric and medical issues associated with teenage pregnancy and birth in WA and how we might tailor our approach to care. Indigenous teenagers need special attention, and there is significant scope for public health interventions around anaemia and smoking in this population.

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

The goal of “closing the gap” in life expectancy between Indigenous and non-Indigenous people by 2030 is probably unattainable. Despite our best efforts, it is implausible that, within 21 years, preventive strategies, social or medical, will extinguish all excess expression and risk of chronic disease, the greatest contributor to excess Indigenous deaths. Developing systems to supply optimal primary care, as we currently know it, will take time. In addition, we have an incomplete understanding of the nature of excess risk, and lack remedies to totally contain it. Furthermore, vertical imprinting of excess risk will take some generations to ameliorate. To avoid failure by specifying unattainable goals, emphasis should be given to process measures that will lead to better outcomes. It is self-evident that sustained change requires better education, nutrition, employment opportunities and infrastructure. Within the health system, access to good quality, integrated primary care, needs-based health services funding, and an urgent and intensified focus on areas with the highest mortality rates, are top priorities.

Wendy E Hoy BScMed, MB BS, FRACP

Economic interventions to improve access to healthy food Poor nutrition is a major determinant of excess morbidity and mortality among Aboriginal and Torres Strait Islander peoples,1 contributing to over 16% of the burden of disease.2 In this issue of the Journal (page 549), consistent with the “economics of food choice” theory,3 Brimblecombe and O’Dea report that the diet of a remote Aboriginal community was high in energy-dense, nutrient-poor foods — the cheapest options to satisfy hunger.4 This energy–cost differential restricts access to healthy food, and helps explain the persistently poor dietary patterns and deplorable health status of remote Indigenous communities.4 Placing nutrition issues in an economic framework highlights the investment required to improve Indigenous nutrition.4 But what has been learned to date about where resources should be directed? Despite the high costs and limited availability of healthy foods in remote community stores, surprising achievements have been made in some areas. Community dietary patterns were found to respond directly to improved stock management and food supply,5,6 and multistrategy, community-directed nutrition programs in some remote communities resulted in marked and sustained improvements in anthropometrical, biochemical and haematological risk factors for chronic disease.7,8 Knowledge gained from such studies has broadened the focus of Indigenous nutrition initiatives to include the “supply side” (improving food quality and access to healthy food in remote communities) as well as the “demand side” (promoting nutrition through behaviour change). In 2003, the FoodNorth study provided a comprehensive analysis of remote food supply issues, barriers and leverage points for improvement.9 More recently, the Remote Indigenous Stores and Takeaways Project developed nine practical resources, including a freight-improvement toolkit and a buyer’s guide, to assist remote stores to stock, promote and monitor the sale of healthy food.10 A major barrier is that community stores are seen as small businesses rather than as essential services, like health and education. Encouragingly, several submissions to the recent House of Representatives Inquiry into community stores in remote Indigenous communities detail specific approaches to secure both health and viable business outcomes.11 Remote store groups that combine buying power and operational efficiency (eg, the Arnhem Land Progress Association and the Retail Stores group in Queensland) have shown the benefits of store nutrition policies.9 Outback Stores, a company established by Indigenous Business Australia in 2006, included provision of nutritious food as a key goal, and provides one potential model to support sustainable employment and economic development in independent remote stores.12 The National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000–2010 provided a broad framework for nutrition interventions, addressing both supply and demand issues.13 However, implementation of the strategy has neither been sustainably nor well resourced and remains fractured and opportunistic. Therefore, what is still urgently required is systematic, widespread, sustained implementation of evidence-based nutrition interventions. Brimblecombe and O’Dea now rightly highlight the need to also include innovative economic interventions.4 In Northern Territory communities, it has been estimated that up to 36% of the family income is needed to purchase food,14 which is at least double the proportion required by non-Indigenous Australians.15 One of the proposed “Close the Gap” equity targets was that, by 2018, 90% of Indigenous families could access a healthy food basket for under 25% of their income.16 However, nutrition issues were not included in the final National Indigenous Reform Agreement of the Council of Australian Governments. Globally, the dominant economic intervention affecting food pricing is national taxation on food to raise general revenue.17,18 In Australia, the basic foods required to maintain health were mostly exempted from the Goods and Services Tax (GST), and the price of these foods was expected to fall after the introduction of the new tax system in 2000.19 However, in Queensland from 2000 to 2001, the price of a basket of healthy foods increased by 12%, more than twice that of less healthy options.20 This highlights the unpredictability of complex economic systems and the need for rigorous testing of economic solutions to increase access to healthy food.18 Such testing is imperative within remote communities, but baseline data are not readily available as Australia lacks a comprehensive food and nutrition monitoring and surveillance system. It is also crucial that economic interventions support broader models of sustainable development in remote communities. Potential economic instruments include greater differential national taxation on energy-dense, nutrient-poor food (the “fat tax”), and subsidisation of healthy food through freight, in-store pricing and/or direct commodity subvention systems. There is a case for combining both approaches17 to better influence diet among lower socioeconomic groups18 and within relatively closed systems, such as schools and workplaces.17 The provision of free fruit in such settings has also produced sustained benefits in some countries.21 Improving remote area housing to include infrastructure for storage and preparation of food is also vital; in one study, this was serviceable in less than 6% of houses.22 Local food production, including that of traditional foods, may hold promise in some areas. Training and employment of Indigenous nutrition workers23 to deliver services, including budgeting programs like Indigenous FOODcents,24 are also required. Welfare reform and income management programs have great potential in some areas. However, in communities where incomes are quarantined and welfare recipients are required to spend a significant proportion of their income on food and other essentials, good public policy dictates that governments must also ensure that a healthy food supply is actually available and affordable in those communities. For the most vulnerable, food supplementation programs,25,26 if desired and controlled by the community, are warranted. The value of such assistance is greatly increased where food costs are high, and can immediately improve recipients’ dietary quality.19 Within a multistrategy approach, economic interventions tailored to community needs will assist low-income Indigenous Australians in remote communities to obtain the food they need for good health. “Best buys” of such an approach are listed in the Box. Solutions must involve sectors beyond health, including food producers, transporters and retailers, educators, economists and policymakers. “Best buys” to improve Indigenous nutrition and health 1. Continue and expand the reach of successful interventions Increase demand for healthy food Brief nutrition interventions and early interventions in primary care, including “well persons” health checks and follow-up action Prenatal, antenatal and postnatal nutrition programs; culturally appropriate infant growth assessment and action programs; and promoting breastfeeding and appropriate introduction of solid foods27 School-based nutrition-promotion projects, and community food-literacy and budgeting projects Improve supply of healthy food Use of resources developed by the Remote Indigenous Stores and Takeaways Project10 to improve store management practices, and transport and stocking of healthy food Local food gardens and traditional food procurement projects Increase capacity to achieve the interventions given above Train and employ an Indigenous nutrition workforce Improve housing, including food-storage, preparation and cooking facilities Develop a national, coordinated monitoring and surveillance system for food and nutrition 2. Trial economic interventions for widespread roll-out, if successful Food supplementation for women, infants and children Free fruit and vegetables for remote schools and other settings Freight subsidies for getting basic healthy foods to remote areas In-store price “mark-up” of less healthy items, and lower price margins on healthier foods Expansion of the current national differential taxation system to further favour competitive retail pricing of healthy foods

Amanda J Lee PhD, BSc(Nutr), GradDipDiet · Dympna Leonard MPH, BSc(Diet) · Aletia A Moloney MCommNutr · Deanne L Minniecon MHSc(HealthProm)

Objective: To explore the relationship between dietary quality and energy density of foods (MJ/kg) and energy cost ($/MJ) for an Aboriginal population living in a remote region of northern Australia.Design: For a 3-month period in 2005, we collected food and non-alcoholic beverage supply data from food outlets available to the study population. From these data, we compared the energy density of foods with their energy cost.Main outcome measures: Energy density and energy cost of food purchases.Results: The diet of the study population was high in refined carbohydrates and low in fresh fruit and vegetables. Foods with high energy density were associated with lower costs and contributed disproportionately to energy availability.Conclusion: The energy–cost differential between energy-dense, nutrient-poor foods and energy-dilute, nutrient-rich foods influences the capacity of Australian Aboriginal people living in remote communities to attain a healthy diet. This is consistent with the “economics of food choice” theory, whereby people on low incomes maximise energy availability per dollar in their food purchasing patterns, and has particular relevance for developing nutrition policy and strategies in Aboriginal communities, where poor nutrition is a major determinant of preventable chronic disease.

Julie K Brimblecombe PhD, MPH, GradDipNut · Kerin O’Dea AO, BSc, PhD

Objective: To evaluate the extent to which the current Pharmaceutical Benefits Scheme (PBS) guidelines for patient eligibility for lipid-lowering medication are applicable to Aboriginal people in Central Australia.Design, setting and participants: A 10-year cohort study of 659 Aboriginal people who participated in population-based cardiovascular disease (CVD) risk factor surveys in 1995 and who were free of CVD at baseline, for the period from 1995 to 2004–2005 or until first CVD event. Evidence of atherosclerotic CVD (ischaemic heart disease, ischaemic stroke, and peripheral vascular disease) was sought from hospital, primary health care and death records. PBS eligibility was assigned according to the current PBS criteria, which were amended in 2006 to include Aboriginal-specific criteria, using participants’ baseline (1995) and 10-year follow-up data.Main outcome measures: Proportions of PBS-eligible and PBS-ineligible participants who had CVD events during the study period; sensitivity and specificity of the criteria.Results: Of 42 participants who had CVD events during the study period, 35 were PBS-eligible (incidence, 1130/100 000 person-years; relative risk compared with PBS-ineligible population, 4.87 [95% CI, 2.19–10.80]) and seven were PBS-ineligible. PBS eligibility was associated with older mean age (37 v 32 years) and male sex (48% v 37%), with 50.7% of participants (334/659) meeting eligibility criteria. The mean high-density lipoprotein cholesterol level at baseline was very low in both groups (0.81 v 0.87 mmol/L). The current PBS guidelines have low specificity (52%) in this population, which was found to improve (to 71%–82%) by incorporating additional non-lipid criteria (age and multiple non-lipid risk factors).Conclusion: The current PBS lipid treatment criteria, which include any Aboriginal person with diabetes and less stringent cholesterol thresholds than the previous version, identify a group at very high risk of CVD. Global risk assessment may better identify those at risk.

Joanne N Luke BSc, MPH · Alex Brown BMed, MPH, FCSANZ · David N O’Neal MB BS, FRACP, PhD · Kerin O’Dea AO, BSc, PhD · Alicia J Jenkins MB BS, MD, FRACP · Margaret Kelaher BSc(Hons), PhD · James D Best MB BS, MD, FRACP · Kevin G Rowley BAppSci, GradDipEpi, PhD