Indigenous health

In reply: The Rural Health Education Foundation is sorry that a statement on its live-to-air, interactive program was interpreted as being racist. We can see how this has occurred and have added an addendum to the program’s website description to avoid any future misinterpretation of what the presenter was intending to communicate.1 The research on fetal alcohol spectrum disorder (FASD) quoted in the Foundation’s program by an Australian Aboriginal health worker is currently unpublished, and was undertaken in 2000 during a fieldwork placement as a requirement for a Master of Applied Epidemiology (Indigenous Health).2 This research identified that 540 out of 614 children aged under 12 in an (unnamed) Indigenous community had prenatal exposure to alcohol that exceeded the National Health and Medical Research Council (NHMRC) recommendations on alcohol consumption during pregnancy,3 and were subsequently at risk of primary and secondary disabilities associated with fetal alcohol syndrome (FAS) and FASD. During the program’s live discussion, the panel member incorrectly stated that the research cohort was already showing signs of primary and secondary disability related to FAS and FASD. Two individual projects within the Masters research contributed to the findings. The first, examining the risks of maternal alcohol use for child physical and psychological development, involved retrospective, longitudinal analysis of a data subset from an existing study over a 5-year period of 8556 women who received antenatal care, with subsequent follow-up of the mothers and their children when the children were 5 years old. The second was a descriptive study involving all women in the (unnamed) Indigenous community who gave birth within a 5-year period immediately before the research. Medical record audit and focus groups (talking circles) were conducted. This research is currently being expanded in the context of PhD studies, and the candidate intends to submit the new findings for publication in the near future. The video program content was developed in consultation with a group of health professionals with expertise in the area of Australian Indigenous health and FASD. At all times, the Rural Health Education Foundation seeks to provide positive examples of “what works” in its location-based filmed case studies. The Foundation and its representatives in no way meant to infer racism or discriminate against this (or any other) group of Indigenous Australians.

Brian D Bowring · Amanda Little

Aboriginal primary health care. An evidence-based approach. 3rd ed. Sophia Couzos, Richard Murray. Melbourne: Oxford University Press, 2007 (i + 862 pp). ISBN 978 0 19 555138 9. Let me tell you a secret. I admired this book for a long time before I actually read it. Like Dickens and Dostoyevsky, it’s a great achievement, and I knew I should read it, but the sheer size put me off. Fortunately, it’s worthy of the trust I had invested in it. The authors, all experts in their fields, have done an incredible job of collating the evidence behind their recommendations. Just as important is the backing of the National Aboriginal Community Controlled Health Organisation (NACCHO). To close the gap in health outcomes, Aboriginal communities must be able to make decisions for themselves. NACCHO’s involvement means these guidelines don’t start off as outside impositions. It’s a dry read at times. The most memorable parts are quotations from other authors. The chapters start with quotes from Puggy Hunter — if you read only these, you will understand more of Aboriginal health than when you started. The opening chapters are essential reading for linking together history, policy and health (or if you want to argue with someone who believes Aboriginal health is overfunded). The heart of the book devotes chapters to important clinical topics. Each chapter sets out the goals to be achieved, goes through interventions on individual, service and community levels, and supplies performance indicators as measures of how well you are doing. Most practices would find useful ideas here, whatever their population. This book should be used alongside good-quality clinical guidelines for more practical detail for individual patients. The references will direct you to the appropriate places, although a bibliography would have been more helpful. In some instances the evidence has moved on since publication, but in many remote clinics a book is still the best way to access information. This one is more than good enough to work from.

Timothy P M Senior

For Indigenous Australians, the “health of country” is inextricably linked with human health The impacts of climate change on human health are now being documented in Australia.1 Not surprisingly, these impacts are unequally distributed across our society, as vulnerability depends on a number of factors, including the degree of exposure, sensitivity and adaptive capacity. However, intranational heterogeneity of climate impacts on health has not been adequately documented to date.2 Using this lens, the vulnerability of Australia’s Indigenous people living in remote areas of the country is revealed. Their vulnerability to climate change is intensified by the social and economic disadvantage they already experience — the result of factors that include decades of inadequate housing and public services, and culturally inappropriate medical services. In addition, specific cultural ties between Indigenous people’s wellbeing and the “health” of their “country” create significant indirect impacts of climate change.3,4 We argue that it is vital to acknowledge the significance of this situation now, so that anticipatory adaptive policies can be implemented. Such policies should ensure that adequate resources are provided to mitigate some of the worst impacts of climate change on these communities, in a way that encourages community participation in decision making. We now know that, across northern Australia, climate change is expected to bring hotter day- and night-time temperatures.5 Elevated temperatures and increases in hot spells are expected to be a major problem for Indigenous health in remote areas, where cardiovascular and respiratory disease are more prevalent and there are many elderly people with inadequate facilities to cope with the increased heat stress. However, while the literature is not clear on the exact effects of increasing heat on people and communities, it does imply that these effects are likely to be less in regions where people are already acclimatised to hot conditions. Communicable diseases such as bacterial diarrhoea, which are more common in hot, dry conditions, may increase in incidence unless additional preventive action is taken. One study predicted that a 1.0–3.5oC increase in average temperature by the year 2050 would lead to an estimated 5%–18% increase in diarrhoea cases in Alice Springs.6 Dengue fever, spread by mosquitoes, also presents a climate-related risk to Indigenous communities. Although the virus is not currently endemic in Australia, there are sporadic epidemics, with occasional cycles over winter in the local mosquito populations in northern Queensland.7 The conceptual divide between Indigenous and non-Indigenous Australians about perceptions of “health” also needs to be recognised and accommodated.8 The Indigenous concept of health is broad and multifaceted, reflecting a different world view to that of the Western biomedical model. For many Indigenous people, a connection with “country” — a place of ancestry, identity, language, livelihood and community — is a key determinant of health.9 If community-owned country becomes “sick” through environmental degradation, climate impacts, or inability of the traditional owners to fulfil cultural obligations through ongoing management and habitation of their land, the people of that land will feel this “sickness” themselves. That is, the elements contributing to Indigenous health and wellbeing are often abstract and based on social interactions with people and the non-human landscape. Thus, as ecosystems change in response to biophysical impacts and extreme weather events, many traditional owners living in remote areas are likely to face increased physiological, psychological, economic and spiritual stress as it becomes more difficult to “look after their country”. At both international and national levels, there is some recognition of the specific needs of indigenous people in relation to the impact of climate change. The World Health Organization’s Commission on Social Determinants of Health and the United Nations Permanent Forum on Indigenous Issues have recently acknowledged the importance of tackling climate change, particularly with respect to health, for the world’s 350 million indigenous people. In Australia, the Garnaut Climate Change Review has recognised the importance of some non-quantifiable costs, including the specific intangible costs associated with improving Indigenous health.10 A challenge for medical practitioners dealing with this issue in the Australian context will be to look beyond the limitations of traditional epidemiology and scientific reductionism to embrace a more ecologically focused, social-determinants approach to health.11 This approach would enable the “health of country” and its inextricable links with human health to be considered in climate impact assessments. To address these different paradigms of health, the first step is to begin discussions with Indigenous people to prioritise activities. This process will certainly require a significant increase in the capacity of medical professionals and health systems in northern Australia, as well as increased education and training programs for Indigenous trainees and cross-cultural programs for nurses and local Indigenous support staff. Changes also need to be made in teaching practice across Australia. Currently, Indigenous health still occupies a peripheral place in many medical school curricula, with government funding and research disproportionally supporting high-cost, acute-care medicine at the expense of preventive and primary health care. In tandem with well planned, properly resourced programs that support strong livelihood activities in remote communities, there is the potential to begin to reduce the additional risk for many Indigenous communities from climate change. There are multiple co-benefits of this approach that would raise social and economic indicators. Ignoring the warning signs and failing to take action is no longer an option.

Donna Green PhD · Ursula King FACRRM, MPH · Joe Morrison MA

Objective: To investigate National Health and Medical Research Council (NHMRC) support over the decade to 2006 for researchers studying Indigenous health and researchers who self-identified as Indigenous.Design and setting: Review of data on all recipients of People Support awards and Capacity Building Grants in Population Health Research who were researching Indigenous health or who self-identified as Indigenous between 1996 and 2006.Main outcome measures: Annual People Support and Capacity Building grants and expenditure, by broad research area, state or territory, administering institution, and Indigenous status (as self-identified by award recipients in their applications).Results: Between 1996 and 2006, 134 People Support awards were made to researchers studying Indigenous health; of these, 27 (20%) were to researchers who self-identified as Aboriginal or Torres Strait Islander. In 2006, about 2.9% of the annual expenditure on all People Support funding was for Indigenous health research, representing a doubling in the proportion of funds since 2001. There was no increase in the number of self-identified Indigenous researchers funded under People Support, but Capacity Building Grants increased the number of people from Indigenous backgrounds supported by the NHMRC, with funds allocated to 36 Indigenous researchers from 2002 to 2006, compared with 14 funded by People Support during the same period.Conclusions: Funding to support Indigenous health research through the People Support scheme has increased since the NHMRC adopted policy changes in 2002, but it has not reached the targeted expenditure of at least 5% of agency allocations. The Capacity Building Grants have been a more effective vehicle for funding researchers from Indigenous backgrounds.

Sophia Leon de la Barra BA, MPH, MPhilPH · Sally Redman BA(Hons)(Psych), PhD · Sandra Eades BMed, PhD · Carey Lonsdale BSc, GradDip(Zool), MApplSci

The issue of “equal health” for Aboriginal and Torres Strait Islander peoples involves a broad range of social determinants, in addition to physical health. The formation of an Australian college of Aboriginal and Torres Strait Islander health would allow a continuing authoritative conference of broad expert opinion, including that of Aboriginal health workers, to address health and social inequality.

Robert M Parker BMed, AFACHSE, FRANZCP

To the Editor: Impacts of alcohol consumption on health and wellbeing in remote Indigenous communities are well documented. In response, governments have applied supply and demand reduction programs, including the “Meeting Challenges, Making Choices” program, which has lowered the rate of serious injury. Although a pattern of heavy, episodic drinking has been documented, the nature of physical dependence in relation to acute alcohol withdrawal syndrome is uncertain. We report the results of sudden, temporary removal of alcohol in a small Indigenous community. In a remote Queensland Indigenous community (population, 1021) with one licensed premises, patterns of extreme drinking (30 standard drinks per session) are commonly seen around paydays. In 2008, the Queensland Government withdrew the sole liquor trading licence with 72 hours’ notice because of a breach of licensing laws. The licence was subsequently renewed after several months. During this time, there was no significant access to alternative (illegal) sources of alcohol within the community, as the prohibition against bringing alcohol into the community (initiated in 2003) was strictly enforced by police. Health services in this community comprised a primary health care centre (PHCC) with Queensland Health resident nursing staff, Royal Flying Doctor Service medical staff on weekdays (the principal doctor was S A M), and visiting specialists provided by both organisations, including a psychiatrist (E H). When the closure was being arranged, Queensland Government authorities requested that these health providers establish a process to treat any patients who developed acute alcohol withdrawal syndrome; this was monitored by S A M. Four weeks after the sudden cessation of alcohol availability, PHCC staff did not notice any outmigration of regular drinkers, and no patients presented with acute alcohol withdrawal syndrome. These findings are consistent with the anecdotal experience of E H, who has not encountered any cases of withdrawal delirium in this community over the past 16 years. By contrast, in recent years E H has observed several cases of withdrawal symptoms from cannabis use in this community, as seen previously in remote Northern Territory Indigenous communities.5 Our results suggest that people can develop physiological or psychological tolerance for heavy episodic drinking, which may be a function of adaptation to the intermittent nature of financial resources. This finding removes a potential health-related impediment preventing governments from considering sudden cessation of legal alcohol supply in these or similar environments.

Stephen A Margolis · Valmae A Ypinazar · Alan R Clough · Ernest Hunter

Objective: To estimate the percentage of preterm (< 37 weeks) and full-term low-birthweight (37–41 weeks, < 2500 g) babies born to mothers who smoke, stratified by Indigenous status and statistically adjusted for the potential confounding effects of social and demographic factors, medical conditions and pregnancy complications.Design, setting and participants: Population-based study of singleton babies born to mothers resident in Queensland who gave birth in Queensland from 1 July 2005 to 31 December 2006.Main outcome measures: Adjusted percentages of preterm birth and full-term low birthweight for babies born to Indigenous and non-Indigenous mothers.Results: Of the 79 803 babies studied, 4228 (5.3%) were born to Indigenous mothers and 16 395 (20.5%) were born to mothers who smoked during pregnancy. The percentage of Indigenous mothers who smoked (54%) was almost triple that for non-Indigenous mothers (risk ratio, 2.90; 95% CI, 2.81–2.99). The adjusted outcomes for babies born to Indigenous non-smokers were similar to those for non-Indigenous non-smokers (preterm, 7.1% v 6.1%; full-term low birthweight, 1.6% v 1.1%). The adjusted percentages for smokers were high regardless of Indigenous status (preterm, Indigenous v non-Indigenous, 8.3% v 7.8%; full-term low birthweight, Indigenous v non-Indigenous, 5.3% v 3.7%).Conclusions: Antenatal smoking remains an important cause of poor health among both Indigenous and non-Indigenous newborn babies. Most pregnant smokers receive their antenatal care in the public sector. State and federal governments, who directly fund this sector, have a particular responsibility to ensure that interventions are offered to all pregnant smokers to help them quit smoking.

Rachael-Anne Wills BAppSc(Hons) · Michael D Coory PhD, FAFPHM, AStat

Objectives: To explore the role of socioeconomic status and Aboriginality on birthweight at an urban hospital.Design, participants and setting: Extraction of data on the demographic characteristics (socioeconomic status, mothers’ single-parent status, age and smoking status) and infants’ birthweight from a clinical record system. Infants delivered at an outer urban hospital to mothers residing in the local government area during 2002 were included. Infants were identified and results interpreted in consultation with Indigenous health workers.Main outcome measure: Infant birthweight.Results: Indigenous infants had a lower mean birthweight than non-Indigenous infants (difference, 127 g), and were more likely to weigh < 2500 g. Mothers of Indigenous infants were more likely to be single, aged < 20 years and to smoke during pregnancy. Lower birthweight was associated with lower socioeconomic status for Indigenous and non-Indigenous infants. Indigenous infants in the most socioeconomically disadvantaged quintile in this study were at higher risk and had a mean birthweight 204 g less than non-Indigenous infants in the same quintile. In multivariate analysis, differences in birthweight were associated with socioeconomic status and smoking during pregnancy.Conclusions: For both Indigenous and non-Indigenous infants, birthweights were associated with socioeconomic status. Differences between Indigenous and non-Indigenous infants were largely explained by low socioeconomic status and smoking during pregnancy.

Angela T Titmuss BSci(Med)(Hons), MB BS, MPH · Elizabeth Harris BA, DipSocWork, MPH · Elizabeth J Comino BVSc, MPH, PhD

Objectives: To explore the understanding of both Indigenous and non-Indigenous Australians with end-stage kidney disease (ESKD) about the cause of their disease, and how this understanding could affect patients’ engagement with their treatment.Design, setting and participants: Qualitative study conducted in 2005–2006 in nine hospital renal units and 17 associated dialysis centres in four states and the Northern Territory as part of the IMPAKT (Improving Access to Kidney Transplants) study. In-depth interviews were conducted with 146 Indigenous and 95 non-Indigenous Australians with ESKD, covering personal history of illness, social and psychosocial context, attitudes to treatments including transplantation, adequacy of information and communication, and satisfaction with services.Results: Indigenous Australians were less certain about the cause of their illness and reported feeling uninformed but eager for information. They commonly reported lifestyle factors as potentially causal, with profound confusion about the role of alcohol. Indigenous Australians had considerable ambivalence towards biomedical explanations.Conclusions: Indigenous Australians are confused, frustrated and feel poorly informed about their illness. This study confirms the need to develop shared understandings about chronic kidney disease and to put in place the high-quality and appropriate educational resources that patients need.

Kate Anderson BSc(Psych)(Hons), BA · Jeannie Devitt PhD · Joan Cunningham ScD · Cilla Preece BAppSci(IPHC) · Alan Cass MB BS, FRACP, PhD

Objective: To assess the impact of a long-term comprehensive control program for sexually transmitted infections (STIs) in remote Aboriginal communities in Central Australia, and to investigate a recent rise in gonorrhoea prevalence.Design: STI prevalence was determined from annual, cross-sectional, population-wide, age-based screening, 1996–2006. During 2006, gonococcal isolates were obtained by on-site culture and tested for antimicrobial susceptibility.Setting: Six remote clinics on the Anangu Pitjantjatjara Yankunytjatjara (APY) Lands, South Australia, which are served by Nganampa Health Council, an Aboriginal community-controlled health service.Participants: All resident Aboriginal people aged 14–40 years at the commencement date of each annual population-wide screen.Main outcome measures: Multivariable logistic regression models were used to compare prevalence of chlamydial infection, gonorrhoea and syphilis measured during each annual population-wide screen; antimicrobial susceptibility of gonococcal isolates obtained in 2006.Results: Between 1996 and 2003, there was a significant reduction in prevalence of gonorrhoea and chlamydial infection, by 67% and 58%, respectively. Subsequently, chlamydia prevalence rate plateaued, but there was a rapid rise in prevalence of gonorrhoea. Syphilis prevalence decreased linearly over the study period (odds ratio, 0.81; P < 0.001). During the first 6 months of 2006, 89 gonococcal isolates were obtained, 39 through on-site culture during the 6-week screening period, and all were sensitive to penicillin (in the less-sensitive category).Conclusions: The decrease in STI prevalence asssociated with the program was maintained until 2006 for chlamydial infection and syphilis, but not for gonorrhoea, which rose in prevalence after 2003. There was no change in antimicrobial resistance to explain this rise, and gonorrhoea transmission dynamics and travel of core transmitters to regions without STI control programs might be responsible.

Rae-Lin Huang MB BS(Hons), MPH, FRACGP · Paul J Torzillo MB BS, FRACP, FJFICM · Vivien A Hammond RN, RM, GradDipNursing · Stephanie T Coulter BLabMed · Adrienne C Kirby BSc(Hons), MSc

To the Editor: In the preceding article, we report on a substantial rise in prevalence rates of gonorrhoea in a population in remote Central Australia.1 This rise occurred in the context of a sustained major reduction in sexually transmitted infections (STIs) in the region, achieved by a comprehensive program of STI control, described in the article1 and previously.2 We found that the gonorrhoea outbreak was not due to penicillin resistance of the causative organism, and we hypothesise that it was due to the introduction and dominance of a more infectious clone.3,4 This rise in gonorrhoea in a region widely acknowledged to have the most successful STI control program in the country prompted several commentators to argue that both this program, and screening as a measure for STI control in remote Indigenous communities, had failed, and to advocate a range of other approaches.5 We recently completed the analysis of the 2008 annual population-wide STI screen, which achieved a 78% participation rate among eligible participants. These data strongly suggest that the gonorrhoea outbreak seen over the previous 4 years has been controlled (Box). Furthermore, the current prevalence rates are among the lowest seen in the past decade. These findings suggest that a comprehensive STI control program, such as that delivered by the Nganampa Health Council, can not only reduce STI rates, but also control outbreaks, provided the program is sustained. During most of the past decade, the prevalence of syphilis remained below 1%, of chlamydial infection below 6%, and of screening test-positive gonorrhoea below 8%, as measured during the annual population-wide screens. This program should be replicable in other regions, if appropriate resources and expertise are applied, thus providing an opportunity to improve an important area of Indigenous health using current public health knowledge. Age-adjusted prevalence rates of chlamydial infection, gonorrhoea and syphilis among 14–40-year-olds on the APY Lands, 1996–2008 APY = Anangu Pitjantjatjara Yankunytjatjara.

Rae-Lin Huang · Paul J Torzillo · Adrienne C Kirby

Consensus recommendations for managing bronchiectasis in Indigenous children and adults living in rural and remote regions were developed during a multidisciplinary workshop and were based on available systematic reviews. Successful diagnosis, management and prevention of bronchiectasis in Indigenous Australians requires access to comprehensive health care services, as well as improved housing, education and employment and reduced poverty levels. Diagnosis of bronchiectasis requires a chest high-resolution computed tomography scan. Children who have bronchiectasis symptoms but non-diagnostic scans are described as having chronic suppurative lung disease (CSLD), rather than bronchiectasis. Untreated CSLD may progress to bronchiectasis. Chronic wet cough (> 4 weeks) or recurrent wet cough (> 2 episodes/year) are important but often under-reported symptoms. Bronchiectasis is suspected when chronic cough is excessively prolonged (> 12 weeks) or if a chest radiographic abnormality persists despite appropriate therapy. Intensive treatment aims to improve symptom control and quality of life while preserving lung function and reducing acute exacerbation frequency. Antibiotics should be prescribed for acute infective episodes according to culture results of respiratory secretions, local susceptibility patterns and clinical severity. Patients not responding promptly to oral antibiotics should be hospitalised for more intensive treatment. Ongoing care requires regular primary health care and specialist review, including monitoring for complications and comorbidities. Corticosteroids, bronchodilators and mucoactive agents may be used in individual cases, but routine use is not recommended. Physiotherapy and exercise should be encouraged, nutrition optimised, environmental pollutants (including tobacco smoke) avoided, and immunisations maintained.

Anne B Chang MPHTM, PhD, FRACP · Keith Grimwood MB ChB, FRACP, MD · Graeme Maguire MB BS, FRACP · Paul T King MB BS, FRACP, PhD · Peter S Morris MB BS, FRACP, PhD · Paul J Torzillo MB BS, FRACP

To the Editor: Trachoma, caused by the bacterium Chlamydia trachomatis, is the leading cause of infectious blindness worldwide.1 In Australia, the burden of disease falls almost exclusively on the Aboriginal population.2 However, there has been little consistent data collection on the prevalence of trachoma in recent years in Australia.3,4 Furthermore, despite Australian Government recommendations for biennial screening of people aged 40–54 years and annual screening of people aged ≥ 55 years in areas where trachoma is or has been endemic,5 very little screening of older people for trachomatous trichiasis has been conducted.2,4 We report on the first large-scale population study in 30 years of the current prevalence of active and cicatricial trachoma in the Northern Territory Aboriginal population. We conducted a standardised clinical screening study of five Aboriginal communities in the Katherine Region of the NT over a 5-week period in 2007. A representative sampling frame of those believed to be currently living in each community was constructed using the medical clinic patient list, the council housing list and the local knowledge of Aboriginal Health Workers seconded from the clinics to assist with the project. All people in each community were invited to undergo a clinical eye examination for trachoma. The parameters of the World Health Organization simplified grading scheme6 were used to determine prevalence of the five signs of trachoma: tarsal conjunctival follicles, intense inflammation, tarsal scarring, trichiasis and corneal opacity. A total of 1316 people (85.2% of the total estimated population), including 415 children aged under 10 years, were screened for trachoma. Across the five communities, active trachoma (assessed as the presence of either follicles or inflammation in one or both eyes) was at an endemic level (> 10%). The prevalences of active trachoma, scarring and trichiasis in different age groups are summarised in the Box. The overall rate of active trachoma in children under 10 years of age was 19.8% (95% CI, 16.0%–23.9%) (n = 82), and two communities had hyperendemic prevalence of trachoma (> 20%) in this age group. The youngest child observed with active trachoma was just over 1 year old. The prevalence of scarring in people aged 20 years and over was 32% (95% CI, 28.3%–35.9%) (n = 193). The youngest person identified with scarring was 7 years old. Six people (2.3% of all people aged 40 years and over) were identified with trichiasis requiring urgent ophthalmological attention. Across the population, this placed the prevalence of unoperated trichiasis at more than four times the acceptable threshold set by the WHO. A seventh person had had trichiasis surgery. That trachoma is still hyperendemic in Aboriginal communities more than 30 years after the National Trachoma and Eye Health Program first identified the extent of trachoma is unconscionable. Urgent and sustained public health and clinical interventions are required, with greater commitment from politicians and health policymakers, if Australia is to join the ranks of other developed nations in eradicating endemic trachoma. The guidelines for trachoma control developed by the Communicable Diseases Network Australia5 need to be resourced appropriately and implemented. Prevalence of active trachoma, scarring and trichiasis in five Aboriginal communities in the Northern Territory in 2007, by age group* TFI = active trachoma (follicles [TF] and/or inflammation [TI]). TS = trachomatous scarring. TT = trachomatous trichiasis. * Vertical bars indicate 95% CIs.

Katrina Roper · Claude-Edouard C Michel · Paul M Kelly · Hugh R Taylor

To the Editor: We describe our experience of using community consultative strategies at a family planning clinic in Dubbo, central-west New South Wales, to increase recruitment of Indigenous women to a human papillomavirus (HPV) prevalence study — WHINURS (Women, Human papillomavirus, Indigenous, Non-Indigenous, Urban, Rural Study).1 The strategies also resulted in a sustained increase in the number of Indigenous women attending the clinic for cervical screening. The Family Planning NSW research team committed to recruit 50 Indigenous and 100 non-Indigenous women from January 2006 to WHINURS. The researchers worked collaboratively with, among others, the National Indigenous Immunisation Coordinator of the National Centre for Immunisation Research and Surveillance and the Dubbo Aboriginal Women’s Advisory Group. The study was approved by the Aboriginal Health and Medical Research Council of NSW Ethics Committee. Non-Indigenous women were recruited within a few months but, despite the clinic team’s efforts, only one Indigenous woman was recruited over 12 months. Strategies to increase recruitment were then developed with input from one of us (C J O, a Wiradjuri Health Promotion Officer). Key strategies included street walks with a family planning nurse in Dubbo’s main street, attendance at community forums (including mothers’ groups and playgroups), and provision of drop-in clinics and transport assistance. As a result, an additional 42 Indigenous women aged 18–40 years were recruited between January and April 2007 for HPV and Pap tests. There are many barriers to Indigenous women participating in cervical screening programs.2,3 An added benefit of our recruitment approach was that the number of Indigenous women attending the clinic for Pap tests increased from 29 in 2006 to 81 in 2007, suggesting that the strategies had a sustained effect on cervical screening rates. The involvement of a respected and trusted Wiradjuri woman (C J O), known in the region as an advocate for Indigenous women’s health, appeared critical to the success of the recruitment intervention. The street walks and community visits with family planning nurses were a strategy to ensure that Indigenous women who are “very skilled at observing people and reading the unspoken word” felt safe and comfortable about undergoing the sensitive examination (C J O). The women were able to discuss their fear of finding an abnormality and balance this against their desire to do the right thing by their children by having a health check. Given that the age-standardised mortality rate for cervical cancer from 2001 to 2004 was 4.7 times higher for Indigenous women than for non-Indigenous women,4 we suggest that lessons learned from our study could help facilitate continued participation of Indigenous women in the national cervical screening program.

Christine M Read · Deborah J Bateson · Christine J Ohrin

Objective: To examine trends in invasive pneumococcal disease (IPD) in Indigenous people in north Queensland following the introduction of the 7-valent pneumococcal conjugate vaccine (7vPCV).Design: Trends in IPD were compared over three 3-year periods: before the introduction of 7vPCV for Indigenous children (1999–2001), and two consecutive periods after its introduction (2002–2004 and 2005–2007).Main outcome measures: Incidences of IPD in Indigenous children and adults in 1999–2001 and 2005–2007; trends in IPD caused by 7vPCV and non-7vPCV serotypes; and trends in indirect protective effects and emergence of non-7vPCV serotype IPD.Results: From 1999–2001 to 2005–2007, there was a 60% decline in IPD, with the virtual elimination of 7vPCV serotype IPD in young (< 5 years) Indigenous children. There is no evidence yet of an increase in non-7vPCV serotype IPD in these children. Although the annual incidence of IPD in Indigenous adults remained virtually unchanged, there was a 75% decline in 7vPCV serotype IPD in these adults (χ2trend = 11.65, P < 0.001). However, the incidence of IPD caused by non-7vPCV serotypes more than tripled in adults (χ2trend = 7.58, P = 0.006). Serotype 1 IPD has been prominent over the 9 years, but there is no evidence of a recent increase in serotype 19A IPD.Conclusions: Vaccinating Indigenous children with 7vPCV has protected Indigenous adults in north Queensland through an indirect “herd immunity” effect. However, this benefit has been offset by a recent increase in non-7vPCV IPD in Indigenous adults. Newer pneumococcal conjugate vaccines could prevent, both directly and indirectly, a considerable amount of the persisting IPD in Indigenous people in the region.

Jeffrey N Hanna MPH, FAFPHM · Jan L Humphreys · Denise M Murphy DipMedTech

It’s time for genuine partnerships as all Australians strive together to Close the Gap A year ago in this Journal, Indigenous health leaders outlined the emergent health equality campaign for Aboriginal and Torres Strait Islander peoples,1 now known as the Indigenous Health Campaign or “Close the Gap”. An early indicator of the depth of support for Close the Gap was the large number of health, human rights, advocacy and community organisations that enthusiastically signed up or offered support for the campaign. Since then, the Indigenous Health Campaign coalition, led by Aboriginal and Torres Strait Islander health leaders and the Aboriginal and Torres Strait Islander Social Justice Commissioner, has worked in genuine partnership with non-Indigenous organisations. Key milestones along the Close the Gap campaign journey are shown in the Box. On 20 December 2007, the Council of Australian Governments (COAG; comprising representatives of federal, state and local governments) committed to: close the life expectancy gap within a generation; halve the gap in mortality rates for Indigenous children under five within a decade; and halve the gap in reading, writing and numeracy achievements within a decade in a partnership between all levels of government and with Indigenous communities. They added: The pathway to closing the gap is inextricably linked to economic development and improved education outcomes.5 On 13 February this year, Prime Minister Rudd delivered the Apology to Australia’s Indigenous people, hopefully heralding a new and promising partnership between governments and Indigenous Australians. He stated: We today take this first step by acknowledging the past and laying claim to a future that embraces all Australians. A future where this Parliament resolves that the injustices of the past must never, never happen again. 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. A future where we embrace the possibility of new solutions to enduring problems where old approaches have failed. A future based on mutual respect, mutual resolve and mutual responsibility. A future where all Australians, whatever their origins, are truly equal partners, with equal opportunities and with an equal stake in shaping the next chapter in the history of this great country, Australia.6 The opportunity for every government in this country to seriously tackle the entrenched disparity and unacceptable outcomes in Aboriginal and Torres Strait Islander health, through strong national leadership, should not be missed. It is time for a long-term approach that secures all of our futures — Indigenous and non-Indigenous — together, as a healed and healthy nation. The success of the campaign for Indigenous health equality will be measured by progress towards clearly stated goals within set timeframes. It is unacceptable to continue with the current situation, in which the health outcomes and life chances of an Indigenous child are substantially worse than those of their non-Indigenous peers. As stated in the Aboriginal and Torres Strait Islander Social Justice Commissioner’s 2005 report2 (the initial trigger for the genesis of the Close the Gap campaign), it is simply not defensible for governments and health and human services systems to argue that inadequate infrastructure, bureaucratic mechanisms or persistent complexity are justifiable speed humps to real change. It also does not hold that championing the rights of human beings is contrary to health gain. The outcomes of the National Indigenous Health Equality Summit will be delivered by June 2008 to the Australian Government and COAG. The Summit deliberations will not only provide governments with a set of specific evidence-based targets for action and investment, but affirm the commitment to genuine partnership by signing the Statement of Intent (Box).8 A whole-of-government response across all levels of government is necessary to address the social determinants of health. COAG’s commitment to employment, education, housing and health are strong indicators of such commitment. The time for genuine partnerships is now; that is, partnerships that strengthen us all in mutually respectful and sustaining ways. Medical bodies, including the Royal Australasian College of Physicians, Royal Australian College of General Practitioners, Australian College of Rural and Remote Medicine, Australian General Practice Network and the Australian Medical Association, have been key partners in this campaign. We must not allow “Close the Gap” to become another shallow slogan. It is a glaring reminder of the continuing inequity in health and life outcomes within this wealthy nation of ours. The commitment to act now — to guarantee a future where Indigenous health inequality is a thing of the past — requires concerted, tangible and immediate action. Our call is for current and future medical leaders to show their commitment by doing what they can within their area of influence and expertise. Key milestones along the “Close the Gap” journey

Tamara Mackean BSc (Med), MB BS · Mick Adams BSocWk, MAppSci, PhD · Sally Goold RN, DipNEd, MNSt · Christopher Bourke BDSc, GradDipPublicHealth, GradDipClinDent · Tom Calma

The Prime Minister has issued a formal, unqualified apology to Australia’s Indigenous peoples for past mistreatment, particularly for the sufferings of those who were affected by the forced removal of children from their families. The Apology needs to be seen as the first step in a reparations process that adheres to human rights principles, involves Australians at all levels, is sustainable and upholds self-determination. The Apology is the first of five steps recommended in Bringing them home: the report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from their Families. Further steps are: guarantees against repetition, measures of restitution, measures of rehabilitation, and monetary compensation, but the Prime Minister has steadfastly refused to discuss reparations or compensation. Monetary compensation has been recognised internationally as an essential component in the redress for similar experiences of the forced removal of children. As long as the final steps in reparation remain unresolved, they will obstruct our pathway to a future that embraces all Australians.

Lisa R Jackson Pulver PhD, MPH, GradDIpAppEpi · Sally A Fitzpatrick

Low socioeconomic status and assumptions about Indigenous people may be jeopardising their access to care In this issue of the Journal, the case–control study by Coory et al1 shows that Indigenous people in Queensland are less likely than non-Indigenous people to receive adequate management for lung cancer, even after controlling for geographic location and socioeconomic factors (→ Survival of Indigenous and non-Indigenous Queenslanders after a diagnosis of lung cancer: a matched cohort study). Other studies and reports have also shown that Indigenous people have a lower cancer survival rate and are much less likely to be offered diagnostic and therapeutic procedures,2-6 but the study by Coory et al is the first to show a clear treatment bias for cancer. Why are Aboriginal people less likely than other Australians to receive treatment for lung cancer? Drawing on my experience in Aboriginal health over the past 20 years, I think there are some likely explanations for this finding, most of which Coory et al have considered. Late diagnosis is a key factor leading to poorer treatment outcomes and lower survival rates for Indigenous people.1,5 As Indigenous people do not have the same level of access to primary medical care as non-Indigenous people, early detection of cancer by general practitioners is less likely. In spite of significant additional Australian Government funding provided through the Office for Aboriginal and Torres Strait Islander Health (OATSIH) (an additional $500 million recurrent since 1995), the gap in access to primary medical care resources appears to be still widening, primarily due to worsening access to the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme, which is not compensated for by the OATSIH funding.2,7 The “Close the Gap” campaign recently announced by the federal government is indeed timely.8 Achieving better participation rates in cancer screening programs has also been recognised as an important issue, and systemic changes are needed.2 In the Northern Territory, breast cancer rates are increasing significantly among Aboriginal women, with a 223% increase reported between 1991 and 2001.3 However, for many Aboriginal women, access to mammography services remains poor. For example, the mammography screening service visits Alice Springs three to four times a year for 3 weeks at a time, but often with only a few weeks’ notice. Women who are more organised and literate can read the advertisements in the newspapers and make their own appointments at short notice, but many Aboriginal women do not do this. Health services can try to contact them to let them know, but this is not always effective. It would be possible to redesign the system to give much better access for Indigenous women, and this needs to occur. For example, the service could again be provided from the more culturally secure local Aboriginal women’s health service, Congress Alukura, on a regular planned basis. This would better utilise transport services, Aboriginal liaison officers and the Patient Assisted Travel Scheme (PATS) to improve attendance for Aboriginal women. Coory et al consider the possibility that access to specialist care could be one of the issues involved. Schemes such as PATS9 allow rural and remote residents to have access to specialists in major centres, but I think it is very likely that Indigenous people from rural and remote areas do not receive the same access to care through such schemes as other rural and remote residents. In addition, the gap fees charged by private specialists in all localities present a more significant economic barrier to many Indigenous people, who are therefore much more reliant on the public hospital outpatient system, with its substantial delays. In Alice Springs, for example, men with raised prostate-specific antigen levels have been waiting 6–12 months or longer to see a urologist and have a prostate biopsy in order to be given a definitive diagnosis and treatment for prostate cancer. If patients can afford to pay about $300 to have the procedure done privately, they are sent by PATS to see a urologist in Adelaide, thus avoiding a long waiting period. However, public patients do not have this option. Although steps are now being taken to reduce the barriers that have led to these unfortunate delays, this is occurring as the result of a complaint from the Central Australian Aboriginal Congress in December 2007, rather than in response to an analysis of routine data, which could have revealed the problem much earlier. It is very unlikely that this type of problem is unique to Alice Springs. What we do not know is whether there is a differential waiting time for Indigenous men compared with non-Indigenous men, or whether the system equally disadvantages all men who do not have private health insurance. Is there a systemic bias against Indigenous men that needs to be better understood and addressed? The results from the study by Coory et al add to other evidence suggesting that barriers to care for Indigenous people need to be systematically explored throughout the Australian health system. Whether it is cancer treatment, access to renal transplantation,10 access to prostate biopsies for suspected cancer, or a range of other key endpoints, it seems that the system is not working well for Indigenous people. A final question that was not considered by Coory et al is whether cancer specialists themselves make different decisions about the appropriateness of certain treatment options for Aboriginal people based on their own assumptions about the socioeconomic and cultural circumstances of Indigenous people. I learned this lesson many years ago when two of my Aboriginal patients with rheumatic heart disease and atrial fibrillation died suddenly and unexpectedly in their early forties, from intracardiac clots. These women had been seeing the visiting cardiologist every 6 months and seeing me as often as needed in between. The use of warfarin in such patients was not yet standard practice at the time, but the cardiologist had already been routinely prescribing warfarin for non-Aboriginal people in these situations for about 12 months. He had never suggested warfarin treatment for these women because he assumed that they would not be able to take it safely and that they would have nowhere to store the drug, thus putting children at risk because of the possibility of them accessing and accidentally taking warfarin tablets. This was the late 1980s, and as a GP who was unaware of recent evidence confirming the benefits of warfarin in such patients, I was assuming I would be getting the best practice advice from the visiting cardiologist. It was not until after the women had died that I spoke to him and discovered the assumptions he had made in deciding against warfarin treatment. These types of assumptions may also be being made by specialists about other routine treatments. In the NT, this situation has been improved over recent years through a range of initiatives, including the strengthening of links between key specialists and Aboriginal health services. Many specialists, including cardiologists, now routinely provide services through Aboriginal health services. However, this still needs to occur more widely and to include a broader range of specialists. Given the evidence now available on the differential survival rates for Indigenous people with cancer, it is imperative that better data be routinely collected on the comparative rates of access to specialists and key diagnostic and therapeutic procedures in secondary and tertiary hospitals. State and territory governments could be induced, as part of the Australian Health Care Agreements, to collect more rigorous data in this area. The Australian Health Care Agreements are agreements reached between the Australian Government and the state and territory governments on the health system. They provide a mechanism through which the Australian Government can influence the states and territories, through financial levers, to improve key health system outputs such as equity of access to specialist services and procedures. Key data to be collected would include the comparative times on waiting lists for specialist appointments in public hospitals; the rate of access to key diagnostic procedures; the frequency of giving radiotherapy and chemotherapy for specific cancers (where these treatments are known to be effective); and the rate of surgery performed on patients with cancers amenable to treatment. These types of indicators have been suggested by Aboriginal health services for more than a decade. It is too often assumed that Indigenous people do not wish to travel long distances to access care and be away from their families, or that they have different priorities in life and do not value treatment for illnesses that are likely to be terminal. While poorer compliance or higher refusal rates for treatment may be pertinent factors in some cases, it is important not to assume these types of explanations when there are obvious systemic barriers to accessing care in the current health system. Once these barriers have been addressed, any remaining barriers, if they actually exist, can be explored and dealt with separately.

John D Boffa MB BS, MPH

Objective: To compare survival of Indigenous and non-Indigenous lung cancer patients and to investigate any corresponding differences in stage, treatment and comorbidities.Design and setting: Cohort study of 158 Indigenous and 152 non-Indigenous patients (frequency-matched on age, sex and rurality) diagnosed with lung cancer between 1996 and 2002 and treated in Queensland public hospitals.Main outcome measures: Survival after diagnosis of lung cancer; effects of stage at diagnosis, treatment, comorbidities and histological subtype on lung cancer-specific survival.Results: Survival of Indigenous lung cancer patients was significantly lower than that of non-Indigenous patients (median survival, 4.3 v 10.3 months; hazard ratio, 1.48; 95% CI, 1.14–1.92). Of 158 Indigenous patients, 72 (46%) received active treatment with chemotherapy, radiotherapy or surgery compared with 109 (72%) of the 152 non-Indigenous patients, and this treatment disparity remained after adjusting for histological subtype, stage at diagnosis, and comorbidities (adjusted risk ratio, 0.65; 95% CI, 0.53–0.73). The treatment disparity explained most of the survival deficit: the hazard ratio reduced to 1.10 (95% CI, 0.83–1.44) after inclusion of treatment variables in the proportional hazards survival model. The remaining survival deficit was explained by the higher prevalence of comorbidities among Indigenous cancer patients, mainly diabetes.Conclusion: Survival after a diagnosis of lung cancer is worse for Indigenous patients than for non-Indigenous patients, and differences in treatment between the two groups are mainly responsible.

Michael D Coory FAFPHM, PhD, AStat · Adele C Green MB BS, PhD, FAFPHM · Janelle Stirling MPHC · Patricia C Valery MD, MPH, PhD

Objective: To compare infection-related mortality rates and pathogens isolated for Indigenous and non-Indigenous adult patients at Alice Springs Hospital (ASH).Design, participants and setting: Retrospective study of inhospital deaths of adults (patients aged ≥ 15 years) associated with an infection during a medical or renal admission to ASH between 1 January 2000 and 31 December 2005.Main outcome measures: Admission- and population-based infection-related mortality rates and mortality rate ratios (MRRs) for Indigenous versus non-Indigenous adults.Results: There were 513 deaths, of 351 Indigenous and 162 non-Indigenous patients. For Indigenous patients, 60% of deaths were infection-related, compared with 25% for non-Indigenous patients (P < 0.001). The admission-based infection-related MRR for Indigenous versus non-Indigenous adults was 2.2 (95% CI, 1.6–3.1) (15.3 v 6.8 deaths per 1000 admissions; P < 0.001). After adjusting for age and year of death, the population-based infection-related MRR was 11.3 (95% CI, 8.0–15.8) overall (351 v 35 deaths per 100 000 population; P < 0.001) and 31.5 (95% CI, 16.1–61.8) for patients aged < 60 years. The median age of patients who died with an infection was 49 (interquartile range [IQR], 38–67) years for Indigenous and 73 (IQR, 58–80) years for non-Indigenous patients (P < 0.001). For Indigenous patients, 56% of infection-related deaths were associated with bacterial sepsis, with half of these due to enteric organisms. Other deaths followed chronic hepatitis B infection, invasive fungal infections and complications of strongyloidiasis.Conclusion: Indigenous patients at ASH are 11 times more likely than non-Indigenous patients to die with an infectious disease. This racial disparity reflects the ongoing socioeconomic disadvantage experienced by Indigenous Australians.

Lloyd J Einsiedel PhD, FRACP · Liselle A Fernandes BMedSci(Hon) · Richard J Woodman PhD, MBiostat

Objective: To describe rates of hospitalisation for head injury due to assault among Indigenous and non-Indigenous Australians.Design, setting and participants: Secondary analysis of routinely collected hospital morbidity data for 42 874 inpatients at public and private hospitals in Queensland, Western Australia, South Australia and the Northern Territory for the 6-year period 1 July 1999 – 30 June 2005.Main outcome measures: Rates per 100 000 population of head injury due to assault by Indigenous status, age, sex and location of residence.Results: The overall rate of head injury due to assault was 60.4 per 100 000 population (95% CI, 59.8–60.9). The rate among the Indigenous population was 854.8 per 100 000 (95% CI, 841.0–868.9), 21 times that among the non-Indigenous population (40.7 per 100 000; 95% CI, 40.2–41.2). Most Indigenous (88%) and non-Indigenous (83%) victims of head injury due to assault were aged between 15 and 44 years. The peak incidence among the Indigenous population was in the 30–34-year age group, whereas that among the non-Indigenous population was in the 20–24-year age group. Indigenous females experienced 69 times the injury rate experienced by non-Indigenous females.Conclusions: Indigenous people, particularly women, were disproportionately represented among those hospitalised for head injury due to assault. Head injury imposes a substantial burden of care on individuals and communities. Along with the costs of treating head injury, these are good reasons to strengthen efforts to prevent head injury generally, with special attention to high-risk population segments.

Lisa M Jamieson PhD · James E Harrison MB BS, MPH · Jesia G Berry BHSc(Hons), GDPH

When I first learned about the Dr Ross Ingram Memorial Essay Competition through the Healthy Vibe section of Deadly Vibe magazine, I realised it was an opportunity to publicly discuss an issue of significance to all Australians, Indigenous and non-Indigenous alike. Specifically, the issue is about cardiovascular health, rehabilitation and, more to the point, the levels of participation and non-compliance with treatment of people affected by cardiovascular disease. Like Ross Ingram, the Koori GP after whom the essay competition is named, I have been directly affected by heart disease. As I read about Dr Ingram and how heart disease cut short a dedicated young Indigenous leader’s life, I decided to do something to sound a warning and be a positive influence on others. I tell my story to raise awareness of cardiovascular disease, which is claiming the lives of our brothers, sisters, uncles, aunties and grandparents. I would also like to discuss what actions we can take to help our people, the Indigenous community and ourselves. First I will give some background information about myself. I am 41 years young, of Aboriginal and Australian South Sea Islander descent. At 39 years of age, I experienced an acute myocardial infarction (commonly referred to as a heart attack). I mistook the severe chest pain for heartburn or indigestion, and did not present to a GP until the following morning. On examination it was clear that I was experiencing acute coronary syndrome. Within less than an hour, I was an inpatient in a hospital coronary care unit receiving all the necessary acute care available. Eventually I was diagnosed with cardiovascular disease (ischaemic heart disease). I was told I had a 99% blockage of the left anterior descending coronary artery and that 10% of my heart was damaged irreparably. Surgery was ruled out, as the affected area was “dead” because I had not recognised the symptoms of a heart attack at the time. Had I sought medical assistance earlier, I might have received thrombolytic medication designed to dissolve the blockage. I did not know any of this information — knowledge is power. I was in total shock and denial when told by the attending GP what was happening inside my body. I thought, “This doesn’t happen to youngish people like me — only to older people in their 60s and 70s!” However, on reflection, all the signs were there: I smoked 30–40 cigarettes per day; I used and abused alcohol habitually and heavily; My diet included anything, any time I wanted, regardless of nutritional value; I had not exercised regularly for over 10 years; and Both my parents had experienced cardiovascular health conditions. On reflection, my behaviour seemed as if I was determined to self-destruct. After adjusting to the new reality that I had experienced a heart attack and survived, I realised it was time to make some deadly serious lifestyle improvements as soon as possible. The changes I made included decisions to attend and complete cardiac rehabilitation, to seriously consider therapeutic lifestyle changes and to comply with all prescribed medications and subsequent follow-up appointments. After I was discharged from hospital, I quit smoking immediately (and have not looked back); completed a hospital-based cardiac rehabilitation program; began to exercise regularly (resulting in gradual loss of 20 kg of excess weight); stopped all use of alcohol; and adopted a low-sugar, low-salt and low-fat diet, including avoidance of red meat and experimentation with low-fat, low-calorie, vegetarian alternatives. From my perspective, I have been given a second chance. I tell people (anyone who will listen) that surviving a cardiac event can present opportunities to make quality-of-life improvements. A heart attack need not be a death sentence. My health and fitness levels have improved dramatically. I have 10–15 kg more to lose, but I know it’s possible now. I have also experienced a spiritual awakening that, in turn, has led me to renew my faith and commit to a purpose-driven life. Despite all this, it took a surprising amount of time to regain my confidence and a healthy level of self-assurance. When this finally happened it was, I think, an outcome of participating in rehabilitation and self-management measures, like taking greater responsibility for my future health. A major factor in my recovery was support from family and friends. It was the existence of these interdependent relationships that was very important in helping me to find my equilibrium again. Cardiac rehabilitation and Indigenous health management in the broader context of cardiovascular health have become important matters for me since my recovery. Even though I have plenty of fight in me, I am always conscious of the need to not overcommit myself. All the while, there is a sense of impending urgency to give back to others in the Indigenous community who also need assistance. I think of others who don’t know or understand what is happening to their bodies. They may not know how to cope with surviving a cardiac event or heart surgery, and may not be aware of what they can do to reduce the risk of future cardiovascular damage. The journey from cardiac patient to cardiovascular health advocateThere were many uncomfortable changes after my heart attack. I was left without a job, as my previous employer decided I was an unacceptable risk as a fly-in-fly-out plant operator on Cape York Peninsula. My personal and social life disintegrated due to psychological aspects such as unanswered questions, post-traumatic stress, self-imposed social isolation, depression and anxiety. Eventually it was family and true friends that made the difference by being there when it really mattered. Prior to operating machinery for mining companies, I had been an Indigenous community development worker, so I decided it was time to do a refresher course at TAFE* to update skills I hadn’t used for over 10 years. With updated community services knowledge and abilities, I approached the Cardiac Rehabilitation Coordinator at Cairns Base Hospital and the Wuchopperen Health Service, offering to serve as a volunteer in some capacity. Their eager response was surprising and welcome. They were keen to try something different to improve Aboriginal and Torres Strait Islander (ATSI) cardiovascular health. We discussed employment in a mentoring/coordinating role in an Aboriginal Medical Service-based outpatient cardiac rehabilitation program. * A Technical and Further Education college. We had several discussions by phone and email about matters that concerned me. I noticed that many of the Indigenous people admitted to the coronary care ward did not go on to attend rehabilitation sessions. I noted the age differences between Indigenous and non-Indigenous people affected with cardiovascular disease, and thought about the reasons why I had not enjoyed the hospital-based cardiac rehabilitation sessions. I was very curious about what was happening to all those Murri and Islander people once they were released from hospital. Indigenous cardiovascular health began to affect me again personally only a few months later, with my older brother (aged 45) experiencing heart problems resulting in several unstable angina events, arrhythmias leading to unconsciousness, and several minor heart attacks. He required triple coronary artery bypass graft surgery and a permanent pacemaker, and has to take medication for the rest of his life. My brother refused to attend rehabilitation and is non-compliant with his medication. He stubbornly believes the heart surgery and the insertion of a permanent pacemaker were a cure-all for his heart problems. He is living on borrowed time as it is, yet he casually spouts that his days are numbered, like everyone else’s, surgery or not. This difficult reality has driven me to become more involved in Indigenous health. Today I am employed with Wuchopperen Health Service, based in Cairns, as a health worker in the chronic disease management program area. I work with the Continuous Improvement Program team as program coordinator for the Healthy Hearts Cardiac Rehabilitation Program. This is a community-based outpatient cardiac rehabilitation (OCR) program operating from an Aboriginal-controlled community health organisation (ACCHO), working in partnership with the Cairns Base Hospital’s Cardiac Rehabilitation Unit to provide a culturally appropriate and relevant program focused on ATSI people. The availability of this support through an Aboriginal health service, as opposed to a hospital, is a major positive point for ATSI people attending the Healthy Hearts program. To date, there have been over 30 people attending regular exercise sessions and education days held at Wuchopperen Health Service since the program began in August 2006. I have been able to assist the cardiac rehabilitation coordinator with a Cardiac Rehabilitation for Indigenous Communities project that is jointly funded by the Australian Government Department of Health and Ageing and Queensland Health. This project is about training staff like me at Wuchopperen and also at the pilot sites of Yarrabah, Coen and Thursday Island. The overall aim of the cardiac rehabilitation project is to enable the delivery of flexible OCR models to these Indigenous communities. I assist the project when and how I can as a cultural adviser, contributing to or participating in cardiac rehabilitation training. Our program provides an Indigenous OCR program role model for similar emerging programs. We have been contacted by over a dozen services seeking advice and information about setting up ATSI OCRs. I have since become the Indigenous representative for the Queensland Cardiac Rehabilitation Association (QCRA), allowing me to raise matters from an Indigenous perspective in a state forum, attend a Queensland Cardiac Rehabilitation Collaborative forum as a guest speaker and contribute Indigenous-related articles to the national newsletter of the Australian Cardiovascular Health and Rehabilitation Association. I enjoy my role and believe that my story also demonstrates the level of interest and support in northern Queensland for workable solutions to very difficult health issues. Recently, I have been seeking to promote the Wuchopperen Health Service Healthy Hearts program through interviews with media groups such as the Brisbane Indigenous Media Association, the local Bumma Bippera Media broadcast service and the national Indigenous newspaper Koori Mail. I think it’s really important to advertise positive things happening in the Indigenous community. In closingIn the past few months, two young men I knew (seemingly fit and healthy) have died from coronary arrest in their mid to late 30s. It is a very sad thing when young Indigenous men leave their wives, children and extended families at such an early age. I am certain that, throughout Australia, many Indigenous families can tell similar stories — but this does not have to continue. It serves as a reminder of why I got involved in this quite serious business, and why people like my two young friends and my non-compliant brother need help. Health crisisEvery article written on Indigenous cardiovascular health problems inevitably calls for an urgent long-term solution. As an inpatient and now as an allied health worker, I can understand both sides of the coin. I deal with people associated with a health system in which the following issues are a daily reality: Tyranny of distance issues; Chronic comorbidities that result in surgery being contraindicated for ATSI people; Non-compliance with medication and follow-up appointments; Mistrust of hospitals by Indigenous people; A high proportion of Indigenous people refusing to undergo cardiac investigations; An unacceptably high rate of people refusing cardiac surgery; Long waiting times for life-saving surgery; Low uptake and follow-through of lifestyle changes and behaviour modification; Unwillingness to attend traditional hospital-based and ACCHO-based cardiac rehabilitation; and Primary, secondary and tertiary prevention measures missing their mark. These are only some of the issues I have become aware of in my work as an Indigenous health worker. I am sure there are far more qualified, knowledgeable people in the health field who can discuss the issues and solutions in more detail than I can. These people need to stand up and speak out too. Regardless, the issues raised represent serious unmet needs that require an urgent solution. Without a concerted effort, I predict the consequences will be dire for the Indigenous community throughout Australia. Governments, health departments, ACCHOs and the Indigenous community must demonstrate they are absolutely serious about improving the future health of Indigenous Australians. All groups mentioned have a role, particularly governments and Indigenous people. What’s needed is strong leadership from both sides and a coordinated effort, including, for example, examining funded regionalised agreements between ACCHOs and government health service providers and non-government organisations as a possible way forward. These kinds of partnerships and other creative solutions ought to be given due consideration before being dismissed. The issue of Indigenous health has always been controversial, certainly in my lifetime, and no doubt will continue to be so until the powers that be, namely federal and state health departments, decide to stop the blame-shifting and buck-passing and work together for the greater interest to create policy-driven outcomes, accordingly matched by funding and providing the right people and the necessary resources. Any review of past and current data relating to Indigenous cardiovascular health makes it clear that it’s time for all of our leaders to show some heart and exercise the political will needed to engage cardiac service/support providers and consumers in a long-term, committed, national response.

Barry N Fewquandie

Research in Aboriginal health may be hampered by a lack of experience with the process of collaboration with Aboriginal communities, and additional ethics approval requirements. Awareness of resources and advice from Aboriginal mentors with in-depth knowledge of clinical and research issues can greatly assist researchers. A collaborative approach between researchers and Aboriginal communities is pivotal to developing a research project consistent with Indigenous cultural values and health concepts, with the potential to improve services and outcomes for Aboriginal peoples. Planning and broad consultation can ensure that research is feasible, ethical, culturally sensitive and beneficial. This article outlines lessons learned from personal experience of developing a project in Aboriginal health, which we hope may serve as a practical guide for others.

Anne P F Wand B(Sc)Med(Hons), MB BS(Hons) · Sandra J Eades BMed, PhD

Accurate data about Indigenous child health is vital to enable us to understand its current state, to acknowledge achievements, and to determine how to reduce inequalities between Indigenous and non-Indigenous children. We have identified a paucity of national, or nationally representative, data relating to Indigenous child health outcomes, and significant deficiencies in available data. A coordinated national approach will help address current data limitations, including lack of identification of Indigenous status, lack of currency, and lack of information about specific health disorders affecting Indigenous children. To ensure that health data collected are relevant and useful, Indigenous communities must have a role in data collection and management.

Emily Fremantle BA(Hons) · Yvonne A Zurynski BAppSc, MAppSc, PhD · Deepika Mahajan BSc(Hons), MSc, PhD · Heather D’Antoine BAppSc, MHEc · Elizabeth J Elliott MD, FRACP, FRCPCH

Oral health problems faced by Indigenous peoples are worsening and require practical long-term solutions In the 1970s, reports noted that oral health was one area in which Indigenous children enjoyed an advantage over other Australian children.1,2 However, as research improved our understanding of oral diseases, interventions to prevent common oral diseases like dental caries became available to most Australian children and oral health steadily improved. Furthermore, the dental caries that was experienced by most Australian children began to be effectively treated by ready access to dental care through school dental services or private dentists. As Indigenous children were largely unable to access these services for geographical and/or financial reasons, their oral health has worsened over time, with the result that Indigenous children now have poorer oral health than non-Indigenous children.3 Indigenous children are on a trajectory of developing further caries through to adulthood, with increasing numbers of teeth affected and eventually extracted. The teeth that are retained will also suffer from much higher levels of periodontal disease, which is likely to be earlier in onset and of greater severity than periodontal disease in other Australian adults.4 This may be the result of complications arising from other non-dental chronic diseases such as diabetes. The higher prevalence and severity of periodontal disease may subsequently place these Indigenous adults at risk of further chronic degenerative diseases such as diabetes and cardiovascular disease. Child oral healthA recent study showed that, compared with non-Indigenous Australian children, Indigenous children are now more likely to have dental caries at all ages. At the age of 6 years, 72% of Indigenous children had some tooth decay compared with 38% of other Australian children.4 The number of teeth with caries experience (ie, with past and/or present caries) among Indigenous children is about twice the number in non-Indigenous children, in relation to both deciduous and permanent teeth. Indigenous 6-year-olds have an average of 3.7 teeth with experience of caries compared with 1.5 teeth for other Australian children.5 Among 12-year-old children, the relative difference is somewhat less (1.3 compared with 0.8 teeth, respectively). The proportion of caries experience that is untreated is also higher among Indigenous children. Without early diagnosis and prompt treatment, multiple affected teeth present with advanced decay and tooth breakdown. This translates into higher numbers of young Indigenous children in remote areas undergoing hospitalisation for treatment under general anaesthetic.6 Solutions lie with caries prevention through adapting successful fluoride programs to the physical and social circumstances in which these children live. A number of approaches are being implemented, including fluoridating water supplies in larger remote communities with deficient levels of fluoride, clinical trialling of 6-monthly applications of fluoride varnish to the teeth of preschool children by primary health care workers, and introducing tooth-brushing and drinking water programs in preschools and schools. Adult oral healthThe National Survey of Adult Oral Health 2004–067 in Australia found that Indigenous adults have a higher perceived need for dental treatment than other Australians, particularly for dentures, fillings and extractions. More Indigenous than non-Indigenous adults reported that they were in urgent need of treatment. Although cohorts of Indigenous adults have similar overall past and present experience of caries to that of other Australian adults, they have higher levels of untreated caries and missing teeth and lower numbers of filled teeth.7 These findings indicate poorer access to timely dental care, resulting in either no care or care that is delayed until the disease process has reached an advanced stage and tooth extraction is required. These dental problems have further repercussions, with more Indigenous people avoiding certain foods because of dental problems, more ranking oral health as fair or poor, and more reporting experience of toothache.7 Indigenous adults have a higher prevalence of severe periodontal disease than non-Indigenous adults and are more than twice as likely to have advanced periodontal disease (after controlling for a number of sociodemographic characteristics).4 Periodontal disease accounts for 30% of tooth loss,8 contributing to the higher number of missing teeth in Indigenous Australians. The increased severity of periodontal disease and tooth loss for adults with non-insulin-dependent diabetes mellitus in Indigenous communities in Central Australia was first identified 20 years ago (Bruce Simmons, Dentist, Northern Territory Health, unpublished data, 1988). To this association between diabetes and risk of periodontal disease has more recently been added an association between periodontal disease and poor control of diabetes.9 Solving the oral health problems faced by Indigenous adults requires two complementary approaches. Firstly, access to dental care needs to be greatly improved. While the experience of dental caries among Indigenous people is no higher than among non-Indigenous Australians, the delay in accessing any care and the resource constraints of the services involved lead to high rates of tooth extraction and its consequences among Indigenous people. Specific dental care could reduce the progression or recurrence of destructive periodontal disease. Secondly, there is an imperative to integrate dental care with medical care, including dental disease in a group of related chronic degenerative diseases. Periodontal disease in Indigenous adults needs to be included alongside nutrition, obesity and diabetes in community health promotion programs. Some possible ways to address these issues are to include oral health in the training and practice of primary health care workers in Indigenous health, to develop pathways to providing priority dental care involving dentists and allied dental professionals, and to ensure that programs have strong community participation, capacity building and skills development for all major health problems.

Kaye F Roberts-Thomson BDSc, MPH · A John Spencer MDSc, PhD, MPH · Lisa M Jamieson PhD