Indigenous health

Objective: To describe diagnoses and correlates of middle ear disease in Aboriginal primary school children in a targeted school-testing program in Perth, Western Australia.Design and setting: Analysis of records of ear testing carried out over a 6-year period in three primary schools in Perth.Participants: Aboriginal children of primary school age (4–12 years) who attended the schools on the day of testing. Data on middle ear disease and hearing impairment were available for 119 and 94 children, respectively, from their first test.Main outcome measures: Proportions of children with middle ear disease and hearing loss.Results: Middle ear disease was diagnosed in 50 children (42.0%; 95% CI, 33.0%–51.4%). Rates were lower in older children (P = 0.002) but did not differ according to season of testing. Hearing loss (mild or moderate) was detected in 18 children (19.1%; 95% CI, 11.8%–28.6%). Hearing impairment was also less prevalent in older children (P = 0.007) and had no association with season of testing.Conclusions: Middle ear disease is a significant problem for Aboriginal children in Perth, and is associated with mild–moderate hearing loss. Health authorities must continue to focus on appropriate identification and management of the disease in this population.

Corinne J Williams BAppSci(Speech and Hearing), BA(AS)(Hons), PhD · Harvey L Coates AO, MS, FRACS · Elaine M Pascoe BSc(Hons), MBiostats · Yvonne Axford · Irene Nannup

In 1994, only 12 Indigenous people attended the mainstream general practice in Inala, south-western Brisbane, Queensland. An Indigenous community focus group and telephone interviews revealed deficits such as: few items (eg, artwork) that Indigenous people could identify with; lack of Indigenous staff; staff perceived as unfriendly; inflexibility regarding time; and intolerance of Indigenous children’s behaviour. Access to the Inala Indigenous Health Service by Indigenous people improved when these issues were addressed, and has grown significantly every year from 1995 to 2008. Other important factors in improving access include: energetic Indigenous leadership; enabling bulk billing to increase funding; moving to a stand-alone clinic; and engaging with teaching, research and community programs. A Centre of Excellence in Indigenous Primary Health Care is envisaged as the next innovation required to improve access and quality of service, and to close the gap between Indigenous and non-Indigenous health outcomes.

Noel E Hayman MB BS, FAFPHM, FRACGP · Nola E White RN · Geoffrey K Spurling MB BS, DTM

To the Editor: The Australian Medical Council (AMC) now includes Indigenous health in its accreditation standards for medical schools,1 with guidelines stating that medical curricula must contain the “. . . appropriate use of educational expertise, including the educational expertise of Indigenous people, in the development and management of the medical course [emphasis added]”.1 These AMC requirements arose from the Indigenous Health Curriculum Framework, which was endorsed by the Committee of Deans of Australian Medical Schools.2 The second encounter of the Indigenous Simulated Patient Program at the University of Melbourne In the second encounter, the “patient” is concerned both about the conflicting information they have been given concerning diabetes and the need to attend multiple clinics. The “patient” attempts to explain that family and work obligations mean they cannot wait in outpatient clinics all day. The students in this session are encouraged to work with the “patient” to problem solve the issues that arise. The “patient” has been instructed to provide realistic reasons why these solutions will not work for them, highlighting possible differences in family responsibilities and living arrangements for some Indigenous community members, and demonstrating the conflicting priorities and expectations between the “patient” and the medical system. The University of Melbourne School of Medicine developed the Indigenous Simulated Patient Program in 2002 as one element of an integrated Indigenous health curriculum. The Program meets some of the goals of the framework by acknowledging and incorporating the educational expertise of Indigenous people, exposing students to Indigenous peoples’ lived experiences and world views, and by linking the simulated patient experience with other teaching content regarding the many ways in which history has affected Indigenous health. Indigenous simulated patients are used both early and late in the medical course. The early patient scenario is used within an uncomplicated communication skills tutorial, in which students practise their developing patient-interviewing skills and discover that the “patient” is Indigenous. The later scenario is more complicated (Box) and builds upon the first experience. In both scenarios, students are encouraged to ask the Indigenous patient, both in and out of character, questions about their personal experiences. The aim is to use the Indigenous Simulated Patient Program to help students understand that they will encounter Indigenous patients in their clinical studies and as junior doctors, and that these patients will have both the same and different issues from non-Indigenous patients. Solutions need to be tailored to meet the individual needs of the patient, and should include lessons from previous teaching within the curriculum — for example, the role of Aboriginal health workers in hospitals. The impact on Indigenous community members who participate in the program has been strongly affirming, with one actor commenting, “Today I felt like I really contributed to the training of medical students in issues that were important to me and my community”. Students also rate the experience very highly.3

Shaun C Ewen · Margo E Collins · Jennifer A Schwarz · Eleanor M Flynn

To the Editor: I read with interest the article by Andreasyan and Hoy,1 in which lower Aboriginal mortality rates were found in “very remote areas” compared with “remote areas” in the Northern Territory. In a previous article,2 I reported a similar finding from national data, based on information published by the Public Health Information Development Unit at the University of Adelaide.3 Thirty years ago, in this Journal, Morice outlined the health benefits that accrue for Aboriginal people moving away from larger settlements to live in smaller, decentralised communities where they can care for their country.4 There is an increasing literature to demonstrate that Aboriginal people living in smaller communities have better health than those living in larger settlements and regional towns. These findings have policy relevance, but they appear to be ignored by policymakers. The current Australian Government is continuing previous policies that do not support decentralised communities, but rather encourage their residents to move to larger communities or regional centres, where mortality is higher. These policies appear to be heavily influenced by allegations based on narrow economic arguments that the lack of “jobs” in small remote communities is a reason for them to be closed down.5 A minister in the previous federal government derided smaller remote communities as “cultural museums”.6 It is disturbing to note that a recent major Australian Government policy announcement stated that funding for the next 6 years . . . will support improvements to the delivery of services across 26 remote locations across the Northern Territory, Western Australia, Queensland, New South Wales and South Australia. These locations represent some of the largest concentrations of Indigenous Australians in remote Australia.7 Apparently, over 1100 smaller communities will not receive new funding. This is likely to accelerate the drift from small communities to larger settlements and towns, increasing exposure to health risks. Evidence from the Journal and elsewhere suggests that this drift will increase Aboriginal mortality. The current Australian Government has made a commitment to “close the gap” between Aboriginal and non-Aboriginal life expectancies. The Prime Minister has also stated that his government’s policies will be based on evidence.8 Yet current policies ignore the evidence for the health benefits that accrue to Aboriginal people living in small decentralised communities. These policies also ignore the known health risks associated with larger settlements. Consequently, such policies may widen rather than close the gap.

David J Scrimgeour

To the Editor: The recent article by Parker1 presents an interesting case for the establishment of a national academic college of Aboriginal and Torres Strait Islander health. The notion has been considered within Aboriginal health policy forums in the past, and the federal parliamentary Inquiry into Indigenous Health2 noted that an exploration of the merits of creating a new medical specialty for health care providers to Aboriginal and Torres Strait Islander peoples was arguably favourable. On the other hand, the concept has not gained significant support from some existing medical colleges. Broadly, the arguments supporting a college of Aboriginal and Torres Strait Islander health are that the subject is a national health priority,3 the subject has its own specialised literature, practice within an Aboriginal cultural framework is a specialised activity,4 technical aspects of health care delivery often require specialist knowledge,5 and providers of health care for Aboriginal and Torres Strait Islander peoples often act as consultants for other practitioners and policy development.6 The contrary view is that Aboriginal and Torres Strait Islander health is a health science sub-discipline within general practice, and that existing structures satisfy training needs. In terms of academic education in relation to the health of Indigenous Australians, Aboriginal community-controlled health organisations have had substantial experience and success over the past 25 years — primarily in the provision of accredited Aboriginal and Torres Strait Islander health worker training, but also in undergraduate and postgraduate training in medicine, nursing and allied health. Aboriginal representative bodies such as the National Aboriginal Community Controlled Health Organisation (NACCHO) and its Affiliates are already the arbiters of standards, benchmarks, codes of ethics, policies and protocols that define health care delivery to Indigenous Australians. With appropriate additional resourcing, it would be feasible to build on such existing expertise and infrastructure to develop a national Aboriginal and Torres Strait Islander health college. Ultimately, consistent with international principles of self-determination, Aboriginal community-controlled health organisations, NACCHO and Torres Strait Islander authorities should determine whether or not to progress the processes required for establishing an Aboriginal and Torres Strait Islander health college. They should also, as a corollary, determine the structure, function and membership of such a college, if it were to be developed.

John Daniels · Sophie Couzos

To the Editor: Compared with non-Indigenous Australians, Indigenous Australians are more likely to smoke, drink at risky levels and use illicit drugs.1 These alcohol and other drug (AOD) use patterns contribute to or exacerbate a wide range of health conditions and are significant contributors to premature death and morbidity among Indigenous Australians.2 Some attention has been paid to the efficacy of Indigenous-specific AOD programs,3 but there has been little investigation into the capacity of mainstream AOD services to respond to the needs of Indigenous Australians. To address this deficiency, we conducted a national postal survey of workers employed in agencies listed in the 2001 clients of treatment service agencies (COTSA) database. A total of 1345 workers employed in 369 agencies responded (a response rate of 38%). Most respondents (86%) indicated that their agency provided services to Indigenous clients, and that there was either strong (53%) or some (38%) need for such services. However, almost two-thirds (64%) felt that Indigenous clients’ needs were only partially met, and 9% reported that such needs were not met at all. Private sector workers were significantly less likely to report that their agency provided services to Indigenous clients than workers in government agencies and non-government organisations (NGOs) (χ2 = 102.4; effect df = 3; respondents = 1335; P < 0.001). NGO workers were significantly more likely to report a strong need for the provision of AOD services to Indigenous Australians than government and private agency workers (χ2 = 22.2; effect df = 6; respondents = 1110; P < 0.001). Workers in remote locations were significantly more likely to report a strong need for AOD services for Indigenous Australians than workers in other locations (χ2 = 24.9; effect df = 8; respondents = 1108; P = 0.002). Nearly two-thirds of all respondents reported they had no (18%) or limited (44%) access to AOD resources designed specifically for Indigenous Australians. NGO and private agency workers were significantly more likely than government workers to report limited or no access to resources designed to meet the needs of Indigenous Australians (χ2 = 17.8; effect df = 6; respondents = 1168; P < 0.001). These findings indicate a clear need to improve the capacity of mainstream AOD treatment agencies, especially those servicing remote areas, to respond to the needs of Indigenous Australians. Until improvements are made, AOD problems will continue to erode the health and wellbeing of Indigenous Australians, with predictable outcomes in relation to injury, mental health, parenting and contact with the criminal justice system. As recently highlighted by Indigenous spokesperson Mick Dodson,4 initiatives, beyond support for Indigenous workers and communities, are required to improve mainstream services for Indigenous clients in a culturally sensitive and appropriate manner.

Ann M Roche · Kenneth J Pidd · Vinita Duraisingam

To the Editor: Silva and colleagues examined the effects of swimming pools on antibiotic use and clinic attendance for infections in two Aboriginal communities in Western Australia from 1998 to 2005.1 They concluded that swimming pools led to large decreases in clinic attendances for skin infections, respiratory tract infections, and antibiotic use. The huge health and social disadvantage suffered by Indigenous children is well documented, and any interventions that demonstrate health gains should be recognised. This study highlighted important issues and the results suggested some positive outcomes. However, two weaknesses of the study deserve comment — the lack of a control community without a pool, and the selective use of baseline years. In the absence of a control community (without a pool), these results could reflect documented secular trends in Aboriginal child health overall. For example, there was a 48% overall decline in hospitalisations for childhood pneumonia in four jurisdictions, including WA, between 1998 and 2005.2 This is not significantly different from the 52% reduction reported by Silva and colleagues. Second, the selective use of baseline years potentially obscures more modest results. The authors use 1998–1999 data for the figure (Box 3) and 1999–2000 as the baseline in the main results table (Box 4). The use of the second time period (1999–2000) gives more favourable results than if the previous year had been used. By interpolation, using the first period as baseline would reduce the effect size from 68% to 35% reduction for skin infections in one community (Jigalong). In the second community, rates of skin infections were actually increasing after 2002. Swimming pools in remote Aboriginal communities appear to have many benefits, including increased showering, school attendance and enjoyment among children. We believe that this study has not demonstrated a health impact of swimming pools in these communities that is different from trends elsewhere. That said, swimming pools are a “public good” that should be available to all Australian children, especially those living in very hot places where there are few alternative recreational opportunities. Arguments about direct health benefits should not be a requirement for one group of disadvantaged Australians when we do not feel we need to make the same arguments for other Australian children.

Yvette Roe · Robyn A McDermott

Planning the next steps in an Indigenous-led journey Tom Calma, 19 Aug 2008, Victorian Government and Opposition signing of the Statement of Intent. Courtesy: Lara McKinley, Oxfam Australia. When Prime Minister Kevin Rudd made his much anticipated formal Apology to Indigenous Australians in early 2008, he described it as a first step [towards] a future where we harness the determination of all Australians, Indigenous and non-Indigenous, to close the gap that lies between us in life expectancy, educational achievement and economic opportunity. Every journey requires preparation before the first step can be taken, and this one was no exception. In his 2005 Social Justice Report, the Aboriginal and Torres Strait Islander Social Justice Commissioner, Tom Calma, highlighted the huge gap in health and life expectancy between Aboriginal and Torres Strait Islander peoples and the rest of the Australian population, and issued an inspiring challenge for closure of the gap within 25 years. By early 2007, “Close the Gap” had become a national campaign supported by more than 40 Indigenous and non-Indigenous organisations and many thousands of individual Australians, and at the end of the same year the Council of Australian Governments promised that all Australian states would work with (and fund) Indigenous communities to address this issue. Soon after Rudd’s Apology, the government signed a Statement of Intent with peak Indigenous health bodies to work together to achieve equality in health status and life expectancy, and established the National Indigenous Health Equality Council. In the past year, targets have been set and considerable funding allocated for ongoing Close the Gap initiatives. The journey has indeed begun! Scattered throughout this special MJA Indigenous Health issue are brief contributions from some of the key organisations in the Close the Gap campaign (Social justice, Psychology, National Indigenous Health Equality Council, Dentistry, Aboriginal community controlled health services, Oxfam Australia, Nursing, Australian Indigenous Doctors’ Association). We asked each of them to outline one or two things that will make the most difference in the short term to the longer-term goal of closing the gap. Ranging from personal, through practical to political, their responses share a common thread: the importance of true partnerships with Aboriginal and Torres Strait Islander peoples at every step along the way. Closing the gap began as an Indigenous-led movement, but it has now inspired Australians at every level and become the foundation for unprecedented political focus on our nation’s biggest challenge. Many of the contributors of these short pieces are telling us that they know what to do next to keep us on track to reach our final destination. Partnerships with and continued leadership by Aboriginal and Torres Strait Islander peoples will be key to the journey’s success.

Ruth Armstrong

We need a stronger focus on the social determinants of health Since 2006, Australia’s peak Indigenous and non-Indigenous health bodies, non-government organisations and human rights organisations have worked together on the Close the Gap campaign for Aboriginal and Torres Strait Islander health equality by 2030. The key elements of their approach are: A comprehensive national plan of action that is properly resourced and that has the goal of closing the health and life expectancy gap between Indigenous and non-Indigenous Australians within a generation. This is vital to ensure that governments work towards Indigenous health equality in a coordinated fashion (including the many reform processes currently underway), and that none of the determinants of Indigenous health inequality are missed. A partnership for Indigenous health equality between government and Indigenous peoples and their representatives. Within the national plan, a targeted approach to achieving Indigenous health equality, focusing on a wide range of health conditions and health determinants. The campaign partners have developed a comprehensive set of Close the Gap National Indigenous Health Equality Targets (http://www.humanrights.gov.au/social_justice/health/targets) to guide this target-setting process. These were presented to the Australian Government in July 2008. Support for Aboriginal community-controlled health services. The good news is that Australian governments have already committed to this approach through: Bipartisan support for the Close the Gap Statement of Intent, signed by the Prime Minister in March 2008 (see: http://humanrights.gov.au/social_justice/health/statement_intent.html) — this alone represents a historic turning point in the approach to Indigenous affairs in this country; and Commitments by the Council of Australian Governments, where Australian governments have committed to closing the life expectancy gap within a generation, halving the mortality gap between Aboriginal and Torres Strait Islander and non-Indigenous children under 5 years of age, and the provision of record levels of new funding to support this. However, despite substantial investments in Indigenous health as a result of the campaign, progress has been slow in turning the commitments around planning and partnership into action, and there needs to be a stronger focus on the social determinants of health rather than simply a health sector response. This remains the challenge of the campaign partners over 2009–2010.

Tom Calma

Addressing psychological distress is key The enormous disparities in social and emotional wellbeing and mental health outcomes, and an apparent worsening of the circumstances of many Indigenous communities, were two of the major reasons that prompted Indigenous psychologists from all over the country to form the Australian Indigenous Psychologists Association (AIPA) in 2008, under the auspices of the Australian Psychological Society. AIPA has the dual aims of increasing the number of Indigenous psychologists and addressing the widening gap in social and emotional wellbeing and mental health outcomes for Indigenous peoples. The National Aboriginal and Torres Strait Islander Health Survey 2004–05 showed that just over one-quarter (27%) of Indigenous adults reported high or very high levels of psychological distress. This proportion was similar to that in New York City 8 months after the attack on the World Trade Center. Regardless of the causes, people who find themselves psychologically overwhelmed or struggling to cope suffer high levels of psychological distress. Such distress is a clear global indicator of poor social and emotional wellbeing among Indigenous Australians, and needs to be addressed early to prevent an increasing burden of mental illness among Indigenous peoples. The integration of culturally appropriate social and emotional wellbeing and primary mental health care services into Aboriginal community-controlled health care settings is essential in addressing the high levels of psychological distress among Aboriginal and Torres Strait Islander peoples. There is evidence that Indigenous peoples do not have universal access to these services, which should be available to all Indigenous populations in urban, regional or remote Australia. Preventing psychological distress is likely to result in a range of beneficial health as well as mental health outcomes for Aboriginal and Torres Strait Islander peoples, and could make a major contribution to closing the gap in life expectancy between Indigenous and other Australians.

Patricia Dudgeon

Guiding policy to end Indigenous health disadvantage The National Indigenous Health Equality Council (NIHEC; http://www.nihec.gov.au/) was established in July 2008 to advise the Australian Government Minister for Health and Ageing. Most of its members are Indigenous Australians, with expertise drawn from across the Aboriginal and mainstream health sectors and Australian Government. The Council’s terms of reference focus on: Its role in the development and monitoring of progress towards a set of health-related goals and targets to support the government’s commitments to Indigenous life expectancy and child mortality. Providing national leadership in responding to the government’s commitment to closing the gap of Indigenous disadvantage by advising the government on working towards the provision of equitable and sustainable health outcomes for Indigenous Australians. Providing strategic advice on: the commitments made under the March 2008 Statement of Intent on achieving Indigenous health equality; the development and monitoring of health-related goals and targets to support the government’s commitments to life expectancy and child mortality; priorities for Aboriginal and Torres Strait Islander health, including strategies for meeting targets agreed upon by the Australian Government and the Council of Australian Governments (COAG); monitoring progress towards closing the gap of Indigenous disadvantage; and any specific matters referred to it by the government and the Australian Health Ministers’ Advisory Council. As a first priority, NIHEC was asked to make recommendations on workforce development and sustainability, including advice on pathways to increase Indigenous workforce representation. Recent NIHEC initiatives include projects to: Map workforce development initiatives (the “Helicopter Project”); Articulate the parameters of a forward-looking workforce agenda in Indigenous health (the “Visions/Futures” Project); and Develop a national instrument for Aboriginal and Torres Strait Islander health goals and targets. NIHEC has also agreed to provide strategic advice supporting the implementation of COAG’s 2008 $1.5 billion investment in Indigenous health.

Ian Anderson

Enhancement of public dental services will improve dental care to the most disadvantaged Aboriginal and Torres Strait Islander peoples have higher levels of dental disease, including more untreated tooth decay and gum disease, than other Australians. Those who do receive treatment have fewer preventive appointments and many more extractions. The impact on general health of dental disease is significant. When inadequately treated, dental diseases can result in higher rates of malnutrition, low birthweight, preterm births and cardiovascular disease. Many Indigenous Australians have insufficient teeth to eat nourishing foods. To close the gap in oral health for Indigenous Australians requires: fluoridation of community water supplies; more Indigenous dentists, dental therapists and dental hygienists; coherent oral health promotion strategies and an Indigenous oral health dataset; and high-quality, comprehensive and culturally appropriate oral health care services organised and coordinated on a regional basis. These goals require federal government resources and coordination. The proposal of the National Health and Hospitals Reform Commission to provide Medicare funding for dentistry will not help close the gap. Schemes based upon universal access, such as Medicare, do not serve disadvantaged groups well. Pharmaceutical Benefits Scheme data, highlighted by the Close the Gap campaign, show per-capita spending on Indigenous health to be half that of spending on non-Indigenous health, despite an incidence of ill health three to four times higher for Indigenous Australians. Medicare-funded dentistry will primarily benefit the better-off in Australian society, and Indigenous Australians will be, in relative terms, further disadvantaged. To provide dental care to the most disadvantaged, current government spending of $1.5 billion on dentistry must be used to build up public dental services. Funds made available by ending the Medicare Enhanced Primary Care dental program, the Medicare Teen Dental Plan, and the private health insurance rebate would, along with existing resources, enable the reinvigoration of public dentistry. Indigenous Australians could then access the culturally appropriate, comprehensive, high-quality care that ought to be a hallmark of public dentistry.

Christopher J Bourke

Aboriginal and Torres Strait Islander peoples have a right to full participation in decisions affecting their health During 2008, the Council of Australian Governments (COAG) made several large-scale funding commitments to close the gap in life expectancy between Aboriginal and non-Aboriginal peoples, and to improve Indigenous child health. These commitments represent a significant first step, but the funding package was devised without the full and active involvement of Aboriginal and Torres Strait Islander peoples — the process failed to comply with the Close the gap statement of intent, which commits all partners to ensuring “the full participation of Aboriginal and Torres Strait Islander peoples and their representative bodies in all aspects of addressing their health needs”. The challenge now is to turn the COAG proposals into programs that will work for the Aboriginal community, particularly for those who are most disadvantaged. To this end, committing to the partnership forums established over the past 10 years between Aboriginal community controlled health services (ACCHSs) and state, territory and Australian Government health departments will be critical. At the national level, ensuring the effectiveness and appropriateness of federal programs is difficult, given there has never been a formal partnership between the Australian Government and the Aboriginal community on health matters. A national framework agreement between the Department of Health and Ageing and the National Aboriginal Community Controlled Health Organisation (NACCHO) will ensure Aboriginal and Torres Strait Islander peoples are in control of their health. NACCHO represents over 145 ACCHSs across Australia, which provide the vast bulk of comprehensive primary health care to Aboriginal peoples. Making sure the programs that result from the COAG commitments are in large part realised through the ACCHSs is critical to closing the gap in Aboriginal disadvantage. A national framework agreement between NACCHO and government will ensure Aboriginal and Torres Strait Islander peoples have the right to full participation in health service design, delivery, monitoring and evaluation. Such an agreement will set the stage for improvements in four key areas: joint planning processes to allow for full participation in decision making and priority setting; transparent and regular reporting; improved service delivery through greater cooperation among key players, and more efficient coordination; and better understanding among key players of one another’s roles and responsibilities. Every inquiry over the past 30 years has confirmed that ACCHSs are the most effective means to close the gap.

Mick Adams

Indigenous health groups know what to do to be effective The Close the Gap campaign has been a major success. With around 1400 community events across the country on three annual National Close the Gap Days, and the gathering of more than 130 000 signatures demanding action from the Australian Government, Oxfam Australia has seen the breadth of support from Australians everywhere. By signing the Close the Gap pledge, signatories have called on the government to develop a comprehensive National Action Plan with Aboriginal and Torres Strait Islander peoples and their representative bodies, increase Indigenous community participation and control in the delivery of health services, and address the critical social issues of housing, education and self-determination. As well as engaging the public, the Close the Gap coalition of more than 40 Indigenous, health and human rights groups has engaged the government. The Council of Australian Governments is holding a special Close the Gap meeting later this year and has earmarked an extra $4.6 billion to close the gap in life expectancy, education and employment, including $1.6 billion for Indigenous health. In March last year, the federal government also signed a pact (the Statement of Intent) with leading Indigenous health groups, showing its intent to create a national action plan in partnership with peak Indigenous health groups. However, after more than a year, we are still waiting for the national plan and the partnership to eventuate. Peak Indigenous health groups have created a comprehensive list of targets they would like to achieve in a plan and are inviting the government to engage with them, as was promised. These Indigenous health groups — such as the National Aboriginal Community Controlled Health Organisation and the Australian Indigenous Doctors’ Association — know what to do to be effective. For instance, the Victorian Aboriginal Health Service in Melbourne has immunisation rates that show an average of 91% of their child patients are fully immunised, compared with rates of less than 50% for Aboriginal children across Victoria. We are asking the government to rethink their relationship with Indigenous Australians, involve them in decision making that affects their lives and work together in partnership to create a national action plan to close the gap.

Andrew Hewett

It’s about change, and we must start with our own attitudes The Close the Gap campaign has brought public focus to the appalling health outcomes of many Aboriginal and Torres Strait Islander peoples. The initiative is welcomed by the Congress of Aboriginal and Torres Strait Islander Nurses (CATSIN) for its collaborative and inclusive approach, and for the determination (so far) with which its goals are being pursued. However, the potential of many Close the Gap programs, both pilots and those already underway, is being curtailed by some campaign shortcomings, perhaps the most obvious arising from stereotypes of Indigenous peoples that persist among health workers. The list of achievements is long. Swimming pools in remote communities improve kids’ health, school attendance and participation. For example, the pool at Yuendumu, built only after years of hard work by the community and a hefty contribution of money raised locally, shows what can be achieved irrespective of the level of government assistance. The provision of local peritoneal dialysis services means people do not have to leave their communities for extended periods to have haemodialysis. Diabetes mellitus is being prevented in some people by regular testing, early intervention and applying effective public health principles. Possibly the most damaging oversight relating to the campaign is the failure by each health professional to critically analyse his or her own personal and professional attitudes and set of norms. For instance: at the “front end” of rheumatic heart disease and hearing loss are runny noses, sore throats and ears, and skin damage, including scabies and impetigo. The long-term consequences of these “simple” childhood illnesses must be considered, and all cases must be recognised and treated by health professionals. Health professionals and the community alike have normalised the snotty-nosed Aboriginal child with open sores on arms and legs. This stereotypical view of Aboriginal children somehow allows obvious illness to go untreated. There is a further dimension to stereotyping “Aboriginal health and welfare”. What we would not tolerate in the non-Aboriginal and Torres Strait Islander kid, we tolerate as normal in the Aboriginal and Torres Strait Islander kid! We have even used unwell children as subjects in health promotion literature. There are glossy photos in current Close the Gap literature showing children with snotty noses and open wounds on top of old scars on limbs. Have those children been treated? Why was it okay to take the photo without first wiping the toddler’s nose? Because of our attitudes and stereotypes, these conditions are untreated and unnoticed. Further, we perpetuate stereotypes in bold colour photos without a second thought. Perhaps reflection on how our own attitudes influence practice is a starting place. The only way to achieve different outcomes is to practise differently. We must start with our own attitudes.

Robyn Coulthard

Education, role models, cultural safety and mutual respect can go a long way I would describe myself as an Aboriginal man who loves being a doctor. I love working one-on-one with my patients and feel a sense of satisfaction in the knowledge that, in my own small way, the work that I do contributes towards closing the gap between Indigenous and non-Indigenous health outcomes. It was a long journey to get to where I am today. I was always interested in becoming a doctor, but I thought that it was only for “rich people” or “doctors’ kids” — not someone like me. After completing my Year 10 certificate, I became an apprentice fitter machinist in a coal mine. My dreams of becoming a doctor might have ended there had I not seen Dr Louis Peachey and Dr Sandra Eades, the first Indigenous medical graduates from the University of Newcastle, interviewed on The Ray Martin Show. On that fateful day in the 1990s, Louis and Sandra’s confidence, determination and passion made me realise that I could do it too. My story, and those of other Aboriginal and Torres Strait Islander doctors like me, illustrates the importance of education, good role models and cultural safety — all the things that the Australian Indigenous Doctors’ Association continues to advocate. Today, our organisation is proud to boast of the 130 Aboriginal and Torres Strait Islander doctors and a further 130 medical students around the country. These are pleasing figures, but there is still much work to do to raise them to reach parity with the proportion of doctors per head of population. “Close the Gap” is not a mere slogan. The opportunity to contribute towards growing the next generation of Indigenous doctors is the reason I took up my current post as Associate Professor of Indigenous Health at the University of Newcastle. One of the things that I try to convey to students is the importance of an all-of-system response. In other words, we’re all in this together — it’s not just up to Indigenous people to make a difference; everyone in the health system needs to contribute to close the gap. Another important aspect is two-way respect. When health professionals go to communities, it is expected that they show respect, but it is also reasonable that community members show them respect too. I think that’s a fair starting block upon which to build relationships.

Peter O’Mara

Crime, Aboriginality and the decolonisation of justice. Harry Blagg. Sydney: Hawkins Press, 2008 (232 pp). ISBN 978 187606 719 9. Widely published, Harry Blagg is one of Australia’s eminent researchers on criminal justice in Aboriginal communities. His Crime, Aboriginality and the decolonisation of justice is both confronting and thought provoking. Every page had me thinking that people who work in the health sector should read this book. There are such parallels. While Blagg does not specifically write about health, I became more and more aware of the dynamic interaction between justice and health — ill health and crime. Blagg demonstrates a profound failure in the systems of justice in Australia for Aboriginal people, and this systemic failure is also applicable to health. There is much to learn. For example, much of the money in the justice system is spent at the rear end, within corrections, where funding is often channelled into preventive measures — prevention attended to too late. When Blagg writes about prison as a source of pain but not shame, with terms of reference that are different from those prescribed by white society, he is illustrating a great tragedy. He says prison becomes a place for acquiring some of the bounties of white society: food, medical services, education, meeting classificatory kin, conducting family business, taking a break and drying out. He acknowledges the cost to Aboriginal families and communities. However, Blagg does not point out that prison has another, deeply disturbing outcome. It is where extreme violence is learnt, and where sexually violent behaviours can be transferred back into communities. Blagg refutes allegations that Aboriginal customary laws condone violence against women and children, pointing to the wealth of research to the contrary. He suggests these laws contain considerable potential for renewal and healing. The book, while easy to read if you know the subject, will confront some readers and cause them to think more deeply about the “decolonisation” of justice. Hopefully, some readers might choose to also think more deeply about the deconstruction of the medical system, so that the development of hybrid initiatives of health and wellbeing might also be possible. At $49.95, the cost is a little more than I would have anticipated for a book of just over 200 pages. Nonetheless, it is good value for money. It has me thinking of links between law and health and the need to explore rather than ignore liminal spaces between Aboriginal notions of ceremony as forms of transition, including syncretic changes in status relationships between social domains — social domains that construct justice and health, or crime and ill health.

Judy Atkinson

Holding men. Kanyirninpa and the health of Aboriginal men. Brian F McCoy. Canberra: Aboriginal Studies Press, 2008 (xviii + 278 pp). ISBN 978 0 85575 658 1. The health of Aboriginal men is a critical issue in the discourse on Aboriginal affairs and policy. The important issues here, though, the author suggests, are not merely the biomedical aspects of health. They are the relational, social and cultural contexts and constructs of Aboriginal men’s health. The cultural process of “nurture” or “Kanyirninpa” (holding) is part of such a construct. Brian McCoy brings an interesting perspective as he is a Jesuit priest and an academic researcher, and has been everything from a footy coach to an Aboriginal Deaths in Custody research officer. He has spent most of the past 40 years working and living with Aboriginal people, particularly in the Western Desert where much of this book was researched. The author addresses one of the salient issues missing in the discussion on the poor health of Aboriginal men: an approach that acknowledges the relevance of culture and accurately reflects the current health status of Aboriginal men within a broader social sphere. He begins with a relatively dry academic style that becomes quite poignant as the nature of his research is developed. He locates his personal frame of reference, builds on his own relationships with Aboriginal people, then examines the past and recent, relevant history of the Western Desert. From there the book delves deeper, into the nature of Aboriginal male relationships and how these have been affected and what the impact has been, in terms of broad health and social and emotional wellbeing. For those of us who work with Aboriginal people, this is an important book, and for those who don’t, and want to have a deeper intellectual understanding of Aboriginal issues, it’s a good read.

Mark Wenitong

My story. Aboriginal and Torres Strait Islander women sharing their experiences of breast cancer. A resource for health workers. Val Alberts, Project Coordinator. Sydney: National Breast and Ovarian Cancer Centre, 2008 (DVD and booklet). Cancer has not been a high priority on the Indigenous health agenda in Australia, despite being a major cause of death. Disparities in cancer mortality between Indigenous Australians and other Australians are not the result of a higher incidence of cancer among Indigenous people overall, but exist for reasons such as lower participation in screening; delayed presentation with symptoms; and poorer uptake of treatment. There have been few resources specifically for Indigenous people with cancer, so this 14-minute DVD, My story. Aboriginal and Torres Strait Islander women sharing their experiences of breast cancer, is a welcome contribution. Six Indigenous women talk about how they came to be diagnosed with breast cancer and their subsequent journeys through treatment. The stories are engaging and rich in important health messages — Indigenous people do get cancer; Indigenous women should participate in mammography screening; don’t ignore symptoms; early diagnosis is important for cure; involving family members helps them know what you’re going through; one cancer doesn’t mean you won’t get another; it’s normal to be scared; breast prostheses help you feel and look better. To reinforce the importance of early diagnosis, the women point to their own survival — they wouldn’t be alive to tell their story unless treated early. The presentation also touches on issues of family history. Several scenarios mention the role that men can play in helping women with breast cancer — encouraging them to seek health care for symptoms, attending medical appointments to provide support, and helping children and other family members to understand. Produced by James Cook University, the DVD has a Far North Queensland feel, with scenes of palm trees and beaches. It has an authenticity and positivity that contribute to it being a valuable health promotion and educational resource for Indigenous people. At the same time, its messages are universal, and the DVD will have broad appeal, especially among the nation’s many breast cancer support groups. An accompanying booklet means people are not reliant on having a DVD player to acquaint, or re-acquaint, themselves with the stories of the women. Here’s hoping for more such endeavours to cover a wider range of cancers, and to convey cancer messages and education for Indigenous men.

Sandra C Thompson

Objective: To estimate the incidence and survival rates of acute myocardial infarction (AMI) for Northern Territory Indigenous and non-Indigenous populations.Design and participants: Retrospective cohort study for all new AMI cases recorded in hospital inpatient data or registered as an ischaemic heart disease (IHD) death between 1992 and 2004.Main outcome measures: Population-based incidence and survival rates by age, sex, Indigenous status, remoteness of residence and year of diagnosis.Results: Over the 13-year study period, the incidence of AMI increased 60% in the NT Indigenous population (incidence rate ratio [IRR], 1.04; 95% CI, 1.02–1.06), but decreased 20% in the non-Indigenous population (IRR, 0.98; 95% CI, 0.97–1.00). Over the same period, there was an improvement in all-cases survival (ie, survival with and without hospital admission) for the NT Indigenous population due to a reduction in deaths both pre-hospital and after hospital admission (death rates reduced by 56% and 50%, respectively). The non-Indigenous all-cases death rate was reduced by 29% as a consequence of improved survival after hospital admission; there was no significant change in pre-hospital survival in this population. Important factors that affected outcome in all people after AMI were sex (better survival for women), age (survival declined with increasing age), remoteness (worse outcomes for non-Indigenous residents of remote areas), year of diagnosis and Indigenous status (hazard ratio, 1.44; 95% CI, 1.21–1.70).Conclusions: Our results show that the increasing IHD mortality in the NT Indigenous population is a consequence of a rise in AMI incidence, while at the same time there has been some improvement in Indigenous AMI survival rates. The simultaneous decrease in IHD mortality in NT non-Indigenous people was a result of reduced AMI incidence and improved survival after AMI in those admitted to hospital. Our results inform population-specific strategies for a systemwide response to AMI management.

Jiqiong You MSc, MBA, MB · John R Condon MPH, PhD, FAFPHM · Yuejen Zhao MB BSc, MBiostats, PhD · Steven Guthridge MB BS, MTH, FAFPHM

Objective: To describe the natural history and risk of early chronic kidney disease (CKD) in Indigenous Australian populations.Design, setting and participants: A prospective cohort of 2266 Aboriginal and non-Aboriginal children enrolled from primary schools throughout New South Wales from February 2002 to June 2004 and followed for 4 years.Main outcome measures: Urinalysis, height, weight, blood pressure, birthweight and sociodemographic status at baseline and 2- and 4-year follow-up; CKD risk factors: haematuria, albuminuria, obesity, and systolic and diastolic hypertension.Results: 2266 children (55% Aboriginal; 51% male; mean age, 8.9 years [SD, 2.0 years]) were enrolled at baseline. 1432 children (63%) were retested at 2-year follow-up, and 1506 children (67%) at 4-year follow-up. Prevalence of baseline CKD risk factors was frequent (2%–7%), but most abnormalities were transient. Besides persistent obesity (5.0%), persistence of CKD risk factors at final follow-up was low: haematuria (1.9%), albuminuria (2.4%), systolic hypertension (1.5%) and diastolic hypertension (0.2%). There was no difference in prevalence of persistent CKD risk factors between Aboriginal and non-Aboriginal children.Conclusions: Over 4 years of follow-up, Indigenous Australian children had no increased risk for early evidence of CKD. More than 70% of baseline risk factors were transient, and persistent risk factors were uncommon. Our findings suggest the increased risk for end-stage kidney disease seen in Indigenous adults is not yet manifest in these schoolchildren, and may be potentially preventable.

Leigh Haysom MB BS, MClinEpi, FRACP · Rita Williams BA · Elisabeth M Hodson MB BS, FRACP · Pamela A Lopez-Vargas BN, BSc, BHSc(TCM) · Leslie P Roy MB BS, MD, FRACP · David M Lyle MB BS, PhD, FAFPHM · Jonathan C Craig MB BS, PhD, FRACP

Objective: To quantify Indigenous mortality in the Northern Territory by remoteness of residence.Design, setting and participants: Australian Bureau of Statistics mortality data were used to compare rates of death from chronic disease in the NT Indigenous population with rates in the general Australian population over the period 1998–2003. Rates were evaluated by categories of remoteness based on the Accessibility/Remoteness Index of Australia: outer regional areas (ORAs), remote areas (RAs) and very remote areas (VRAs).Main outcome measures: Mortality from cardiovascular disease, diabetes and renal disease; standardised mortality ratios (SMRs); percentage change in annual death rates; changes in mortality between 1998–2000 and 2001–2003.Results: In 1998–2000, SMRs for all-cause mortality were 285% in ORAs, 875% in RAs and 214% in VRAs. In 2001–2003, corresponding SMRs were 325%, 731% and 208%. For the period 1998–2003, percentage changes in annual all-cause mortality were 4.4% (95% CI, –2.2%, 11.5%) in ORAs, –5.3% (95% CI, –9.6%, –0.8%) in RAs, and 1.1% (95% CI, –7.2%, 11.3%) in VRAs. In 2001–2003, compared with 1998–2000, changes in the number of Indigenous deaths were +35 in ORAs, –37 in RAs and +32 in VRAs. Similar patterns were observed for cardiovascular mortality.Conclusions: Compared with mortality in the general Australian population, Indigenous mortality was up to nine times higher in RAs, three times higher in ORAs and two times higher in VRAs. The fact that rates were lowest in VRAs runs contrary to claims that increasing remoteness is associated with poorer health status. Despite the high death rate in RAs, there was a downward trend in mortality in RAs over the study period. This was partly attributable to a fall in the absolute number of deaths.

Karen Andreasyan DMD, MPH · Wendy E Hoy BSc, MB BS, FRACP

The effects of cannabis use on health and social adjustment are profound Substance misuse by Indigenous people has long been recognised as one of the devastating consequences of contact with Western culture. Misuse of tobacco, alcohol and petrol among Indigenous Australians has received much attention. Cannabis, by contrast, has not been viewed as a major problem. But since the 1990s, it has become apparent that heavy cannabis use is common in some remote Indigenous communities.1 The associated health and social burdens are now being recognised.1,2 Indigenous Australians, whether living in urban or rural settings, are more likely than other Australians to report cannabis use.3 Recent reports suggest that cannabis use is also relatively high among Indigenous populations in New Zealand, Canada and North America.4 Limited data are available on patterns of cannabis use among Indigenous Australians.3 However, a recent 5-year study of adolescents and young adults in three remote communities in Arnhem Land in the Northern Territory has found that not only is cannabis use common in remote Indigenous settings, but its effects on health and social adjustment are profound.4-6 These three communities are close to one another but very isolated, being over 550 kilometres from the nearest city. There is one local Indigenous language, and English is a secondary language. Tobacco use was found to be the norm in these communities, with over 90% of adolescents and young adults smoking.7 Because of restricted access to alcohol, problem drinking was uncommon.7 In contrast, cannabis use was endemic, with over 70% of males and 20% of females being current users.5 Cannabis was typically consumed mixed with tobacco and smoked using a locally fashioned “bucket bong” that gives the user a rapid and intense dose with little smoke lost.5 Regular heavy use (≥ 6 “cones” daily) was found in almost 90% of users.7 This is around twice the consumption of regular cannabis users elsewhere in Australia.1 Furthermore, about 90% of the Indigenous users reported symptoms of cannabis dependence.1 This compares with about 20% of users aged 18 or over in the general Australian population.3 Of even greater concern was a suggestion that, for most Indigenous users, cannabis was not a passing adolescent phase. After 5 years of follow-up, the great majority reported continuing heavy use.4 Cannabis use was linked to substantial health problems and social burdens in these communities, which are already disadvantaged by isolation and poverty.2,5,8 Up to 10% of the communities’ total income and between 31% and 62% of a user’s median weekly income was spent on cannabis.5 Cannabis users were less likely than non-users to participate in education or training5 and more likely to report auditory hallucinations, suicidal ideation,6 symptoms of depression,7 and having been imprisoned.6 Community violence increased when cannabis supplies were scarce.1,2 The effects on traditional life were described by one NT Indigenous mental health clinician in the following way: Too many of my people are chained to [cannabis]. They don’t go out hunting or spend time by the river with their family. They just sit and smoke [cannabis], then look for money to buy more [cannabis] and get into fights when they can’t get any (Muriel Jaragba, personal communication). What accounts for the unusual patterns of cannabis misuse in these remote Indigenous communities? There is little evidence that cannabis is grown locally,9 but much anecdotal evidence that market networks supplied by dealers based in urban or regional centres are extensive and resilient, making cannabis readily available (A R C, unpublished observation). Alcohol restrictions have been effective in reducing problem drinking within communities, but may have had the undesirable consequence of encouraging an increase in cannabis use where it could be easily obtained.5 As with risks for other forms of substance misuse in these communities, the social context is important. Limited employment and education opportunities; crowded, poor-quality housing; community-wide feelings of disempowerment; and grief and loss related to high mortality, morbidity and incarceration rates are all likely risk factors for substance misuse. Cannabis misuse is likely to be both a consequence of this type of social disadvantage and a perpetuating influence. Cannabis misuse in remote Indigenous communities has been overlooked for too long. It is now clear that it is yet another major problem for these already disadvantaged communities, with evidence of cannabis misuse across a broad area of northern Australia.1,2,9 As well as in the NT, concerns about the level of cannabis use have recently been noted in Cape York8 and anecdotally in other parts of remote and regional Australia. Further research is needed to investigate the impact of cannabis use on urban Aboriginal and Torres Strait Islander Australians. Effective responses will not be easy. Controls on supply by state- or territory-based police are one of the few available measures.6 In order to be effective, policymakers and service providers would need to work collaboratively with local communities to tie in local prevention and treatment initiatives with existing supply control initiatives. Such programs would need to use Indigenous language and cultural frameworks, build capacity of local Indigenous professionals, and improve understanding of the harms associated with cannabis misuse.10 Ultimately, tackling the misuse of cannabis and other substances in remote settings will depend on creating opportunities for social development and for continuing education, training and employment of adolescents and young adults.

K S Kylie Lee BMus(Hons) · Katherine M Conigrave FAFPHM, FAChAM, PhD · George C Patton MD, FRANZCP · Alan R Clough PhD

Closing the gap in life expectancy between Indigenous and non-Indigenous Australians needs to start in the womb. Rates of perinatal mortality, preterm birth and low birthweight are two to three times greater among the babies of Indigenous women than among those of non-Indigenous women; low birthweight predisposes infants to greater risks of chronic illness in later life. Indigenous women in Australia tend to present for antenatal care later in pregnancy than do non-Indigenous women. There are many barriers for Indigenous women seeking to access antenatal care — geographical, social, cultural, financial and in some cases a lack of service provision. Many of these problems are being addressed within the public health system and by Indigenous community-controlled health services. However, more needs to be done. While antenatal care cannot solve all medical and social problems, commencing such care as early as possible in pregnancy has the potential to improve maternal health and hence pregnancy outcomes. Changes in the way the government Baby Bonus is paid to new mothers could act as an incentive not only to service providers but also to women themselves to initiate antenatal care in the first trimester of pregnancy. Such a system has been well established for many years in France. Any changes to the Baby Bonus scheme should provide incentives and not be punitive in nature.

Caroline M de Costa FRANZCOG, FRCOG, MPH · Mark Wenitong BMed

To the Editor: A causal connection between alcoholic mothers and developmental delays and physical abnormalities in their babies was identified in the 1970s and termed fetal alcohol syndrome (FAS). Other less extreme but still disabling effects fall under the umbrella term of fetal alcohol spectrum disorder (FASD).1 Some studies have found higher prevalences of FAS among indigenous children in several countries, including Australia.2-4 However, none are as high as those cited in a webcast video program produced by the Rural Health Education Foundation and accredited by (and examinable for professional development points awarded by) the Royal Australian College of General Practitioners, Australian College of Rural and Remote Medicine, Pharmaceutical Society of Australia, Royal College of Nursing Australia, and the Australian Physiotherapy Association.5 In this program, an Indigenous Australian health worker states that 540 out of 614 children aged under 12 in an (unnamed) Indigenous community are “already showing signs of primary and secondary disabilities associated with FAS and FASD”.5 These findings are not sourced and therefore not verifiable. We believe that unsubstantiated claims such as this can fuel racism against Indigenous children. Research conducted within a Queensland Aboriginal community school found that teachers were using information such as that provided in the video program to explain students’ poor school performances, when no formal diagnoses of FASD had been made for the children.6 It is racially discriminatory to impute a lifelong and incurable disability to Indigenous children when no teratogenic condition has been diagnosed. The prevalence of FAS and FASD has not been comprehensively established in Indigenous or non-Indigenous communities in Australia. There are other reasons why Indigenous students might not be succeeding in school, such as hearing impairments, being taught in Standard English (which is not their first language), or being assessed with culturally and linguistically biased school and IQ tests.6,7 Stigmatising them as intellectually impaired can lead to low self-esteem, behavioural problems, and absences from school. These outcomes have been noted here and overseas,7 yet some educationalists persist in blaming prenatal factors (including “bad genes”) rather than addressing the more difficult issues of systemic racism in the educational setting. In light of the federal government’s campaign to protect Indigenous children and to encourage their educational potential, as well as its general attack on binge drinking, it is essential to fund programs that address FAS and FASD in both Indigenous and non-Indigenous communities. Further, all governments need to support the dissemination of clear and substantiated information on this preventable cause of intellectual impairment.

Loretta R de Plevitz · Judith S Gould · Terrina M Smith