Indigenous health

High rates of this disease are the face of Indigenous disadvantage While acute rheumatic fever (ARF) has become a rare curiosity in Australia’s non-Indigenous population, its incidence in Indigenous Australians living in remote areas remains among the highest reported in the world. It is unlikely that such a stark contrast between two populations living within the same national borders exists for any other disease or on any other continent. The new evidence-based review and guideline for diagnosis and management of ARF and rheumatic heart disease (RHD) is an important tool for clinicians who care for Indigenous Australians (→ An Australian guideline for rheumatic fever and rheumatic heart disease: an abridged outline).1 But the guideline also prescribes a clear course of action for health policymakers. It makes a compelling case for focusing on the provision of secondary prophylaxis via coordinated, register-based RHD control programs that have guaranteed long-term funding. At the minimum, programs are needed in the Top End of the Northern Territory, Central Australia (including areas of South Australia and Western Australia near the NT border), northern WA, and northern Queensland. Other jurisdictions may also require control programs, but further disease burden data are needed to establish this. It is critically important to ensure that people with ARF and RHD receive good treatment and preventive care. But let’s not lose sight of the main game. Treatment of ARF and RHD, and secondary prevention-based control programs, are bandaid solutions to an underlying tragedy. ARF and RHD are classic diseases of social injustice. The past 50 years have witnessed dramatic declines in the prevalence of ARF and RHD throughout the industrialised world, resulting mainly from improvements in living conditions, socioeconomic conditions, sanitation and medical care, and from reduction in household crowding.2 Unfortunately these improvements are yet to be seen among a number of populations defined by socioeconomic status, ethnicity or geographical location.3 In essence, ARF and RHD are not only diseases exclusively borne by the disadvantaged, but also key indicators of disadvantage itself. In remote Australian Indigenous populations, the effects of disadvantage are so entrenched that it is likely to take several generations, and steadfast political will, before they are overcome. Rates of death from RHD among Aboriginal people in the Top End of the NT exceed those reported in many industrialised countries over a century ago.4 There is little or no evidence of improvement over at least the past three decades.5 As a consequence, Indigenous Australians continue to die before their time from a highly preventable, highly treatable and completely avoidable illness.4 Ongoing disparities in the burden of ARF and RHD reflect a number of failures in the development and delivery of health and health-related services. Failure to provide secondary prophylaxis can be due to missed diagnoses, poor continuity of care, a lack of trust and communication between patients and care providers, high staff turnover, a lack of appropriate health education, and, perhaps most importantly, a lack of political and bureaucratic commitment to solving the problem. Failure in primary prevention of ARF and RHD (ie, in preventing the acquisition of group A streptococcal infections) reflects the failure to provide Indigenous communities with the appropriate type and level of housing and environmental conditions that all Australians should expect. The federal government has targeted a 50% reduction in death due to RHD by 2008.6 While this is an unrealistic expectation, significant achievements are possible within the short to medium term, as has been witnessed with comprehensive approaches to control of ARF and RHD in the French Caribbean7 and with the establishment of register-based ARF/RHD control programs across New Zealand.8 Perhaps the most frustrating thing is that preventing premature death due to RHD is more achievable than solving an ever expanding list of other health and social problems facing Indigenous Australians. To prevent premature death due to RHD, a number of concrete steps must be taken. Firstly, we must commit to alleviating the underlying socioeconomic determinants of ARF and RHD. The most important of these determinants — overcrowded housing — is also the easiest to address, but requires a dramatically greater investment by governments than we are currently seeing. A recent study confirmed the extreme levels of household crowding experienced in many remote communities:9 in two large NT Aboriginal communities, the median number of people per house was 17 and 14, respectively, with a median of 6.9 and 7.5 people per bedroom, respectively. Secondly, we must ensure that each person with a history of ARF or RHD receives appropriate care. This entirely achievable goal would prevent Aboriginal children dying unnecessarily from this disease. Thirdly, we must ensure that political will delivers the deliverable and prevents the preventable. As long as modern Australia continues to accept the large and growing health and social disparities experienced by its Indigenous people, it fails in its duty to protect and provide for the most vulnerable. Will we be brought to account for our failure to deal with these disparities, or will cries for justice be silenced, as has happened with so much of the history of Australia’s first people?

Alex Brown BMed, MPH, FCSANZ · Malcolm I McDonald FRACP · Tom Calma

Objective: To describe the outcome of valve surgery, for rheumatic heart disease (RHD) and non-RHD, in residents of Cape York Peninsula and the Torres Strait Islands referred to the Cairns Base Hospital specialist outreach service.Design and participants: Retrospective review of medical records on all patients residing in the outreach area who had surgery for valvular heart disease between 1 January 1992 and 31 December 2004.Main outcome measures: Operation type and perioperative characteristics; 5- and 10-year survival rates; reoperation rates; complications.Results: Forty-seven patients met the selection criteria; the median age was 40 years (range, 4–76 years); and 39 patients were Indigenous. RHD was the predominant cause of valve dysfunction (30/47 patients). Thirty-seven patients had valve replacements, six had valve repair and four had balloon valvotomy as the initial procedure. There were three bleeding complications, two episodes of operated valve endocarditis, and six embolic complications. There were nine valve-related deaths (six in the first 5 years). At 5 years, all seven patients who had had valve repair or balloon valvotomy were alive. Seven of the 47 patients required reoperation. Survival analysis showed freedom from valve-related deaths to be 83% (95% CI, 66%–92%) at 5 years and 61% (95% CI, 33%–80%) at 10 years. Freedom from reoperation at 5 years was 88% (95% CI, 71%–95%). Among the 30 patients with RHD, freedom from valve-related death was 80% (95% CI, 60%–92%) at 5 years and 52% (95% CI, 21%–75%) at 10 years. In patients with RHD, freedom from reoperation at 5 years was 87% (95% CI, 65%–96%).Conclusion: Valvular heart disease results in substantial morbidity and mortality, despite intervention. Efforts need to focus on prevention of rheumatic fever and closer follow-up.

Anna McLean MB BS · Michael Waters MB BS(Hons) · Emma Spencer MB BS · Clive Hadfield MB BS

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are diseases of poverty. They occur at world-record rates in Indigenous Australians, yet individual cases are often poorly managed, and most jurisdictions with high rates of these diseases do not have formal control strategies in place. New Australian guidelines formulated in 2005 by the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand for diagnosis and management of ARF and RHD are a valuable resource for clinicians and policymakers. Key recommendations of the guidelines include: New diagnostic criteria for ARF in high-risk populations, including Indigenous Australians, which include echocardiographic evidence of subclinical valvular disease, and polyarthralgia or aseptic monoarthritis as major manifestations. Clear guidance about treatment of ARF. Non-steroidal anti-inflammatory drugs should be withheld until the diagnosis is confirmed, and corticosteroids may be an option in severe acute carditis. Most cases of chorea do not require medication, but use of carbamazepine or sodium valproate is recommended if medication is needed. Clear guidance about dose, dosing frequency and duration of secondary prophylaxis. Benzathine penicillin G is the preferred medication for this purpose. Establishment of a coordinated control program for all regions of Australia where there are populations with high prevalence of ARF and RHD. Key elements and indicators for evaluation are recommended. Active screening and legislated notification of ARF and RHD, where possible. Development of a structured care plan for all patients with a history of ARF or with established RHD, to be recorded in the patient’s primary health care record.

Jonathan R Carapetis MB BS, PhD, FRACP · Alex Brown BMed, MPH, FCSANZ · Nigel J Wilson MB BS, FRACP · Keith N Edwards MB BS, FRACP, FRCP(Edin)

A united stand from medical professionals and organisations will send a powerful message May 2007 is the 40th anniversary of the 1967 Referendum, when an overwhelming majority of the Australian population voted to end discrimination against Aboriginal and Torres Strait Islander peoples.1 While some gains have been made since 1967,2 inequalities in health status between Aboriginal and non-Aboriginal Australians remain. In the Medical Journal of Australia alone, medical and health professionals have contributed to over 150 articles about Aboriginal and Torres Strait Islander health in the past 6 years. All levels of government have set out frameworks, strategies and recommendations to improve the health of Indigenous Australians, and have celebrated their commitments.3 Aboriginal and Torres Strait Islander leaders and representative organisations have supported exemplary health programs and shared these success stories in the hope of having their capacity enhanced to better provide for their community’s health needs.4-6 The research has been done,7 so why are governments not acting on their own recommendations? Since the release of the Aboriginal and Torres Strait Islander Social Justice Report 2005,8 leading Indigenous and non-Indigenous medical and health organisations and human rights groups have been asking this question. This momentum led to an open letter published in The Australian newspaper in December 2006,9 and the beginning of a campaign calling on all Australian governments and the public to “commit to a plan of action to achieve health equality for Indigenous peoples within twenty-five years.” The letter was signed by 37 key health and human rights agencies, and more agencies are signing up to the campaign daily. The purpose of the open letter (reproduced in the Box) is to campaign for a national commitment to achieving health equality for Aboriginal and Torres Strait Islanders by tackling areas where there is insufficient action, and where evidence indicates that action will deliver substantial gains. This approach is laid out in the Social Justice Report 2005.8 The open letter: sets a target of achieving health equality within a generation (25 years), thereby challenging incremental policy approaches that have avoided benchmarks, timeframes, comprehensive measures and accountability; directs attention to the evidence-based priority areas; is led by strong, united Aboriginal and Torres Strait Islander health organisations and an Indigenous workforce providing cultural and professional leadership, challenging views that Indigenous Australians are not taking responsibility; and is supported by a significant and increasing number of powerful Australian health and human rights groups. The open letter states that “Indigenous Australians continue to needlessly suffer and die early, not from a lack of solutions or government commitments, but from a lack of political will and action.” How can the Australian medical community assist? First, they must ask themselves if they are prepared to remain complicit in the real lack of will and action shown by Australian governments at all levels. Australia’s shameful record in incremental (and hence ineffectual) actions to redress health disparities between Aboriginal and non-Aboriginal Australians reflects particularly poorly on medical and health professionals. Is it acceptable that international governments have made significant advances in the health of their indigenous peoples while ours lags behind?10,11 Are we happy to keep writing the reports and advocating for resources only to have those efforts fail? (For every dollar spent per person on health goods and services for non-Indigenous people in the 2001–02 financial year, only 18 cents more per person was spent on Indigenous peoples, despite their health status being three times poorer.12) The interest of this Journal’s readership on this matter, and our professional organisations’ policies indicates we are not. Second, as distinguished and respected people in prominent positions in society, medical and health professionals must not underestimate their ability, and indeed their responsibility, to advocate for health equity. If the missing ingredient is a lack of political will, perhaps the medical profession can shift that will and public opinion. Unity on this matter as a profession and an organised course of action sends a powerful message that we are both willing and able to make the health of Aboriginal and Torres Strait Islander peoples a top health priority. Many important public health and humanitarian gains have been made through targeted campaigning. A good example is the recent mental health campaign, led by “beyondblue”, which resulted in an announcement of $1.8 billion in new funds in the 2006 budget.13 As leading advocates for the health of Aboriginal and Torres Strait Islander peoples, we are humbled and honoured to be working with many committed and skilled colleagues — both Indigenous and non-Indigenous. We know many of these colleagues share our frustrations at the funding shortfalls preventing the delivery of adequate health care to Aboriginal and Torres Strait Islander peoples.7 We now appeal to the Australian medical community to support us. Here we present the open letter again to coincide with the 1967 Referendum celebrations, inviting you to come on board. Speak or write to your federal and local politicians. To be a party to the open letter and the Indigenous health campaign, send your support, your signatures and your logo to sjreportAThumanrights.gov.au. Nothing will send a more powerful message than every medical and health organisation in this country joining together in a campaign for health equality for our nation’s first peoples. Open letter calling for equity in Indigenous health Signed by: National Aboriginal Community Controlled Health Organisation, Human Rights and Equal Opportunity Commission, Congress of Aboriginal & Torres Strait Islander Nurses, Aboriginal Medical Services Alliance Northern Territory, Australian Indigenous Doctors’ Association, and 32 other health and human rights agencies. Full list and further information available at: http://www.humanrights.gov.au/social_justice/health/health_OpenLetter.html

Mark Wenitong BMed · Romlie Mokak BSocSci, GradDipSpecEdu · Henry Councillor · Dea Delaney Thiele PostGradDipHealthManage · Tom Calma

Reducing the burden of diabetes will require action well beyond the health service sphere Type 2 diabetes represents a serious public health problem for Indigenous Australians, occurring at a much higher prevalence than in the non-Indigenous population, and with a much earlier age of onset of the disease and its micro- and macrovascular complications.1,2 It is likely that diabetes is an important contributor to the considerably higher circulatory disease mortality rate among Indigenous Australians at young ages (9–10 times higher in Indigenous men aged 25–44 years, and 12–13 times higher in Indigenous women aged 35–54 years).1 Thus, diabetes imposes significant financial and human costs on Australian society, which are disproportionately borne by Indigenous individuals, families and communities. Of three articles about diabetes in Indigenous Australians in this issue of the Journal, two provide evidence that the problem is escalating. Craig et al3 analysed data from the Australasian Paediatric Endocrine Group NSW Diabetes Register and found that type 2 diabetes accounts for 11% of new diabetes cases among 10–18-year-olds, and that the incidence in Indigenous children was about six times higher than that in non-Indigenous children (→ Type 2 diabetes in Indigenous and non-Indigenous children and adolescents in New South Wales). McDermott et al4 found that, for Torres Strait Islanders, there were significant increases in body mass index (BMI) — the major risk factor — between 1999 and 2005, and a very high 5-year incidence of diabetes (→ Diabetes in the Torres Strait Islands of Australia: better clinical systems but significant increase in weight and other risk conditions among adults, 1999-2005). Is it possible to prevent type 2 diabetes? International studies indicate that, in people with impaired glucose tolerance, an intensive focus on diet and physical activity can substantially reduce progression to diabetes, and to an equal or greater extent than pharmacological interventions.5 Although BMI and age are the two strongest predictors of diabetes for Indigenous Australians, leanness is protective.6,7 As in all Australians, preventing diabetes goes hand in hand with preventing excessive weight gain, but trends in overweight and obesity are unambiguously upwards. Preventing excessive weight gain in Indigenous communities, which are profoundly disadvantaged relative to mainstream Australia, is complicated by the strong link between poverty and obesity. People living in poverty tend to maximise calories per dollar spent on food,8 and energy-dense foods rich in fats, refined starches and sugars represent the lowest cost options. Healthy diets based on lean meats, whole grains, and fresh vegetables and fruits are much more costly. Poverty in Indigenous communities is related to high unemployment and welfare dependency; living conditions are overcrowded, and community infrastructure is poor, with limited access to good quality foods.1 Many of these factors are compounded by remote living, although successful prevention of obesity in some outstation communities has been associated with greater physical activity, consumption of bush foods, and ownership of and access to traditional homelands.9 Are there any opportunities for practical intervention? Low birthweight, which is linked to an increased risk of central obesity and type 2 diabetes in adult life, is more common in Indigenous and other socially disadvantaged communities, and is linked to maternal smoking, overcrowded living conditions and mothers’ perceived stress.10 Furthermore, diabetes in pregnancy increases the risk of early onset obesity and diabetes in the offspring. This can be attenuated by improved control of gestational diabetes, and by the mother breastfeeding for at least 2–3 months. A systematic approach to improving nutritional status of infants should be a priority — including the option (controversial in some circles) of providing subsidised food. We have observed that a community decision to provide a healthy breakfast and lunch 5 days a week for primary school children was a major step towards the children achieving their recommended daily intakes for a number of key nutrients (unpublished data). Improved maternal and child health could be an important and cost-effective contributor to diabetes prevention programs at the population level. Preventing and managing the complications of diabetes, such as cardiovascular risk factors, also involve lifestyle modification. Through changes in food supply, increased opportunities for physical activity, and health promotion, Indigenous communities were able to achieve amelioration of dyslipidaemia, improved insulin action (even in the absence of weight loss), and increased in red cell folate and reduced homocysteine levels.11 A large international trial has shown that fish and fish-oil supplements reduce coronary heart disease mortality.12 There seems little argument that improving the quality use of medicines (including through greater access) is one of the most cost-effective approaches to reducing the additional and preventable burden of chronic illness among Indigenous people.13,14 Angiotensin-converting enzyme (ACE) inhibitors have been shown to reduce mortality in an Aboriginal community with a high prevalence of end-stage kidney failure.15 Internationally, numerous trials have reported the effectiveness of statin therapy in reducing vascular mortality. Metformin improves glycaemic control in diabetes, without weight gain. Yet, the gaps between the evidence and actual practice, in both Indigenous communities and the broader community, remain unacceptably large, and are limiting gains for those at risk of diabetes and for those who already have the disease and related conditions. The article by McDermott et al4 illustrates the value of systematic primary health care approaches to diabetes control, including electronic health information systems, screening, management protocols, recall systems, improved specialist access, quality improvement activities, and staff support and training (→ Diabetes in the Torres Strait Islands of Australia: better clinical systems but significant increase in weight and other risk conditions among adults, 1999-2005). Such systems are integral to improving the quality and outcomes of clinical care. All three articles on diabetes in Indigenous people in this issue3,4,16 also address aspects of screening. Taken together, they support a critical role of coordinated health system approaches to diabetes identification and control. Simple point-of-care procedures, as developed by Marley et al16, could form the basis of cost-effective screening for diabetes (and other vascular risk factors) in high-risk populations, and may be able to accurately identify those who could benefit from more immediate pharmacological and non-pharmacological therapies (→ Point-of-care testing of capillary glucose in the exclusion and diagnosis of diabetes in remote Australia). The prevention and management of diabetes are critical to the future health of Indigenous as well as non-Indigenous Australians. But, there is no simple solution. The effectiveness of clinical and public health interventions is limited in Indigenous people, by the added burden of systematic historical and contemporary discrimination. Getting it right will require better clinical treatment and action well beyond the health service sphere. This is one of contemporary Australia’s greatest challenges.

Kerin O'Dea AO, BSc, PhD · Kevin G Rowley PhD · Alex Brown BMed, MPH, FCSANZ

Objective: To determine the incidence of type 2 diabetes mellitus (T2DM) in 2001–2006 in young people < 19 years and the characteristics of T2DM in the Indigenous group.Design and setting: Prospective population-based incidence study, New South Wales.Participants: Primary ascertainment was from the Australasian Paediatric Endocrine Group NSW Diabetes Register, with secondary ascertainment from the National Diabetes Register (Australian Institute of Health and Welfare).Main outcome measures: Incidence of T2DM in young people in NSW; incidence of T1DM and T2DM in Indigenous young people; characteristics at diagnosis.Results: There were 128 incident cases of T2DM (62 boys, 66 girls) in the study period. The median age at diagnosis was 14.5 years (interquartile range, 13.0–16.4), and 90% were overweight or obese (body mass index > 85th percentile for age). Mean annual incidence was 2.5/100 000 person-years (95% CI, 2.1–3.0) in 10–18-year-olds. Of the ethnic groups represented, white Australian comprised 29%, Indigenous 22%, Asian 22%, North African/Middle Eastern 12% and Māori/Polynesian/Melanesian 10%. The incidence of T2DM was significantly higher in the Indigenous than the non-Indigenous group (incidence rate ratio, 6.1; 95% CI, 3.9–9.7; P < 0.001), but incidence rates of T1DM were similar (15.5 v 21.4/100 000, respectively).Conclusions: T2DM accounts for 11% of incident cases of diabetes in 10–18-year-olds, and the majority are overweight or obese. The high rate among Indigenous Australian children supports screening for T2DM in this population.

Maria E Craig PhD, FRACP, MMed · Giuseppe Femia BSc · Vitali Broyda BSc, MB BS · Margaret Lloyd RN · Neville J Howard FRACP, FRCP

Objectives: To determine the utility of point-of-care (POC) capillary blood glucose measurements in the diagnosis and exclusion of diabetes in usual practice in primary health care in remote areas.Design: Cross-sectional study comparing POC capillary glucose results with corresponding venous glucose levels measured in a reference laboratory.Participants: 200 participants aged 16–65 years enrolled: 198 had POC capillary glucose measurements; 164 also had acceptable venous glucose laboratory results.Setting: Seven health care sites in the Kimberley region of Western Australia from May to November 2006.Main outcome measures: Concordance and mean differences between POC capillary blood glucose measurement and laboratory measurement of venous blood glucose level; POC capillary blood glucose equivalence values for excluding and diagnosing diabetes, and their sensitivity, specificity and positive-predictive value.Results: The concordance between POC and laboratory results was high (ρ = 0.93, P < 0.001). The mean difference in results was 0.48 mmol/L (95% CI, 0.23–0.73; limits of agreement, − 2.6 to 3.6 mmol/L). The POC capillary glucose equivalence values for excluding and diagnosing diabetes were < 5.5 mmol/L (sensitivity, 53.3%; specificity, 94.4%; positive-predictive value, 88.9%; for a venous value of < 5.5 mmol/L) and ≥ 12.2 mmol/L (sensitivity, 83.3%; specificity, 99.3%; positive-predictive value, 95.2%; for a venous value of ≥ 11.1 mmol/L), respectively. While the choice of glucometer and whether or not patients were fasting altered these results, they did not have a significant influence on the diagnostic utility of POC glucose measurement in this setting.Conclusion: POC capillary blood glucose analysers can be used as part of the process of diagnosing and excluding diabetes in remote rural communities using these locally established capillary equivalence values.

Julia V Marley PgDipSc, PgDipPolSt, PhD · Stephanie Davis MB BS · Kerryn Coleman MB BS, MPH · Bradleigh D Hayhow BA(Hons), BM BS · Greg Brennan BNurs · Jacki K Mein MAE, FAChSHM, FAFPHM · Carmel Nelson MPH · David Atkinson MB BS, MPH · Graeme P Maguire FRACP, MPH

Objectives: To (i) assess changes in clinical indicators of adults diagnosed with diabetes and (ii) estimate changes in risk factors and incidence of diabetes among adults without diabetes living in the Torres Strait and Northern Peninsula Area Health Service District in Queensland from 1999 to 2005.Design and participants: (i) Annual audit of clinical records of Torres Strait Islander adults on diabetes registers in 21 primary care clinics, and (ii) a 5-year follow up of a community cohort of 207 Torres Strait Islander adults without diabetes who participated in the Well Person’s Health Check in 2000–01 and 2005–06.Main outcome measures: Weight, height, waist circumference, fasting blood sugar (those without diabetes) and glycated haemoglobin (HbA1c; those with diabetes) levels, blood pressure (BP), fasting triglyceride and high-density lipoprotein cholesterol levels, urinary albumin-to-creatinine ratio and smoking status.Results: The number of adults included on the diabetes register increased from 555 in 1999 to 1024 in 2005. The mean age of patients diagnosed with diabetes decreased from 53.3 to 51.5 years, and their mean weight increased from 86.8 kg to 95.6 kg. Mean HbA1c level remained unchanged at about 9%, but the proportion with HbA1c level < 7% increased from 18.4% to 26.1%, and the proportion prescribed insulin increased from 14% in 2002 to 22% in 2005. The proportion with BP < 140/90 mmHg increased from 40.3% in 1999 to 66.8% in 2005. In the sample of 207 adults without diabetes, from 2000 to 2006, there was a weight gain of about 1 kg per person per year, and an annual increase in waist circumference of 0.8 cm in men and 1.2 cm in women. Crude incidence of diabetes was 29 (95% CI, 19–41) per 1000 person-years. There was a significant increase in diastolic blood pressure and fasting blood sugar levels, and no change in smoking habits.Conclusions: Clinical care of adults with diabetes has improved and more people with diabetes are being diagnosed. However, weight gain and high rates of glycaemia remain a challenge and will result in a large burden of complications, including renal failure. Incidence data from this sample extrapolate to 120 (95% CI, 103–147) new cases of diabetes in the District each year. Urgent action to improve nutrition, decrease smoking and increase physical activity is required to improve metabolic fitness in younger people.

Robyn A McDermott MB BS, MPH, FAFPHM · Bradley G McCulloch BSc, MPH · Sandra K Campbell RN, MAE · Dallas M Young BAppSc, MHP

Objective: To determine whether remoteness category of residence of Indigenous women affects the perinatal outcomes of their newborn infants.Design and participants: A population-based study of 35 240 mothers identified as Indigenous and their 35 658 babies included in the National Perinatal Data Collection in 2001–2004.Main outcome measures: Australian Standard Geographical Classification remoteness category, birthweight, Apgar score at 5 minutes, stillbirth, gestational age and a constructed measure of perinatal outcomes of babies called “healthy baby” (live birth, singleton, 37–41 completed weeks’ gestation, 2500–4499 g birthweight, and an Apgar score at 5 minutes ≥ 7).Results: The proportion of healthy babies in remote, regional and city areas was 74.9%, 77.7% and 77.6%, respectively. After adjusting for age, parity, smoking and diabetes or hypertension, babies born to mothers in remote areas were less likely to satisfy the study criteria of being a healthy baby (adjusted odds ratio [AOR], 0.87; 95% CI, 0.81–0.93) compared with those born in cities. Babies born to mothers living in remote areas had higher odds of being of low birthweight (AOR, 1.09; 95% CI, 1.01–1.19) and being born with an Apgar score < 7 at 5 minutes (AOR, 1.63; 95% CI, 1.39–1.92).Conclusions: Only three in four babies born to Indigenous mothers fell into the “healthy baby” category, and those born in more remote areas were particularly disadvantaged. These findings demonstrate the continuing need for urgent and concerted action to address the persistent perinatal inequity in the Indigenous population.

Simon Graham BIS · Lisa R Jackson Pulver PhD, MPH, GradDipAppEpi · Yueping Alex Wang MB BS; MPH · Paul M Kelly DTM · Paula J Laws BA(Hons) · Narelle Grayson BA(Hons) · Elizabeth A Sullivan MB BS, MPH, MMed(Sexual 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