Indigenous health

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

Our aim was to disseminate research results about the very high rates of cannabis use in three remote Aboriginal communities in Arnhem Land, Northern Territory, to the study populations. To achieve this we translated prevalence estimates, using local concepts of life stages, numbers and quantities. The reaction of the local community to results presented in this way was characterised by the phrase used when understanding something for the first time: Wa! Ningeningma arakba akina da! (“Oh! Now I know, that’s it!”). To successfully disseminate research findings in these communities, it is critical to undertake comprehensive community liaison, to find common conceptual understandings and to build the skills of local Indigenous researchers.

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

For the first time, there is a real opportunity to deal comprehensively with the shameful situation of Indigenous communities in Australia — but the commitment needs to be huge The girl undergoing a health check in a remote community in the Northern Territory has a delightfully cheeky grin. Recently arrived from a town camp on the outskirts of Alice Springs, she is in the care of a woman unrelated to her. About 9 years old, she pops up everywhere, desperate for attention. The health check reveals that she has ringworm, dental problems and a perforated eardrum from a chronic middle-ear infection. She also has a heart murmur brought on by an earlier bout of rheumatic fever. It is vital that she undergo an echocardiogram as soon as possible. A boy aged 5 years is brought in by his mother, who is 36 weeks’ pregnant and has had no antenatal care. He and his mother have been camping rough. Although he is not here for a health check, the opportunity is taken to give him one with his mother’s consent. Although he looks happy and healthy, he is found to be anaemic and is given iron injections as well as the vaccinations he has missed. A boy of about 14 seems depressed, although this has not previously been diagnosed. The only male adults he has to model himself on are dependent on drugs and alcohol. He frequently plays truant from school. He is on a slippery slope, and much needs to be done if he is not to slide into disaster. There is so much promise for these Indigenous children, but it will only be fulfilled if their living conditions are fundamentally changed. Health crisis in a land of plentyIt is remarkable to contemplate that in parts of Australia, there is a health crisis that is in some respects more devastating than anywhere else in the world. The Australian Medical Association has called the state of health and lack of health services endured by Aboriginal peoples and Torres Strait Islanders a national tragedy and a national shame. The former president of the association, Dr Mukesh Haikerwal, wrote earlier this year: “I think we are being kind in that assessment.”1 The figures for renal and coronary heart disease among Indigenous peoples could well be the worst in the world. For instance, Indigenous Australians are three times more likely to have a major coronary event than other Australians, and 1.5 times more likely to die after such an event.1 Through my two decades of involvement with the health of Aboriginal communities, I have watched in frustration as health levels improved only marginally and self-esteem and pride were destroyed. When the “sit-down money” arrived each fortnight, in the form of numerous government handouts, many communities went into self-destructive alcohol binges for 3 or 4 days, during which time women and children were abused, children did not go to school and remained hungry. Those of us working in the field of Indigenous health have watched this happening and have tried to influence the outcome, but despite this, both the health of Indigenous peoples and the level of their education have continued to show great disparity with the rest of the population. We all know that social factors such as overcrowded housing, lack of education and limited employment opportunities, along with environmental health issues such as lack of clean water, washing facilities and functioning septic systems, all influence health outcomes of individuals and the community. These factors, combined with a cycle of welfare dependency, lead to a loss of pride and low self-esteem. Substance (particularly alcohol) misuse is a direct result. Therefore, any targeted medical strategy must have a broad focus and address all these wider issues which have an impact on the health of individuals. Some good things have been done, but not on a scale to make a real difference — until now. Massive interventionThe Australian Government’s Northern Territory Emergency Response2 is without precedent in Australia. It is the largest and most significant whole-of-government initiative yet carried out in this country. The government set up the Northern Territory Emergency Response Taskforce (Box) to provide advice and to oversee the implementation of the emergency measures. The intervention has three broad objectives: stabilisation to protect children and secure their communities; normalisation of services and infrastructure; and in the longer term, sustainability, bringing Indigenous Australians fully into line with the choices other Australians enjoy. The government committed $587 million for the stabilisation phase in the 2007–08 financial year. This is for urgent and immediate actions. It includes over $83 million specifically for improving child and family health, with $205.8 million for employment and welfare reform and the balance for promoting law and order, enhancing education, supporting families and for housing and land reform.2 On 18 September 2007, the government announced further funding of $740 million to highlight its long-term commitment, bringing the total committed so far to $1.3 billion. This includes $100 million over 2 years from the 2008–09 financial year for more doctors, nurses, allied health professionals and specialist services.2 When the response was announced on 21 June 2007, many were concerned about its motivation and methods.3 Was this not paternalism or yet another attempt to dominate Indigenous communities? Well, while it is still early days in an intervention to which the Australian Government has committed itself for at least 5 years, I have seen how this response is already bearing fruit and believe everyone with concern for Indigenous health should continue to support this initiative. We cannot let this opportunity go. For instance, the introduction of strict controls over alcohol consumption had a huge impact almost immediately. An Indigenous woman told me that, for the first time she could remember, she had had a week of sleeping peacefully. A sharp reduction in the physical abuse of women and children has also been seen. The Chair of the Northern Territory Emergency Response Taskforce, Dr Sue Gordon (Box), reports that in communities across the NT, women are talking about the positive effects of alcohol bans in reducing violence, abuse and antisocial behaviour. The same thing is probably happening with levels of child sexual abuse — the horror which sparked off this emergency response — although it will only be when more trust has been built up that we will be able to explore this more fully. A comprehensive program of health checksOne of the pillars of the initial phase of the Northern Territory Emergency Response from a health point of view is the health checks to be carried out on up to 17 000 children aged 15 years and under in 73 target communities. By 19 October 2007, medical teams had already completed checks on more than 3200 children. The findings of these checks are sobering, and underline the need for the intervention. We already knew that the children in many of these communities had very high rates of chronic diseases, but have found that the situation is even worse than the official picture. The Indigenous population has a burden of disease up to six times higher than in the non-Indigenous population.4 Probably 80% of the Indigenous children have middle-ear diseases. Intestinal parasites and skin infections are rife. An absence of water for washing — taps don’t run, toilets don’t flush, there is no soap — has led to skin hygiene so poor that pathogens thrive. This in turn contributes to the devastating levels of renal disease and heart disease, the latter particularly associated with rheumatic fever. Type 2 diabetes is also increasingly common in children.5 Of course, painting a full picture of the burden of disease is only the start. It must lead to a massive increase in treatment resources, and, beyond that, to a transformation of these communities. Only the synchronous rollout of many measures will be truly effective. This will take a lot of time and a lot of money. Fortunately, the government is committed to this initiative for at least 5 years. Step by stepStrategies in the stabilisation and normalisation phases of the initiative include: voluntary health checks available for all children aged under 16 years in target communities; development of a range of special services for children and their families who have suffered trauma from physical, sexual and emotional abuse or neglect; increased police presence to guarantee safety and security for community members; implementation of alcohol-management plans; a focus on getting children to school; support for and an extension of the current nutrition programs for Indigenous children; establishment of crèches in communities; funding for new housing and renovations; a focus on creating real jobs within the communities and incentives to develop local businesses; the appointment of government business managers in each community; government assistance to the Northern Territory Government to expand child-protection services and increase the number of safe houses; changed welfare payment rules to ensure money meant for children is spent on them, including quarantining welfare payments to parents or carers if children do not attend school; a licensing program for community stores to ensure families have access to a range of healthy foods; acquiring 5-year leases over the main townships to ensure the job is done quickly; and opening up communities by changing the permit system so that people can visit common areas within them. A well resourced primary health care system — enough doctors, health workers and nurses — is integral to long-term sustainability. Further, interventions to manage the diseases identified by both the child health checks and data from the Northern Territory Government will need to be implemented. Talks have already started about this. I would like to think that extensive treatment programs will be underway within a year to deal with the ear, dental, cardiac and renal problems. Along with educating children and parents about the importance of personal hygiene, we need to make this feasible. Installing taps that work will make a huge difference. However, a sustainable solution will require much more than this, and the key will be education. That is the only way out of poverty, and away from the debilitating system of government handouts. Pride has to be restored to shattered communities. Seize the opportunityThis intervention is not going to be perfect; there will be many problems to overcome, but it gives us a tremendous opportunity. Of course, some people, particularly those with vested interests (like those making money out of selling alcohol), will feel threatened. Others will claim the response is paternalistic. To them, I have two things to say. First, in many of these communities, there is a complete breakdown of normal mores. It is not paternalistic to be firm about what is not acceptable. Second, the ultimate aim is to restore these communities, their resources and self-esteem to the point where they are in charge of their own destinies. I believe this initiative offers a real chance to restore the health not just of the rural and remote Indigenous communities of the NT, but of Australian society, wounded by these enormous disparities. It is up to us to seize this one-time opportunity to finally solve a problem that has been decades in the making. We dare not let the momentum be lost. Northern Territory Emergency Response Taskforce2 The Taskforce was established to advise the Australian Government on how best to protect Indigenous children in the Northern Territory, oversee the Northern Territory Emergency Response Taskforce Operational Group, and promote public understanding of the issues involved. It is made up of people with experience in areas such as medicine, government, the law, education and business. Its members are: Dr Sue Gordon AM (Chair), a magistrate in the Perth Children’s Court and chair of the Australian Government’s National Indigenous Council. Major General Dave Chalmers AO, CSC (Operational Commander), who has considerable organisational and command experience, notably in East Timor and as commander of the joint taskforce that provided humanitarian relief to Sumatra after the 2004 Boxing Day tsunami. Dr Bill Glasson, ophthalmologist and former president of the Australian Medical Association, who has worked on a voluntary basis in a number of Aboriginal communities and in East Timor. Roger Corbett AM, member of the Reserve Bank of Australia Board and former chief executive of Woolworths. Miriam Rose Baumann AM, principal of St Francis Xavier Catholic School in Daly River, a member of the National Indigenous Council, and chair of the Aboriginals Benefit Account Advisory Committee. Dr Peter Shergold AC, secretary of the Department of the Prime Minister and Cabinet. Paul Tyrrell, chief executive of the Northern Territory Department of the Chief Minister.

William J H Glasson FRACO, FRCOphth, FRACS

The Aboriginal Medical Services Alliance sees the Australian Government’s recent intervention to protect Indigenous people, the Northern Territory Emergency Response, as an opportunity to improve primary health care. Despite its serious reservations about other aspects of the intervention, the Alliance considers that sustained improvements in primary health care can be achieved via genuine engagement of government with Aboriginal communities The view portrayed to mainstream Australia in the introduction of the intervention was that an emergency response was essential because nothing in the Northern Territory was working. However, Aboriginal community-controlled health services (ACCHSs) in the NT have been collaborating for some time with the federal Office for Aboriginal and Torres Strait Islander Health and the NT Department of Health and Community Services, to reform and expand the delivery of primary health care services. A challenge and opportunity for these existing services has been, and continues to be, to harness the intervention’s child health checks to ongoing efforts to develop comprehensive primary health care services for Aboriginal communities in the NT. In recent years, before the intervention, there was progress in dealing with key identified inadequacies in primary health care and related health services. Remedies included: initiatives related to needs-based planning, with delivery of more equitable and increased primary health care funding; training, recruitment and retention of the health workforce and planning for comprehensive, regional primary health care services; development of state-of-the-art information technology systems for patient information and access to records; and development of high-quality-care initiatives based on key performance indicators. These changes have been recognised as leading to the current improvements in the life expectancy of Aboriginal people and the reduction in the rates of some chronic diseases.1,2 The Northern Territory Emergency Response and its effectsThe emergency intervention came from left field. The health component, like the intervention as a whole, got off to a bad start. Individual health checks on children were not recommended in the Ampe akelyernemane meke mekarle: “little children are sacred” report,3 but the Australian Government initially talked about compulsory forensic examinations of all children to ascertain a level of sexual abuse. This would have been a form of assault if carried out, and it is likely that no doctor would have agreed to participate in such a process. Thankfully, this never occurred. As with other parts of the intervention, it appears not to have been properly thought through. Within a week, the Minister for Health had publicly given guarantees that the checks would be voluntary and would be carried out by a procedure already being used throughout Australia —Medicare item 708, Aboriginal and Torres Strait Islander child health check.4 Developed in collaboration with ACCHSs, the health checks, if properly done, contribute to children’s health in a broad and holistic manner. Nearly 1000 of these checks had been completed in the NT before the intervention. If providers had suspicions of sexual abuse or neglect they would refer the children to the appropriate person or authority, as was already their mandatory duty, but it was recognised that the health checks were not designed to detect child abuse. Unfortunately, the initial suggestion of compulsory sexual examinations generated widespread fear and misinformation about the health checks. It has taken much work to explain to Aboriginal communities that these were the same checks that were already being done by ACCHSs. The only reason they had not already been provided to all Aboriginal children was a lack of resources. Another concern that was raised in some quarters was the cost of doing the health checks. It could be argued that the $83 million could be better spent on other priorities. While this may be true, there was little room to discuss doing anything else with the money. The Australian Government had already decided that the checks would be done and had allocated the necessary funding. Undertakings by Aboriginal medical servicesThe Aboriginal Medical Services Alliance Northern Territory (AMSANT) decided that it was important to engage with the process of children’s health checks for two reasons. First, without the full cooperation of and engagement with existing ACCHSs, the health checks would not be done as well, would not reach as many children, and would not be properly coordinated with the systems and ongoing responsibilities of ACCHSs. ACCHSs across the NT had begun providing the checks, so this part of the intervention was seen as an opportunity to do them much more quickly and with a commitment to ensuring that the necessary follow-up was available. An average of 67% of children across the NT have been brought by their families to have a health check by the visiting teams in the more than 40 prescribed communities that have been visited so far. The second reason for AMSANT to engage with the health checks was to enable it to continue to work with the Department of Health and Ageing to secure the longer-term needs of the primary health care system. This has led the Department to commit an additional $100 million over 2 years for improving comprehensive primary health care in the NT. The total current expenditure on Aboriginal primary health care in the NT is about $80 million a year. Therefore, an additional $50 million a year is a substantial commitment. An improved primary health care system can sustainably and routinely deliver better health care for children. Since the intervention began, AMSANT and its members have lobbied effectively for an improved and more participatory process. As a result, the Australian Government has worked constructively with AMSANT in planning the details of the follow-up programs. In contrast to the previous approach of offering health checks in the absence of adequate services to provide subsequent treatment, we have the opportunity here to significantly expand primary care and specialist follow-up. The key barrier to the successful implementation of the Australian Government’s initiative is the workforce shortage. In particular, further teams of nurses, general practitioners, ear health workers and others are needed to ensure apprpriate follow-up. It would be unacceptable for deficiencies in the workforce to prevent the children who have been checked from being followed up. The intervention has provided an opportunity for health professionals from mainstream Australia to work in the NT, and we hope they will return to work again with our dedicated teams in the bush. Continued support from various peak health professional associations and the Australian Government is required for this recruitment process now and into the future. The futureThe health checks and an improved primary health care system are now clear potential benefits of the intervention. Also, the additional police and other improved services have been needed and are welcome. Some other aspects of the intervention are less likely to be positive and others are likely to be harmful. In particular, its initial implementation was profoundly disempowering to many Aboriginal people in an environment where disempowerment and loss of identity lie at the root of community dysfunction. The medical profession knows that lack of control of life circumstances can contribute significantly to worse health outcomes. This could be a very damaging effect of the intervention, particularly in the light of the already large gap in life expectancy between Aboriginal and Torres Strait Islander peoples and other Australians (17 to 20 years’ difference). It is also vitally important that the racially discriminatory aspects of the intervention, such as the welfare changes and the forced prohibition of alcohol, be repealed, as there is a clear and well established relationship between the protection of fundamental human rights and population health.5,6 Welfare reform may have merit, but any reform needs to be applied to all welfare recipients across Australia or targeted at particular people who are identified as not acting appropriately with their children. The discriminatory quarantining of income of Indigenous people is also not in the spirit of the Australian Government’s stated aim of encouraging individual responsibility. Similarly, alcohol reform is desperately needed, but the measures the intervention has imposed — forced prohibition in certain places and the need to record takeaway alcohol purchases of more than $100 — have no evidence to support them, are unevenly applied and do little to reduce the supply of alcohol. The need to reform the Community Development Employment Projects, in which an estimated 7500 Aboriginal people in the NT are employed in community-controlled projects funded by block unemployment benefit grants, is widely accepted. To scrap them altogether will rob many of meaningful work, self-esteem and confidence, and diminish the capacity of Aboriginal organisations and communities. This may add to, rather than diminish, social dysfunction. The medical profession has been aware for a very long time of the importance of education to improving the health of populations. The need to fund adequate preschool, primary school and secondary school places for Aboriginal children across the NT is paramount, but this has largely been ignored up to now. The small amount of new funding allocated by the NT Government to education is just a fraction of what is needed to ensure that all Aboriginal children can access all tiers of education. Additional housing is also urgently needed. Chronic overcrowding contributes to poor health outcomes and places children at risk of sexual abuse. The additional $780 million for housing currently offered is a welcome new investment, but will probably not be enough. AMSANT’s experience with the intervention’s child health checks is instructive for other aspects of the intervention. It has required refocusing an initial highly inappropriate measure (compulsory checks for sexual abuse) so that an existing appropriate service (the health checks under Medicare) can be advanced and so that an improved, sustainable primary health care system will ensure the capacity and resources for proper follow-up. A similar rethinking, focused on child protection, is required for other aspects of the intervention. Crucially, this can only occur through a process that achieves genuine engagement of Aboriginal communities as well as the support and cooperation of both the federal and NT governments. This, after all, was the central thrust of the “Little children are sacred” report. For the sake of the children, we must continue to pressure governments to adopt its recommendations.

John D Boffa MB BS, MPH · Andrew I Bell FAFPHM, FACRRM, DRANZCOG · Tanya E Davies FACRRM, FRACGP, DRANZCOG · John Paterson · David E Cooper PhD

Has the federal government’s intervention in Aboriginal communities taken a respectful, tolerant, partnership approach? The timing of the federal government’s intervention to protect little children in the Northern Territory has been viewed by some with cynicism. And well it might be. The intervention needs to be seen in the broader context of what could be called the “white blindfold” view of history. The white blindfold obscures the benefits that modern Australians have inherited as a consequence of European colonisation of this country. It hides any understanding of how dispossession of the Aboriginal first nations has resulted in the poverty, illness and violence that the government is now, belatedly, seeking to rectify. The current neoliberal ideology also prevents understanding of the mechanism of how dispossession and marginalisation have caused the spiritual, mental, social and physical dis-ease that we see at present. In not understanding the causal links, the government is not able to properly arrive at a workable solution. In fact, the approach being trialled stands a good chance of making the underlying problem worse. Work by Marmot1 and Wilkinson2 and insights from de Botton3 and Freire4 throw light on the background and mechanisms whereby the process of colonisation and the ongoing situation of Indigenous people in Australia today translate into physical and mental illness and social discord. The argument, most simply put, is that inequalities, especially overt economic and social inequalities, cause people lower in the pecking order to feel inferior. Even worse, the “lower orders” feel disrespected by their “superiors”. It is the perception of disrespect, manifest in many minor ways, and perhaps not even consciously expressed and received, that drives the sense of inferiority. Through neurological, endocrine and immunological networks, disrespect and inferiority become internalised as immune suppression, inflammation, and acute and chronic illness. Externally, they emerge as substance misuse, risk-taking, violence and social discord. The foundation social determinants of health are social equality and respect. In today’s Australia, particularly in relation to Indigenous people, these are fragile, tenuous, or perhaps even lacking. The logical solution is to create a more equal, tolerant and respectful society. That doesn’t mean handouts and welfare. It does mean working in a respectful manner and offering a partnership approach to helping with economic and community development. The most respectful approach involves listening to community leaders. After all, it is the leaders who have been struggling with the problems for a long time and may have some ideas about locally applicable solutions. Has the federal government’s intervention taken a respectful, tolerant, partnership approach in seeking to improve the lot of children in the NT? No one can claim that it has. From the outset, the intervention has been styled as strong, decisive action. The situation has been framed as an emergency. Consultation with Aboriginal leaders has come later and has been approached in the vein of “this is how you are going to do what we want”. In the federal government’s haste to be seen to be responding to the Ampe akelyernemane meke mekarle: “little children are sacred” report,5 there has been talk of children being forensically examined and uncertainty about what will happen. Scared parents are disturbed by these developments and by the stories of older people who still hold clear memories of the stolen generations — another thing obscured by the white blindfold. Are Aboriginal leaders and the communities they lead feeling respected? The intervention is not implementing any of the recommendations of the “Little children are sacred” report. There are moves to change rules of access to Aboriginal land and there is talk about changing the Aboriginal Land Rights (Northern Territory) Act 1976 (Cwlth). The links between such changes and saving little children are not well spelt out. It is not clear what impact these aspects have on economic development. How does this leave Aboriginal people feeling? In 1989, the National Aboriginal Health Strategy was developed by Aboriginal leaders in partnership with government. It recommended that $2.5 billion be spent nationally over 5 years to achieve improvements in Aboriginal health. In fact, only $232 million was allocated over the 5 years. Since then, Aboriginal health leaders have repeatedly called for adequate funding. In the NT, calls to establish the Primary Health Care Access Program have, until recently, received a muted response from all levels of government. Now, in the lead-up to a federal election, between $0.6 and $1.3 billion has suddenly become available to save Aboriginal children. How do you think Aboriginal people are feeling about that? The other collateral damage is occurring among the doctors, nurses and Aboriginal health workers who, for years, have been doing their best in a resource-poor environment to treat the sick and improve health. How do they feel about this sudden flood of resources that is bypassing the services they are working in, and the unspoken implication that perhaps they haven’t been doing their job well enough? Not that this new bucket of money is not recognised as potentially useful. People are only too aware of the need. As the local analogy goes, the steamroller is coming through: no point lying in the road and getting squashed — let’s run alongside and see what falls off. Maybe we can even nudge it in a more appropriate direction. The key question is whether the government’s intervention will be effective. The answer depends mainly on one’s definition of “effective”. If we were to define effective as creating healthier, more economically robust and socially cohesive Aboriginal communities in the NT, then I am not confident that the present approach can deliver that. This is because the current approach is essentially disrespectful of Aboriginal people and is further marginalising their leadership. In other words, the fundamental social determinants of NT Aboriginal health are being undermined. Were the intervention to be reconfigured and the money invested in a way that supported Aboriginal leaders to build their own capacity and to develop a community response, then I would be much more confident that long-term good will come from it. Community building projects that have been run in other Australian jurisdictions have demonstrated that this approach works — for example, the Windale Community Renewal Scheme in New South Wales.6 There is, besides, an established primary health care sector operating in the NT which, with adequate funding, would be well positioned to do more of what it is already doing. The political will to take action has obviously been present. There is bipartisan support for it to continue. What will be most interesting will be to see what happens once the election is over and the process of governing the country for the next 3 years begins. Will the federal government continue in the same disrespectful manner or will it be open to a change in approach that might truly make a difference?

Peter W Tait MB BS, FRACGP

Coercive reconciliation: stabilise, normalise, exit Aboriginal Australia. Jon Altman, Melinda Hinkson, editors. Melbourne: Arena Publications, 2007 (ix + 342 pp). ISBN 978 0 9804158 0 3. In June 2007, in response to a Northern Territory report on Aboriginal child sexual abuse, the Australian Government declared a national emergency, with interventions aimed at protecting Aboriginal children. While few deny the need for action to address the problems in Aboriginal communities, the sheer scale of the intervention has left many confused. We now have, in one volume, a series of 30 (mainly critical) essays about various aspects of the intervention, written by knowledgeable commentators, many of whom are Aboriginal. One overriding theme that emerges from the essays is that a lack of community engagement means that the intervention is destined to fail, with potentially disastrous results for Aboriginal people. Tom Calma states that the “. . . fundamental elements of good Indigenous policy . . . engagement, participation and accountability” are missing. Raimond Gaita argues that “No plausible description of the plight of the Aboriginal communities can justify . . . the lack of consultation and the reckless disregard for the consequences of the intervention”. He asks: “Could such disrespect be shown to any other community in this country?” He believes not, suggesting that “. . . Aborigines and their culture are still seen from a racist, denigrating perspective”. John Sanderson (former Australian Army Chief and Western Australian Governor) suggests that the intervention ignores the known effects of cultural and social disempowerment on physical and mental health. Some suggest that the child health checks, at least, may be worthwhile. However, as Ian Anderson points out, the health checks were initially going to be mandatory and forensic, but were appropriately changed to be wellness-focused and voluntary. As the Government had already started to roll out Medicare-funded Indigenous child health checks, this aspect of the intervention is just window-dressing — other components of the intervention will have bigger and more worrying effects. After reading the essays, the reader must be concerned about the potentially devastating impact on Aboriginal health and wellbeing of this perhaps well intentioned, but ultimately ideologically driven, intervention. The medical profession has a responsibility to be informed about what is happening. This book will help — it should be widely read.

David J Scrimgeour

It remains unclear how federal government intervention measures in Indigenous communities in Central Australia will create sustainable, safe and nurturing communities There are none among us who would question the sanctity of our children. Children lie at the core of Aboriginal existence and of our survival. Furthermore, there are none among us who would not welcome any just measures to protect our children. Child protection and survival remain central to the fight for Aboriginal rights, identity and cultural continuity. Yet now we bear witness to a moment in time when the very foundational principles on which Aboriginal existence are built — community, culture and collective rights — have been shaken, demonised and exposed to a level of scrutiny unparalleled in recent times. In no place has this been felt more acutely than in Central Australia. In 2006, revelations offered by the Alice Springs Crown Prosecutor outlining an accumulated dossier of abhorrent cases of child sexual abuse in Central Australia were met with immense public horror.1 The response was understandable, but failed to acknowledge that the dossier echoed the voices of Aboriginal communities’ repeated calls for action over the span of several decades — voices that had been ignored. The response, from public commentary and an increasingly vocal anti-Aboriginal-rights sector, was swift and damning, editorialising the suffering of Aboriginal communities. In many respects, a new (or rekindled) language emerged, the language of “Aboriginal deficit”. The media were awash with claims of “paedophile rings”, of a culture that “accepted and protected” the raping of children, of “customary law being used as a shield to protect abusers”.2,3 The inference was that all Aboriginal men are “perpetrators”, all Aboriginal children are abused, and that these abuses — fuelled by alcohol, petrol and kava — are compounded by social dysfunction that is largely the consequence of a “primitive” and “barbaric” culture. Public commentary allowed the seeds of change to be sown, change that “required” a “new paternalism”, “normalisation” or “mainstreaming”; that called for the closure of “unviable remote communities”; that touted the “failure of self-determination”; that required an end to “political correctness gone mad” and the “pouring billions of dollars down the toilet”.4,5 Unfortunately, such language has been used to justify blatantly discriminatory policy. In response to public reports, the Northern Territory Government initiated an investigation into the issues of child sexual abuse. These issues were recorded, collated and considered within the Ampe akelyernemane meke mekarle: “little children are sacred” report.6 The ill health and profound disadvantage of Indigenous Australians, particularly of Indigenous children, is well documented, persistent and inadequately addressed. Aboriginal and non-Indigenous professionals and advocates have long called for necessary long-term commitment to and adequate resourcing of health, housing, education, employment and development. Communities have long demanded support for structures for civil society; sustainable environments; respect for cultural diversity; investment in social and human capital; access to high-quality, appropriate child and adult education; and equality of opportunity in the face of enormous disadvantage. Reams of recommendations have been listed, skimmed, ignored and filed — any number of which, if put into practice, could have made a sustainable difference on the ground for Indigenous Australians. The “Little children are sacred” report, irrespective of its integrity and worthiness, joins a disturbingly long list of reports whose recommendations have been largely ignored. In comparison, however, it may well stand out as one of the most blatantly bastardised of all Aboriginal health reports, in that the federal government has “delivered” the NT intervention, in rhetoric, as a means of protecting Aboriginal children. Yet, despite claims that the report guided and was the impetus for the federal government’s intervention, surprisingly few of the report’s recommendations have been considered or implemented. In fact, many commentators have suggested that the report has been used as a shield to force the imposition of an existing federal government agenda to dismantle any semblance of collective and individual rights, native title, and self-determination among Australia’s first people.7 The announcement of the NT intervention was met with an almost audible collective sigh of despair across much (but not all) of Aboriginal Australia. In an instant, another weight was placed on Aboriginal communities, spelling a potential end to the progress made in generations of struggle for acknowledgement and recognition of Aboriginal people’s right to have some control over the future of their families and communities. This is not to suggest that communities are not supportive of an array of intervention targets. Indigenous communities have long called for improved policing; measures to reduce alcohol-related harm; enhanced educational and vocational opportunities; and improved infrastructure, health services and community safety. In fact, in discussions with communities directly involved in the intervention in the NT, there remains strong support for any just and appropriate measures that deliver these. Yet there remains enormous confusion and concern over other elements of the intervention that seem unconnected to child health, such as compulsory land acquisition by the federal government; the abolition of entry permits for Indigenous communities and of Community Development Employment Projects programs; the appointment of government business administrators to “run” Indigenous communities; and the potential threat of community asset-stripping. Further, the legislation covering the NT intervention places unparalleled control of Indigenous affairs in the hands of the Minister (or his designated delegate), and is largely discretionary and, in critical elements, poorly defined. Unfortunately, we also bear witness to a moment in time when Parliament has allowed the passage of racially discriminatory legislation. The most fundamental of all questions remains: will the intervention actually make children safer? Unfortunately, there has been little public or professional debate on this issue. The federal government has largely polarised public discussion, reducing complex issues to narrow, unsophisticated arguments with little recognition of the inherent complexity of the causes and consequences of abuse, in all its forms — particularly in the context of profound disadvantage, marginalisation, trauma, grief and loss, and generations of governmental inaction and under-resourcing. Public debate has been dampened. In simplistic terms, the line is that “you are either with us or against us”. To fail to support the package in its entirety is to either be a child abuser or to accept and support child abuse. Yet, as professionals and citizens, it is our inherent responsibility to question the how, even if we agree with the why. In the weeks and months following the announcement of the NT intervention, it has become clear that decisions were made in a policy and strategy vacuum. Activities have been poorly coordinated, poorly planned, and liable to change and backtracking. This has fuelled confusion and paranoia, and created enormous concern about the squandering of desperately needed resources, which are being used largely to install the bureaucracy rather than provide services.8 Worse still, the current approaches are undermining successful programs already in place in communities. The long fought-for resourcing and community actions required for healing, protecting and nurturing Indigenous children are being de-funded and ridiculed. Child health checks are already occurring; vaccination rates are generally high in Central Australia; many communities already have complete bans on alcohol; families voluntarily submit to “income management programs”; communities have established their own child protection services (because of the failure of government departments), and have progressed towards improved partnerships with police and child protection agencies, who, by their own admission, lack the capacity to adequately respond to reported cases of abuse. Labelling the intervention as the response to a crisis that could not wait a single day longer to be rectified is a fallacy. The government has had countless offers of guidance to better direct the intervention elements, the child health checks, the necessary follow-up and long-term health and social needs. Yet these offers have been ignored. The most worrisome elements of the intervention may lie in the likely and unintended consequences. Communities remain deeply concerned that there will be direct casualties of the intervention, casualties that communities can ill afford, but that the government considers necessary and acceptable “collateral damage” — worsening poverty, suicide and unemployment (particularly of Aboriginal men); disempowerment; the creation of an atmosphere of fear, in which complaints of abuse are less likely to be reported; and a “one size fits all” approach that frames all Aboriginal communities as dysfunctional, all Aboriginal people as abusers, and all Aboriginal children as abused. It remains unclear how any of the intervention measures will create sustainable, safe and nurturing communities, or whether they will protect Aboriginal children at all, particularly in the face of decades of under-investment in the basic building blocks of healthy societies. Despite the likely negative consequences, the intervention may offer opportunities to improve health and social outcomes and promote safer communities, but it remains to be seen whether this potential can be realised. The opportunity exists to focus our attention on the needs and priorities of our young people, to use best-practice models of health promotion and care for Aboriginal adolescents, and to make their safety and development a national priority. However, without a focus on healing, mental health and support for Indigenous youth, both now and over the long term, the intervention is likely to fail. As a society, we must ask ourselves whether the current interventions will empower communities and support them appropriately, in a spirit of collaboration and respect, to adequately deal with the causes, triggers and consequences of abuse. Marginalisation, poverty, disempowerment, colonisation and trauma are the upstream contributors to psychological, physical and sexual abuse in the present. Yet the current policy is likely to deliver the very same things, and, as a consequence, risks perpetuating dysfunction and abuse. The government has yet to explain how the removal of Aboriginal people’s right to control or participate in decision making and implementation will promote their survival and protection. The likely success or failure of the NT intervention may well rest on what mainstream Australia sees as Aboriginal people’s place within contemporary Australia. Are Aboriginal people simply an echo of a past worth forgetting, a relic of a barbaric and uninformed culture? Are we only good as footballers, athletes or performers in opening ceremonies? What of Aboriginal Australia’s aspirations for its own future, or is this something that a globalised community can ill afford to consider? The current policy approach rests on a false underlying assumption that all Australians must share the same values and aspirations. The success or failure of the intervention may also depend on what we consider that Indigenous people offer contemporary Australia. Strength in diversity, wisdom, connectedness, humility and survival against the greatest of odds . . . in any other context these attributes would be regarded as national treasures, as a collective identity worth nurturing, building and embracing. Yet, in 2007, these qualities of our Indigenous people seem to be unrecognised or even disdained. A nation and its people are judged on how they treat their most vulnerable, disadvantaged and marginalised. The significance of our current federal government’s refusal to ratify the United Nations Declaration on the rights of indigenous peoples9 has not been lost on Aboriginal people and their advocates.10,11 On the one hand, the government purports to be taking action to protect vulnerable Aboriginal children, yet on the other, it fails to support any national or international requirement or responsibility to recognise and acknowledge native title, cultural integrity, self-determination, and preservation of Indigenous knowledge and sovereignty, as set out in the UN Declaration.9 It is our responsibility, then, as individuals, professionals and as a nation, to ask how our government’s stance on these issues can coexist with the stated aim of protecting our most vulnerable, our children, our future.

Alex Brown BMed, MPH, FCSANZ · Ngiare J Brown BMed, MPHTM, FRACGP

Lands of shame. Helen Hughes. Sydney: The Centre for Independent Studies, 2007 (xv + 237 pp). ISBN 978 1 864321 35 7. Lands of shame was the blueprint for the Howard Government’s “national emergency” intervention in the Northern Territory. In spite of its influence, I would not recommend Lands of shame to anyone desirous of gaining an insight into the history of Indigenous policy, because of its simplistic generalisations and ideological bias. According to Hughes, poverty in remote Indigenous communities is a legacy of the “Coombs socialist homeland model” introduced 30 years ago. Elements of this model included communal property rights, the apparent use of customary law and other “separatist policies” designed to resurrect “hunter–gatherer economies”. Hughes’ description of the evolution of Indigenous policy is incongruous with the history of my home state of Queensland. Many of Queensland’s remote Indigenous communities are former reserves that were established during the protectionist era that preceded the 1970s. Far from being hunter–gatherer economies, the reserves were akin to Dickensian workhouses that left little room for human dignity, let alone the sanctity of family life. I can still remember the first time that I visited one of the former reserve communities, and a colleague pointed out to me the old dormitory where young children were once forced to live. Years later, the inevitable pain that would have been suffered by the children’s parents still makes me shudder. Arguably, such indignities offer a far more plausible explanation for the contemporary social problems of some remote Indigenous communities, than communal land tenure. Yet this history is largely overlooked by Hughes. Hughes’ greatest flaw is her failure to comprehend the immorality of writing a manifesto for Indigenous people in the absence of a meaningful dialogue with us. Hughes routinely dismisses the Indigenous leadership as corrupt “Big Men”, with only Noel Pearson (who conveniently shares her ideological position) spared rebuke. Her apparent view of respectful engagement with Indigenous people as superfluous makes Hughes no better than those she condemns. Indeed, the very lack of empathy that enabled bureaucrats to remove Indigenous children into dormitories is a disturbing, though unacknowledged, presence throughout the entire book.

Nicole Watson

To the Editor: Cannabis use is implicated in serious social disruption in many Northern Territory Aboriginal communities.1 Rising levels of cannabis use were first reported in Aboriginal communities in Arnhem Land in 2002, along with associated concerns about escalating social impacts and mental health effects compounded by other substance use.2 A random sample of 164 people in Arnhem Land initially interviewed and assessed in 2004 were followed up between October 2005 and June 2006. Their cannabis use was measured using health worker assessments and self-reports from interviews. Ethical approval was granted by the NT Health Department, Menzies School of Health Research, and James Cook University. Despite a modest decline in cannabis use in this population between 2002 and 2004,3 the 2005–2006 data indicate persisting high rates, with 61% of males and 58% of females (aged 13–34 years) using cannabis at least weekly. In a subsample of 60 cannabis users opportunistically recruited for in-depth interviews in 2005–2006 (37 male and 23 female, aged 13–42 years), 92% of males and 78% of females used cannabis daily; 88% reported cannabis dependence symptoms. These figures appear to be far higher than national rates, although national data for similar age groups are not available.4,5 Research has found that, nationally, 6% of males and 3% of females (aged ≥ 14 years) reported using cannabis in the past week; 18% of males and 13% of females smoked cannabis daily;4 and 21% of adults (aged ≥ 18 years) using cannabis were dependent.5 Beyond high rates of cannabis use in Arnhem Land communities, we also found local characteristics and perceptions that illustrate the drug’s distinctive context of use (Box). Quantities of cannabis used appear to be higher than in the general population; unemployment among users is higher; and violence related to diminished supply is common. One Indigenous community leader described attitudes to cannabis use: “... if there’s a bowl of it on the table, it is smoked until gone, morning to night”. Interestingly, some respondents reported that using cannabis prevents them from engaging in criminal activity (Box). While key community members may believe that cannabis is a tool for social control — “good for calming down people” — they are increasingly recognising the significant social and mental health problems it causes: People get chained by [cannabis], they don’t go hunting with family ... lots of fights when they can’t get any ... [Cannabis] becomes the boss. Continued concerns about adverse mental health consequences for Aboriginal people in Arnhem Land who use cannabis seem to be warranted. Cannabis appears to be firmly entwined in these isolated communities in a manner not seen nationally. High levels of concurrent drug use, particularly tobacco, raise additional health concerns. Resources are urgently needed for prevention programs and targeted interventions for chronic cannabis users and those with psychiatric comorbidity. If these patterns of use continue, the implications for compounding of pre-existing mental illness and the potential mental health burden are disturbing. Characteristics and perceptions of cannabis use in Arnhem Land Aboriginal communities (57 males and 49 females, aged 13–42 years*) in 2005–2006 compared with available national data from 1997† and 2004‡ National4,5 Arnhem Land* National4,5 Arnhem Land* Number of cones smoked Per cent unemployed current users / daily users 3.2 (average per day)‡ 7.4 (average per occasion) 25.6%† / nd 60% / Males, 41%; females, 94% Concurrent drug use Motivations for use Alcohol (86.2%); stimulants§ (8.2%–27.9%); none (10.8%); analgesics (6.6%); antidepressants (5.7%); tranquillisers/sleeping pills (4.4%); other (3.9%)‡ Tobacco (100%); alcohol, restricted access (40%); kava (15%); petrol (5%)¶ nd Socialisation (tempted, lonely, copying friends); mood altering (“calms me down”, “gets me going in the morning”, “makes my mind straight”); drug substitution (from alcohol or petrol); prevents criminal activity (stealing or other trouble) Drug substitution (when cannabis unavailable) Motivations for ceasing/moderating use Alcohol (60.4%); no substitution (34.2%); ecstasy/designer drugs (1.3%); painkillers/ analgesics (0.8%); tranquillisers/sleeping pills (0.5%); heroin (0.3%); antidepressants (0.2%); cocaine/crack (0.1%); other (1.1%)‡ No substitution (83%); kava (7%); alcohol (5%); petrol (5%)¶ nd Limited supply; starting a family (females); “sick of fighting when cannabis runs out”; “made me sick”; “mind not straight”; expenses and time spent looking for cannabis; employment (males) * Self-report interview data from an opportunistically recruited sample (using age and sex quotas) of respondents, including people who had never used cannabis as well as current and former cannabis users. † People aged ≥ 18 years.5 ‡ People aged ≥ 14 years.4 § Including ecstasy. ¶ There have been no reliable reports of stimulant, benzodiazepine or barbiturate use in these communities. nd = data not available.

K S Kylie Lee · Alan R Clough · Katherine M Conigrave

Objective: To describe changes in delivery of preventive services among adults in Aboriginal communities that occurred in association with a systems-oriented intervention.Design, setting and participants: A quality improvement intervention with a 2-year follow-up was undertaken at 12 Aboriginal community health centres in the Northern Territory between January 2002 and December 2005. The study involved 360 well adults aged 16–49 years who had no known diagnosis of chronic disease.Intervention: Two annual cycles of assessment, feedback workshops, action planning, and implementation of system changes. Assessment included a structured review of health service systems and an audit of clinical records.Main outcome measures: Adherence to guideline-scheduled preventive services including taking basic measurements, laboratory investigations, lifestyle counselling and pneumococcal vaccination.Results: Of 12 preventive services measured, delivery of four services showed improvement over the study period: counselling on diet increased from 3% to 8% (P = 0.018); counselling on physical activity from 2% to 8% (P = 0.006); counselling on smoking from 2% to 11% (P = 0.003); and counselling on alcohol from 2% to 10% (P = 0.007). There was no improvement in important measures such as monitoring of waist circumference, blood pressure and blood glucose level, and delivery of pneumococcal vaccination.Conclusion: Our systems-oriented intervention was associated with some improvement in counselling activities, but no significant improvement in delivery of other preventive services. The main reason may be that implementation focused more on chronic illness management than preventive services for generally well adults.

Damin Si PhD · Ross S Bailie MB BS, MD · Michelle Dowden MPH · Lynette O’Donoghue BSc · Christine Connors MB BS, MPH · Gary W Robinson PhD · Joan Cunningham ScD · John R Condon PhD · Tarun S Weeramanthri PhD

Objective: To determine the risk of suicide and drug overdose death among recently released prisoners.Design, setting and participants: Retrospective cohort study of 85 203 adult offenders who had spent some time in full-time custody in prisons in New South Wales between 1 January 1988 and 31 December 2002.Main outcome measures: Association between time after release and risk of suicide and overdose death.Results: Of 844 suicides (795 men, 49 women), 724 (86%) occurred after release. Men had a higher rate of suicide than women both in prison (129 v 56 per 100 000 person-years) and after release (135 v 82 per 100 000 person-years). The suicide rate in men in the 2 weeks after release was 3.87 (95% CI, 2.26–6.65) times higher than the rate after 6 months. Male prisoners admitted to the prison psychiatric hospital had a threefold higher risk than non-admitted men both in prison and after release. No suicides among women were observed in the 2 weeks after release. No increased risk of suicide was observed among Aboriginal Australians in the first 2 weeks after release. Of 1674 deaths due to overdose, 1627 (97%) occurred after release. Drug-related mortality in men was 9.30 (95% CI, 7.80–11.10) times higher, and in women was 6.42 (95% CI, 3.88–10.62) times higher, in the 2 weeks after release than after 6 months.Conclusions: Prisoners are at a heightened risk of suicide and overdose death in the immediate post-release period. After 6 months post-release, the suicide rate approaches the rate observed in custody.

Azar Kariminia MSc · Matthew G Law PhD · Tony G Butler PhD · Michael H Levy MD · Simon P Corben MSc · John M Kaldor PhD · Luke Grant MSc

Aboriginal and Torres Strait Islander people are three times more likely than non-Indigenous Australians to report vision loss due to cataracts, but are four times less likely to have cataract surgery. To increase access for Aboriginal and Torres Strait Islander people to cataract surgery, we need to identify the barriers to current services and trial strategies to overcome these barriers. Barriers to cataract surgery exist at the health service, community and individual level. Health service factors include infrastructure, cost, and provision of interpreters, escorts and transport. Community factors include social support, perceptions about the success of surgery, and beliefs about the causes of cataracts. Individual factors include ignorance that cataracts can be cured, fear of surgery or poor outcome, and comorbidity. Strategies proven to increase uptake of cataract surgery in other countries could be trialled in remote Australia.

Susan M Wearne

To the Editor: In a recent article,1 Scrimgeour showed the differences between death rates in Aboriginal people and in the general Australian population. He used the Accessibility/Remoteness Index of Australia (ARIA)2 to show that Aboriginal people in remote areas generally had higher death rates than those near major health facilities. However, this widely used tool is inaccurate when applied to some health facilities. Cherbourg Aboriginal community (population about 2600) is located in the South Burnett district of south-eastern Queensland, 260 km by road from Brisbane. It has a 10-bed hospital with two resident doctors. There are several small towns (population 1000–3000) in the district. Two have hospitals with no full-time medical staff. The main centre is Kingaroy (population about 12 000), 50 km from Cherbourg. It has a 60-bed hospital with resident staff, but no specialists or consultants. There are general practitioners but no medical specialists in the district, although some specialists visit for a day or so per month. Most patients needing specialised services go to public hospitals in Brisbane (220 km away [from Kingaroy]), Toowoomba (170 km away) or Nambour (140 km away), where waiting lists are long. Children go to children’s hospitals in Brisbane, either by road (a 3-hour journey) or by helicopter. The ARIA index ranges from 0.0 (major city) to 12.0 (very remote area). Cherbourg (classed with Murgon, 5 km from Cherbourg) has an index of 2.9 and Kingaroy, 2.6. The cities of Darwin, Cairns and Townsville, all with major hospital and health facilities, have an ARIA index of 3.0, while Alice Springs, which also has a major hospital and specialists, has an ARIA index of 6.0. Clearly, the remoteness index is not a good indicator of the availability of local specialist health services. The ARIA classification is widely used. The anomaly of the South Burnett and Cherbourg Community may (or may not) be the only problem with the index. Until such anomalies are corrected and ARIA is validated, any results derived using the index should be treated with caution.

Alan E Dugdale

A chance to make real gains in eliminating child abuse and the health, social, and economic problems associated with it The vigorous involvement of the Australian Government in addressing issues of child abuse in Aboriginal communities in the Northern Territory has been widely welcomed. The discussion that followed the Howard Government’s announcement (Box 1)1 has not been about whether there is a need to act — some of these interventions, in particular increased policing and better health services, have been called for by these NT communities for many years — but there has been debate about the way in which action should be taken. The intervention is attempting to confront a real and acute problem of child sexual abuse, using a legalistic and “tough love” policy approach. However, as well as an urgent response, sustainable solutions are needed to deal with the broader health and social issues that underpin child abuse, and it is important that these articulate with the longer-term aspirations of Aboriginal and Torres Strait Islander peoples and communities. These aspirations are much more comprehensive than a law and order approach delivering an “absence of fear”. A complex set of factors are associated with the occurrence of child abuse. A review of child abuse in the United States found poverty to be the most frequently and consistently noted risk factor.2 Community-related risk factors included a high crime rate, lack of social services, and a high unemployment rate. Parental-related factors included a history of physical or sexual abuse, being teenage or single parents, poor coping skills, low self-esteem, substance misuse, lack of parenting skills, mental health problems, and having multiple young children. Although there is far from an exact parallel between the situation in the US and that in the NT, there are some factors in common. Strategies recommended for preventing child abuse in the US included: increasing economic self-sufficiency; discouraging all forms of violence against children, including corporal punishment; making health care more accessible; expanding and improving the coordination of social services; improving treatment for psychological problems, and for substance misuse and spouse abuse; providing affordable child care; and educating parents about child behaviour, discipline, safety and development.2 The recent report from the Australian Productivity Commission entitled Overcoming Indigenous disadvantage3 provides contemporary information on many of these risk factors in the Aboriginal population. The report shows that rates of substantiated notifications of child abuse have increased. However, unemployment rates are down, there is more home ownership, basic education levels are improving, and there have been increases in native title determinations. While some aspects of child health are improving (although there is still a considerable way to go), a lack of progress or even deterioration in some health indicators point to continuing inadequacies in health services for Indigenous Australians. The problem of overcrowding in houses has not been solved, and risky alcohol consumption has not abated for men and has increased for women. Imprisonment rates for adults have increased, and the gap between Indigenous and non-Indigenous juvenile detention rates has widened. In announcing the measures that the government would take to deal with child sexual abuse, the Prime Minister drew attention to the comprehensive report into child sexual abuse in the NT by Pat Anderson and Rex Wild entitled Little children are sacred. However, the government’s response, at least as regards the initial strategies, has been in direct contrast to the recommendations of this report,4 in both content and philosophy.5 The government measures involve considerable reliance on uniformed services and coercive interventions, and limited consultation with the Aboriginal communities and leaders concerned. Evidence for the effectiveness of some of the Howard Government’s strategies does not appear to exist; nor does this seem to have been a dominant consideration. The relationship of land tenure to child sexual abuse is very poorly defined in the intervention, and detailed clarification of this aspect by the government would help to instil some trust in this aspect of the government’s response in the relevant communities. The same applies to the removal of the permit system: the need for permits would logically appear to be a deterrent to predators entering Aboriginal communities. Finally, it is not clear whether alcohol prohibition really works in the long-term. No one would say it was a spectacular success in the US or Russia, and in Indigenous communities in the Cape York Peninsula and in Canadian Indigenous communities the results of this measure have been mixed. In Native American communities in the US, it has been counterproductive,6 but it has provided some benefits in the particular circumstances of Alaska.6 A majority of remote NT Aboriginal communities are already “dry” by choice, and any such action should be negotiated with individual communities, and must include planning for the withdrawal of alcohol, as well as counselling. On the positive side, the government’s intervention will focus much more attention on the issues associated with child abuse, and give voice and opportunity to attempts to say much louder that the unacceptable really is unacceptable. So, at least, some short-term gains may be made, and there is some prospect of a residual shift in attitudes to child abuse and domestic violence. More importantly, the intervention engages the government and a committed Minister in efforts to tackle these vitally important issues. Nevertheless, the abuse of children cannot be dealt with effectively as a separate issue without also addressing the related health, social, education, and economic issues — and it will not occur without the full engagement of Aboriginal communities. Attempts to confront this emergency will immediately come up against longstanding problems, not just of the welfare system and exposure to alcohol and pornography, but of environmental and housing issues; and deficiencies in mental and other health services, in the law enforcement system, and in social services; and, finally, the manifest weaknesses of the criminal justice system. There are also problems related to workforce, training and accommodation for staff working in Aboriginal communities. Most importantly, there is the lack of self-esteem, the need for cultural strengthening, and the paucity of meaningful activities for individuals and communities. The record of those initiatives in Australia, no matter how well intentioned, which have been largely driven by the non-Indigenous community and lacked full Indigenous partnership, is pretty bleak. Disempowerment of Aboriginal people is a significant factor in the complex set of problems, and measures that lead to further disempowerment have, at best, doubtful prospects. We urge that, at the earliest possible stage, the government consider enlisting the support and involvement of Indigenous leaders in the health field, and give much more serious consideration to the community-engagement strategies and the more comprehensive approach outlined in the Anderson Wild report (Box 2).4 Child sexual abuse is not restricted to the NT, and the proper vehicle for addressing this issue at a national level is the Council of Australian Governments. The starting point ought to include those strategies that have been found to be effective in dealing with the abuse of children in Australia and other countries. Intervention trials, such as the initiative led by Noel Pearson in the communities of the Cape York Peninsula, should provide valuable information. The solution lies in taking action with Aboriginal people and communities rather than for them. With the Prime Minister’s promise7 that whatever resources are needed will be provided by the federal government, there is a tremendous opportunity for innovation, as well as effective implementation of the many strategies that have appeared in numerous government reports over many years in both health and other fields. It is a chance to make real gains in eliminating child abuse and the health, social, economic and other problems that are associated with it, but this requires bipartisan commitment for sustained, long-term interventions. The worst that could happen is that these communities are promised real, positive changes and the promise is again not fulfilled. We must do whatever it takes to save these children from sexual abuse today, but we must also ensure safe, healthy communities and a meaningful life for the children born into these communities in the years to come. 1 Measures announced by the Australian Government to halt child abuse in Indigenous communities of the Northern Territory On 21 June 2007, the Australian Prime Minister, John Howard, announced the following measures to combat child abuse in Indigenous communities in the NT:1 Widespread alcohol restrictions on NT Aboriginal land for 6 months Medical examinations of all Indigenous children in the NT under the age of 16 years Quarantining of 50% of the welfare payments to parents of children in the affected areas for the purchase of food and other essentials Enforcing school attendance by linking income support and family assistance payments to school attendance for all people living on Aboriginal land Taking control of townships through 5-year leases to ensure that property and public housing are improved Requiring an intensive clean-up of communities to make them safer and healthier, by marshalling local workforces through Work for the Dole arrangements Scrapping the permit system for common areas and road corridors on Aboriginal lands Banning the possession of x-rated pornography in the proscribed areas Increasing policing levels, and making law and order a central focus of the measures announced Amending NT land rights legislation 2 The Anderson Wild report4 The 97 recommendations covered: Leadership by the federal and Northern Territory governments in consultation with Aboriginal people, government responses to ensure child safety, the role of the Family and Children’s Services program in the NT, and family support services; Health aspects, both crisis intervention and prevention through primary health care; Policing, police education, cooperation with the Family and Children’s Services program, support for victims, bail applications (when the alleged offence is sexual abuse of a child), and offender rehabilitation; School attendance, the role of communities, community education and awareness, and housing; Alcohol and other substance abuse, pornography, and gambling; Community justice; Cross-cultural training of staff; and Implementation of the report.

Ian T Ring MB BS, MSc(StatsEpid), FAFPHM · Mark Wenitong BMed

Social determinants of Indigenous health Bronwyn Carson, Terry Dunbar, Richard D Chenhall, Ross Bailie, editors. Sydney: Allen & Unwin, 2007 (xxviii + 306 pp). ISBN 978 1 74175 1420 Forty years have passed since the 1967 referendum on whether Aborigines should be counted in the census. This anniversary led, yet again, to demands for greater effort and tangible improvement in Aboriginal and Torres Strait Islander health. Then, suddenly, a report on the neglect of children in the Northern Territory provoked action by the federal government. Whether this will help is hard to predict, but the matter certainly has national attention. Right now, at least, some politicians have joined the new President of the Australian Medical Association in making Indigenous health priority number one. Is a text on the social determinants of Indigenous health relevant to this election-year drama? The book is based on a series of courses funded by the Public Health Education and Research Program (an initiative of the Australian Government Department of Health and Ageing). It provides introductory material that belongs to the cultural curriculum of modern Australia in general, and medical education specifically. The authors first explain social models of health and epidemiology, and then move on to topics of more or less immediate importance to health status, including racism, poverty, education, employment, welfare, housing, and human rights. These issues were never more relevant than now. A second question applies more to the average reader of the Journal, concerned with the provision of medical care. What does this book add to the coverage of Indigenous health topics needed by clinicians? These readers will probably turn to the last chapter, on interventions and sustainable programs. Three examples cover “healthy lifestyle”, with a focus on diet, exercise, and smoking cessation; injury prevention and safety promotion; and the measurement of the impact of alcohol and drug treatment programs. The key elements identified are not surprising, including governance, accountability, and appropriate staffing. Any clinician can get involved by contributing to the provision of health services. These examples show that it is possible to reach beyond the current rhetoric of disgrace.

Charles Guest

Objective: To evaluate the impact of a sustained, community-based collaborative approach to antenatal care services for Indigenous women.Design: Prospective quality improvement intervention, the Mums and Babies program, in a cohort of women attending Townsville Aboriginal and Islanders Health Service, 1 January 2000 – 31 December 2005 (MB group), compared with a historical control group (PreMB group), 1 January 1998 – 30 June 1999.Main outcome measures: Proportion of women having inadequate antenatal care and screening; perinatal indicators.Results: The number of antenatal visits per pregnancy increased from three (interquartile range [IQR], two to six) in the PreMB group to six (IQR, four to ten) in the MB group (P < 0.001). There were significant improvements in care planning, completion of cycle-of-care, and antenatal education activities throughout the study period. About 90% of all women attending for antenatal care were screened for sexually transmitted diseases, 89% had measurement of haemoglobin level, and serological tests for hepatitis B and syphilis (minimum antenatal screening). There was increased attendance for dating and morphology scans. In the MB group compared with the PreMB group, there was a significant reduction in perinatal mortality (14 v 60 per 1000 births; P = 0.014).Conclusion: Sustained access to a community-based, integrated, shared antenatal service has improved perinatal outcomes among Indigenous women in Townsville.

Kathryn S Panaretto MB BS, MPH, FAFPHM · Melvina R Mitchell · Lynette Anderson · Sarah L Larkins MPH, MPH · Vivienne Manessis MB BS, FRACGP · Petra G Buettner PhD · David Watson FRANZCOG

To the Editor: Women of the remote Indian Ocean Territories (Christmas Island and the Cocos Islands [see map]) regularly question why their comprehensive obstetric service, allowing deliveries on the Islands, ceased in 1998. A study in 20051 aimed to provide answers for these women. There is one general practitioner on the Cocos Islands and two on Christmas Island. Previously, procedural GPs attended to most deliveries. Now, pregnant women must leave the Islands 4 weeks before their expected delivery. The financial, physical, emotional, and cultural costs of this are substantial. Reports published in 20022 and 20043 identified community concerns, but resisted recommendations to resume on-Island birthing, because of perceived low birth numbers and difficulty sustaining the skills of clinicians. Both studies relied on external birthing data, as the Indian Ocean Territories Health Service (IOTHS; administered by the Department of Transport and Regional Services) had not documented numbers of deliveries. The Alberton Report,3 extrapolating from Australian Bureau of Statistics (ABS) data, assumed that the population of children aged less than 1 year in a census year equalled the number of deliveries the year before. The ABS has a system to protect the confidentiality of small isolated populations and purposely does not report these numbers. The Bath Report2 relied on data from the Western Australian Midwife Notification System (MNS). The MNS reported 136 births to Island women from 1995 to 2004, while our study (Western Australian Centre for Remote and Rural Medicine)1 recorded 326 births. Thus, the MNS attributed only 41% of known births to Island women during 1995–2004, and only 23% during the period considered by the Bath Report. We believe that the MNS data shortfall occurred for two reasons. Firstly, women frequently provide their temporary mainland address on the MNS form for practical reasons. Secondly, one in seven women leaving the Islands to deliver their babies choose to give birth in a state other than Western Australia to be closer to family, and these births are not attributed to women from the Islands. The methods used by the Alberton Report, the MNS and the Bath Report result in underestimations of the number of confinements for Island women by up to 77%. It is regrettable that this situation has not been previously recognised or acknowledged, and that recommendations for the resumption of obstetric services by the IOTHS have repeatedly been based on incomplete data. If records of the numbers of births for Island women had been collected and considered by the IOTHS, Island families might again enjoy a comprehensive on-Island delivery service for low-risk pregnancies.

Susan Downes · Sally M Roach