Indigenous health

Objective: To determine whether installation of swimming pools in remote Aboriginal communities reduces infection-related outpatient attendances and prescription of antibiotics.Design and setting: Swimming pools were opened in Jigalong and Mugarinya, Western Australia, in September 2000. We examined local clinic records to document illnesses occurring in children and adolescents under 17 years of age between 1998 and 2005. In Jigalong, we examined records of those enrolled in an ongoing study evaluating the effect of swimming pools on health. In Mugarinya, we examined clinic records of those residing there permanently.Main outcome measures: Clinic attendance rates for skin, middle-ear and respiratory tract infections and trauma, and prescription rates for antibiotics were analysed by using a community-based selection method in Jigalong, and a clinic-based selection method in both communities for comparison of the two communities and the two methods.Results: We examined records of 131 children in Jigalong and 128 children in Mugarinya. After the pools had been installed, clinic attendance rates for skin infections declined by 68% in Jigalong and by up to 77% in Mugarinya. In Jigalong (where the pre-pool prevalence of infections was higher than in Mugarinya), rates of antibiotic prescription declined by 45%, as did clinic attendance for middle-ear infections (61% reduction) and respiratory tract infections (52% reduction).Conclusion: Swimming pools in remote communities are associated with reduced prevalence of skin infections. Where disease prevalence is high, pools are also associated with reduced rates of antibiotic prescriptions and middle-ear and respiratory tract infections. In communities with resident health staff, examination of clinic records is an efficient method of monitoring the effects of public health interventions on the burden of infectious diseases.

Desiree T Silva FRACP, MPH · Deborah Lehmann MB BS, MSc · Mary T Tennant RN, BAppSc, MPH · Peter Jacoby MSc · Helen Wright MB BS, FRACP · Fiona J Stanley MD, FAFPHM, FRACP

Objectives: To determine the risk of otitis media (OM) associated with passive smoking in young children, and any competing effect between passive smoking and childcare attendance.Design, participants and setting: Prospective cohort study of 100 Aboriginal and 180 non-Aboriginal children born in Kalgoorlie Regional Hospital between 1 April 1999 and 31 January 2003. These children underwent routine clinical examinations by an ear, nose and throat specialist up to three times before the age of 2 years, and tympanometry at routine field follow-up visits from the age of 4 months. Childrens’ mothers were interviewed at 1–3 weeks postpartum to provide sociodemographic data.Main outcome measures: Associations between OM and exposure to environmental tobacco smoke (ETS) and childcare attendance.Results: 82 Aboriginal and 157 non-Aboriginal children attended for routine clinical examinations. OM was diagnosed at least once in 74% of Aboriginal children and 45% of non-Aboriginal children; 64% of Aboriginal children and 40% of non-Aboriginal children were exposed to ETS. Exposure to ETS increased the risk of specialist-diagnosed OM in Aboriginal children (OR, 3.54; 95% CI, 1.68–7.47); few attended childcare. Non-Aboriginal children exposed to ETS but not attending childcare were at increased risk of OM (OR, 1.91; 95% CI, 1.07–3.42) while those attending childcare had no increased smoking-related risk. Tympanometry was performed on 87 Aboriginal and 168 non-Aboriginal children; a type B tympanogram (suggesting fluid in the middle ear) was also associated with passive smoking in Aboriginal children.Conclusions: Reducing the exposure of children to ETS is a public health priority, especially for the Aboriginal population. A smoke-free environment will help reduce the burden of OM.

Peter A Jacoby MSc · Harvey L Coates MS, FRACS · Ashwini Arumugaswamy MB BS, BMedSci · Dimity Elsbury RN · Annette Stokes AHW · Ruth Monck RN, RM · Janine M Finucane RN · Sharon A Weeks MSc · Deborah Lehmann MB BS, MSc

Objective: To determine the extent to which depressive symptoms are associated with heavy cannabis use in an Aboriginal population in Arnhem Land, Northern Territory.Design, participants and setting: Cross-sectional study involving interviews with 106 Indigenous participants (57 males, 49 females) aged 13–42 years in three remote Aboriginal communities in Arnhem Land, NT, Australia.Main outcome measures: Measures of depressive symptoms (a raw score of ≥ 6 out of a possible 18 on a modified version of the Patient Health Questionnaire-9) and self-reported heavy cannabis use (six or more cones daily).Results: After adjusting for other substance use (tobacco, alcohol and lifetime petrol sniffing), age and sex, heavy cannabis users were four times more likely than the remainder of the sample to report moderate to severe depressive symptoms (odds ratio, 4.1; 95% CI, 1.3–13.4).Conclusions: Given its high prevalence in Indigenous populations, the development of clinical and prevention strategies for cannabis misuse are warranted.

K S Kylie Lee BMus(Hons) · Alan R Clough PhD · Muriel J Jaragba Cert III (Mental Health) · Katherine M Conigrave FAChAM, FAFPHM · George C Patton MD, FRANZCP

Objectives: To define and compare the prevalence, risk factors and understanding of hepatitis C transmission among Aboriginal and non-Aboriginal young offenders.Design, participants and setting: Cross-sectional study of young offenders (aged 12–19 years; median age, 16.6 years) in custody or serving community orders with the New South Wales Department of Juvenile Justice who participated in a physical and mental health survey between March 2002 and December 2005, and who provided blood samples for analysis of biochemistry, bloodborne viruses and sexually transmitted infections.Main outcome measures: Risk factors and prevalence of hepatitis C antibody positivity.Results: Of the 1042 young offenders studied, 709 provided blood samples, 179 (25%) of whom identified as Aboriginal. Aboriginal adolescents had more markers of social disadvantage and higher rates of hepatitis B (9.6% v 5.2%; P = 0.04) than non-Aboriginal young offenders. Hepatitis C rates were high in both groups (7.3% v 5.3%; P = 0.33). Risk factors for hepatitis C were the same in both groups, the most important being injecting drug use (OR, 19; P < 0.001) and prior use of heroin (OR, 15; P < 0.001). Current custodial sentence doubled the risk of hepatitis C. Knowledge of hepatitis C transmission was very poor in both groups, with over 50% not knowing how it is transmitted and fewer than 10% able to identify sharing needles as a risk.Conclusions: Hepatitis C rates are extremely high in all young offenders, and interventions to halt its spread are urgently needed. Aboriginal adolescents, who are over-represented in this population, are particularly at risk.

David van der Poorten BSc(Med), MB BS, FRACP · Dianna T Kenny PhD, MA(ScCouns), BA(Hons) · Jacob George PhD, FRACP

Objectives: To describe delivery of child health services in Australian Aboriginal communities, and to identify gaps in services required to improve the health of Aboriginal children.Design: Cross-sectional baseline audit for a quality improvement intervention.Setting and participants: 297 children aged at least 3 months and under 5 years in 11 Aboriginal communities in the Northern Territory, Far West New South Wales and Western Australia in 2006.Main outcome measures: Adherence to guideline-scheduled services including clinical examinations, brief interventions or advice on health-related behaviour and risks, and enquiry regarding social conditions; and recorded follow-up of identified problems.Results: Documentation of delivery of specific clinical examinations (26%–80%) was relatively good, but was poorer for brief interventions or advice on health-related behaviour and risks (5%–36%) and enquiry regarding social conditions (3%–11%). Compared with children in Far West NSW and WA, those attending NT centres were significantly more likely to have a record of growth faltering, underweight, chronic ear disease, anaemia, or chronic respiratory disease (P < 0.005). Only 11%–13% of children with identified social problems had an assessment report on file. An action plan was documented for 22% of children with growth faltering and 13% with chronic ear disease; 43% of children with chronic respiratory disease and 31% with developmental delay had an assessment report on file.Conclusion: Existing systems are not providing for adequate follow-up of identified medical and social problems for children living in remote Aboriginal communities; development of systems for immediate and longer-term sustainable responses to these problems should be a priority. Without effective systems for follow-up, screening children for disease and adverse social circumstances will result in little or no benefit.

Ross S Bailie MD, MPhil, FAFPHM · Damin Si MMed, MPH, PhD · Michelle C Dowden RN, GradCertPublicHealth, MPH · Christine M Connors MB BS, MPH, FAPHM · Lynette O’Donoghue BSc, DipIndigHlthProm, BAppSci · Helen E Liddle BA · Catherine M Kennedy BSc(Hons), MSc · Rhonda J Cox Cert III/IV(AHW) · Hugh P Burke MB BS, MPH, FAFPHM · Sandra C Thompson MB BS, FAFPHM, PhD · Alex D H Brown BMed, MPH, FCSANZ

Aboriginal healthworkers. Primary health care at the margins. Bill Genat with Sharon Bushby, et al. Perth: UWA Press, 2006 (xiii + 226 pp). ISBN 978 1920694 76 0. This book is a little gem. It could not be more timely and essential a read for anyone interested in how best to deliver preventive, truly holistic and primary health care to Australian Aboriginal families and communities. Bill Genat uses ethnographic methods to study the roles, challenges and lives of five urban Aboriginal health workers, each of whom have between 10 and 20 years working experience. The book describes Aboriginal health worker practice at the grass roots, with many real-life case studies demonstrating breakdowns in family caring and the outcomes of intergenerational exclusion and oppression. It describes clearly the challenges faced (and not always overcome) by these women as they strive to help the families for whom they are responsible with all the variety of situations they face. The section describing how Aboriginal health workers are neither valued nor appropriately used by either the health system or the doctors, nurses and others is captured in the opening quote: This book is unique, and a “must read” for anyone working in Aboriginal health, for those in charge of health systems, and for students interested in ethnographic methodology and the social sciences. It would be great if it were read by politicians too, who then might understand that an important piece of the jigsaw to “solve” poor Aboriginal health status is staring them in the face.

Fiona Stanley

The WHO recommends whole-of-community antibiotic treatment for chlamydial eye disease (trachoma). a recent article suggested the same approach should be taken to manage endemic chlamydial disease when the same organism is sexually transmitted. This controversial approach has sparked debate. (MJA 2008; 188: 182-184) Sandra C Thompson, Darryl M Kickett and Timothy G Leahy — Med J Aust 2008; 188 (10): 620. Michael S Gracey and Randolph M Spargo — Med J Aust 2008; 188 (10): 620-621. David J Scrimgeour — Med J Aust 2008; 188 (10): 621. Bryan G Walpole — Med J Aust 2008; 188 (10): 621. Francis J Bowden and Katherine Fethers — Med J Aust 2008; 188 (10): 621.

To the Editor: Bowden and Fethers’ provocative recommendations for mass antibiotic treatment to reduce the prevalence of sexually transmissible infections (STIs) in remote Aboriginal communities is based on the failure of the current approach of screening and treatment of individuals to reduce STI prevalence.1 However, approaches that address a single health issue in isolation will not succeed in improving Aboriginal health. The biomedical approach proposed could reduce the likelihood of a sexually active person becoming infected with an STI, but, in our experience, many Aboriginal people object to the “sheep-dip approach” of mass indiscriminate treatment. Moreover, it is ethically difficult to justify giving a cocktail of four antibiotics with potentially adverse side effects to all people in a population when only one or two out of 10 will benefit. The proposed staggering of doses would only increase the difficulty and reduce compliance. The people who don’t participate in current programs are the same people who would be least likely to comply with a new program. The greatest merit of Bowden and Fethers’ proposal is in addressing the social determinants of poor health. The ancillary “life skills” programs they suggest could also be useful, and to this we could add interventions with the core groups2 and multifaceted interventions to reduce the use of alcohol and other drugs that fuel disinhibited and violent behaviour, including sexual abuse. Most importantly, tackling STIs in isolation will fail to bring about improvements in the many areas of Aboriginal health requiring attention. Arguably, given the profound health inequalities experienced by Aboriginal Australians, the best approach would be to resource culturally secure, comprehensive primary health care services adequately,3 at a level greater than that available for urban middle class Australians. This has not yet been achieved in remote areas. Yet the complexity of Aboriginal social and health issues demands the most experienced and skilled health professionals rather than the current workforce, which is characterised by high turnover and consists too often of overseas-trained medical staff, nurses on short-term contracts and Aboriginal health workers, many of whom suffer from illness or family trauma. Before contemplating mass community treatment, priority must be given to improving the social determinants of health, enabling Aboriginal people to have control over their own lives. This would effectively involve Aboriginal leadership at community level generating Aboriginal-led solutions. This would have a longer-term effect on health improvement and ensure good access to quality primary health care that could respond to the complex needs of Aboriginal people.4 It would require continuity of care from committed, appropriately trained health professionals who understand and work within the values and priorities of Aboriginal people. Aboriginal people want primary health care that delivers culturally secure, empowering and holistic care.5 Mass treatment fails in this. Enhancing multidisciplinary primary care with linkages to the community outside the clinic could help address the many other causes of chronic illness that contribute to the shameful gap in morbidity and life expectancy between Indigenous and non-Indigenous Australians.

Sandra C Thompson · Darryl M Kickett · Timothy G Leahy

To the Editor: The proposal by Bowden and Fethers1 to abandon “screen, treat and contact trace” methods of managing endemic sexually transmissible infections (STIs) in remote Indigenous communities and replace them with mass treatment programs in groups with defined threshold prevalence levels is flawed. Primacy must go to the question of why some STIs are so prevalent. Why deal only with the consequences rather than the causes of STIs? Without resolving these questions, the problems will persist. Bowden and Fethers’ approach has serious shortcomings. A major one is sweeping aside the concepts of one-on-one advice, counselling, opportunities to cooperate with health staff, avoidance of hazardous behaviours, and maintenance of effective follow-up. These cornerstones of public health strategies to control STIs depend on the ability of health professionals to establish meaningful relationships with Indigenous people. Transient populations move frequently between towns and remote communities. Therefore, the authors’ strategy neglects the serious risk to remote communities from inadequately controlled reservoirs of STIs that allow the diseases to be repeatedly reintroduced from rural or remote towns. The authors say, ironically, “Let’s not talk about sex”, but an essential part of the public health response to STIs must be to talk about sex. It is our observation that many Indigenous people are more comfortable talking about this subject than other Australians. Another risk in the authors’ approach is to overlook detection of HIV infection. Their proposal could also be interpreted by many Indigenous people as suggesting that they no longer need worry about STIs because the new blanket approach from their health carers will protect them from all such infections. Our long experience working in remote northern Western Australia suggests to us that a mass treatment approach would not resolve the problem of STIs. Control of many of the main chronic diseases of Indigenous people living in remote areas can be significantly enhanced by increased Indigenous community involvement, decision making, and trusting collaboration with health professionals.2 Crucially, additional government commitment is urgently needed to provide enough locally stable and adequately trained staff, facilities, and related resources to control these persisting problems in remote Australia.

Michael S Gracey · Randolph M Spargo

To the Editor: It was pleasing to see Bowden and Fethers raising the issue of public health approaches to sexually transmissible infection (STI) control in remote Indigenous communities.1 However, their suggestion that mass treatment programs would be more effective than screening programs is flawed. They note that screening programs have had some success in reducing the prevalence of STIs, but that an unacceptable prevalence persists. Rather than rejecting screening as an appropriate strategy, it would be more useful to investigate the reasons why screening programs have had limited success. It is likely that the main drawback has been inadequate coverage, and one of the main reasons for this is that there are hard-to-reach groups who are not being included in screening programs. In particular, this would include people with alcohol problems or other addictions, whose lifestyle makes them more at risk for STIs. People in this group, who often live a transient or homeless lifestyle in regional centres, have problems of access to health care and health programs. A mass STI treatment program would not overcome this difficulty and would be just as likely as current screening programs to miss this crucial target group. What is needed is better support for comprehensive primary health care programs, to allow an extension of current health programs to reach out to these groups. Bowden and Fethers suggest that screening programs are inadequate because of problems with current levels of staffing and health infrastructure. This is what needs to be addressed. Greater support for community-controlled comprehensive primary health care, to ensure adequate levels of staffing and infrastructure for STI screening (including outreach programs for hard-to-reach populations), would produce better results from STI screening and would also allow better control programs for other health problems. Furthermore, it would help reduce the problem of increasing antibiotic resistance that is likely to result from mass treatment programs.

David J Scrimgeour

To the Editor: With their radical population-based approach, Bowden and Fethers1 bring a refreshing perspective to the management of sexually transmissible infections (STIs) in Indigenous communities — normally a taboo subject with those at risk and their families. I recently participated in the federal government’s Northern Territory Emergency Response, and was told, both centrally and locally, that looking for STIs was off limits, as it might destroy the trust of Aboriginal communities. This meant that I could neither enquire about nor examine children or adolescents below the umbilicus. I noted that most teenage girls had contraceptive implants (a good public health measure), but no STI prophylaxis. I think this is a failure of the Response.

Bryan G Walpole

In reply: Although the title of our article was intentionally provocative, our suggested rethink of current approaches to control of sexually transmissible infections (STIs) in remote communities emphasises the role of individual autonomy and consent, education, health promotion and community involvement. We do not dismiss one-on-one advice, counselling, follow-up, the need for meaningful relationships with Indigenous people, or the risk of an HIV epidemic. However, we do suggest that there should be a separation of the strictly medical components of the strategy from the community development components. Furthermore, in the presence of endemic disease, we propose that presumptive treatment should be based on an assessment of risk made at a community level rather than at the individual level, and that removing the otherwise unavoidable delays between screening and treatment may be a more effective first step in reducing the burden of STIs in remote populations. A “screen, recall, treat and contact trace” approach works to some degree in the mainstream population, in which the prevalence of STIs is much lower than in remote communities, but what is considered “best practice” in suburban Australia does not automatically translate into best practice in the bush. We acknowledge the logistic difficulties of offering any type of broadly based community program in remote areas and we specifically address the problem of treating hard-to-reach groups in communities. We recognise the risk of giving a false sense of security to the target audience, but current approaches provide people in remote areas little protection from STIs. The recent roll-out of the human papilloma virus vaccination in young women could be similarly criticised, but it is possible to implement a biomedical intervention and still continue with education and health promotion. The question of antibiotic resistance is an important one. The aim of increasing the intensity of treatment over a defined time period is to reduce the total amount of antibiotics prescribed in the longer term. An increase in the level of resistance is the price that is paid for a reduction in the prevalence of disease in any population receiving antibiotics. Nevertheless, we indicated the need for monitoring of resistance patterns in any trials that are undertaken. The eradication of the eye disease trachoma is dependent on the availability of clean water and better housing, but while this crucial infrastructure is being built we have to continue to treat the condition where it occurs and apply “traditional” public health approaches to population-level control. We think it is reasonable to consider doing the same for STIs.

Francis J Bowden · Katherine Fethers

To the Editor: Recent media reports1 of events in Aurukun, Palm Island and other Indigenous communities in Queensland may have left the impression that most Indigenous people in the state live short, violent lives in remote, dysfunctional communities. However, census data from the Australian Bureau of Statistics (ABS) contradict one aspect of this impression: in fact, few Indigenous people live in remote communities, with the majority widely spread through the general population (Box). Over the past 10 years, the Indigenous population of Queensland has increased by 33.7% (Box). However, the number of people living in Aboriginal and Torres Strait Islander land council areas was almost stationary, dropping from 17 855 in 1996 to 17 739 in 2006, and the proportion of Indigenous people living in these areas decreased from 18.7% to 13.9% over the 10 years. The other six out of seven Indigenous people lived in the general community (Box). Twenty-four per cent lived in Brisbane city; suburb-by-suburb analysis showed most lived in less affluent areas of Brisbane but, even in these, the percentage of Indigenous people was only 1%–8% in each area. There are no major ghettos. In 2006, 32.4% of Indigenous people lived in south-east Queensland (classified as the “Brisbane Indigenous Region” by the ABS, Box); there is no land council area in this region. On North Stradbroke Island, a group of 366 Indigenous people living in the general community comprised 18% of the local population, but in all other locations the percentage of Indigenous people was well under 10%. Indigenous Australians have also moved to other cities in Queensland. In 1996, 42 571 Indigenous people (44.6% of the state’s Indigenous population) lived in a major city (Brisbane, the Gold Coast, Toowoomba, Rockhampton, Townsville or Cairns). By 2006, 61 672 Indigenous people lived in these cities. This is below the 67.1% for all Queenslanders, but is still nearly half (48.3%) of the Queensland Indigenous population. In the 1996, 2001 and 2006 ABS censuses, an Indigenous person was defined as someone who had ticked one of three boxes on the ABS census form stating that he or she is Aboriginal, Torres Strait Islander or both. All censuses have problems with accuracy of the data submitted and missing returns;2 however, as the results presented here were determined using the same methodology, show linear trends across the datasets, and identify only broad trends, I believe they are robust. Much of the increase in the Indigenous population is probably due to the higher birth rate of Aboriginal and Torres Strait Islander people (26.4/1000 v 12.9/1000 in the overall Queensland population).4 However, “migration” — people reclassifying themselves as Indigenous — may also contribute. These census data show that, as with other Australians, there is a net movement of Aboriginal people from rural to urban areas. Anecdotally, many people move from Indigenous communities and other rural areas to relatives in “town”; some stay for only a short time, but others remain in the city. This move is sometimes to the rural or urban fringe, but more often is into a stable integrated family group. Most Indigenous people in Queensland are widely spread through the general population. ABS census data on Queensland Indigenous people* 1996 2001 2006 Queensland population Total 3 368 850 3 655 139 4 046 880 Indigenous (% of total population) 95 518 (2.8%) 112 772 (3.1%) 127 684 (3.2%) Brisbane population Total 1 468 617 1 605 650 1 782 973 Indigenous (% of total population) 21 462 (1.5%) 26 453 (1.6%) 30 769 (1.7%) Indigenous population (% of Queensland Indigenous population) Brisbane 21 462 (22.5%) 26 453 (23.5%) 30 769 (24.1%) Brisbane Indigenous Region† na 36 323 (32.2%) 41 369 (32.4%) Major Queensland cities‡ 42 571 (44.6%) 52 385 (46.5%) 61 672 (48.3%) ATSI land council areas§ 17 855 (18.7%) 16 567 (14.7%) 17 739 (13.9%) ABS = Australian Bureau of Statistics. na = not available. ATSI = Aboriginal and Torres Strait Islander. * Data are collated from numerous sections of the 1996, 2001 and 2006 ABS censuses.2 † The Australian Indigenous Geographical Classification used by the ABS.3 ‡ Includes Brisbane. § Population for ATSI land council areas is total population.

Alan E Dugdale

To the Editor: As a junior doctor working in Central Australia, who has spent the past year rediscovering my own Aboriginal heritage, I read the recent articles on the Northern Territory intervention- with interest. All authors agree that the current state of health in NT communities is shameful, and that the causes include a wide range of social determinants. However, beyond these similarities there is almost complete discordance between the article by Glasson (of the NT Emergency Response Taskforce) and the other three articles by NT-based doctors (Tait, Boffa et al, and Brown and Brown). Glasson paints a demeaning and misleading picture of NT communities as exhibiting “a complete breakdown of normal mores”. This fits snugly with the “white blindfold” view, described by Tait, that will only further disempower marginalised Aboriginal people and communities. Glasson ignores the vast accumulated knowledge and successes attained by Aboriginal community-controlled health services (ACCHSs) and health workers, relegating their contribution to a half-sentence in his acknowledgements. Boffa and colleagues clearly outline the remarkable successes of ACCHSs and their repeatedly ignored calls for more resources. Glasson leaves no room for real community participation, and justifies the government’s heavy-handed approach as necessary for such a “crisis”. Brown and Brown describe convincingly the absolute necessity of Aboriginal rights and participation in any intervention conducted on their behalf, and the valiant long-term struggles by Aboriginal people to tackle the current situation. In response to the government’s intervention, in June 2007, Mark Wenitong, President of the Australian Indigenous Doctors’ Association, expressed concerns that remain relevant today: “As medical professionals, we question the notion that you can treat poverty, dispossession, marginalisation and despair (the root causes of substance misuse and sexual, physical and emotional abuse) with interventions that further contribute to poverty, dispossession, marginalisation and despair.” Indeed, the Ampe akelyernemane meke mekarle: “little children are sacred” report was very clear about the necessary approach to addressing the issues it raised: “What is required is a determined, coordinated effort to break the cycle and provide the necessary strength, power and appropriate support and services to local communities, so they can lead themselves out of the malaise: in a word, empowerment!” My experience working in NT Government hospitals and ACCHSs has revealed both the enormous challenges facing Abori-ginal people in the NT, and their remarkable resilience and capacity to achieve against all odds. As health professionals and Australian citizens we must recognise these efforts and support interventions that are evidence-based, respectful, and conceived in partnership with Aboriginal communities and their ACCHSs. Without this, the most expensive intervention will only ever amount to a superficial facelift.

Hamish R Graham

In reply: While I acknowledge the arguments many have put forward that the Northern Territory Emergency Response (NTER) has been too rapid and implemented without optimal community consultation — which some perceive to have disempowered Indigenous people — I stress the need to continue and indeed step-up momentum so that communities can regain control of their own futures as soon as possible. The positive impact of the NTER measures in creating better health, social and economic outcomes for Indigenous Australians will only be realised with the total support and focused energy of those “on the ground”, charged with delivering vital primary care and secondary intervention in NT communities. Without the continued engagement of these hardworking individuals who are able to establish the trust required to build bridges into these communities, the initiative is not sustainable. It is into the hands of those who live and work in Aboriginal communities that the NTER Taskforce and government agencies will pass the baton of change — we hope they will run with it.

William J H Glasson

What impact has the NHMRC Road Map had on Aboriginal and Torres Strait Islander health? A review process now underway aims to find out There are significant disparities in health status between Aboriginal and Torres Strait Islander peoples and other Australians across the life cycle, including lower birthweight, higher death rates, lower life expectancy, and a much higher incidence of a range of illnesses that affect social and emotional wellbeing.1 * The Aboriginal and Torres Strait Islander Health and Research Advisory Committee members are: Professor Cindy Shannon (Chair), Professor Ian Anderson, Dr Ngiare Brown, Professor Yvonne Cadet-James, Associate Professor Terry Dunbar, Associate Professor Jacinta Elston, Associate Professor Lisa Jackson-Pulver, Mr Daniel McAullay, Dr Mark Wenitong and Dr Tim Williams. The National Health and Medical Research Council (NHMRC) is Australia’s peak body for supporting health and medical research. It is also responsible for developing health advice for the Australian community, health professionals and government, and advising on ethical behaviour both in health care and in the conduct of health and medical research. The role of the NHMRC in the Australian Government’s strategic framework for improving the health status of Aboriginal and Torres Strait Islander peoples includes: developing culturally appropriate health advice and guidelines; funding research to improve the health and wellbeing of Aboriginal and Torres Strait Islander peoples; providing information on the ethical considerations that arise in research; supporting Aboriginal and Torres Strait Islander peoples in participating in research capacity building; and commissioning health and medical research in priority areas. The Road MapIn 2002, the NHMRC promoted the development of the Aboriginal and Torres Strait Islander Research Agenda Working Group “Road Map” — a strategic framework to identify agreed national research priorities in Aboriginal and Torres Strait Islander health. More than 250 people had direct input into the development of this framework through attendance at four workshops held in Perth, Darwin, Brisbane and Melbourne. Representatives were drawn from all states and territories and included a balance of Aboriginal and Torres Strait Islander and non-Indigenous participants. Additional input was received from 23 organisations through a written submission process. This process of open consultation and discussion highlighted a number of areas where priority research was urgently needed, to complement existing research-driven programs. The resulting Road Map outlines six research themes crucial to achieving substantial health gains for Aboriginal and Torres Strait Islander peoples (Box).2 The overall objective of the Road Map has been: to advise Aboriginal and Torres Strait Islander communities throughout Australia on the achievement and maintenance of the highest practicable standards of individual and public health, and to foster research in the interests of improving those standards.2 Underlying principles of the Road MapThe Road Map was implemented in 2002, advocating research and development underpinned by the following principles: Health is not just the physical wellbeing of the body but a whole-of-life and unending phenomenon; Community involvement is integral to the development, conduct and communication of research; Research must be conducted ethically3-5 and be of practical value to Aboriginal and Torres Strait Islander peoples and their service providers; Communication of research plans, progress and results is essential; It is important to support research, including enhancing the development of skills, knowledge and capacity in the Aboriginal and Torres Strait Islander research workforce; and It is important to identify “positive models” or examples of success. NHMRC-funded researchWithin the framework of the Road Map research themes, the NHMRC has initiated programs that aim to improve the health of Aboriginal or Torres Strait Islander people or build capacity in the Aboriginal and Torres Strait Islander health research sector. These programs currently include: the Indigenous Short-Term Exchange/Study Scheme; the International Collaborative Indigenous Health Research Partnership; Training Scholarships for Indigenous Health Research; and the Aboriginal and Torres Strait Islander Health Research Fellowship. Funding is also allocated to research on the health of Aboriginal or Torres Strait Islander people through project grants and in response to specific needs, including the Capacity Building Grants in Population Health Research initiative and the Healthy Start to Life for Aboriginal and Torres Strait Islander Communities initiative. Based on the research outcomes reported to date, the NHMRC has been able to develop some understanding of the Road Map’s impact by tracking the extent of employment of Aboriginal or Torres Strait Islander people on projects, the numbers and types of publications and presentations that have resulted from research, the effectiveness of research methodologies, and the level and context of researchers’ relationships with communities. Review of the Road MapThe Road Map continues to be part of a strategic research framework that commits the NHMRC to all research relevant to health — biomedical, clinical, public health and health services — and consultation with all levels of government, the health and medical research sector, and the community about priority research areas. During its development in 2002, it was anticipated that the Road Map would be reviewed in 2007. The review is being undertaken by the NHMRC in consultation with its key advisory committee on Indigenous health issues, the Aboriginal and Torres Strait Islander Health and Research Advisory Committee, chaired by Professor Cindy Shannon. Consultation workshops similar to those used to develop the Road Map will be held in Townsville, Sydney, Melbourne, Alice Springs and Perth during May 2008. Participants will be invited to provide information on their use of the Road Map and its perceived impact, and whether or not the research themes are still valid and important. The NHMRC welcomes the participation of individuals and organisations at these workshops and in a written submission process. Details of the workshops and the written submission process can be found at the NHMRC website (http://www.nhmrc.gov.au) or by contacting Cathy Mitchell, Director of Strategic Partnerships, on (02) 6217 9384 or cathy.mitchellATnhmrc.gov.au. The Road Map’s six research themes2 1. Descriptive research which outlines patterns of health risk, disease and death. This information should be used to inform the development of sound preventive, early diagnosis and treatment-based interventions which are likely to result in meaningful health gain for Aboriginal and Torres Strait Islander peoples. 2. A research focus on the factors and processes that promote resilience and wellbeing — in particular, but not exclusively, during the periods of pregnancy, infancy, childhood and adolescence — and form the basis of good health throughout the lifespan. 3. A focus on health services research which describes the optimum means of delivering preventive, diagnostic and treatment-based health services and interventions to Aboriginal and Torres Strait Islander peoples. 4. A focus on the association between health status and health gain and policy and programs that lie outside the direct influence of the health sector. 5. A focus on engaging with research and action in previously under-researched Aboriginal and Torres Strait Islander populations and communities. 6. Development of the nation’s Aboriginal and Torres Strait Islander health research capacity (including training Aboriginal and Torres Strait Islander researchers) and ethical health research practice in relation to Aboriginal and Torres Strait Islander communities.

for the Aboriginal and Torres Strait Islander Health and Research Advisory Committee*

Objective: To determine what preventive models or programs are most likely to improve patterns of growth faltering in children aged under 5 years in remote Australian Indigenous communities.Methods: Nine electronic databases and the websites of key stakeholder, government and non-government agencies were searched. Two reviewers independently assessed articles for inclusion and for study quality. All types of study design were eligible.Results: 140 studies assessing a diverse range of interventions were identified. Of these, 51 articles referring to 44 individual programs and 7 review articles met the review criteria. The evidence for the effectiveness of many interventions to prevent growth faltering is not strong, and any observed effects are modest. Community-based nutrition education/counselling and multifaceted interventions involving carers, community health workers and community representatives, designed to meet program best-practice requirements and address the underlying causes of growth faltering, may be effective in preventing growth faltering. Other interventions, such as food distribution programs, growth monitoring, micronutrient supplementation and deworming should only be considered in the context of broader primary health care programs and/or when there is an identified local need.Conclusion: For remote Indigenous communities, development and implementation of programs should involve a consideration of the evidence for potential impact, strength of community support and local feasibility. Given the lack of strong evidence supporting programs, any new or existing programs require ongoing evaluation and refinement.

Elizabeth L McDonald PhD · Ross S Bailie MD, MPhil(MCH), FAFPHM · Alice R Rumbold BSc(Hons), MPH, PhD · Peter S Morris MB BS, FRACP, PhD · Barbara A Paterson FFPHM, MPH, MRCGP

Objective: To determine the association between smoking in pregnant teenagers and baby birthweight.Design, setting and participants: A retrospective population-based study of women aged < 20 years who gave birth to liveborn singletons in Australia between January 2001 and December 2004. Data were drawn from the National Perinatal Data Collection.Main outcome measures: Maternal smoking, birthweight, low birthweight (LBW).Results: The prevalence of LBW in babies born to teenage smokers was 9.9%, compared with 6.0% in babies born to teenage non-smokers (odds ratio [OR], 1.72 [95% CI, 1.57–1.90]). On average, babies born to teenage smokers were 179.8 g lower in birthweight than babies born to teenage non-smokers (95% CI, 165.5 –194.1 g; t = 24.6, P < 0.001). Smoking, Indigenous status, Socio-Economic Indexes for Areas category and parity were independently associated with LBW (all ORs > 1.3; P < 0.001) after adjusting for maternal age group. Teenagers smoking > 10 cigarettes a day had babies with lower birthweight that those who smoked ≤ 10 cigarettes a day, demonstrating a dose–response relationship. The babies of teenage smokers who stopped smoking before 20 weeks’ gestation had birthweights similar to those of babies born to teenage non-smokers. One in 15 teenage smokers stopped smoking during pregnancy.Conclusion: Babies whose mothers smoked during pregnancy were more likely to have LBW than babies whose mothers did not smoke. Mothers who continue to smoke in the second half of pregnancy increase their baby’s risk of LBW. There is significant scope to improve the quitting rate, and health professionals need to target smoking cessation at all contacts with pregnant women who continue to smoke.

Denise L Chan · Elizabeth A Sullivan MB BS, MPH, MMed(Sexual Health)

Re: “Respiratory syncytial virus infections in children in Alice Springs Hospital”, the letter to the Editor by Apakasimaka Dede, David Isaacs, Paul J Torzillo, John Wakerman, Rob Roseby, Rose Fahy, George Clothier, Andrew White and Paula Kitto, in the 18 February issue of the Journal (Med J Aust 2008; 188: 261). A processing error caused the ninth and final author, Paula Kitto, BSc, BM BS, General Practice Registrar at the Centre for Remote Health, Alice Springs, NT, to be omitted from the authors’ byline. The web version of the article was corrected on 10 March 2008.

Apakasimaka Dede · David Isaacs · Paul J Torzillo · John Wakerman · Rob Roseby · Rose Fahy · George Clothier · Andrew White · Paula Kitto

Objective: To examine mortality from all causes and from cardiovascular disease (CVD), and CVD hospitalisation rate for a decentralised Aboriginal community in the Northern Territory.Design and participants: For a community-based cohort of 296 people aged 15 years or older screened in 1995, we reviewed hospital and primary health care records and death certificates for the period up to December 2004 (2800 person-years of follow-up).Main outcome measures: Mortality from all causes and CVD, and hospitalisation with CVD coded as a primary cause of admission; comparison with prior trends (1988 to 1995) in CVD risk factor prevalence for the community, and with NT-specific Indigenous mortality and hospitalisation rates.Results: Mortality in the cohort was 964/100 000 person-years, significantly lower than that of the NT Indigenous population (standardised mortality ratio [SMR], 0.62; 95% CI, 0.42–0.89). CVD mortality was 358/100 000 person-years for people aged 25 years or older (SMR, 0.52; 95% CI, 0.23–1.02). Hospitalisation with CVD as a primary cause was 13/1000 person-years for the cohort, compared with 33/1000 person-years for the NT Indigenous population.Conclusion: Contributors to lower than expected morbidity and mortality are likely to include the nature of primary health care services, which provide regular outreach to outstation communities, as well as the decentralised mode of outstation living (with its attendant benefits for physical activity, diet and limited access to alcohol), and social factors, including connectedness to culture, family and land, and opportunities for self-determination.

Kevin G Rowley PhD · Kerin O’Dea PhD, AO · Ian Anderson MB BS, FAFPHM, PhD · Robyn McDermott FAFPHM, MPH, PhD · Karmananda Saraswati MB BS, FAMAC · Ricky Tilmouth · Iris Roberts EN · Joseph Fitz · Zaimin Wang PhD · Alicia Jenkins MD, FRACP · James D Best MD, FRACP, FRCPath · Zhiqiang Wang PhD · Alex Brown BMed, MPH, FCSANZ

To the Editor: Little is known about the epidemiology of respiratory syncytial virus (RSV) in arid, desert regions generally, and in central Australia in particular. We performed a 5-year retrospective study from 2000 to 2004, inclusive, of children aged less than 2 years who were admitted to Alice Springs Hospital and identified as having RSV infection. RSV was detected using direct immunofluorescence (Light Diagnostics SimulFluor; Millipore, Billerica, Mass, USA) on nasopharyngeal secretions. The test has a reported sensitivity of 92%.1 We extracted demographic data from case notes and obtained population data from the Northern Territory Department of Health2 and the Australian Bureau of Statistics.3 From case notes over the 5 years, we identified 173 eligible children with RSV infection. The annual incidence rate was 21.4 per 1000 children under 2 years old. The rate in Aboriginal children was 30.9 per 1000, and the rate in non-Aboriginal children 11.6 per 1000 (P < 0.0001). The monthly distribution of cases is shown in the Box. Cases occurred throughout the year, and in every month, but there was a peak in admissions from March to August, which covers the Australian winter. Because Alice Springs Hospital is the only large hospital in the region, and almost all children needing hospital admission for RSV infection will be admitted there, our incidence rates of hospitalisation for RSV infection closely approximate population rates. However, we may have under-estimated the incidence because we only included children in hospital with proven infection, so we may have missed children who were not tested, or whose immunofluorescence test results were falsely negative. There may have been selection bias regarding admissions. Nevertheless, we found that Aboriginal children were more likely than non-Aboriginal children to be hospitalised with RSV infection, a finding in keeping with the known high incidence of pneumonia and bronchiectasis in Aboriginal children.4,5 While the incidence of RSV infection peaked in winter in central Australia, infections occurred throughout the year, and the winter predominance was less marked than is the case in temperate Australia.6 These data provide valuable information about RSV infection in an arid, desert region and can inform decisions about active or passive immunisation against RSV infection in central Australia. Monthly distribution of admissions to Alice Springs Hospital of children aged less than 2 years with respiratory syncytial virus, 2000–2004* * Inclusive.

Apakasimaka Dede · David Isaacs · Paul J Torzillo · John Wakerman · Rob Roseby · Rose Fahy · George Clothier · Andrew White · Paula Kitto

To the Editor: We agree wholeheartedly with Skull and Nolan’s call for a lifetime immunisation register to enhance monitoring of coverage, provide a clinical support service and provide data for program evaluation.1 An expanded register could also provide information on the vaccine coverage for childhood diseases that may increasingly affect adults (such as varicella and measles), for immigrants who may receive childhood vaccines after childhood, and for occupational groups (eg, influenza vaccine for health care workers). However, we note some policy implications that need to be addressed before such an expanded register could be implemented. In August 2007, at a La Trobe University seminar on human papillomavirus vaccination, the 180 participants (mainly students and staff of La Trobe University) were asked to fill out a survey that included a question about the acceptability of a lifetime vaccination register. Of the 154 who responded, 8.5% were not in favour of such a register and another 8.5% declined to answer that question (unpublished data). This suggests that there may be significant barriers to the implementation of a lifetime register. Principal among the concerns cited were the implications for privacy, which were also noted by consumer groups.2 As with the existing Australian Childhood Immunisation Register, people will need to be aware of what data are being collected (including policies for data retention), their choice to opt out, and a clearly defined purpose in gathering the data (in particular, that the data will not be used in a punitive manner). People will also need to be assured that there are unambiguous policies governing access to the register and penalties associated with breaches of confidentiality. These concerns have led to the suggestion that a private health record should be developed instead,2 but such a record would be unlikely to be adopted widely and could not be used for monitoring or program evaluation. Development of an expanded register could also present potentially significant logistical problems. We would suggest a staged approach, beginning with expanding the current childhood register to include adolescents of school age and elderly people. Incentives to improve vaccine coverage in these groups could be modelled on the current General Practice Immunisation Incentives Scheme, which provides service incentive payments, outcomes-based payments and immunisation infrastructure funding. Many Indigenous Australians are currently covered through Aboriginal-controlled community health organisations. With the consent of those organisations, data could be absorbed into a national register. Later stages of implementation might see the inclusion of special groups (such as post-splenectomy patients and immigrants) and people receiving occupation-related and travel-related vaccines. The register could eventually be expanded to encompass the full Australian population. The current redevelopment scoping study for the Australian Childhood Immunisation Register3 is due for completion in 2008. We support enhancing the current central register, but clearly defined policies to protect privacy are required to address public concerns.

Allen C Cheng · Carmel M Hobbs · Priscilla M Robinson

In reply: We welcome additional dialogue on the important issue of developing a whole-of-life immunisation register in Australia. As with introduction of any register, logistics and concerns about privacy must be carefully considered, and a stepwise approach may well be appropriate. However, it is important to note that a non-acceptance rate of 8.5% derived from a small and potentially non-representative survey of seminar attendees does not necessarily represent a significant barrier to implementation of such a register.

Susan A Skull · Terrence M Nolan

Sexually transmissible infections (STIs) are hyperendemic in some remote Indigenous populations in Australia. Screening programs have had some success in reducing the prevalence of STIs in specific populations, but there has been little overall improvement in the past 10 years. We question the usefulness of current practice and urge consideration of a new and radical approach. Instead of a “screen, treat and contact trace” strategy, we suggest adopting the same approach as currently accepted for trachoma control: populations reaching a threshold prevalence for a set of marker STIs (identified through sentinel surveillance) should be offered a treatment program aimed at the entire sexually active population. We also recommend a parallel program of health promotion and “life skills” education and outline the arguments for such a departure from currently accepted public health policy.

Francis J Bowden FRACP, FAChSHM, MD · Katherine Fethers MB BS, FAChSHM, MMed(STD/HIV)

To the Editor: Russell and colleagues recently wrote an open letter to the new Minister for Health.1 In response, we call for the Minister to champion the cause of Indigenous health. Dear Minister,Russell et al raise a number of pressing issues directly relevant to the health portfolio.1 However, of all the challenges that face you, perhaps the greatest is reversing the neglect and extreme health disadvantage experienced by Australia’s Indigenous people.2 Although the task is daunting, and detractors may argue that there are no evidence-based solutions, 150 years of collective experience from across the globe provides compelling support for real investment in the spheres of water, sanitation, housing, education, employment and primary health care to reverse health disadvantage. Tragically, while these basic necessities are taken for granted by most Australians, they remain a dream for many Aboriginal and Torres Strait Islander peoples. The greatest public health gains during the previous two centuries resulted from ensuring that communities had sustained access to clean water, adequate sanitation and appropriate housing.3 It is astonishing that these basic rights should remain on the unresolved agenda of a highly developed country. To our shame, these basic direct health determinants are not yet guaranteed for Aboriginal and Torres Strait Islander Australians.4 Relative poverty, absolute poverty and social exclusion all have a major impact on health.5 In Australia, relative poverty denies many Indigenous communities access to housing, education, transport and other societal benefits. It would be naïve to argue that this inequitable distribution of Australian resources has not been a major determinant of the poorer health of Indigenous Australians.6 The recent Auditor-General’s report on whole-of-government Indigenous service delivery arrangements clearly indicates that current approaches are inadequate and fall short on service delivery.7 There is therefore a critical need for decisive direct investment in basic infrastructure and its maintenance in Indigenous communities, along with comprehensive primary health care. This must extend to equipping and developing individuals and communities through a major investment in education and creation of employment opportunities that engages the community and is developed in true and equal partnership with respected Indigenous leaders and communities You may argue that many of these health determinants fall beyond your direct sphere of accountability. You may choose to point to the small-scale success stories, particularly in Indigenous primary health care. However, as Minister for Health and Ageing, you will continually be confronted by the direct evidence of the deleterious results of these health determinants on the life expectancy and health of Indigenous Australians.8 The time is ripe for a bold national leader to champion this cause in the corridors of power. We encourage you to become that advocate among your Cabinet colleagues. The challenge is yours. Will you have the courage and moral fortitude to make your mark on Australian history?

David N Durrheim · Mark Wenitong · Clare Huppatz · George Rubin