Indigenous health

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

To the Editor: As I have said elsewhere, “The last thing the majority wants is that the tyranny of the majority be applied to it. It is much easier to apply the tyranny of the majority to a minority. In a properly functioning democratic society minorities are not subjected to, but are protected against, the tyranny of the majority. Is the tyranny of the majority being applied through the medium of the Howard government onto the Aboriginal communities of Australia in this matter of ‘shared responsibility agreements’?”1 I note with interest recent articles by Collard and colleagues2 and by Kowal,3 debating “shared responsibility agreements”. The expressions “shared responsibility agreement”3 and “mutual obligation” are variations of the expression “social contract”. The concept of “social contract” underlies the concept of democracy originating in the writings of Thomas Hobbes, John Locke and Jean-Jacques Rousseau. Present-day political scientists discuss social-contract theory in their writings about democracy, and may mention “mutual obligation” or “shared responsibility”. While it is commonplace for aspects of the social contract to apply to subgroups in the population, it is discriminatory to make arrangements that apply only to a particular racial or ethnic group. Even though the agreements are declared to be voluntary, it is likely that Aboriginal communities are under pressure to do as they are told to achieve social contracts with the Australian Government. If Indigenous people must comply with certain conditions before they can achieve social contracts, how might similar conditions be applied to the rest of the Australian population? The “ticking time bombs” of Australian public health are smoking and obesity. If non-Indigenous Australians refuse to stop smoking and refuse to eat less and take more exercise, should access to public hospitals and pharmaceutical benefits be denied them? Should they be denied petrol to force them to walk and to use public transport? Obviously not. These services are not subject to social-contract agreements as thiswould be a clear violation of Australian law. Australian members of parliament in particular, and Australians in general, for the sake of themselves, their families and of Australian health care costs, would benefit from negotiating “shared responsibility agreements” with themselves to stop smoking and to lose weight. In current circumstances, “shared responsibility agreements” with Aboriginal communities represent inequality of sharing the responsibility for health.

John N Burry

The prevalence of vitamin D deficiency among Aboriginal people in Australia is unknown. One of the possible sequelae of vitamin D deficiency, muscle pain, appears to have a higher prevalence in Aboriginal people. A deficiency of vitamin D can cause osteoporosis,1 rickets in children, muscle pain and weakness.2-4 It is one of the main causes of undiagnosed muscle pain in adults.2,3 Such pain resolves rapidly with adequate doses of vitamin D.3-5 Risk factors for vitamin D deficiency include darker skin pigmentation, urban lifestyle, veiling of women for cultural reasons, and intestinal malabsorption or a diet deficient in vitamin D.1,6-10 Refugees from Africa and the Middle East are known to have a high risk of rickets and muscle pain caused by vitamin D deficiency.2-4,8-11 There is also research showing a deficiency in asymptomatic patients, both those at high risk as well as those with no obvious risk factors.12 This is important for the infants of women who are deficient in vitamin D during their pregnancy, as their children will also be deficient in vitamin D,13,14 and hence at increased risk of both short- and long-term sequelae.8,13 A study of a rural Aboriginal community found that 95% of the population had chronic non-specific musculoskeletal pain, compared with 30% in the general population.15 Traditional Aboriginal people spent much of their day outdoors, but most now have an urban lifestyle.16 They are less likely to spend enough hours in the sun1 or have a diet rich in vitamin D.1,6 After noting a high prevalence of muscular pain among patients at our health service (Nunkuwarrin Yunti, an Aboriginal Community Controlled Health Service, at Elizabeth Downs in the northern suburbs of Adelaide), we conducted a case–control study to determine if muscle pain was associated with low vitamin D levels. MethodsDiscussions about the study’s relevance with Elder Aboriginal Women in the community, and with the staff and Chief Executive Officer of Nunkuwarrin Yunti acknowledged its importance to individuals, families and the community. Ethics approval was obtained from the University of Adelaide and the Aboriginal Health Research Ethics Committee. Results from Indigenous patients seen in our clinical practice before the study showed a serum vitamin D (25-hydroxyvitamin D) range of 35–55 nmol/L (standard deviation, 5 nmol/L). Anticipating a difference between cases (with muscle pain) and controls (without muscle pain) of 10 nmol/L, we calculated that a sample of six cases and six controls would be required, assuming a power of 0.8 and a significance level of 0.05. Data were collected from eight patients in each group in October and November 2005, at the end of the Australian winter. Blood samples were collected from patients aged 18 years and older with muscle pain and from a sex- and age-matched control group without muscle pain. People with renal failure or who had recently taken vitamin D supplements were excluded. All patients had what would be classed as medium skin pigmentation.17 The blood samples were sent to the local pathology service, where 25-hydroxyvitamin D was measured. Serum levels were tabulated and analysed using SPSS version 13.0 (SPSS Inc, Chicago, Ill, USA). ResultsOur results are summarised in the Box. All patients with muscle pain had a vitamin D level below the normal value of 50 nmol/L.1,18 The mean vitamin D level was 40.88 nmol/L (SD, 3.52 nmol/L) for patients with muscle pain, and 58.25 nmol/L (SD, 15.90 nmol/L) for controls. Data were normally distributed and equal variances could not be assumed. A t test showed a mean difference between cases and controls of − 17.38 nmol/L (P = 0.017). DiscussionThe eight Aboriginal patients with muscle pain had lower vitamin D levels than those without muscle pain. Vitamin D deficiency was not observed in asymptomatic patients except for one with mild deficiency. Despite being at a lower risk of osteoporosis,19 Aboriginal people may have an increased risk of muscular symptoms of vitamin D deficiency. We did not assess intercurrent illness, severity of symptoms, skin pigmentation, diet, time spent outdoors and success of treatment, and this limitation may affect the generalisability of our findings. We found that muscle pain is an indicator of vitamin D deficiency in urban Aboriginal patients. General practitioners are well placed to screen those at high risk and may be able to improve the lifestyle and level of function of many previously undiagnosed patients with chronic muscle pain by having a high index of suspicion for vitamin D deficiency. As more research reveals the sequelae of vitamin D deficiency, its importance to general health is likely to increase. A larger study looking at the prevalence of muscle pain in the urban Aboriginal population, its effect on lifestyle, how that pain relates to vitamin D deficiency, and whether pain is reduced with treatment would clarify some of the issues. The potential for better quality of life resulting from successful treatment of muscle symptoms caused by vitamin D deficiency makes the clarification of this association a priority for Aboriginal health. Sex, age, vitamin D level and vitamin D class* for patients with muscle pain and controls with no muscle pain With muscle pain Without muscle pain Sex Age (years) Vitamin D level (nmol/L) Vitamin D class Sex Age (years) Vitamin D level (nmol/L) Vitamin D class F 50 37 3 F 50 50 4 F 38 40 3 F 35 70 4 F 39 38 3 F 40 78 4 F 72 37 3 F 55 28 3 F 19 41 3 F 20 50 4 F 48 46 3 F 47 56 4 F 62 45 3 F 55 63 4 M 53 43 3 M 53 71 4 * Vitamin D class: class 4, ≥ 50 nmol/L, normal; class 3, 26–49 nmol/L, mild deficiency; class 2, 12.5–25 nmol/L, moderate deficiency; class 1, < 12.5 nmol/L, severe deficiency.1,18

Jill Benson MB BS, DCH, FACPsychMed · Anne Wilson PhD, RN, MN · Nigel Stocks MD, FRACGP, FAFPHM · Nicole Moulding BSW, GradDipPublicHealth, PhD

There is compelling evidence for the success of the “rural pipeline” (rural student recruitment and rurally based education and professional training) in increasing the rural workforce. The nexus between clinical education and training, sustaining the health care workforce, clinical research, and quality and safety needs greater emphasis in regional areas. A “teaching health system” for non-metropolitan Australia requires greater commitment to teaching as core business, as well as provision of infrastructure, including accommodation, and access to the private sector. Workforce flexibility is mostly well accepted in rural and remote areas. There is room for expanding the scope of clinical practice by non-medical clinicians in both an independent codified manner (eg, nurse practitioners) and through flexible local medical delegation (eg, practice nurses, Aboriginal health workers, and therapists). The imbalance between subspecialist and generalist medical training needs to be addressed. Improved training and recognition of Aboriginal health workers, as well as continued investment in Indigenous entry to other health professional programs, remain policy priorities.

Richard B Murray MB BS, MPHTM, FACRRM · Ian Wronski MB BS, SM(Epi)(Harvard), FAFPHM

Objective: To assess the effect of employing Aboriginal health workers (AHWs) on delivery of diabetes care in remote community health centres, and to identify barriers related to AHWs’ involvement in diabetes and other chronic illness care.Design, setting and participants: Three-year follow-up study of 137 Aboriginal people with type 2 diabetes in seven remote community health centres in the Northern Territory.Main outcome measures: Delivery of guideline-scheduled diabetes services; intermediate outcomes (glycated haemoglobin [HbA1c] and blood pressure levels); number and sex of AHWs at health centres over time; barriers to AHWs’ involvement in chronic illness care.Results: There was a positive relationship between the number of AHWs per 1000 residents and delivery of guideline-scheduled diabetes services (but not intermediate health outcomes). Presence of male AHWs was associated with higher adherence to the guidelines. Barriers to AHWs’ involvement in chronic illness care included inadequate training, lack of clear role divisions, lack of stable relationships with non-Aboriginal staff, and high demands for acute care.Conclusions: Employing AHWs is independently associated with improved diabetes care in remote communities. AHWs have potentially important roles to play in chronic illness care, and service managers need to clearly define and support these roles.

Damin Si MMed · Ross S Bailie MB BS, MPhil(MCH), MD · Samantha J Togni MA · Peter H N d'Abbs PhD · Gary W Robinson PhD

Objective: To compare patterns of epilepsy in Indigenous and non-Indigenous people presenting to hospital.Study design: Retrospective cross-sectional survey of individuals admitted to hospital with a diagnosis of epilepsy (1 January 2001 – 31 December 2004); presenting to the emergency department with a seizure (2004); or presenting to the epilepsy clinic (1 September 2002 – 31 March 2005).Setting: Cairns Base Hospital, the major referral centre for Far North Queensland, including Cape York and the Torres Strait, with a population of 230 000 (13% Indigenous).Main outcome measures: Proportion of Indigenous patients presenting for epilepsy; proportion of Indigenous and non-Indigenous groups affected by each of the main epilepsy syndromes.Results: Of 359 patients attending the epilepsy clinic and 918 patients having electroencephalography (EEG), 11% and 13% were Indigenous, respectively (in proportion with the catchment population). However, 30% (146/486) of patients presenting to the emergency department with seizure, 31% (130/418) of inpatient admissions with epilepsy, and 44% (28/63) of patients admitted with status epilepticus were Indigenous. Indigenous patients were more likely to have an abnormal EEG result (P = 0.025), while non-Indigenous patients presenting to the clinic were more likely to be classified as non-epileptic (31% v 18%). In those with abnormal EEG, the frequency distribution of abnormalities was similar, and, in those with epilepsy, syndrome classification also showed similar frequencies. There was no significant difference in occurrence of epileptogenic abnormalities detected by imaging (13% non-Indigenous v 18% Indigenous) or in alcohol consumption (38% v 37%).Conclusions: Indigenous Australians have similar epilepsy syndromes to the non-Indigenous population, but they present with more serious disease. This discrepancy may relate to inequitable health care utilisation due to cultural issues or geographic isolation.

John Archer FRACP, PhD · Ruth Bunby BAppSc

Objective: To determine the prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) carriage and infection among children living in an Indigenous community in Queensland.Design, setting and participants: Swabs for culture of S. aureus were collected from the nose, throat and skin wounds of primary school children.Main outcome measures: MRSA carriage, antibiotic sensitivity, genotype, and presence of the virulence factor Panton–Valentine leukocidin (PVL); and epidemiological risk factors for MRSA carriage.Results: 92 (59%) of 157 eligible children were included in the study. Twenty-seven (29%) carried S. aureus; 14 of these (15% of total) carried MRSA. MRSA was isolated from 29% of wound swabs, 8% of nose swabs, and 1% of throat swabs. Fourteen of 15 MRSA isolates were sensitive to all non-β-lactam antibiotics tested. Eight children (9%) carried CA-MRSA clonal types: six carried the Queensland clone (ST93), and two carried the South West Pacific clone (ST30). All these isolates carried the virulence factor PVL. The remaining six children carried a hospital-associated MRSA strain (ST5), negative for PVL.Conclusions: We have identified a high prevalence of CA-MRSA carriage in school children from a Queensland Indigenous community. In this setting, antibiotics with activity against CA-MRSA should be considered for empiric therapy of suspected staphylococcal infection. Larger community-based studies are needed to improve our understanding of the epidemiology of CA-MRSA, and to assist in the development of therapeutic guidelines for this important infection.

Susan Vlack FAFPHM · Leonie Cox PhD · Anton Y Peleg FRACP · Condy Canuto MAE · Christine Stewart · Alzira Conlon · Alex Stephens BSc(Hons) · Philip Giffard PhD · Flavia Huygens PhD · Adam Mollinger MB BS · Renu Vohra FRCPA · James S McCarthy FRACP

Solutions for Indigenous health problems may hold the key to solving those of other disadvantaged groups in our society There is a substantial and chronic shortage in the health care workforce for Indigenous Australians.1 Of the many factors that contribute to this, one is the lack of suitably trained and willing doctors. In the past 25 years, there have been major efforts to improve medical education to address this problem. As shown by Paul et al in this issue of the Journal 2 and others,3,4 medical schools have slowly changed their curricula to include material specific to Indigenous health, several Australian medical schools have introduced recruitment and support programs for Indigenous and rural students and, more recently, clinical colleges and other medical organisations have promoted cultural awareness activities.5,6 These initiatives rely largely on providing information to a (presumably receptive) profession, based on the underlying premise that most Australian doctors are not aware of the cultural mores and the socioeconomic and health problems of Aboriginal and Torres Strait Islander peoples. It seems to be assumed that informing them will be enough to change their attitudes and behaviours, and that this will improve access to health care for Indigenous Australians. However, despite these and many other initiatives, as several articles in this issue of the Journal (Hayman et al,7 Zhao and Dempsey,8 Ho et al,9 and Harrington et al10) indicate, lack of timely access to quality medical care continues to be a major problem. The ongoing inertia suggests that despite current educational efforts, the medical profession may still have poorly conceived attitudes and beliefs about Indigenous peoples’ health that are unrelated to the realities of Indigenous life, and an impediment to overcoming the workforce shortages. Three separate but related issues — competing priorities, victim-blaming and individualism — stand out. We all prioritise information. As we know from our attempts to help patients change unhealthy lifestyle practices, raising awareness is only a part of what is needed to change behaviour. Few smokers believe that smoking is healthy but, for many, smoking cessation is not at the top of the list of their personal priorities, as they have other pressing issues which seem much more acute than dealing with nicotine addiction.11 It may be that Indigenous health is just not high on the list of many doctors’ priorities. Victim-blaming is still prevalent in community attitudes,12 and may also be reflected in the beliefs of some doctors.13 Why should doctors, whose central focus is to alleviate suffering, harbour attitudes that are less than helpful for marginalised and disenfranchised Australians? A paradoxical explanation may be our reverence for those who overcome adversity. Since the Enlightenment, people of European descent have been enthralled with the concept of struggle. This is demonstrated in Australian political campaigns, in which all the candidates vie for underdog status. Two sentinel publications that irrevocably changed the 20th century focused on struggle — Darwin’s The Origin of Species (1859; struggle for life) and Marx and Engel’s tract The Communist Manifesto (1848, struggle of classes). In our modern age of plenty, we seem to have a deep-seated need to have our own struggles acknowledged. Unfortunately, many of those who have struggled successfully show disdain for those who have, in their judgement, not struggled hard enough to overcome adversity. Another societal attitude that may find expression among medical professionals and diminish their interest in Indigenous Australians is individualism. The more we progress and the more individualistic we become, the less we show concern for those who are most unlike “us” (see McDermott14). Recently, in Queensland, an Aboriginal Elder who had a stroke at a bus stop outside the tertiary institution at which she is an “Elder-In-Residence” was left to suffer on the footpath by other Australians.15 Ironically, the people who eventually stopped to help her were Japanese students. In their own “otherness”, the foreign students were unencumbered by the prejudices and racial stereotypes that afflicted the many other bypassers. Can we continue to perceive the problems of Indigenous Australians with dispassionate disinterest? The causes of Indigenous morbidity and mortality are now dominated by non-communicable chronic diseases (see Zhao and Dempsey8), such as diabetes and heart disease; these conditions are also the major causes of morbidity and mortality in the non-Indigenous population. It is possible that if health professionals work with Indigenous communities to find solutions for chronic disease in Indigenous populations, they will be repaid with solutions for epidemics of the same diseases among non-Indigenous Australians. This point was made last year in a keynote address by Professor John Hamilton (former Dean of Newcastle medical school in New South Wales) to the Towards Unity For Health conference in Vietnam. He recalled a public statement made by our first author (L G P), that if non-Indigenous Australians would walk with Indigenous Australians to find solutions for the health problems of Indigenous people, their gift in return will be a better understanding of non-Indigenous people who are marginalised and disenfranchised. Professor Hamilton later bore witness to this phenomenon when he was able to apply the lessons he had learned from the recruitment program for Indigenous Australians at the Newcastle medical school to the creation of a new medical school in his native England, which needed a program to reach out to a group of disadvantaged young people. We can look on the terrible state of Indigenous health in Australia, and see a burden for health care, or we can see an opportunity. We know that simple and relatively inexpensive measures in Indigenous health can make substantial differences.16 In many Indigenous communities, grandparents are the primary carers for young children. An extra 5 years of life for a “nanna” can mean that these children do not have to lose the single most important adult figure in their life during the vulnerable adolescent years; this would translate into many more years of health for future generations. As a profession, we are confronted with an opportunity to give Indigenous health priority, upskill ourselves with appropriate cultural and clinical training, cease to blame the victims, and acknowledge that “their” health problems are actually “our” problems. We can loose the bonds of individualism and recover an understanding of what it means to live in a community. The state of Indigenous health ought to matter to all Australians, and it should be regarded as an opportunity rather than a burden. Let us not miss the opportunity.

Louis G Peachey BMed, FACRRM · Kristin E McBain BSocSc(Hons) · Ruth M Armstrong BMed

Accessible and culturally appropriate services are needed The National Heart Foundation of Australia and the World Health Organization recommend that all patients with cardiovascular disease are routinely referred to an appropriate cardiac rehabilitation program.1,2 Their recommendations are based on firm evidence that three-phase rehabilitation programs — inpatient, outpatient and maintenance — provide a range of short-term and long-term benefits to health and wellbeing. Key points for success Ensure that cultural competency is integral to the core business of an organisation and supported at all levels within the organisation (eg, employ Indigenous staff across the organisation, support cultural awareness training for non-Indigenous staff, ensure availability of and support for interpreters and cultural mentors). Involve Aboriginal health workers and family members in the care of Aboriginal and Torres Strait Islander patients and develop flexible approaches to raising awareness of the importance of cardiac rehabilitation. Ensure community involvement in planning, implementing and evaluating health promotion, including the development of culturally appropriate materials. Incorporate elements of cardiac rehabilitation and secondary prevention into existing activities or set up activities that draw on existing networks within the community. Develop and sustain partnerships between organisations (eg, a hospital providing outreach cardiac rehabilitation services through the local Aboriginal Community Controlled Health Service). Take the specific needs of Aboriginal and Torres Strait Islander patients into consideration in planning and delivering mainstream cardiac services and develop policies and procedures to address these needs (eg, identifying Aboriginal or Torres Strait Islander status, providing culturally appropriate information on hospital discharge). Develop a specialist education base for continuing training and support of all health professionals working in cardiac care, including Aboriginal health workers. Although the benefits of cardiac rehabilitation are clear, only a small proportion of the people in the general population who have experienced cardiac events attend programs.3 Aboriginal and Torres Strait Islander people are even less likely to participate in cardiac rehabilitation programs than non-Indigenous Australians,3-5 despite being twice as likely to die from cardiovascular disease.6 As there is little published literature specific to cardiac rehabilitation among Aboriginal and Torres Strait Islander peoples, the National Health and Medical Research Council convened a committee to investigate barriers to effective practice and develop guidance for health professionals working in the area. In November and December 2004, the committee conducted workshops, hosted by Aboriginal Community Controlled Health Services in Darwin, Townsville and Mt Druitt (Sydney). Indigenous health professionals and consumers were asked to share their stories and make suggestions about how cardiac rehabilitation services could be made more accessible. This information contributed to the development of a practical guide for health professionals — Strengthening cardiac rehabilitation and secondary prevention for Aboriginal and Torres Strait Islander peoples: a guide for health professionals.7 The guide was tested for suitability by potential users of the manual at a workshop held in Adelaide in June 2005 and was published in September 2005. Through the workshops, the following barriers to uptake of cardiac rehabilitation among Aboriginal and Torres Strait Islander people were identified. “Not enough black faces”: Aboriginal and Torres Strait Islander people are not sufficiently involved in planning, delivering and evaluating relevant health care services. Contributing to this is a lack of training, education and support for Aboriginal health workers. Communication and understanding: Cultural factors that are often not understood and therefore not taken into account in mainstream services include the diversity of Aboriginal and Torres Strait Islander peoples and culture; the complexity of Aboriginal law; the importance of family and community involvement; and a holistic view of health that includes the body, the land and spirituality. Continuity of care: The process of cardiac care usually involves many different settings and people. Lack of continuity and linkages between services, in particular between mainstream and Aboriginal and Torres Strait Islander services, mean that people can miss out on important aspects of care. This is made worse when people live in remote communities and have to travel long distances to access services. Taking the message back home: It can be difficult to maintain a healthy lifestyle back in the community, where adopting healthy behaviours may be less of a priority than meeting basic needs such as food and housing, expectations of health may be low, and there may be strong counteracting social pressures. Self-determination and control: Health intervention programs may be implemented without appropriate consultation and community involvement from the outset. Programs are unlikely to succeed unless they build on the leadership provided by the community and on real partnership with the local community. Addressing these barriers presents considerable challenges. No single solution can be applied, due to the diversity within the population, as well as the need to find approaches that are suitable to remote, rural and urban areas and that take into account cultural issues and staff availability. Multidisciplinary methods are therefore required2 that can be adapted to make use of the skills available in each setting while taking a standardised approach to supporting system change. The Indigenous health sector and Indigenous health professionals are best placed to provide cardiac rehabilitation to Aboriginal and Torres Strait Islander people and should be supported to do this. However, cardiac rehabilitation is more likely to comprise a combination of both Indigenous and mainstream services (ideally a team including an Aboriginal health worker and general practitioner, with other health professionals as required). Establishing and maintaining links between individuals and organisations involved in cardiac rehabilitation is therefore fundamental to improving outcomes. Such linkages support continuity and quality of care, broaden the capacity of the health organisation, increase access to resources and help to integrate mainstream and Indigenous health services, so that it is easier for patients to move between the two systems. At the centre of care are the patients themselves. Showing cultural respect, as well as learning from patients and their families, carers and the community, will increase understanding of how culturally competent health care can best be provided.8 For example, addressing chronic diseases together in an holistic way is more consistent with Aboriginal and Torres Strait Islander concepts of health and illness than considering single diseases or body parts. This approach can also better take into account the importance of spirituality to health and wellbeing, depression and other psychosocial factors increasing the risk of cardiovascular disease,9 and the cultural, environmental and historical risk conditions that place Aboriginal and Torres Strait Islander people at greater risk of the onset and complications of chronic diseases. There is considerable activity under way across Australia to improve the cardiovascular health of Aboriginal and Torres Strait Islander peoples. Systems are in place to assist health services to improve preventive and coordinated care for these patients10 and there is a growing knowledge base to support improved practice. However, continuing efforts are needed across all health care settings, at both individual and organisational levels, to implement sustainable changes that will ensure that appropriate cardiac rehabilitation services are available for Aboriginal and Torres Strait Islander Australians.

Noel E Hayman MB BS, MPH, FAFPHM · Mark Wenitong MB BS · Jenny A Zangger BA, DipApplSci · Elizabeth M Hall BSc

New guidelines and funding for this preventable disease have been long awaited In line with its Vision 2020 initiative, the World Health Organization adopted a resolution to eliminate blinding trachoma by 2020. To achieve this goal, WHO recommends the SAFE strategy (Surgery, Antibiotics, Facial cleanliness and Environmental improvement) for countries implementing trachoma control programs. Australia is the only developed country of the 57 trachoma endemic countries listed by WHO.1 Trachoma was endemic and a significant cause of blindness in many parts of the Western world, including Australia, until the early 1900s. As housing, hygiene and living conditions improved, trachoma disappeared from most parts of Australia.2 However, these improvements are yet to occur in remote Aboriginal populations in Australia, where trachoma is still endemic. Why is Australia the only developed country with endemic trachoma? Firstly, the socioeconomic determinants of trachoma (ie, poverty and overcrowded living conditions) are highly prevalent among Aboriginal people living in remote areas. Secondly, Australia’s trachoma control efforts have been patchy and inconsistent since the National Trachoma and Eye Health Program finished in 1978.3 In the absence of a national approach, some trachoma-endemic states or areas have prioritised trachoma control and have implemented programs based on the 1993 WHO trachoma control guidelines, while others have not. Furthermore, while all current programs include periodic trachoma screening and antibiotic treatment, very few include the “S”, “F” and “E” components. Thirdly, epidemiological data on trachoma, an essential element of any control program, are difficult to obtain and interpret because each trachoma control program has its own data collection system, and data from different regions and states are not collated. Trachoma is not a nationally notifiable disease. Thus, despite availability of a highly effective one-dose treatment (azithromycin) provided free through remote Indigenous health clinics and regional population health units since 1998, trachoma transmission continues. Recent molecular epidemiological research from the Northern Territory showed different Chlamydia trachomatis strains in coastal compared with inland communities, indicating that trachoma transmission may occur more within communities or within groups of neighbouring communities rather than between far-flung, distant communities.4 In contrast, a similar Western Australian study showed that most WA trachoma strains were of the Ba Apache type, which circulated in both coastal and central communities across the length and breadth of WA and was identical to one of the NT strains.5 This finding is consistent with anecdotal reports of high levels of mobility of Indigenous people within and between regions, and suggests that the effectiveness of trachoma control activities may be improved by enhanced inter-regional coordination (eg, conducting trachoma screening and treatment at the same time in all affected areas). Key recommendations of the Guidelines for the public health management of trachoma in Australia6 Trachoma control should be the responsibility of government-run regional population health units, working in collaboration with primary health care services and Aboriginal community representatives. Regional population health units should collect trachoma data in accordance with the minimum national trachoma dataset. Surgery In regions where trachoma is endemic but trichiasis prevalence is unknown, the burden of trichiasis should be quantified. In areas where trachoma or trichiasis is or has been endemic, Aboriginal and Torres Strait Islander people aged 40–54 years should be screened every 2 years and those aged 55 years and older should be screened annually for trichiasis as part of an adult health check. Antibiotics The minimum target group for active trachoma screening should be Indigenous children aged 5–9 years living in communities/towns where trachoma is endemic. All children found to have active trachoma and their household contacts aged 6 months and older should be treated with single-dose azithromycin. Antibiotic treatment of affected people, household contacts and community members (when required) should be completed within 2 weeks of screening. Where population mobility is high, all screening and treatment activities within the region should be completed in as short a timeframe as possible to minimise the likelihood of reinfection and to achieve higher population coverage. Facial cleanliness Facial cleanliness in children should be promoted by including regular face-washing as part of a holistic personal hygiene program. Environmental health Environmental health, school and health promotion staff should be involved as key stakeholders when regional population health units and primary health care services plan and implement trachoma control activities so that “F” (Facial cleanliness) and “E” (Environmental health) strategies appropriate to individual communities/regions can be implemented. The publication of the Guidelines for the public health management of trachoma in Australia,6 which were developed by the Department of Health and Ageing and the Communicable Diseases Network of Australia (CDNA), and the Australian Government’s allocation of $920 000 towards trachoma control over the next 3 years7 represent a long-awaited national approach to controlling this preventable disease. The states and territories will receive $470 000 of this new funding, to train health workers to implement consistent trachoma screening and control measures. The remaining $450 000 will be used to establish a national trachoma surveillance unit to enable consistent data collection on trachoma. The CDNA’s trachoma steering group, which has representatives from states and territories where trachoma is endemic, will provide expert advice regarding trachoma surveillance and control. The guidelines cover trachoma screening, control and data collection (Box). They recommend that trachoma control, including data collection and reporting, should be the responsibility of, and coordinated by, government-run regional population health units, working in collaboration with primary health care services and Aboriginal community representatives. The guidelines stress the importance of implementing all four components of the SAFE strategy. In accordance with one of the resolutions of the 2003 Global Scientific Meeting on Trachoma, the guidelines recommend single-dose azithromycin for all children and all adult household contacts of affected people when childhood active trachoma prevalence is 10% or greater.8 Monitoring of azithromycin resistance is recommended.9 The guidelines are consistent with the spirit of, but do not replicate, the WHO guidelines because high level evidence from randomised controlled trials or meta-analyses of randomised controlled trials exists only for one component (Surgery) of the WHO’s SAFE strategy, and because it is considered important that Australian guidelines reflect Australian experiences of trachoma control.10 Not all stakeholders may agree with the recommendations. Some may dispute the need, given the magnitude of death and ill health in Aboriginal communities due to diabetes, heart disease, mental illness and injury, to channel health resources towards a condition that they believe rarely or no longer results in blindness.11 Others may consider the guidelines too conservative to be able to eliminate blinding trachoma by 2020. Despite these criticisms, the guidelines will at least establish, for the first time, a national minimum best-practice approach for the public health management of trachoma, which if implemented can only strengthen Australia’s efforts towards controlling and eliminating trachoma. Furthermore, they provide yet more impetus for further and broader initiatives to address socioeconomic deprivation, the underlying cause of continued trachoma transmission in Australian Aboriginal communities.

Donna B Mak MB BS, MPH, FACRRM, FAFPHM

Objective: To identify the causes of the gap in life expectancy between Indigenous and non-Indigenous populations of the Northern Territory and how the causes have evolved over time.Design and setting: Analysis of NT death data over four 5-year periods, 1 January 1981 to 31 December 2000 inclusive. A decomposition method using discrete approximations (Vaupel and Romo) was applied to abridged life tables for the Indigenous and non-Indigenous populations of the NT.Main outcome measures: Contribution of causes of death, grouped according to global burden of disease groups and categories, to the life expectancy gap.Results: The gap between the life expectancy of Indigenous and non-Indigenous people in the NT did not appear to narrow over time, but there was a marked shift in the causes of the gap. In terms of disease groups, the contribution of communicable diseases, maternal, perinatal and nutritional conditions halved during the 20 years to 2000. Meanwhile, the contribution of non-communicable diseases and conditions increased markedly. The contribution of injuries remained static. In terms of disease categories, the contribution of infectious diseases, respiratory infections and respiratory diseases declined considerably; however, these gains were offset by significantly larger increases in the contribution of cardiovascular diseases and diabetes for Indigenous women and cardiovascular diseases, cancers and digestive diseases for Indigenous men.Conclusions: The main contributors to the gap in life expectancy between the Indigenous and non-Indigenous populations were non-communicable diseases and conditions, which are more prevalent in ageing populations. With the life expectancy of Indigenous people in the NT expected to improve, it is important that public health initiatives remain focused on preventing and managing chronic diseases.

Yuejen Zhao PhD · Karen Dempsey BN, MPHTM, MAE

Objective: To investigate the short-term outcome of critically ill Indigenous patients.Design and participants: Retrospective cohort study using de-identified audit data from a tertiary intensive care unit (ICU) in Western Australia for the 11-year period 1 January 1993 to 31 December 2003.Main outcome measures: Hospital mortality (crude, and adjusted for severity of illness).Results: Of 16 757 ICU patients, 1076 (6.4%) were identified as Indigenous. The Indigenous patients were younger and more commonly had chronic liver and renal diseases. Indigenous people represented 3.2% of the population of Western Australia in 2001, but represented 3.1% and 9.5% of all elective and emergency ICU admissions, respectively. Diagnoses of sepsis, pneumonia, trauma, and cardiopulmonary arrest were common among critically ill Indigenous patients. Following emergency admission, the crude hospital mortality for Indigenous patients was higher (22.7% v 19.2%; crude odds ratio, 1.24; 95% CI, 1.04–1.47) than for non-Indigenous patients. The crude hospital mortality of critically ill Indigenous patients was lower than that predicted by the APACHE II prognostic model and was similar to that of non-Indigenous patients after adjusting for severity of illness and chronic health status.Conclusions: The pattern of critical illness affecting Indigenous Australians in Western Australia was different from that affecting non-Indigenous patients. The crude hospital mortality was high, but similar to that of non-Indigenous Australians after adjusting for severity of illness and chronic health status.

Kwok Ming Ho MRCP, FANZCA, FJFICM · Judith Finn PhD · Geoffrey J Dobb FRCA, FANZCA, FJFICM · Steven A R Webb PhD, FRACP, FJFICM

Each Indigenous health problem calls for its own unique mix of descriptive and intervention research in both clinical and public health fields The Aboriginal and Torres Strait Islander Social Justice Commissioner, Tom Calma, has challenged all governments to commit to achieving Indigenous health outcomes equal to those of non-Indigenous Australian people within 25 years.1 Governments have set similar goals in the past, but have avoided such clear deadlines. What role should research play in a properly funded program for Aboriginal and Torres Strait Islander health equality? Research can provide useful evidence to better target health policy and strategy, and to guide more effective health services. Researchers can also intervene with empirically-based good sense when the debate gets sidetracked by slogans from all points in the political spectrum. The debate will not be depoliticised, but researchers may help in moving it along. In fact, researchers would be wise to be humble about their impact. They only act as small — if sometimes crucial — wheels in the complex social and political machinery that drives the necessary changes to health services and to the broader social determinants of health. They also must bear the legacy of unhelpful or damaging past health research that fuels Indigenous distrust of research and researchers today.2 Since the social changes of the late 1960s, Australian researchers have increasingly turned their attention to the health of Aboriginal and Torres Strait Islander peoples. Indigenous health publications occupied less than one per cent of the pages of the Medical Journal of Australia in the years before 1970, but by the 1990s this had risen to more than four per cent.3 In this issue of the Journal, Sanson-Fisher and colleagues describe the trends in the numbers of Indigenous health publications in Australia, New Zealand, Canada and the United States since 1987 (Indigenous health research: a critical review of outputs over time).4 They do not tell us who wrote these publications, nor do they tell us much about what was written. Nevertheless, they report that the greatest increase in the number of Indigenous health publications was in Australia, where the total number rose from 28 in 1987–1988 to 167 in 1997–1998 then fell to 147 in 2001–2003. Original research publications were dominated by descriptive research. We agree with their concern about the much smaller (albeit increasing) number of publications assessing health interventions, and the consistently low number assessing measurement tools. How do we find the right balance between these different types of research? We need research that assesses new interventions for diseases or clinical syndromes, such as chronic suppurative otitis media, that are common among Aboriginal and Torres Strait Islander peoples, but relatively uncommon in other Australians. We may also need to evaluate the transferability of some well tested interventions when we suspect that they will work differently in an Indigenous health setting, which is the case for chronic disease programs. Often, however, we can readily apply research from other settings without the need for new research. Some descriptive research can still be necessary when it fills gaps in knowledge that undermine the capacity to make good policy decisions. Different problems will require research programs with different mixes of descriptive and intervention research, and different research methods. Health-service providers, policy makers and Indigenous communities can tell us which uncertainties are impeding action to improve Indigenous health, and so need answers from new research programs. The “road map” produced by the National Health and Medical Research Council (NHMRC) describes what areas of new research are agreed to be most useful: from patterns of risk factors to researching resilience and well-being.5 The NHMRC has also produced guidelines to help non-Indigenous researchers build more ethical relationships with Aboriginal and Torres Strait Islander communities.6 The Journal has not just been a passive recipient and publisher of an increasing number of manuscripts about Aboriginal and Torres Strait Islander health. The first of many special supplements on Aboriginal health was published in 1975.7 This issue, like several earlier issues, is devoted to Aboriginal and Torres Strait Islander health. There are other less visible changes at the Journal: editors can now usually recruit at least one Indigenous reviewer for every Indigenous health manuscript. No longer is Indigenous health research only a matter of white researchers writing about Aboriginal people for a white readership:8 there are slowly more and more Indigenous people involved in all stages of the research process — from setting the research question, to doing the research, to writing, reviewing and reading the final publication. There have been changes in how Indigenous health problems are framed in the Journal. Sixty years ago, the Journal reported a conference paper which compared the falling Australian Aboriginal population with the increasing indigenous populations of the United States, Canada and New Zealand.9 The author did not call for more research on health interventions but for more scientific research on “hybrid vigour”, reflecting the prevalent but misguided political obsession with the “half-caste problem”. However, he then moved to a more familiar issue. He linked the unfavourable international comparisons to the “outstandingly mean, neglectful and backward” approach of Australian governments to Aboriginal people: the 63 shillings of Australian government annual spending per Aboriginal person compared with much higher spending in the United States (£23) and Canada (£10). Recent research has documented that Australia now spends only 18% more on health services for each Aboriginal and Torres Strait Islander person than for each non-Indigenous person, in spite of the much greater burden of illness among Indigenous people, and the higher costs of providing services to them, especially in remote areas.10 This descriptive research on expenditure has been invaluable in cutting across polemical argument about the “buckets of money” that are “thrown” at Indigenous health. This descriptive work now needs to be complemented by research that will evaluate financial and administrative interventions in Indigenous health against progress towards the other goal set by the Social Justice Commissioner: equal access to primary health care and health infrastructure within 10 years.

David P Thomas PhD, FAFPHM · Ian P Anderson MB BS, FAFPHM

Objective: To determine the number and nature of publications on Indigenous health in Australia, Canada, New Zealand and the United States) in 1987–1988, 1997–1998 and 2001–2003.Data sources: MEDLINE and PsychLit databases were searched using the following terms: Aborigines or Aboriginal; Torres Strait Islander; Maori; American Indian; North American Indian, or Indian, North American; Alaska/an Native; Native Hawaiian; Native American; American Samoan; Eskimos or Inuit; Eskimos or Aleut; Metis; Indigenous.Study selection: Publications were included if they were concerned with the health of Indigenous people of the relevant countries. 1763 Indigenous health publications were selected.Data extraction: Publications were classified as either: original research; reviews; program descriptions; discussion papers or commentaries; or case reports. Research publications were further classified as either measurement, descriptive, or intervention. Intervention studies were then classified as either experimental or non-experimental.Data synthesis: The total number of publications was highest in 1997–1998 for most countries. The most common type of publication across all time periods for all countries was research publications. In Australia only, the number of research publications was slightly higher in 2001–2003 compared with other time periods. For each country and at each time, research was predominantly descriptive (75%–92%), with very little measurement (0–11%) and intervention research (0–18%). Overall, of the 1131 research publications, 983 were descriptive, 72 measurement and 76 intervention research.Conclusions: The dominance of descriptive research in Indigenous health is not ideal, and our findings should be carefully considered by research organisations and researchers when developing research policies.

Robert W Sanson-Fisher BPsych, MPsych, PhD · Elizabeth M Campbell BPsych, PhD · Janice J Perkins PhD · Steve V Blunden GradDipHealth Admin · Bob B Davis GradDipEpidemiol

Australian Aboriginal people have the highest rates of these diseases in the world This issue of the Journal provides a range of insights into acute rheumatic fever (ARF) and rheumatic heart disease (RHD), highlighting the divergent perspectives of health providers, health care services, researchers and those afflicted with poor health. From the exposé of the realities of biomedical research in remote Aboriginal communities by McDonald and colleagues,1 through discussions with patients and families by Harrington et al,2 and finally a study of the association of ARF/RHD with B-cell antigens by Harrington et al,3 clinical and biochemical aspects of ARF/RHD are explored. We also gain insights into the realities of usually urban, non-Aboriginal researchers working in remote Aboriginal communities; the intercultural gap between urban and remote, and Aboriginal and non-Aboriginal concepts of disease, health and health care. Successive generations of medical students trained in southern Australian hospitals will have seen the advancing age of the cohort of patients with “interesting and educational” murmurs attributable to RHD, to the extent that it is now rare to come across a non-Indigenous Australian with RHD. ARF/RHD is an eradicable condition, rates of which have declined dramatically in industrialised countries where social and economic disadvantage has decreased.4 Importantly, this is not a condition to which Aboriginal people are innately susceptible — in the past, RHD affected all Australians. However, although Australia is among the world’s wealthiest nations, Australian Aboriginal people today hold the dubious distinction of having the world’s highest rates of ARF/RHD.5 In the study by Harrington et al of prophylaxis for ARF, participants describe the broad range of impediments to accessing regular penicillin prophylaxis, highlighting the importance of venturing beyond the new mantra of chronic disease “self-management” and individual autonomy to understand the reasons behind “the problem of non-compliance”.2 An empiric response to non-compliance with ARF prophylaxis is to refer to an individual patient’s autonomy, assuming that failure to attend is a conscious decision based on avoiding the pain of injections. The beliefs and attitudes of those surveyed contradict this premise, raising questions about the concepts of autonomy and paternalism as they relate to Aboriginal health. Cass and colleagues have previously described how communication between Aboriginal Australians and a largely non-Aboriginal health workforce can result in frequent and often unrecognised miscommunication.6 Along with the experience of McDonald et al of what was viewed by some research participants as the unsympathetic behaviour of researchers seeking written consent,1 this challenges all non-Aboriginal Australians involved in health care to respect and reflect the wishes and beliefs of Aboriginal people in both health care and health-related research. Active participation of Aboriginal people is imperative at all levels of health research and health care delivery involving Aboriginal people. Further, as was borne out in the National Aboriginal Community Controlled Health Organisation chronic ear infection trial, Aboriginal control of health care and health research is both attainable and effective.7 The two articles by Harrington and her colleagues further exemplify barriers residents of remote Australia may face in accessing primary health care services.2,3 The vast majority of staff in the community health service described were female and, despite nothing to suggest a substantial female susceptibility to ARF/RHD, only 7% of those surveyed were male.2 Unfortunately, without the views of a significant sample of men, it is not possible to extrapolate these findings beyond women. Aboriginal men bear a disproportionate level of health disadvantage, and impediments they face in accessing health care are a cause of concern and a focus for action.8 The insightful studies seen in this issue of the Journal underscore the importance of recognising, as a minimum standard, the active participation of Aboriginal people through all phases of health research and health service provision involving Aboriginal individuals and communities. Only by doing so will we recognise, celebrate and bridge the intercultural divide as it relates to a chronic disease such as RHD. While the underlying socio-economic determinants of ARF/RHD may be clear, the solutions are neither simple, nor exclusively in the domain of health services and health resources. Primary prevention of ARF/RHD requires broad-scale political commitment to addressing the social, economic and environmental inequities experienced by Aboriginal Australians. In the meantime, there is great capacity for health care providers to concentrate on meeting the needs of those with ARF/RHD through better diagnosis, prevention and access to care.

Graeme P Maguire FRACP, MPH · Carmel Nelson DRANZCOG, FRACGP, FACRRM

Objective: To test the B-cell antigen D8/17 as a marker of past rheumatic fever (RF) in a predominantly Aboriginal Australian population, and to evaluate technical modifications to allow its use in remote settings.Design and setting: Cross-sectional survey in a remote Aboriginal community, a regional tertiary referral hospital and a tertiary paediatric centre in Melbourne.Participants: 106 people, including three with acute RF, 38 with a history of past RF, 20 relatives of these people, and 45 healthy controls.Main outcome measure: D8/17 expression in B cells.Results: Blood was collected from each participant and the expression of D8/17 and CD19 in each sample was analysed by flow cytometry. The mean proportion of D8/17-positive B cells was 39.3% (SD, 11.8) in patients with previous RF, 22.5% (SD, 5.2) in first-degree relatives, 11.6% (SD, 7.2) in controls, and 83.7% (SD, 10.1) in patients with acute RF (analysis of variance test between means, P = 0.001). A cut-off of 22.1% of D8/17-positive B cells to indicate past RF yielded the highest percentage of correct results (95.4%). Delayed staining of whole blood (mean, 0.55 days; SD, 0.2) gave equivalent results to immediate staining, but the D8/17 assay on peripheral blood mononuclear cells was unreliable.Conclusions: The B-cell antigen D8/17 accurately identifies Australians with a past history of RF, and the assay is feasible in remote settings with access to facilities capable of performing D8/17 staining within half a day of sample collection.

Zinta Harrington MB BS, BA · Kumar Visvanathan PhD, FRACP · Narelle A Skinner BSc · Nigel Curtis PhD, FRACP · Bart J Currie FRACP, DTM+H · Jonathan R Carapetis PhD, FRACP

Before embarking on an epidemiological study of acute rheumatic fever in remote Aboriginal communities, researchers engaged in the processes of community consultation, consent and household enrolment. Community expectations and time constraints are not necessarily those of the funding bodies, and a considerable investment of time and local engagement was required before the project proceeded with local support. The remoteness of the communities, harsh climate and limited infrastructure made working conditions difficult. Nevertheless, the study was completed and the results are being returned to the local councils and households. The research team continues to maintain its relationship with each study community.

Malcolm I McDonald FRACP, FRCPA · Norma Benger BFineArts, DipHealthPromotion · Alex Brown BMed, MPH · Bart J Currie FRACP, DTM · Jonathan R Carapetis PhD, FRACP