Indigenous health

Objective: To gain some understanding of the attitudes and behaviours of Indigenous young people in Townsville concerning relationships, contraception and safe sex.Design: Cross-sectional study using a computer-assisted self-administered survey and single-sex focus group discussions designed by a Young Mums’ Group operating on participatory action principles and acting as peer interviewers.Participants and setting: 171 Indigenous students in Years 9–11 at three high schools and 15 residents of a homeless youth shelter in Townsville, Queensland, 27 April – 8 December 2004.Main outcome measures: Self-reported attitudes and behaviour about relationships, sexual intercourse and contraception.Results: 84/183 participants (45.9%) reported past sexual intercourse, with 56.1% commencing intercourse at age 13–14 years. The likelihood of having had sex increased with being male (P = 0.001), increasing age, increased perceived sexual activity of peer group (both P = 0.000), and drinking alcohol at least weekly (P = 0.015). Young women were more likely to report unwanted sexual touching (P = 0.031), and less likely to report enjoying sexual intercourse (P = 0.001). The main qualitative themes concerned females’ reputations, coercion, and denial of female desire. Only 49/80 participants (61.3%) reported always using condoms. The main reasons for not using contraception were “just not thinking about it”, shame, and problems with access. Despite having reasonable knowledge about contraception, most lacked the confidence and negotiation skills to communicate with partners about condom use.Conclusions: Like teenagers elsewhere, Indigenous teenagers in Townsville are becoming sexually active at a young age, and not practising safe sex reliably. The need to protect their reputations puts young women at risk by not being prepared for safe sex by carrying condoms.

Sarah L Larkins MB BS, MPH, FRACGP · R Priscilla Page CertIII · Kathryn S Panaretto MB BS, MPH · Robert Scott CertSexualHealthCounselling · Melvina R Mitchell EN · Valerie Alberts MSocPol, GradCertTeaching · P Craig Veitch DipAppSci(RT), BA, PhD · Suzanne McGinty DipEd, MA, PhD

Aim: To describe the pattern of disease and other health problems in children living in remote Far North Queensland (FNQ).Design, setting and participants: Retrospective review of the FNQ Paediatric Outreach Service’s Medical Director database for the period June 2001 to February 2006. Three subpopulations were compared: children from predominantly Aboriginal communities, predominantly Torres Strait Islander communities, and other communities. All children referred to the service during the study period were reviewed.Main outcome measures: Number of children seen and common diagnoses.Results: 3562 children were referred during the study period, and a total of 3932 diagnoses were made; 56% of the paediatric population of the Aboriginal communities and 23% of the paediatric population of Torres Strait Islander communities were seen. Of 40 separate diseases/health problems reviewed, the three most common reasons for presentation were chronic suppurative otitis media, suspected child abuse and neglect, and failure to thrive. In the paediatric population of Aboriginal communities, the prevalence of fetal alcohol spectrum disorder was at least 15/1000 (1.5%), and in Torres Strait Islander children, rheumatic heart disease prevalence was at least 6/1000 (0.6%). Rheumatic fever rates were among the highest in Australia.Conclusion: Rates of preventable complex and chronic health problems in Aboriginal and Torres Strait Islander children in remote FNQ are alarmingly high. Areas requiring urgent public health intervention include alcohol-related conditions and rheumatic fever.

Jonty Rothstein MB BS, FRACGP, DCH · Richard Heazlewood MB BS, FRACGP, FACRRM · Marnie Fraser MB BS, MPHTM

There is evidence that Australia is not meeting its obligations to Aboriginal and Torres Strait Islander peoples for their right to the “highest attainable standard” of health, required under the International Covenant on Economic, Social and Cultural Rights (ICESCR). Poor access to primary health care for Aboriginal peoples and substantial shortfalls in government spending to address this are in violation of the ICESCR. Aboriginal and Torres Strait Islander peoples’ share of the universal health coverage expenditure offered to all Australians is less per person than for other Australians. The failure to monitor the provision of mainstream health services to Aboriginal peoples and inequitable distribution of health facilities and services compound these violations. Equality in health between Indigenous and non-Indigenous Australians is achievable, but not until the shortfall in health services expenditure for Indigenous Australians is addressed.

Sophie Couzos FRACGP, FACRRM, FAFPHM · Dea Delaney Thiele PGDipHlthMgt

The Australian government’s Healthy for Life program is supporting capacity development in Indigenous primary care using continuous quality improvement (CQI) techniques. An important influence on the Healthy for Life program has been the ABCD research project. The key features contributing to the success of the project are described. The ABCD research project: uses a CQI approach, with an ongoing cycle of gathering data on how well organisational systems are functioning, and developing and then implementing improvements; is guided by widely accepted principles of community-based research, which emphasise participation; and adheres to the principles and values of Indigenous health research and service delivery. The potential for improving health outcomes in Aboriginal and Torres Strait Islander communities using a CQI approach should be strengthened by clear clinical and managerial leadership, supporting service organisations at the community level, and applying participatory-action principles.

Ross S Bailie MD, FAFPHM · Damin Si PhD · Lyn O'Donoghue BSc · Michelle Dowden RN

Aboriginal and Torres Strait Islander health services are heavily dependent on overseas-trained doctors (OTDs). These OTDs are increasingly from countries with variable English language and educational equivalency compared with locally trained doctors. Aboriginal and Torres Strait Islander health services create particular demands for all doctors, such as negotiating “cultural domains” and acknowledging the contribution of Aboriginal health workers. Little is known about the roles and experience of OTDs in health service provision in Indigenous communities. Barriers to effective research into the experience of OTDs include privacy legislation and a lack of standardised data. Researching the narratives of OTDs in Indigenous health services offers an opportunity to explore the diversity and complexity of the cultural interfaces in health service provision.

Rachelle S Arkles MA · Peter S Hill MB BS, FAFPHM, PhD · Lisa R Jackson Pulver GradDipAppEpi, MPH, PhD

Some commentators suggest that the poor health of Australia's Indigenous population is due to misguided ideology-driven policy that has forced people to live in remote communities, preventing them from benefiting from the mainstream economy. The evidence shows that the poor health status of Indigenous people is found in all areas where they live and that, on some indicators, living in remote areas has health benefits. Government policies aimed at relocating Indigenous people from their traditional lands are not supported by evidence, and may further entrench Indigenous disadvantage.

David Scrimgeour MB BS, MPH

In August 2006, the Aboriginal Land Rights (Northern Territory) Amendment Bill 2006 (Cwlth) was passed into law, introducing, among other things, a system of 99-year leases over Indigenous townships. The leasing scheme will diminish the control that traditional owners previously exercised over their lands. This is at odds with research indicating that control over land is a positive influence on Indigenous health.

Nicole L Watson LLB, LLM

People need to feel like themselves and believe that the health care is connected to their lives As a medical student in 1989, I did my final year elective in Alice Springs and at an Indigenous community on the Pitjantjatjara Lands. In the depressed and squalid town camps of Alice Springs I came to understand that, even if a swab from a discharging ear grew Haemophilus, the patient didn’t have middle ear disease because of a bacterium. It triggered an ongoing interest in the determinants of health and disease — socioeconomic, personal and political. I discovered that Indigenous Australia is like Europe. There are different ethnic and language groups. Many people speak several languages and may speak English as their second, third, or fourth language. I understood that Australia’s interior is inhabited, not empty. I started to understand the magnitude of insult embedded in terra nullius. I had my first adult glimpse into Indigenous cultures and came away fascinated and respectful, knowing that we — me and my culture and they and their cultures — had fundamentally different ways of experiencing the world. I finished my degree, did the early years, travelled overseas, worked in general practice in community health settings, did a couple of brief stints in urban Aboriginal health services and a 4-month locum in the Pilbara, had two children, and quietly waited until I could get back to Central Australia. The time came, and I accepted a job-share position with my partner Niall in a remote Indigenous community about 300 km north-east of Alice Springs in Alyawarr country. Between 250 and 400 people live in the community, but we tracked the health business of around 700 people from the area. Life as a doctor in a remote Indigenous community is rich and fraught. People are so sick and die so young. It is deeply shocking. As I grew to understand more powerfully that these are real lives, and to grasp the amount of grief that people live with, and to comprehend how much time is lost to sickness and death, I was able to better appreciate the context in which I was providing medical care. In this setting you must be medically meticulous but also, to access the population, you need to offer services in a way that people recognise and want. People need to feel like themselves and believe that the health care is connected to their lives, that they are involved and have choices, that it’s not primarily someone else’s agenda. It’s often not so much about empowering people as not disempowering. This is what I think of as cultural safety. The clinic had a nurse and an administrator, but we knew that we also needed health and cultural liaison workers from the community. We needed language support and translation and a way to find out who and where people were, but also a way of checking understandings and beliefs about health and disease. People slowly began to feel comfortable and trust us, and within 6 months we had several health and cultural liaison workers. Only then could we start providing effective primary health care, including effective acute health care. Under guidance from the community-based Health Council and with other community members, we steadily built the clinic as a culturally safe place. We discussed, listened, made suggestions, checked and tried always to do things in a transparent and inclusive way. The look of the clinic transformed. The women chose the colour for the outside of the clinic and all the clinic doors were painted with bush tucker and local stories. We employed community members to collect and prepare a topical bush medicine that was given out as liniment and for various skin conditions. As well as being particularly effective for burns, this bush medicine gave the whole clinic a smell that was deeply familiar to the community and strongly associated with health care. I was struck at some stage by the fact that the local people never or rarely saw themselves reflected in positive ways on television or in books. I wondered how you can value and acquire literacy if you cannot relate to anything you read, and so had the idea of building a mini-library in the clinic. People loved it. We obtained a book depicting local artists and their batik work, and other books about snakes, spiders, bush foods, and plants. We got maps of the surrounding areas and an aerial photograph of the community, allowing many — some of them for the first time — the experience of seeing their world and their lives depicted in books. It was very powerful. At some point I expanded on the usual letter of referral and made a much fuller letter of introduction. This had so much impact on staff in Alice Springs and in Adelaide hospitals that I wondered that I hadn’t thought of it earlier. I really understood this as part of building safety in how Indigenous people accessed health services outside culturally familiar territory. People came to the clinic in droves. It became easier and easier to establish robust primary health care programs: We increased and maintained vaccination rates to more than 95% cover. We provided antenatal care for all women from the first trimester. Most of the 12 or so women per year had their babies in Alice Springs by choice — ours and theirs. Children younger than 5 years were all mapped on a wall chart, recording when they were due for vaccination, weights, haemoglobin, developmental checks and so on. The community accepted this degree of visibility for the children’s health business. More than that, I would say this was consistent with the sense of collective responsibility for the welfare of the kids. By the time we left, most of the women had had a Pap smear. Most adults had had chronic disease screening and a large proportion came to the clinic for regular checkups and monitoring. (Our audits showed that around 30% of adults had diabetes and around 25% had impaired renal function.) Regular screening for and treatment of sexually transmitted infections was in place. A healthy dogs program included an annual visit from a vet backed up by Niall and health workers who would spay dogs, put down sick dogs, etc. We conducted annual school screening. The community had access to the industrial washing machine that had been installed in the clinic for washing blankets. Our predecessor had initiated this — a simple, powerful public health measure that resulted in a dramatic and sustained fall in scabies infestation and related skin infections. We provided palliative care for several people, including extensive family consultation and support. As well as these programs, we tried to visit the elderly people in their camps each week. Many of them never came to the clinic, so this was the only way they accessed health care. We were also providing acute care day to day in the clinic, which was busy in itself. We were on-call all the time, second on call to the nurse half the time. We did a weekly 150 km round-trip visit to three satellite communities. And lurking in the background were the could-happen-at-any-moment medical emergencies, which of course did happen. Together with the nurse we treated a gunshot wound to the chest (and I put in my second-ever chest tube), a ruptured ectopic pregnancy, births, cardiac emergencies, and road and various other traumas. Although work was full-on, there was also a simplicity about our lives. I got enough sleep for the first time in years. We were absorbed by life within the community. I felt like I had time to think. I read and thought and reflected a lot. Niall and I had time to talk and didn’t have to have conversations about shopping, who’d pick up the kids, babysitting and other domestic arrangements. It was sparse and refreshing. Under the vast sky in that uncluttered country, I connected to seasons, phases of the moon, movement of the stars. I got the kids up one night to see the Leonids, which is a meteor shower that happens to a greater or lesser extent every year in November. By luck, that year was the greatest shower in years. We lay on the trampoline and saw maybe 200 shooting stars in half an hour. It was exhilarating. I went hunting many times with the women. As well as the time with people and experience of culture, my way of seeing the country transformed. I saw it was fecund, fertile, providing. I saw and learned how to find and collect seasonal foods — beans, potatoes, all sorts of fruits, wild honey. I ate kangaroo, turkey, echidna, witchetty grubs, the honey sac of honey ants, and goanna. I also understood that the land was knowable. That people were at home in their country, the land was steeped in the events and stories of their lives. That nomad didn’t mean moving willy-nilly around, but was actually travelling within country that was all home. That, in comparison, non-Indigenous Australians move to places we have no connection to — country, city, suburb. I learned to see things, but not everything. A close friend and I went out one day tracking goanna and I couldn’t see the tracks. I asked her to show me and she laughed and pointed. We squatted down on the ground and she pointed exactly to the tracks. I still couldn’t see anything. We just both ended up laughing and laughing — she truly disbelieving that I couldn’t see anything . . . and I thinking about how you can never really know what you’re not seeing. I know we can’t change history. We can change our knowledge and understanding of it. My understanding is that many Indigenous people are sick because of the accumulated losses and trauma and now the burden of sickness and early death and the grief that comes with that. They are sick because of not having access to or not being able to or not knowing how to or not believing in the value of making life-affirming choices. I don’t believe there has yet been real political will to change the health of Indigenous people, despite there being substantial knowledge about what makes a difference. People (we) need to have a sense of power in their (our) lives, and the principle of cultural safety is fundamental to the design of services that support this. I think we understood this well enough to have been able to go to this community and provide medical and health care in a way that people found useful. It was certainly a most enriching experience for me and my family.

Mary Belfrage MB BS

Indigenous people make up more than 4% of the Canadian population, but less than 0.25% of the physicians. National initiatives are being undertaken to increase the representation of First Nations, Inuit, and Métis people in the medical workforce. This is a necessary step in developing a health care system that is culturally safe and responsive — one step towards equity in health for First Nations, Inuit, and Métis people. Initiatives focus on recruitment and retention of indigenous physicians, and development of a curriculum framework to ensure all physicians can provide culturally safe care.

Marcia Anderson MD, FRCPC · Barry Lavallee CCFP, MClSc, FCFP

Substantial progress has been made in Māori health and disability workforce development in the past 15 years. Key factors in successful programs to increase Māori health workforce recruitment and retention include Māori leadership, mentorship and peer support; and comprehensive support within study programs and in the transitions between school, university and work. The interventions to date provide a strong basis for ongoing action to address inequities in Māori health workforce participation, and are likely to be relevant to health workforce development approaches for other indigenous peoples.

Mihi M Ratima DipMaoDev, DPH, PhD · Rachel M Brown DipSocCom, DipComm · Nick K G Garrett BSc, MSc, MS · Erena I Wikaire BHSc · Renei M Ngawati BHSc · Clive S Aspin MA, DipELT, DipTchg, PhD · Utiku K Potaka BBS, DipMDev

Advocates, mentors and leaders in Indigenous health are emerging from our medical schools According to the Australian Indigenous Doctors’ Association (AIDA), there are currently about 90 Indigenous doctors in Australia.1 This amounts to 0.18% of the medical profession, despite 2.4% of the Australian population being Indigenous. Many organisations have called for an increase in the numbers of Indigenous doctors and other health care workers as part of a strategy to improve the health and wellbeing of Indigenous Australians and to reduce the terrible disparities between their health and that of the general Australian population. These increasingly urgent calls have come from the Australian Health Ministers’ Advisory Council,2 the Australian Medical Association (AMA),3 AIDA,4 and many other leading Australian health, human rights, aid and development organisations.5 To increase the proportion of Indigenous doctors to the non-Indigenous level, the AMA estimated in 2004 that 928 more doctors need to be trained.3 As a start, AIDA has identified a goal of 350 extra Indigenous students enrolled in medicine by 2010.4 Although many medical schools have strategies to recruit and retain Indigenous students (Box), the goal set by AIDA may not be easy to achieve. Three of the schools are recognised as “leaders” in Indigenous medical education — the University of Newcastle, the University of Western Australia and James Cook University. We interviewed key representatives from each of these schools to discover what they have achieved, their strategies, and their plans for the future. Newcastle: the trailblazerWhile not the first medical school to graduate an Indigenous doctor, the school at the University of Newcastle was the first to make a concerted effort to train Indigenous doctors, and has produced the most — 51, or around 60% of doctors in Australia who identify as Indigenous. The school’s first two Indigenous graduates, Sandra Eades and Louis Peachey, and many who followed, have become leaders both in medicine and in their communities. The Indigenous entry program was a “natural fit” for Newcastle, explained Michael Hensley, Head of the School of Medicine and Public Health. It was made possible by the combination of the receptive environment created by Foundation Dean, David Maddison — with its strong focus on community, equity and engagement by the medical profession — and an individual with a passion in Robert Sanson-Fisher, Professor of Behavioural Science, who came with extensive experience in Indigenous health from Western Australia. In the early 1980s, with the support of the then Dean, John Hamilton, the school explored the barriers to Indigenous entry, as well as experiences of similar programs in Canada and New Zealand. The program had its first intake in 1985 and currently has 25 Indigenous students enrolled. However, the program “was not without its objections, that we would be creating a special stream with lower academic standards”, said Hensley. “I think it was important to have those comments up front and to work through them. We said we would have evaluation beforehand, and a strong mentoring and academic support system. Once the students were in the course, there would be no difference in assessment procedures. And we had support from the University to have these as additional places, not replacing Commonwealth-funded ones.” Western Australia: a model of Indigenous leadershipInitially, Newcastle medical school drew Indigenous students from around Australia, but in 1996 it acquired a competitor with the founding of the Centre for Aboriginal Medical and Dental Health at the University of Western Australia (UWA). The Centre’s goal was both to improve the recruitment and retention of Indigenous medical students and to assist departments in Medicine and Dentistry with teaching about Aboriginal health and with improving links with Aboriginal organisations. It grew, explained Helen Milroy (Director of the Centre and a child and adolescent psychiatrist from the Palyku people), out of the success of the pre-existing Centre for Aboriginal Programmes (now the School of Indigenous Studies), which provided alternative entry and support schemes for Indigenous students in other disciplines. In fact, she attributes her Centre’s success partly to its collocation with the School of Indigenous Studies and access to its staff. In 1996, there were two or three Indigenous students in the medical course; since then, another 11 Indigenous doctors have graduated, while 23 Indigenous students are currently enrolled. James Cook: a strategic initiative for the northThe medical school at James Cook University (JCU) in northern Queensland was the first new medical school for 25 years, and producing Indigenous doctors was integral to its rationale and accreditation in 1999, explained Jacinta Elston (Assistant Dean [Indigenous Health], from the Kalkadoon people). The school was planned with a focus on rural and remote health, Indigenous health, and tropical medicine, as well as on training a medical workforce for northern Australia. In 2003, the Indigenous Health Unit was created under her leadership to improve Indigenous recruitment and retention across the Faculty of Medicine, Health and Molecular Sciences, as well as to support development of an appropriate Indigenous health curriculum and Indigenous health research, and to engage with the community. The medical school has produced six Indigenous doctors in its first two graduating years, including its first Torres Strait Islander doctor, and has another 19 Indigenous students currently enrolled. How do the programs work?The programs at these three schools are all based around alternative entry schemes that assess a student’s ability using a wider range of criteria than an academic score. But the programs are much more than this, comprising various combinations of recruitment strategies, premedical preparation, academic, social and personal support during the course, and flexible pathways. All have a school-determined quota of places available for Indigenous students (ranging from five places at JCU to 10 at UWA), although if more applicants are deemed suitable this may be flexible. As Milroy explained, it is important to have a quota, rather than having to argue case by case. The interviewees dismissed the suggestion that their programs are in themselves discriminatory and might create envy among other students. “This is a strategy to improve the health of a very disadvantaged group in Australia. I think it is a legitimate measure to have a special entry and support program”, said Hensley. Indeed, the programs are analogous to the widespread alternative entry schemes for rural students that aim to reduce the health care inequities in rural areas. All interviewees emphasised that the programs do not create a subclass of doctors with lower academic standards. As Elston warns her students, “There is only an alternative entry process, there is no alternative exit process. All our students graduate the same way, by meeting the same standards”. Selection — picking stayersAll three medical schools have a rigorous selection process that aims to select students who will successfully complete the course. At JCU, appropriate selection is the main emphasis. For Elston, this means first assessing an applicant’s motivation to undertake medicine. “Most Aboriginal or Torres Strait Islander people want to do something for their community. This is important, but whether it is enough to get you through a 6-year program is a different issue. If an applicant said, ‘I’m just sick of being broke. I want to be a heart surgeon and drive a red Lamborghini, because my family have been broke all our lives, and I don’t want to be, I don’t want my kids to be’, then we would see that as probably just as motivating.” Secondly, Elston assesses the applicant’s support structures and ability to balance study with family and community commitments, and only after that whether they are at the right stage of their lives academically. If applicants are not considered ready, then Elston may suggest enrolling in another degree such as biomedical science; if they achieve a certain academic level in the first year, they will be considered again. Elston attributes the JCU retention rate — 25 out of the 29 students enrolled so far — to this policy, but admits her school might be seen as too rigid at times. In fact, Hensley pointed out that “it is difficult at times to decide on a background that guarantees completion, and we have had remarkable success stories from a range of academic backgrounds”. However, Newcastle is grappling with a 25% non-completion rate over the first 15 years of its program, which Hensley attributes to a combination of the major family and community responsibilities borne by many students and less-than-ideal school preparation. He feels that, in the balance between giving “higher-risk” students a chance and achieving a high completion rate, the pendulum at Newcastle perhaps swung too far, and it would be fairer to individuals and the school to be tougher in screening. Preparation — many pathways to medicineUWA medical school is also very careful with student selection, explained Milroy. “We look at their educational background, whether they finished high school, and other education, and put them through a series of interviews and tests.” However, UWA also offers an extensive program of preparation for potential students. “We offer many pathways into medicine. If they require a lot of academic top-up, we suggest they take an orientation course for a year focusing on sciences, such as physics, chemistry and human biology. If they do well in that, we offer a 5-week intensive pre-med course, and if they are successful in that, they gain entry into medicine. If they don’t do so well, we might suggest they start a health science degree, which is slightly less intense, and they can either do that for a year and then come into medicine, or complete that degree and be considered for postgraduate entry a couple of years later.” Academic and social support — a home away from homeFrom the beginning, Newcastle had an Aboriginal liaison officer who set up academic tutoring and mentoring to supplement the standard teaching program, and a physical unit, where students could meet and access textbooks and computers. The program also provided social and financial support, and scholarship and travel information (as many students came from interstate). This was initially within the medical school, but later through the university’s general Indigenous support unit, Wollotuka. Although Hensley thinks the ideal is to provide both academic and other support in a “seamless process” within the medical school, “the reality is that universities, especially small ones, cannot afford to have multiple individual support units”, he said. UWA places particular emphasis on student support and alternative pathways when they are not doing well, and Milroy is proud of having “lost” only two students overall, and even they may return. “However, our students do sometimes take a year off if they have just too many life stressors, or do a year of health science if they are not doing well. Because of being part of the larger School [of Indigenous Studies], we have people dedicated to looking at scholarships, accommodation and financial support, and others who look after emotional and social wellbeing, and a large student body which offers support and camaraderie.” The Centre also provides academic and personal support. We talked with Paula Edgill, a graduate of UWA medical school from the Noongar people, who is a lecturer at the Centre: she has an open-door policy for students and gives them her mobile telephone number for after-hours contact about academic or even personal issues. Milroy also emphasised cultural safety. “I think a reason we have been so successful is that we’re Indigenous-led and have a very holistic approach, with a generational view — we’ve had a mother and son graduate. We really get to know our families and communities well, it is a culturally affirming place, the students feel safe here and feel their identity is supported and respected. It’s a home away from home.” The Centre also addresses any issues of discrimination at a personal or faculty level, so that the students do not have to be apologists or experts in Indigenous health. Recruitment — revealing the possibilitiesRecruitment is an issue for all the medical schools, as they often have difficulty filling their quotas. “You can’t rest on your laurels, every cohort is a new group you have to enthuse and support”, said Hensley. All have recruitment programs in high schools, not only to encourage school leavers to apply for medicine, but also to motivate younger students to aspire to university and medical school. “I think the decision is made in the early years of high school, or even in primary school, whether someone will commit themselves to the work required to be ready for medicine”, Hensley explained. At JCU, Elston sends a team of Indigenous students to every high school in northern Queensland with the Indigenous health careers “road show” to talk to Years 10–12. At UWA, the medical school participates in the extensive recruitment programs run by the School of Indigenous Studies, including careers expos in high schools around WA, a Year 8 “discovery day” at the university and a Year 12 seminar. Milroy’s Centre also runs a health careers camp for Years 10–12, where 25–30 Aboriginal students from around WA stay at the university for a week to learn about different health careers. She finds that students may have come in contact with the Centre and the University for a number of years before enrolling. And the success of their program is an inspiration in itself. “If a Year 8 kid comes to the uni and sees a medical student from their community, then they think that is fantastic.” Milroy also believes that it is important to gain the trust of Indigenous communities, and that the medical school has been helped by the long-term success of the School of Indigenous Studies. “It is very hard to bring in something new and be successful straight away. You have to build up a lot of trust with the community in terms of saying, ‘If you send your students to us, we will look after them’. I think they actually believe that now.” What are the benefits?All interviewees saw multiple benefits from their programs and the creation of Indigenous doctors. “It is a comprehensive strategy with a number of aims, one being to have Indigenous doctors who want to work in areas of Indigenous health, either rural or urban”, said Hensley. It can thus provide workforce where it is needed. However, the effect on access of Indigenous people to health care may be even greater than just having a doctor available. Milroy cited research by Noel Hayman, an Indigenous academic and general practitioner, showing a rapid rise in Indigenous patients attending a general practice because of the presence of Indigenous staff.6 “When you’ve had such discriminatory experiences, fear of going into health care is always going to be an issue. That sense of relief in having someone you think will not only understand you, but also look out for you, is really important. We need culturally secure non-Indigenous doctors, but also doctors from within culture, if we are going to change things.” Yet the benefits are even wider — the programs contribute to equity, giving the Indigenous community the educational opportunities to be doctors, wherever they wish to work. And Indigenous doctors also bring non-medical benefits to their communities — increasing “the economic base” through their incomes, said Milroy, and inspiring young Indigenous people to achieve. Hensley cited the comment of Kelvin Kong, the first Australian Indigenous surgeon, that his desire to study medicine arose when graduates of Newcastle’s Indigenous program told his high school group, “Look, you can do it”. “Indigenous doctors can provide very strong role models for young Indigenous people, whether their ambitions are in medicine or any other field”, Hensley said. Indigenous doctors are also becoming advocates for Indigenous health. “I think the primary thing I’ve observed since AIDA has been around is the increased advocacy and political leverage we get from having Indigenous doctors, and I think it is the same for Indigenous doctors in a health service, they are going to advocate for Indigenous patients”, said Elston. “They’re influencing the mainstream in a way that the mainstream probably wasn’t aware.” These advocacy and leadership roles have also now extended into medical education, as exemplified by Elston, Milroy and Edgill themselves. Edgill explained that “during my training, we only had three lectures in 6 years on Aboriginal health. Now that it is being added to all the years, I thought it would be fantastic to come back to the University and help with the change and produce doctors with better knowledge in this area”. Further, one reason that Milroy employed Edgill was that she wanted “a whole cohort of students, whether Indigenous or not, to actually be taught medicine by an Indigenous doctor”. Indeed, the increasing presence of Indigenous students and staff in medical schools is enriching and influencing their curricula and engagement with Indigenous issues. Hensley confirmed that Newcastle’s Indigenous entry program was “an important contributor to having Indigenous health discussed in a number of parts of the medical program. It has made us a stronger medical school in Indigenous health”. Hensley also described how Indigenous health is assuming a higher profile in the core medical curriculum, with the adoption of revised Australian Medical Council (AMC) accreditation standards from the beginning of 2007.7 He chaired the AMC working group on the Indigenous health curriculum: “We worked closely with the Committee of Deans of Australian Medical Schools [now Medical Deans Australia and New Zealand], AIDA and other groups to put within the standards for accreditation a number of points that emphasised the need for Indigenous health to be embedded within the medical school structure. As of this year, medical schools have to report what they are doing for Indigenous health within the curriculum. Every year, colleges and societies submit new requirements, such as a comprehensive curriculum in oncology, for the standards. They are all worthy, but the medical course would end up about 20 years. The Indigenous health curriculum framework was the only one that the AMC agreed fully was an appropriate part of every medical school.” Challenges to the programsThere was general optimism about the future of the programs, even in the face of reduced funding and other pressures on universities, such as privatisation. At JCU, the Indigenous program is part of the rationale for the medical school, and, at UWA, Milroy hopes that the success of the program will speak for itself. At Newcastle, Indigenous collaboration is one of five priority areas in the University’s current strategic plan. Furthermore, the medical school is planning a partnership with the University of New England that will double its size and tap into the New England population, which has the highest proportion of Indigenous people in New South Wales. The immediate challenge is to replace the former head of the Indigenous program, Gail Garvey. “At this stage we wish to build up the discipline of Indigenous health and are looking for a senior academic and Indigenous medical graduate”, said Hensley. In fact, the real challenges to the programs lie with recruiting enough Indigenous students to fill their places and developing Indigenous academics to fill the developing roles in the discipline of Indigenous health. The way forwardWe asked the interviewees for their wish list if they had $5 million to spend on their programs. A high priority was scholarships to make the medical course a more practical option for Indigenous students — maybe similar to the rural-bonded scholarships (about $22 000 annually), but also grants to cover tertiary fees, textbooks and equipment. Milroy would also like to expand the scope for recruitment by taking recruitment programs into primary schools, and delivering pre-med programs in rural settings, such as Broome. However, increasing the scope for recruitment may ultimately require early educational intervention, said Elston, linked to the Years 3, 5 and 7 literacy and numeracy tests. “For Indigenous kids, the educational outcomes are so poor that that is where intervention should start — with a network of school-based programs that takes them out of the system into a more nurturing environment to help them get back up to scratch.” To help support Indigenous students at JCU, Elston also wanted more space for tutorials and study groups — she has one large room available for 50 students — as well as more staff “on the ground”. Staff were also a priority for Hensley, who explained that, because the support of Indigenous students requires personal interaction, the efficiencies obtained in other areas of the medical school with information technology are not possible. In addition, they all wanted higher-level positions for Indigenous health academics to strengthen the position of the discipline in the medical school and university. While all thought that Chairs of Indigenous Health would be a step forward, they identified a need first to develop the academics to fill them. Milroy suggested that fast-tracking Indigenous academics would be possible. “There are a lot of Indigenous people with reasonable skills, who just need some additional support and training. It would not take 10 years”, she said. And an Indigenous-led research centre is an ultimate goal. Hensley also pointed out the need to implement the new AMC curriculum standards and the role the Medical Deans are taking in advancing Indigenous health: “Indigenous health is a high agenda item with the Medical Deans and has unanimous support. We have produced the [Indigenous] curriculum,8 we have worked closely with AIDA on the Healthy futures document,4 and we are hoping to promote specific spending from the Commonwealth on Indigenous education. We want to make sure that the Indigenous health curriculum is much more than just a document. I am confident it will get there.” An initiative driven by the Medical Deans and AIDA to help medical schools implement the new standards is the LIME Network (Leaders in Indigenous Medical Education). This brings together Indigenous and non-Indigenous medical educators and Indigenous health and community professionals from across Australia, to share information and resources and develop tools for implementing the Indigenous curriculum, and recruitment and retention strategies for Indigenous students. Although there are increasing numbers of Indigenous students in Australian medical schools, further growth will be needed to meet AIDA’s goal of an extra 350 students by 2010. Australian medical schools have come late to these initiatives, yet we are already beginning to reap the benefits. Just as the growing numbers of Indigenous doctors may improve the health of Indigenous people, so may the growing numbers of Indigenous medical educators enrich the training of doctors, both Indigenous and non-Indigenous. Indigenous medical graduates and students in Australian medical schools, 2007* University Previous graduates Current students Indigenous entry scheme (quota or target) Adelaide 4 7 Yes (6) ANU 0† 0 Yes (2) Bond 0† 0 No (possibility if funded) Deakin 0† 0‡ In development Flinders 4 2 Yes (5) Griffith 0† 1 No formal quota James Cook 6 19 Yes (5) Melbourne 3§ 5 Yes (3) Monash 1 3 Yes (5) Newcastle 51 25 Yes (8) New South Wales 12§ 15 Yes (no quota) Notre Dame 0† 0 In development Queensland ~ 8 8 Under review Sydney 7§ 4 Yes (no quota) Tasmania 4§ 6 Yes (1–2) Western Australia 13 23 Yes (10) Western Sydney 0† 5 Yes (5%–10%) Wollongong 0† 1 Yes (3) * Information obtained from an email poll of Deans of the medical schools. † School has not yet had a graduating year. ‡ Deakin medical school has not yet enrolled students. § Information available for recent periods only: Melbourne, since 1989; New South Wales, since 1980; Sydney, since 1997 (graduate program); Tasmania, since 1996. ANU = Australian National University. na = not available.

Kerrie A Lawson BSc, PhD · Ruth M Armstrong BMed · Martin B Van Der Weyden MD, FRACP, FRCPA

We hope you have enjoyed reading the 2007 Indigenous Health issue of the Journal. The theme that has emerged this year is one of strong leadership — a leadership that more than ever makes us look optimistically to a future in which Aboriginal and Torres Strait Islander peoples enjoy health parity with other Australians. While this issue features more Indigenous authors than ever before, we are unable to publish a winning essay from the Dr Ross Ingram Memorial Essay Competition. After 2 years of very high-quality entries, we did not receive enough essays for the competition to run this year. We are disappointed with this outcome, but strongly believe that there are many more Aboriginal and Torres Strait Islander people whose stories and ideas would bring important insights to our readership. We plan to broaden our advertising of the competition this year, and look forward to bringing you a winning essay next year (as well as awarding the prize!). We would like to acknowledge the many authors, reviewers and advisors who contributed to the issue. In particular, Dr Lisa Jackson Pulver, Director, Muru Marri Indigenous Health Unit, University of New South Wales, for arranging access to the impressive and unique paintings from the Shalom Gamarada art exhibition; Jane Magnus, Senior Policy Officer at the Australian Indigenous Doctors’ Association, for suggesting a cover image and coordinating several of the articles; and Dr Louis Peachey, Senior Lecturer at the Mount Isa Centre for Rural and Remote Health, James Cook University, for his much-valued guidance, wisdom and advice on many aspects of the Indigenous Health issue. Indigenous Australia has been widely criticised in the past few years for its lack of leaders. This issue, with its many examples of speaking, writing, teaching and mentoring by Indigenous leaders, suggests this criticism is unfounded.

Ruth M Armstrong · Martin B Van Der Weyden

Objective: To compare the location and accessibility of current Australian chronic heart failure (CHF) management programs and general practice services with the probable distribution of the population with CHF.Design and setting: Data on the prevalence and distribution of the CHF population throughout Australia, and the locations of CHF management programs and general practice services from 1 January 2004 to 31 December 2005 were analysed using geographic information systems (GIS) technology.Outcome measures: Distance of populations with CHF to CHF management programs and general practice services.Results: The highest prevalence of CHF (20.3–79.8 per 1000 population) occurred in areas with high concentrations of people over 65 years of age and in areas with higher proportions of Indigenous people. Five thousand CHF patients (8%) discharged from hospital in 2004–2005 were managed in one of the 62 identified CHF management programs. There were no CHF management programs in the Northern Territory or Tasmania. Only four CHF management programs were located outside major cities, with a total case load of 80 patients (0.7%). The mean distance from any Australian population centre to the nearest CHF management program was 332 km (median, 163 km; range, 0.15–3246 km). In rural areas, where the burden of CHF management falls upon general practitioners, the mean distance to general practice services was 37 km (median, 20 km; range, 0–656 km).Conclusion: There is an inequity in the provision of CHF management programs to rural Australians.

Robyn A Clark BN, MEd, FRCNA · Andrea Driscoll BN, MN, MEd · Justin Nottage BEnv, GradDipSpISc · Skye McLennan MPsych · David M Coombe BApplSci(BioEnv · Errol J Bamford BEcon · David Wilkinson PhD, DSc · Simon Stewart PhD, FCSANZ

Trends in meningococcal disease (MD) over the 20th century in Australia, as in other industrialised countries, have been characterised by epidemics during the two World Wars, a transient rise in incidence in the 1950s followed by endemic disease, and in the 1980s the emergence of a sustained hypersporadic phase. Epidemics occur at times of social upheaval and among marginalised populations, and resolve when living conditions improve. Periodic serogroup A epidemics have been replaced since the 1950s by endemic disease caused mainly by serogroups B and C meningococci. The current hypersporadic plateau in Australia, as in other industrialised countries, is associated with the intercontinental spread of hypervirulent clones of meningococci. The conjugate serogroup C vaccine has reduced the incidence of MD and carriage rates of serogroup C meningococci. However, the vaccine is expensive and its long-term impact on the emergence of non-vaccine strains and on nasopharyngeal microecology is unknown. A rising incidence of MD should not be viewed as the action of a virulent microbe exploiting a vulnerable population, but as the emergence of an “accidental pathogen” from an evolving host–microbial ecology. While it is essential to monitor the impact of vaccines on this ecology, we must find ways that can optimise our coexistence with microbes.

Mahomed S Patel MB BCh, FRACP, FAFPHM

Government, industry and the community can work together to reduce price disparities An Aboriginal Health Worker, Marinka Burton, shops at one of the Mai Wiru (good food) stores in the Pitjantjatjara Lands, South Australia. Details of the Mai Wiru program can be found at http://www.nganampahealth.com.au With the New Year come those grand statements of good intent — to eat less and live longer. But resolving to eat less is a luxury reserved for affluent people. This New Year, most of the world’s population will still be seeking to increase their food supply. This is not a matter irrelevant to Australia: Harrison and colleagues (page 9) remind us that not all Australians have an abundant, affordable and continuous supply of food.1 In their article, they report on a series of surveys — the Healthy Food Access Basket (HFAB) surveys — of selected food stores in Queensland. The surveys showed that, to meet their families’ basic food needs, Australian residents in very remote areas paid an average of about 30% ($114) more each fortnight than people living in cities. The price disparity was greater for basic, healthy food items than for “unhealthy” items such as takeaway food, soft drinks and tobacco. Moreover, at the time of the surveys, fewer of the basic healthy foods were available in remote stores than in city stores. Of particular concern were the higher increases in food prices over time in very remote areas — for example, between 2001 and 2004, the cost of the HFAB in very remote areas increased by 18% ($77.00), which was greater than the rise in the Consumer Price Index. Remote Australia is home to many Indigenous Australians. They are doubly disadvantaged, paying more for food and other essential goods, and having the lowest incomes of any population group. A detailed study of costs and incomes in a remote Indigenous community in South Australia found that basic living costs consumed up to 85% of family incomes, with food accounting for 35% of the total.2 In contrast, Australians in general spend less than 20% of the family income on food.3 Although remote Indigenous communities obtain their food from various sources, the local store remains the largest supplier of foods.4 Self-sufficiency in food (especially in the face of increasing drought) is not a viable option. Thus, inequitable food pricing is an issue for all remote communities. The poor health and nutritional status of Indigenous Australians, including extreme rates of obesity, diabetes mellitus, cardiovascular disease and end-stage renal disease, have been amply documented.5 The links between poverty, food insecurity and obesity have recently been outlined by Drewnowski and Specter,6 who argue that poor people all over the world maximise calories per dollar spent. Thus, less expensive, energy-dense foods with high fat and sugar content always win out in the shopping basket over more expensive, less energy-dense foods such as fruit and vegetables. Reducing the disparity between food prices in cities and remote areas would be one way to help Indigenous families make healthier food choices. Why are food prices higher in remote areas? Investigators have identified several reasons.7,8 Refrigerated road transport for food is expensive, and made more so by the goods and services tax (GST) and rising fuel costs. In addition, in the wet season, some communities rely on air transport for their supplies. Poor business and stock management practices, lack of accountability, and unusual or corrupt behaviour by store managers have meant higher mark-ups in stores. The lack of clear store governance roles and procedures set down by community committees has hindered attempts to improve store management practices. Store expenses, including managers’ salaries (set high to encourage recruitment to remote areas), electricity, shipping, refrigerated storage and stock spoilage costs, are often higher than those incurred by city retailers. Because of the small populations in remote areas, opportunities for achieving economies by bulk-buying from large wholesalers are limited. What is being done? An impressive array of local initiatives has been described in FoodNorth, a report commissioned by the Western Australian Government on behalf of the “Top End” states and the Northern Territory.7 The report investigated the issues of excessive food costs and limited availability, and documented examples of promising programs from remote Australia that address these problems. Recently, federal, state and territory agencies have initiated more expansive programs, including the Remote Indigenous Stores and Takeaways project and a new company, Outback Stores, established by Indigenous Business Australia with significant federal funding.9,10 These projects have been established in recognition that remote-area food stores are commercial enterprises (although in many cases community-controlled) and must make a profit to survive. At the same time, those concerned with the health and wellbeing of remote communities argue that remote stores have a social responsibility to supply healthy foods to communities that depend entirely on their stock. These dual, and potentially opposing, objectives of profit and social responsibility present a difficult, but not insurmountable, tension for food retail businesses in remote areas. Indeed, there have been considerable shifts in recent years in some communities, whose stores are pursuing better business practices for bigger profits, while improving the quality of the produce they sell — for example, by using multiple strategies that outline the roles and responsibilities of the store, the types of foods to be stocked and promoted, and the accountability requirements of managers to reduce store expenses. Improving retail management practices is expected to cut the need for high mark-ups on prices. Some communities are establishing buying groups to enable stores to bulk-buy at wholesale prices. Community stores are developing guidelines and manuals to improve training and industry practice. An example is the Freight improvement tool kit, which is designed to improve the efficiency of cold-chain perish-able food transport to remote areas.11 Schemes to recruit and train Indigenous people in retailing aim to improve the efficiency of store operations as well as providing employment opportunities. Leaders in the retail grocery industry, including Coles and Woolworths, are providing considerable pro bono support. In parallel, local communities are expanding and improving banking services to minimise stores’ financial losses from unofficial loans and credit lines. What can others do to help and support these heroic efforts? There is no shortage of ideas and plenty of work for us all — food retailers, bankers, food transport companies, land councils, Indigenous-run businesses, employment program managers, governments, health professionals, health-related data collection agencies, and academics. Public–private partnerships, particularly for retail and business training for Indigenous communities, need to be fostered and maintained. Government assistance to minimise GST costs and perhaps subsidise food transport costs is worthy of consideration. Continued support and investment in the current promising initiatives are required, including funding to evaluate programs and ensure they lead to reduced prices of healthy foods in remote areas, as well as other expected benefits such as improved employment rates, incomes and health of remote-dwelling Australians. To this end, several groups have argued for the development and maintenance of a system for routine monitoring of prices of selected foods, and a family food basket, Australia-wide.7,12,13 The HFAB surveys provide a useful model for further development of a national food price monitoring initiative. This New Year, let us resolve to help solve the problems of Australians living in remote areas who pay higher prices for food than we pay, but whose ability to pay is less than ours. Indeed, let us go beyond a resolution and — through greater citizen action, good business and a modicum of government intervention — assist our remote communities in righting this wrong.

Karen L Webb PhD, MPH · Stephen R Leeder AO, PhD, FRACP, FAFPHM

Awareness of a serious Indigenous health problem in Australia did not emerge until the 1960s and 1970s. Much attention was focused at the time on poor pregnancy outcomes, high infant and young child mortality rates, and childhood malnutrition and impaired growth, often associated with high infectious disease burdens. Although that situation has improved somewhat, Indigenous infant and child health is still poor compared with that of other Australian children. Over recent decades, there has been a rapid rise among Indigenous people of nutrition-related “lifestyle” disorders such as obesity, cardiovascular disease, type 2 diabetes mellitus and chronic renal disease and their complications. This epidemic of disabling and often fatal chronic diseases in Indigenous Australians is also occurring in disadvantaged groups in many other countries. Control of this potentially disastrous epidemic must become a much higher priority in Indigenous health programs. Governments must commit to this task in cooperation and collaboration with Indigenous organisations and communities.

Michael S Gracey AO, MD, PhD, FRACP

If all outlets for venting anger come with heavy costs, then unresolved injustice simply simmers Some time back, my high school matriculation class held a reunion at a Tamworth motel. Many of us hadn’t seen each other for 27 years. Over those years, people, and times, had changed in unexpected ways. I was surprised by the vehemence of one former classmate, who berated me for still having my hair! Then I was angered by another, who now radiated the same kind of menace as the crims he’d put away in the intervening years. What really threw me, though, were the four or five separate occasions when I was pulled aside by someone wanting to personally apologise for “the way they had treated me” all those years ago. Their change in awareness was heartening, their behaviour sincere. Yet I was left groping for words. There was no Indigenous–settler lingua franca from which I could pull a response. I thought back to a particular, clued-in science teacher taking my class to task — in code — for negative responses to “a particular class member’s difference”. Then there were the examples, over the years, of my presence provoking inexplicable hostility: puzzling kicks in the shin in the primary school playground, group taunts at Cubs and Scouts, or the quick-fisted farm boy who spotted me as soon as I turned up at high school. I’d come to believe, though, that the problem was me — that, in some irremediable way, I was simply unacceptable. Not so much that I didn’t, but that I could never, measure up. My mother dealt with our Aboriginality like her mother before her, by simply denying it. My father’s side of the family made their way from Ireland to the south of New South Wales around the 1860s. My mother grew up in Gadigal country in the 1920s, less than a kilometre from “The Block” in Sydney’s Redfern, yet the family fiction bequeathed to her was that her father came off a boat from Trinidad. Detective work, much later on, teased out a different picture of my grandfather. What emerged was a Gamilaroi man from the north-western slopes of NSW. It took my experience as a psychologist — in particular, work with blackfellas in crisis — to bring home to me that my tussles with identity in fact echo those of many other Aboriginal men. * Clayton’s tonic: the non-alcoholic, Scotch whisky look-alike advertised as “the drink you have when you’re not having a drink”. The West Indian fantasy was neither unique nor unusual. The historian who coined the term “stolen generations”, Peter Read, estimates that 100 000 Australians deny, or are denied, their Aboriginality.1 This country is awash with dubious “ancestors”, such as Javanese royalty and surprisingly skinny-legged Māori. When I work with medical students, registrars or even long-practising mental health professionals, I see them struggle to grasp how such severance from self came about. Our education system has failed them: they have only the haziest idea of how all-encompassing — and how deleterious to Indigenous wellbeing — was the system of “Clayton’s”* apartheid that still ruled in the 1950s and 60s. (For example, the Queensland Government’s Aboriginals Preservation and Protection Act 1939 was still affecting the way its enforcers went about their business as late as 1969.) In a sense, this is not surprising. The Australia that decreed that newly married women must give up their jobs is incomprehensible to contemporary young women, yet this was just one of a range of social strictures applying at the time. My daughter’s high school friends thought it “weird” that business shirts for men only came in colours from the late 1960s on. The “white shirt” mentality ruled more than men’s wardrobes: expectations about how one should present were proxies for inflexibility about how one should behave — for Indigenous Australians, about how one should be. When you’re unaware how far-reaching was the control of Aboriginal lives by mission managers, “The Welfare” or police, it’s hard to comprehend the lengths to which Aboriginal Australians went to escape that control. Many simply identified as Indian, Fijian, Italian . . . whatever would get the authorities off your back and keep your children by your side. Tamworth was blindingly “white”. Apart from Wilga and her brother at my school, and my mother, there were few black faces to be seen in town. The experience of growing up “brown”, in a landscape configured for something else, shaped an isolation that took a long time to resolve. A continual awareness of underlying antipathy — one that occasionally snapped its leash — left me confused and angry. Walking the few blocks from home to high school churned my stomach. My arms and legs lost connection, my head went down as I broached the rows of early arrivals astride Globite school cases, a gauntlet that ran from school gate to assembly area. My anxiety played out bodily and mentally. The facial tics of early high school years progressed to specific obsessions and compulsions: counting to 15 before making any major, or even minor, decision; washing and rewashing; scratching imaginary itches throughout a conversation. I functioned sweetly in some environments, but fell apart in others. I left for university with relief. As long-standing Aboriginal social exclusion and the bite of lived racism played no small part in my mental distress, letting go my anxieties was never going to be a straightforward task. There was no prescription. Education, the opportunities of improved income, a strengthening of identity — the usual suspects — all played a useful role. Negotiating my hybrid identity and the contradictions of the Australian mantra of a “fair go” meant I learnt as much off campus as on. My high school belief in an omnipresent “British justice”, for example, was swiftly quashed at 18, as I left an Armidale pub. From a group of otherwise strictly Anglo-Celtic students, I was the one selected to see the inside of a steel-benched police wagon, then introduced to a new sport: speed up and brake . . . speed up and brake . . . Your head quickly becomes intimate with metal. For blackfellas, racial profiling is no new-millennium phenomenon, though fresh manifestations stoke old fires. If all the outlets for venting anger come with heavy costs, then unresolved injustice simply simmers — a physical charge that won’t go away. As the Acting Social Justice Commissioner noted in his analysis of responses to the 1997 Bringing them home report:2 The Indigenous sense of injustice is so deeply inscribed that it forms an expectation of injustice [emphasis added].3 Personal narratives are a way to comprehend the push of the past into the present. They can, though, label the teller as both victim and whinger. This is a risk that needs to be run. Unless settler Australia comprehends the pervasive, yet casual, nature of state-sanctioned violence in Indigenous lives — in particular in male lives4 — it will remain puzzled as to the violent responses engendered in turn. My experiences are small beer compared with those of many other blackfellas. I wasn’t attacked with a broken pool cue, in the proud, pioneer town of Orange, as was a nephew of mine; I didn’t have to jump from a slowing-down car, on a remote Tasmanian road, to avoid a bashing from the group who’d offered me a lift, as did a former partner of my sister. Racist violence, immediate or threatened, is the razor wire around Aboriginal lives. The effects are potent. If enough are served up to you, small beers will still get you drunk. The experience of the Foundation President of the Australian Indigenous Doctors’ Association, Dr Louis Peachey, gives insight into the treatment dilemmas facing non-Indigenous health professionals in a non-reconciled Australia — why they may still fail to grasp the full magnitude of the combined effects of social stress and percolating threat within Indigenous life contexts. Peachey was astounded to discover, some years ago, as a young man on a night out with non-Aboriginal friends, that whitefellas didn’t feel a need to check every dance hall, pub or party for problematic people, quick exits or, failing that, for the availability of makeshift weapons (reported by Peachey in a speech given at the Australian Indigenous Doctors’ Association Annual Symposium, Sydney, 2003). Aboriginal Australians live in a climate of thick air: often the sense is that the storm may break at any moment. The work of the US researcher, Bruce Perry, suggests it can be psychologically fraught to leave the living culture of a Native American or Canadian reservation, a Māori whānau or hapu (extended family or tribal group), or an Australian Aboriginal community to become a “minority” individual in a Western cultural framework.5 I grew up with a distinct awareness that I was “Other” to the default setting. For Murri, Koori or Nyoongah men, this doesn’t occur in a historical vacuum: a number of authors have noted the concurrent, spirit-sapping loss — through colonisation — of our traditional Indigenous male roles.6,7 The “Othering” process, then, extends the experience of loss. The primary way it unfolds is through mechanisms that demean or diminish. In conservative-led Australia, the dominant equation is a simple one: member of a “minority” = reduction in regard.8 The infantilisation of Indigenous men has served the colonial project well. Even innocuous-seeming advertisements have played a significant role in reinforcing an image of people insufficiently civilised — or evolved — to be worthy of owning the land that was taken from them. For 40-odd years, from the end of World War I to the diminution of overt stereotyping in the 1960s, Pelaco shirts — crisp, white and tailored just right — became a market leader under the logo of “Pelaco Bill”, a skinny caricature of Aboriginal maleness: brown, maniacally grinning, barefoot — in fact naked, apart from his crisp, white . . . You get the drift. Bill’s “Kriol” (read “kiddie English”) caption, the original Pelaco slogan, completed the picture: Mine tinkit they fit.9 In an Australia that refuses the cultural imbrication of Aotearoa/New Zealand, or the “we’re a nation of minorities” pluralism of Canada,10 “Othering” continues, serving ends related to the apogee of “wedge politics” and notions of being “comfortable” with history. Cultural practices are now the locus of intense attack. Aboriginal “men’s business” — the gender-specific cultural imperative alive in urban, as much as remote, settings — is in the process of being repositioned as an archaism, other to “Australian” values. In recent federal government and media forays, it is portrayed as a dangerous, alien tenet — the cultural motif underpinning monstrous violence against women and children.11,12 Such attacks “sanitise” our history and continue an inexplicable blindness to the contemporary consequences of past policies. In particular, they obscure the disastrous legacy of “Clayton’s” apartheid and ignore the contribution of a range of variables — such as poverty, overcrowding, overincarceration and transgenerational trauma — that are well recognised for their potency.13-15 They threaten not only to derail promising initiatives that work with, rather than against, Indigenous culture, but also to subsume a complex public health issue under a simplistic law-and-order response. Conversely, things are turning around, at least in terms of Indigenous male dynamism for change. In the past decade, Indigenous male health conferences and health service innovations have championed a need to see “men’s business” as the positive social force it has always been for blackfellas.16,17 In these forums, participants say they want to regain a sense of a valued role for Aboriginal men — a concept quite distinct, it needs pointing out, from hegemonic masculinity, yet imbued with the potential to turn around our health outcomes.18,19 The change of heart so evident in that Tamworth function room — people growing up, not just growing older — has not yet made it to Canberra. Demonising Aboriginal men as a precursor to mainstreaming Indigenous services is not only inexcusable vilification, but demonstrably ineffective public health policy.20 As with any distinct population, generic approaches just don’t cut the mustard. The only services that are likely to deliver real improvements in Indigenous male health are ones tailored to our cultural and contextual realities. Ask us why we avoid mainstream services, and we’ll tell you — we think they don’t fit.

Dennis R McDermott BEc, BA Hons(Psych), MA

Aboriginal and Torres Strait Islander males arguably have the poorest health of any racial group in Australia. In 1999–2001, it was estimated that they have a life expectancy of 56 years (compared with 77 years for all Australians) and that 75% of Indigenous males die before 65 years of age (compared with 27% of their non-Indigenous counterparts).1 The recent media debate on the abuse of women and children in Indigenous communities unfortunately failed to highlight the very poor health status of Indigenous men and the fact that Indigenous male death rates from assault are similar to, if not higher than, the rates among females.1 This does not challenge in any way the critical plight of women and children in these communities and their need for protection, but does add some context to the debate, which has thus far depicted Indigenous males as perpetrators of violence rather than being, also, victims. The interpretation that community violence somehow reflects Aboriginal gender constructs also confuses the issue. The violence against women and children occurring in some communities is by no means a part of traditional culture, in which both men and women have valued, specific and complementary roles. There have been numerous calls for Aboriginal and Torres Strait Islander male leadership in this area. Indigenous men have themselves attempted to take on this mantle at a national level over a number of years, following the Ross River Aboriginal and Torres Strait Islander Men’s Health Conference in 1999. Indeed, a group formed at this conference produced a National Framework for Improving the Health and Wellbeing of Aboriginal and Torres Strait Islander Males2 in 2003, but this has not subsequently been implemented. Aboriginal men’s groups have existed at a local level for many years. These groups attempt to work with Indigenous men to address the many issues facing them and their families. Rather than addressing male issues exclusively, the groups place a high priority on a “whole of family” approach. They address male roles and the loss of these — teacher, hunter and lore-man, but also father, provider, partner and community leader — and include such things as diversionary programs, domestic violence programs and parenting programs.3,4 The groups comprise grassroots Aboriginal and Torres Strait Islander men who are committed to making a difference, but they are largely unfunded and generally too poorly resourced to have the broader “systems” community approach that is known to be necessary. While some of these men’s groups function very well, others have floundered, and struggle with governance and finance issues. This is not completely unexpected, as, while these men are expected to take responsibility and leadership upon themselves, many are untrained in any aspects of governance and finance and come from communities with low literacy and numeracy levels. To learn to incorporate and run an organisation and to manage a business, in often dysfunctional circumstances, requires capacity development, skills transfer and support. None of the preceding removes Indigenous men from their “personal” responsibility to ensure the health and safety of their women and children, but it does indicate a need for other Australians to help and support those who are attempting to address their own issues in a spirit of mutual responsibility. In contrast with the media portrayal of Indigenous men as perpetrators of violence, the accompanying excerpt from “Do’s and Don’t’s” rules for an Aboriginal men’s group (Box) illustrates the simple principles this group has developed.3 It is simplistic in the extreme to suggest that radical changes, such as relocating all remote Aboriginal communities to urban centres, will fix the problems,5 while failing to address the underlying issues of loss of self-esteem, culture, land and identity. The following is taken from an assignment by an 18-year-old Aboriginal male student health worker, describing the plight of Aboriginal men in his community: In my community our men are always being put lowest down to the ground, that is why they are always fighting with each other and committing suicide, because we know that white people think we are “apes” and so forth . . . If our young Aboriginal men have this perception of their place in this “lucky” country, we have a long way to go. However, positive change can be accomplished in time, and the health professions will have a role. We rightfully call on Indigenous men to stand up and be the leaders they were traditionally, but it will require a broad approach, with support from Australia as a nation and powerful groups such as the medical profession, as well as Indigenous men themselves, to comprehensively address these issues. Excerpt from “Do’s and Don’t’s” rules formulated by an Aboriginal men’s group Do’s Don’t’s Be loving, kind, compassionate, forgiving, respectful, honest and truthful Hate, reject and put down people Support family by working and paying bills Argue and fight in front of kids Have a job, employment Abuse wife or kids Be a role model for wife and kids Gamble money away Communicate with wife and kids regularly Be a slave to alcohol, drugs or gambling Resolve conflict by talking rather than fighting Be violent to others and families Show more positive leadership in family and community Be ashamed of who you are Teach your kids to read Be selfish — think of others

Mark Wenitong BMed

To the Editor: Meningitis is one of the most serious infections in young children. The annual incidence of Haemophilus influenzae type b (Hib) meningitis between 1984 and 1988 was 150 per 100 000 population in Aboriginal children and 27 per 100 000 in non-Aboriginal children younger than 5 years.1 A conjugate Hib vaccination program was introduced in Western Australia in January 1993, before a nationwide program commenced in July 1993. Subsequent marked declines in incidence of Hib meningitis have been reported.2-4 However, there are no recent reports on trends in overall admissions for meningitis. The WA Data Linkage System (WADLS) encompasses statewide population-based record linkage of the statutory birth and death registers, midwives’ notification system, and hospital morbidity database,5 and is one of few such resources worldwide. As part of a larger study to determine the burden of infection in a cohort of births between 1990 and 2000 using the WADLS, we investigated hospitalisation for all-cause meningitis (International classification of diseases, 9th revision, diagnosis codes 003.21, 036.0, 047, 049.0, 054.72, 320-322) in 17 296 Aboriginal and 252 775 non-Aboriginal children younger than 2 years between 1992 and 2000. In Aboriginal infants (< 12 months), the meningitis rate fell by 41% between 1992 and 1993–1994 and by a further 54% in 1995–1996, and has remained stable since (Box). In Aboriginal children aged 12–23 months, rates declined by 44% between 1993–1994 and 1995–1996 and again by 50% in 1997–1998, and no meningitis admissions were reported in 1999–2000. In non-Aboriginal infants, meningitis rates declined by 36%, from 1.8 per 1000 child-years in 1992 to 1.2 per 1000 child-years in 1993–1994, with a further 50% decline in 1997–1998, since when rates have remained stable. Rates declined by 57% between 1992 and 1993–1994 in non-Aboriginal children aged 12–23 months, declined a further 47% in 1995–1996, and have since remained stable at about 0.2 per 1000 child-years. With the decline in meningitis admissions, the disparity between Aboriginal and non-Aboriginal children has narrowed: the relative rate (RR) of Aboriginal to non-Aboriginal meningitis admissions fell from 7.3 in 1992 to 5.0 in 1999–2000 in infants, while in children aged 12–23 months, the RR was > 7.0 in 1993–1996, fell to 3.0 in 1997–1998, and was indefinable in 1999–2000 (Box). In the absence of other relevant interventions, we attribute declines in meningitis admissions to the introduction of Hib vaccine. This is supported by other studies showing a reduction in Hib meningitis following vaccination.2-4 Retrospective data provide an opportunity to assess overall trends in admissions. Future linkages with immunisation and laboratory data will allow us to investigate pathogen-specific admissions and evaluate vaccination programs. Our findings show that substantial improvements can be achieved given government commitment to implement appropriate preventive measures. Adequate funding and continued commitment is needed to ensure these measures are accessible to all WA children. Hospital admission rate for meningitis in Aboriginal and non-Aboriginal children aged (a) < 12 months and (b) 12–23 months in Western Australia, 1992–2000 Relative rate of Aboriginal to non-Aboriginal admissions is shown at the top of each graph.

Hannah C Moore · Deborah Lehmann

Objective: To examine trends in suicide in the Northern Territory between 1981 and 2002, and demographic and other characteristics of people completing suicide in the Top End region in 2000–2002.Design: Retrospective descriptive analysis of Australian Bureau of Statistics death registration data and data from the NT Coroner’s Office.Setting and participants: All residents of the NT who completed suicide between 1981 and 2002.Main outcome measures: Changes in the age-adjusted and age- and sex-specific rates of suicide in Indigenous and non-Indigenous NT residents over time; prior diagnosis of mental illness and use of alcohol or other drugs by those completing suicide.Results: The age-adjusted suicide rate in the NT increased significantly between 1981 and 2002 (P < 0.001). Over this period, the rates among the Indigenous and non-Indigenous male populations increased by 800% (P < 0.05) and 30% (P > 0.05), respectively. Indigenous males aged under 45 years and non-Indigenous males aged 65 years and over were most at risk. In the Top End, a history of diagnosed mental illness was present in 49% of suicide cases, and misuse of alcohol or other drugs around the time of death was associated with 72% of suicide cases.Conclusion: Our study highlights the rising rate of suicide in the NT and suggests that suicide prevention initiatives need to specifically target Indigenous and non-Indigenous males in the age groups most at risk.

Mary-Anne L Measey MPH · Shu Qin Li MPH · Robert Parker FRANZCP · Zhiqiang Wang PhD

Objective: To examine trends in Northern Territory Indigenous mortality from chronic diseases other than cancer.Design: A comparison of trends in rates of mortality from six chronic diseases (ischaemic heart disease [IHD], chronic obstructive pulmonary disease [COPD], cerebrovascular disease [CVD], diabetes mellitus [DM], renal failure [RF] and rheumatic heart disease [RHD]) in the NT Indigenous population with those of the total Australian population.Participants: NT Indigenous and total Australian populations, 1977–2001.Main outcome measures: Estimated average annual change in chronic disease mortality rates and in mortality rate ratios.Results: Death rates from IHD and DM among NT Indigenous peoples increased between 1977 and 2001, but this increase slowed after 1990. Death rates from COPD rose before 1990, but fell thereafter. There were non-significant declines in death rates from CVD and RHD. Mortality rates from RF rose in those aged ≥ 50 years. The ratios of mortality rates for NT Indigenous to total Australian populations from these chronic diseases increased throughout the period.Conclusions: Mortality rates from IHD and DM in the NT Indigenous population have been increasing since 1977, but there is evidence of a slower rise (or even a fall) in death rates in the 1990s. These early small changes give reason to hope that some improvements (possibly in medical care) have been putting the brakes on chronic disease mortality among Aboriginal and Torres Strait Islander peoples.

David P Thomas MMedSc, PhD, FAFPHM · John R Condon MPH, PhD, FAFPHM · Ian P Anderson MB BS, FAFPHM · Shu Q Li MB, MPH · Stephen Halpin BSc, MSc · Joan Cunningham ScD · Steven L Guthridge MB BS, MTH, FAFPHM

The 2006 Dr Ross Ingram Memorial Essay Prize was presented to Dennis McDermott, Koori psychologist, academic and poet, at the AMA National Conference in Adelaide in May 2006. This year we were honoured by the presence of Ross Ingram’s wife, Julie Neville, who joined MJA editorial staff and federal AMA president, Dr Mukesh Haikerwal, in presenting the prize named in her late husband’s memory. Dennis McDermott is Conjoint Senior Lecturer in Indigenous Health at the Muru Marri Indigenous Health Unit of the School of Public Health and Community Medicine, University of New South Wales. He won the prize of $5000 for his essay, Unknown family at the taxi stand, which was published in the 15 May 2006 issue of the MJA (http://www.mja.com.au/public/issues/184_10_150506/mcd10107_fm.html). In presenting the prize, MJA Deputy Editor Dr Ruth Armstrong commented that Dennis had combined the stories of his Aboriginal family, the insights of a psychologist, the analytical abilities of an academic and the beautiful, layered writing style of a poet to produce an elegant and thought-provoking essay that emerged as a clear winner with the external panel of judges. Dennis McDermott thanked the Journal for providing a platform for the voices of Indigenous people to be heard, noting that the complexities of Indigenous health were not being adequately represented in current media debates. He urged the doctors present to be bold in supporting initiatives to improve the health of Aboriginal and Torres Strait Islander peoples and to resist measures that are counterproductive. Entries for the 2007 Dr Ross Ingram Memorial Essay Competition close on 15 January 2007. The competition is open to any Aboriginal or Torres Strait Islander person who is working, researching or training in a health-related field. See the eMJA for details (http://www.mja.com.au/public/issues/180_10_170504/arm10277_fm.html). The runner-up essay, A journey of Indigenous identity, by Dr Marshall Watson, is published in this issue of the Journal (A journey of Indigenous identity). From left: Mukesh Haikerwal, Dennis McDermott, Ruth Armstrong, Martin Van Der Weyden and Julie Neville.

Ruth M Armstrong

Tearing down the road on a mountain bike that was three sizes too big (or at least that’s what it felt like) on another 40-God-knows-what degrees Celsius day in Karratha, the heat reflecting off the road, I was stopped by a familiar voice booming from the weatherboard house on the corner. “Hey Esme, what you doin’? You wanna come fishin’?” It was Ritchie, a Torres Strait Islander bloke my age, and a good mate. “Nah, mate, goin’ to mow lawns — besides, don’t have a rod, unless you got a spare”, I replied. Ritchie smiled. “What you want a rod for? It’s much better this way”, and held up a fishing spear. * An Australian television drama series. “Well, if you change your mind I’ll be down the back beach” he added, and I continued on my way. I had Ritchie to thank for the nickname “Esme”, after Esme Watson of A Country Practice* — he liked it so much he even named his dog Esme. Now I didn’t liken myself to my namesake at all, and could not be stuffed with gossip, but the name stuck like mud. Ritchie was part of a big Torres Strait Islander family in town and had rellies around Karratha, Roebourne and Wickham. His dad had a bloody good reputation as being one of the best trades assistants around. Ritchie was not the academic type, and went to school if and when he liked. When I look back, I realise he taught me a lot about Indigenous identity and I have a lot to thank him and his family for. My family moved to Karratha from Perth when I was 12, as my dad Noel got a job with Hamersley Iron. Even though Noel is not my biological dad, nor is he Aboriginal, he always said to me, from when I was a young age, “You’re Aboriginal ya know, and it’s something to be proud of”. I had no idea what being Aboriginal meant. All I’d learnt about Aboriginal people was what I’d seen on TV and snippets from other family and friends, neither of which were positive. I always knew I was different, but couldn’t define how. Growing up is hard enough, but growing up in a country town during adolescence and trying to find your identity as an Indigenous Australian is even harder. This is where it gets a little complex, but follow as you can. I knew who my biological father was, and it was his brother and his family that I grew up around in my younger years in Perth. However, I was like the secret, the “black sheep” of the family, if you will — the one who was not spoken about in a family that denounced their Aboriginality. Just as my biological dad was not spoken about when mum was around. So how did this young kid — who knew he was Aboriginal, knew his family was Aboriginal and knew they did not accept it — have a hope in hell of figuring out his place in the world? I didn’t know where to start; all I had to go by was what I’d heard from my family, such as “you’re only part Aboriginal”, and sneaking in looks at photos of my grandmother (because I was too afraid to ask any questions). The only Indigenous family I had contact with was Ritchie’s. This is how it remained for several years. † Tertiary Entrance Examination. During my university years I found it tough going at times. Don’t get me wrong — I have some great memories of my uni days. It was funny that while all the white mob were discussing TEE† scores, the Aboriginal mob were more interested in where you were from and who your mob were. But still I didn’t know much more about my Aboriginal family and in some ways I felt isolated and sad, but my stubbornness and anger at my biological dad held me back. There were those who accepted and understood my viewpoint and others who did not. Occasionally I was called a “coconut” (black on the outside and white on the inside) because I hadn’t found my family. Of those who knew my pain and helped me over the years, two stand out. Both are Indigenous, one a doctor and the other soon to graduate in medicine. Furthermore, it was another friend’s mother who gave me hope. When I mentioned my Aboriginal grandmother’s name, she replied, “Edith Oldridge, I remember her from the AMS [Aboriginal Medical Service]. She was a Holmes.” Jackpot! I had a connection and it all seemed to steamroll from there for a short time. Although I found out that the Holmes were related to the Williams, any other information that I wanted to get required me to go through the Department of Indigenous Affairs, and to do that I would need to get the permission of my biological dad. This I was still not ready to do. I became scared that, if I didn’t find my family, all the elders would die and I’d be forgotten and I wouldn’t find my country — a fear that would make me cry and keep me awake at night. But what I was to learn in the years to come was that I was not forgotten. As people do not forget, neither does country, and I was to discover that returning to your country is both embracing and healing. I visited the mission at New Norcia recently; this was where my great grandmother was in her younger years. To walk the same ground as my ancestors was a very restorative experience, even if it had been a mission. I met the Aboriginal woman who would become my wife several years ago and moved to Adelaide from Melbourne to be with her. It was coming to know her and her family, whom I absolutely adore, that made me truly understand the fundamental nature of Aboriginal family. Nobody was perfect but everybody was loved, and all efforts were made to locate family members who were lost. It was from this that the fire to find my roots was rekindled. I was no longer angry, just bloody curious and had had a gutful. I wanted to know about my family and I wanted to know yesterday! In January 2005, I made contact with Alan, my biological dad. He and I both had lots of questions, so we organised a meeting. It was emotional, but when we met I learned more from him about my family in the first 10 minutes than I had in the previous 30 years — he knew it all. Being Aboriginal, however, did not mean a great deal to him at this time. He grew up as the youngest of 10 children and remembers being taken away to Sister Kate’s (Parkerville) Children’s Home with his other three youngest siblings. Eventually he returned to the family, but as a matter of survival the family denounced their Aboriginality, claiming that they were either Afghan or Tahitian. For reasons that are another story altogether, dad became separated from the family and, over the years, joined the army and then became a member of the Patriots Bikers Club. This may make some uncomfortable, but the core business of the club was raising money for children’s charities. The point is that both of these became the extended family that my dad didn’t have but yearned for. Since I have known him over the past year, he has come out of his shell, to say the least. He has embraced his Aboriginality and is on his own journey of identity. He has returned to Parkerville Children’s Home to face his demons, met people who remember him from his early years, and met cousins that he never knew he had. As a result of this, he has changed as a person and is much more at peace with himself now that he has found his place — unlike his brothers and sisters, who are not yet ready to do this. My sister, who until a year ago was unaware that she had an older brother, is now also on her own journey of identity. Many Aboriginal and Torres Strait Islander peoples are unaware of their family relationships, their kinship structures, that are the strength of Aboriginal society and that place them in the context of their family, their country and their culture. This is a result of the process of colonisation and assimilation policies. Current understanding of the determinants of Indigenous health highlights the negative effects of the denial of sovereignty, cultural dislocation, dispossession and disempowerment, particularly in relation to social and emotional wellbeing.1 Our children need to have a nurturing and loving environment to grow up in, with family on all sides; our adolescents need to be able to learn how to be young adults and parents; our young adults need to be active members of the community, rearing children and caring for others; and our elders need to be able to pass on family stories and traditions to educate the younger generations. All of this has to occur in a society that, in many instances, has been unjust to Indigenous Australians. As an Indigenous health professional, and because my people are the “statistics”, I know all too well the reality of Aboriginal and Torres Strait Islander health. It is not all bad, however — we are a resilient mob. What keeps us going is our love and respect for one another and our land. The titbits of information I had when I was young were precious to me and sustained me through difficult times. I lament for those Aboriginal and Torres Strait Islander people who know nothing of their history. I know I am not the first — nor will I be the last — Aboriginal person with a story about discovering identity. As health professionals we need to be aware of its significance for social and emotional wellbeing, recognise the effects of “missing” or “lost” identity, and understand how the smallest amount of knowing can heal.2 In response to loss, all humans grieve. Aboriginal and Torres Strait Islander peoples have been deprived of their normal grieving processes, and this has resulted in an overwhelming burden of grief, both recognised and unrecognised. A reconnection with identity is one pathway to resolving some of this burden.3 Finding the self and coming to terms with individual loss is a prelude to communities finding their collective value in the richness of culture and reconciliation. I am first and foremost an Aboriginal man, then a son, brother, husband, father-to-be and doctor. This all started with a young Aboriginal bloke wanting to know more about himself. There’s no rocket science in it, just a hunger for identity. It’s fortunate that my children will grow up from Day 1 knowing about their history, family, connections to country, and place within the world. So, what about Ritchie? As I remember him, he was a proud man and, in hindsight, someone who was (and I hope still is) looking out for family, especially his nieces and nephews. He came from a strong family who loved and supported him in the way that Indigenous families do. I’m sure that many outsiders would not have seen his family’s dynamics as their cup of tea, but, looking back on it, I realise that none of those kids ever went without food, shelter or clothing, nor love or spirituality. This is my journey to date. Take from it what you will and learn from it. The discovery of identity and the journey of reconnection is one that many Indigenous Australians travel at some point in their lifetime and it is fundamental to our wellbeing. I hope my story gives readers the courage to search for the truth with Aboriginal and Torres Strait Islander people and the strength to be a lifeline for those struggling in the abyss of the unknown.

Marshall R Watson MB BS

To the Editor: “... what a difference can be made and how bureaucracies can stuff things up”. “... systematic testing and treatment of people with high blood pressure and kidney disease dramatically improved blood pressure and resulted in a 50% reduction of deaths”. “... excellent results were achieved by good management and they were lost when intensity of management was relaxed”. The above quotes are from an episode of The health report broadcast late last year on Radio National.1 The episode, which described a deterioration in the health of an Indigenous community after a chronic disease treatment program was handed over to a community health board, caused me to take a closer look at the articles in the Journal by Hoy and colleagues on which the claims were based.2,3 I found several issues of concern. The small numbers of deaths each year in the study community and the analysis and presentation of the death data mean that the conclusions about trends in mortality over time are tenuous. This is highlighted by the discrepancies between the two articles in the terminology used to classify deaths, in the numbers of deaths reported, and in the trends over time. Discrepancies in terminology or numbers of reported deaths are not explained. The declining trend in the number of “natural” deaths described in the 2000 article is not apparent in the “non-renal” deaths in the 2005 article. The rate of “non-renal” death for the period 1996–97 to 1998–99 reported in the 2005 article appears to be increasing rather than declining, as described in the 2000 article (rates for earlier years are not presented in either article). It is clear that, with these small numbers, the reclassification or misclassification of a single death can affect the trends in “renal death” or end-stage renal disease over time, and that the use of “rolling averages” hides the year-to-year variability that would be expected in these data. The trend over time in the key intermediate outcome indicator of blood pressure control does not support the conclusion regarding impact of the “handover” on the program. The data presented in the 2005 article show a decline in control commencing in the third year. An earlier analysis of the same data showed the decline in blood pressure control began as early as the second year after entry into the program.4 Neither analysis shows any clear change in the declining trend in blood pressure control around the time of “handover” of the program. While the discussion of the findings of the 2005 article is circumspect, at the time of interview, Hoy conspicuously did not deny the statement of The health report host that the primary cause of the apparent loss of the early impact of the program was the bureaucracy “stuffing up”. The article makes some important points about the operation of chronic disease programs, but makes no mention of the commonly experienced difficulties of sustaining health programs,5,6 or the research requirements for understanding sustainability.7 These issues raise serious questions about the validity of the conclusions and the simplistic claims arising from the articles.

Ross S Bailie MD, FAFPHM

In reply: I appreciate the feedback on the 2000 and 2005 articles describing the dynamics and outcomes of the “Tiwi treatment program”.1,2 Thorough and timely identification and enumeration of deaths is a problem, especially for people not enrolled in the treatment program. Without a register of such people, systematic checking of their fate was not possible. The additional “non-renal” deaths in the community-at-large presented in our 2005 article, compared with previous articles, seem to have been captured largely by the broad net spread by the Tiwi Health Board when it assumed responsibility for its primary care services, in an attempt to identify all its potential clients. This process identified several hundred more people than expected and captured additional deaths, several dating back years. The precise definition of a community member is also a problem, especially for people living permanently or intermittently elsewhere (eg, in Darwin or other communities). The broadened definition of “renal deaths” in the 2005 article,2 which accommodates people who died with renal failure but did not begin dialysis, more fully represents the impact of renal disease. Conversely, recording only those who began dialysis allows estimates of the impact on health services and potential savings from better management.3 Both approaches have their place. Rolling averages, which indeed have limits, were used in view of the overall small and erratically spaced number of terminal events in any year. The figures we reported in our 2005 article did not show a deterioration in blood pressure at Year 2, either in the treatment group as a whole, or in the smaller cohort followed for a full 6 years.2 An earlier analysis, which largely embraced the active years of the program, also showed that blood pressure at Year 3 was not significantly different from that at Year 2 (systolic blood pressure, P = 0.68) (Box). With time, the number of people who had moved through 3 years of treatment increased, and the timing of their 3-year blood pressure measurements moved from a mix of 1998–1999 to 1999–2002, when, as program dynamics suggest, intensity of management was relaxed, and mean values deteriorated, as we reported in 2005. The blood pressure measurements in the report by Bailie’s group5 were compiled from a review of paper-based medical records, the clinic’s newly implemented Coordinated Care Trial Information System, and the Territory’s Information System (Systematic Health Information Logically Organised), as well our from our treatment program database. Those blood pressures were allocated time definitions in a different way, and the summary data were derived from adjusted predictions from cross-sectional time series modelling, rather than from factual recordings at the stated intervals.5 I did not solicit the interview for The health report, nor determine its directions nor the resulting headlines. However, the under-resourcing of primary care relative to needs in remote Aboriginal settings, and the lack of stability in the organisations in which it is delivered, are very detrimental. I regret that, once the Tiwi Health Board was constituted, it was not mentored and supported through its difficulties. More recently, the fledgling community-controlled Gulf Health Service in the Borroloola region of the Northern Territory met a similar fate. Chronic disease remains underserviced in both these regions, where the people are among the sickest in Australia. Blood pressure measurements (mm Hg) over 3 years of follow-up after enrolment in 123 people who had observations at every interval4 Baseline 6 months 1 year 2 years 3 years Mean systolic BP (SD) 136.2 (21.6) 125.4 (21.6) 123.6 (20.3) 120.6 (21.6) 121.7 (21.5) Mean diastolic BP (SD) 81.9 (13.2) 75.5 (13.7) 76.3 (12.9) 74.5 (13.7) 74.0 (11.0)

Wendy E Hoy