Indigenous health

Aim: To identify factors that affect rheumatic fever prophylaxis for remote-living Aboriginal patients, and to determine the proportion who received adequate prophylaxis.Design and setting: Interview (with analysis based on principles of grounded theory) of patients with a history of rheumatic fever or rheumatic heart disease and their relatives, and health service providers in a remote Aboriginal community; audit of benzathine penicillin coverage of patients with rheumatic heart disease.Participants: 15 patients with rheumatic heart disease or a history of rheumatic fever, 18 relatives and 18 health care workers.Results: Patients felt that the role of the clinic was not only to care for them physically, but that staff should also show nurturing holistic care to generate trust and treatment compliance. Differing expectations between patients and health care providers relating to the responsibility for care of patients absent from the community was a significant factor in patients missing injections. Neither a biomedical understanding of the disease nor a sense of taking responsibility for one's own health were clearly related to treatment uptake. Patients did not generally refuse injections, and 59% received adequate prophylaxis (> 75% of prescribed injections).Conclusion: In this Aboriginal community, concepts of being cared for and nurtured, and belonging to a health service were important determinants of compliance.

Zinta Harrington MB BS, BA · David P Thomas FAFPHM, PhD · Bart J Currie FRACP, DTM+H · Joy Bulkanhawuy

The 2006 Dr Ross Ingram Memorial Essay Prize has been won by Dennis McDermott for his essay Unknown family at the taxi stand, published in this issue. Dennis is a Koori psychologist and conjoint senior lecturer in Indigenous health at the University of New South Wales. He is also a published poet, including a collection entitled Dorothy’s skin, published in 2003. Unknown family at the taxi stand uses stories from the author’s own family to flesh out some of the complexities of mental ill-health in Indigenous Australians. Dennis wrote and submitted the essay in the belief that . . . narrative can carry a complexity that epidemiology lays out as so many bones. Coolly useful as data are, when statistics have real human faces there’s a chance that a lost emotional resonance might return. For Gubbas (non-Indigenous Australians) to come to grips with what’s happening in Indigenous health in this country doesn’t require a bleeding heart. It does require new means to “de-Other” Indigenous Australians — to situate us, and our experiences, inside the national consciousness. Blackfella health won’t change until we are no longer the exotics of our own land. The Dr Ross Ingram Memorial Essay Prize is awarded for the best essay by an Aboriginal or Torres Strait Islander person on Indigenous health. It carries a prize of $5000 (donated by the Australasian Medical Publishing Company). For details on how to enter next year, see our website (www.mja.com.au). Thanks to our external panel of judges and to Dennis, as well as our runner-up Marshall Watson (whose essay A journey of Indigenous identity will be published in the MJA later this year) and all the other entrants who shared their stories of sorrow, discovery, joy and hope with us. The universe is made of stories, not atoms. (Muriel Rukeyser)

Ruth M Armstrong

The summer before last, two members of my family died. For an extended Aboriginal family, the fact that they died within 6 weeks of one another wasn’t unusual — no less hurtful, but not out of experience. Blackfellas, unfortunately, bury often. Both deaths were unexpected: my mother’s, from postoperative complications, and my never-met, distant in-law’s, from violence. My mother’s was unusual (she’d made it to 87), my unknown relative’s less so: shocking, distressing to all connected to her, but not unheard of for black women, or men, in their twenties. It was unclear whether the violence was self- or other-inflicted — the stories of the male relative who found her and the cops differed (“there was a piece of rope”/“there was no rope to be seen”). What was not in dispute was the fact that two young boys, who had accompanied the relative to the woman’s front door, now carried the picture of her legs protruding from a door frame down the hall. This is a difficult essay to write, even to justify: it’s personal — involving current and possible future pain for people I’m close to and care about — yet it relates to concerns that I research and talk about professionally all the time. As a Koori psychologist who has worked for some years teaching Indigenous health to medical students and registrars and Indigenous wellbeing to mental health professionals, it’s undertaken in the belief that narrative can carry a complexity that epidemiology lays out as so many bones. Coolly useful as data are, when statistics have real human faces there’s a chance that a lost emotional resonance might return. For Gubbas (non-Indigenous Australians) to come to grips with what’s happening in Indigenous health in this country doesn’t require a bleeding heart. It does require new means to “de-Other” Indigenous Australians — to situate us, and our experiences, inside the national consciousness. Blackfella health won’t change until we are no longer the exotics of our own land. * The Great Dividing Range. My Aboriginal country is in New South Wales, west of the divide.* The day I was due to fly to New Zealand, to spend a few days with my Wellington-based partner before she headed to Europe to give a paper, my mother’s condition worsened. I grabbed a flight to my old home town instead. My mother died the next day. After a few days, out-of-town relatives arrived for the funeral. My partner crossed the Tasman and brought my daughter and grandniece up with her from Sydney. On our way from stocking up on groceries at the local ShoppingWorld, we noticed a public phone by the exit. We thought a quick call or two might help sort out our travel mess, but were there for the next hour. While my partner worked through the complexities of rescheduling a later departure for her conference in winter-dark Copenhagen, I watched people in sun-dresses, shorts and thongs drift out of the glass doors into the dry, inland heat of the car park. Hearing the sound of running feet, I turned to see two small girls in vividly coloured tutus coming down the last avenue of shops. Once through the exit, they took off for the taxi stand, ballet slippers in hand, some way ahead of their mother, who followed with stroller and shopping bags. There was a momentary halt inside the taxi shelter while slippers were pulled over bare feet and ribbon wound around calves, then they were out and dancing. One tutu, a full-on orange, glowed in the late-afternoon light like a fiery variety of gum blossom. The younger one’s was a complementary wattle. Both were fluorescent against deep-brown limbs. While their mother bent to the small figure in the stroller, the girls pirouetted behind the shelter, arms curved against the blue sky, calling out to each other as they turned. A few minutes later a taxi turned up and off they went to their lesson. A few weeks after the burial, I thought I was done with the visceral jolt of sudden death, at least for a while. Grief was a different beast, to be grappled with in the coming months. When my partner returned from Europe, I flew with her to New Zealand to begin a 6-month sabbatical term looking at Indigenous mental health internationally. But my private and professional life kept overlapping. My thoughts kept coming back to my mother. Just a year before, my sister and I had battled to have my mother taken off antidepressants. After caring for her terminally-ill second husband for some years, she’d developed a reactive depression. There had been no consultation with family before she’d been prescribed SSRIs (selective serotonin reuptake inhibitors), nor when she was maintained on them for some years after her husband’s death. Maintained, but not monitored. The family was left to puzzle the restless, even manic, energy and the apparent lack of empathy in a normally loving woman — the SSRI stimulant effect at work. After professional weight was used to have these concerns taken seriously, she was taken off her medication, abruptly (without her knowledge and, again, without family consultation), enduring a roller-coaster of withdrawal emotionality until we twigged what was happening. And there I was, in Aotearoa (New Zealand) and soon off to Canada to look for pointers, to ponder the central puzzle: does the fact that we do mental health badly in Australia fully explain how we get blackfella mental health so comprehensively wrong? Once in a while, when I became too sombre, I’d conjure up the pure joy of that scene in the ShoppingWorld car park. I had no idea who the young Aboriginal family I’d seen at the taxi stand were, and, seemingly, they had no particular connection to me. I described them to my sister and found an unexpected one. The mother of the young girls and the child in the stroller was, in fact, the sister of a particular in-law: they were unknown family. The vibrancy and sense of possibility emanating from the tutu sisters seemed a hopeful sign. Professionally, in my teaching, I found it easy to point to Aboriginal resilience and give example after example of positive programs that were being piloted. Yet the shut-down of serious reconciliation in Australia and the decade-long growth of historical revisionism — the refusal to consider Indigenous/settler history and contemporary Indigenous health on the same page — had made it increasingly hard to maintain that hope. Creating a positive future for the current generation of Aboriginal children had felt, more and more, a hard ask. I didn’t know whether to feel quaint or subversive, giving seminars on the inescapable nexus — even in the clinical setting — between politics and Indigenous health outcomes. But I became increasingly convinced that, along with conceptual freshness, a sophisticated political boldness was vital, particularly in relation to turning around Indigenous mental distress. A few weeks after I’d commenced my sabbatical, my sister called. My newly-found relative was dead. The picture was confused: she was estranged from the children’s father, he was out of jail, there’d been disturbances, she was found on the floor of her house. What was indisputable was that she hadn’t made 30, that the dancers and a younger child were motherless and that the two little boys at the door had seen too much. Investigations take time: I still don’t know what really occurred, but, regardless of what actually happened on the day, I could sense what might have happened on all the prior days. While I’d been working on a research project in south-west Sydney, it was put to me that the most commonly used instrument to pick up postnatal depression (PND) in Aboriginal mothers, the Edinburgh Scale, couldn’t be relied on to sift out Aboriginal mothers at risk. The community nurses and infant mental health workers reported too much background “noise” to pick up a clear PND “signal”: the women were routinely carrying such an accumulated load of mental distress that it was hard to sort out birth-related changes. Whether it’s the NSW Chief Health Officer reporting on levels of east-coast Aboriginal mental distress, or Western Australian studies on the everyday stress levels and burden of negative life events borne by Nyoongah kids, a similar picture emerges. The greatest difficulty in improving Indigenous mental health is not finding data, but finding mechanisms to convince governments — ultimately, the program funders, workforce developers and agenda-setters — and, in particular, the current federal government, that to connect the unresolved trauma of dispossession, child removal, missionisation, racism and over-incarceration to contemporary distress is not adopting a “black armband view of history”. The dots are on the page. There is a lack of political will to join them up. When you make the connection between psychoneurobiological research, historical data and Aboriginal testimony, what emerge are the processes by which the long, slow legacy of colonisation and the human consequences of “virtual” apartheid are enacted: the physiologically and psychologically corrosive stress of having to deal, daily, with racist acts; the multiplier effect of the actions of each paedophile nun or unchecked abusive lay children’s home worker; the undischarged body memory of beatings at Cootamundra Girls’ Home, Kinchela Boys’ Home or Beagle Bay; the brutality of Grafton Gaol or the Palm Island lock-up; the lack of both identity and hope when your comings and goings, your bank account, your ability to marry — your life — are controlled by the mission manager. When eyes aren’t averted, these processes become clear. Let’s take just one process: a check of major newspapers for the summer of 2005–06 would show a number of current Australian governments denying even the existence of entrenched racism in this country, let alone the cumulative effects of its operation. Unless you’re the one on the receiving end, the one on the performing end makes sure it’s difficult for anyone else to perceive the racist act. Even more rarely do we connect racism, and constant discrimination, to physical and mental health consequences. Racism takes an invisible toll. When you’re the last one served in the sandwich shop, when you’re on the corner waiting for the lights to change and the abuse from a wound-down car window slaps you in the face, or when you’re young and brown and profiled by the cops as you perform your bravado shuffle down Glebe Point Road, it piles up in your head and chest. † University of New South Wales. In December 2005, as I walk home from the Coogee shops to my flat, I pass a sooty smear on Arden Street, the residue of a recently fire-bombed van. Across the road are the gas barbecues behind the beach, where every night an easygoing smorgasbord of UNSW† students cook up their diverse fancy. Both events are the real Australia: we are both a tolerant and a racist society. The bogey-man is currently “of Middle Eastern appearance”, although he shape-shifts: when I was growing up, he looked aggressively out from May Gibbs’ books, the bushy-eyebrowed, spindly-legged and nulla nulla-clutching Big Bad Banksia Man. Maybe Jung was right when he said that part of really growing up is reclaiming our own projections. Yet all the Australian Prime Minister’s 2006 Australia Day address can offer is racism as a “behavioural problem”. The solution, as ever in our country, is more “punishment”. But a century of research on behavioural change tells us that punishment doesn’t change behaviour. At best, it temporarily amends it, drives it underground, ahead of a later, volcanic re-emergence. In 2006, health professionals must work in a climate reductive of complexity. There is certainly no will to explore the reality of Australian racism, let alone its hard-to-pin-down, but profound, impact on physical health and what blackfellas prefer to call social, spiritual and emotional wellbeing. If we health professionals are to genuinely care for our patients and clients, the times call for informed, professional boldness. Not only is the “political” an everyday element in our funding and workforce shortfalls, but in our governments’ data-denying intellectual shortfall. Reversing Indigenous mental distress requires awareness that new mechanisms of consensus building, beyond mere lobbying, need developing before we can effectively discharge our duty of care. In 2006, the political is the clinical. We need — sorely need — a bridge between Western ways of approaching mental health and a body of Indigenous knowledge on maintaining, or recovering, wellbeing. We need to reconceive what actually underlies Indigenous mental distress before we can reconceptualise our praxis and develop the infrastructure to support a renaissance of wellbeing. Understanding is insufficient: the task requires recognising and incorporating the complex transgenerational effects of colonisation on blackfellas. The final step — no mean feat — would be the “de-Othering” of Indigenous Australia. You’ve got relatives out there.

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

Objective: To describe the implementation of an integrated Aboriginal health curriculum into the medical course at the University of Western Australia (UWA) and the early effect on students’ perceptions of their knowledge and ability in the area of Aboriginal health.Design, setting and participants: Final-year medical students at UWA in 2003 (first cohort) and 2004 (second cohort) were surveyed by questionnaire (with answers on a five-point Likert scale) to assess their attitudes to various aspects of Aboriginal health. A subset of students provided open-ended comments on key priorities in Aboriginal health, cultural security and suggestions for Aboriginal health policy.Interventions: Integrated learning experiences were implemented within each year of the medical course, based on specific learning outcomes in Aboriginal health.Main outcome measures: Changes in students’ self-perceptions of their preparedness for and future commitment to working for change in Aboriginal health.Results: Response rates were 76% and 85% in the 2003 and 2004 cohorts, respectively. Compared with first-cohort students, second-cohort students were more likely to agree with items relating to their preparedness and ability to work with and care for Aboriginal and Torres Strait Islander people (P < 0.05); second-cohort students also reported greater preparedness to advocate and improve the health of Aboriginal people (P < 0.05); 65% of respondents in the second cohort (versus 34% in the first) agreed they had a social responsibility to work for change in Aboriginal health (P < 0.05).Conclusion: With a relatively small amount of targeted and structured teaching and learning in Aboriginal health, significant shifts in students’ self-perceived levels of knowledge, skills and attitudes are possible.

David Paul MB BS, BPolicyStudies(Hons) · Sandra Carr RN, RM, MPH · Helen Milroy MB BS, FRANZP

The first Aboriginal medical service was established in the Sydney suburb of Redfern in 1971, with the aim of improving access to health services for the local Aboriginal community by creating a culturally appropriate environment. Since then, there have been many changes to primary health care arrangements for Indigenous Australians (and even now, the Aboriginal medical service sector is only part of the story). However, the important concepts behind the establishment of the first service remain. According to the National Aboriginal Community Controlled Health Organisation, the national body representing Aboriginal community controlled health services (ACCHSs) throughout Australia (http://www.naccho.org.au), an Aboriginal medical service is “a primary health care service initiated and operated by the local Aboriginal community to deliver holistic, comprehensive and culturally appropriate health care to the community that controls it (through a locally elected board of management)”. There are currently over 130 Aboriginal medical services in Australia, varying greatly in size and staffing levels. These services are unique in their management and funding structure, and their community base. As the provision of adequate primary care for Indigenous people has been identified as one of the cornerstones of improving their health, we asked representatives of two large ACCHSs in north Queensland — general practitioners, Aboriginal health workers and managers — to tell us about their community, their service and their roles. A tale of two cities: Townsville and Cairns Townsville and Cairns in north Queensland are among nine Aboriginal and Torres Strait Islander (ATSIC) Regions that account for almost 48% of Australia’s Indigenous population.1 The Townsville region has a population of 325 000, with an Indigenous population of 16 875 (5.2%), while the Cairns region has a population of 196 000 and an Indigenous population of 17 049 (8.7%). Townsville Aboriginal and Islanders Health Services (TAIHS) is a large Aboriginal community controlled health service situated in one of the inner suburbs of Townsville. Its over 150 employees provide medical and dental care, social and emotional wellbeing services, a youth shelter, a volatile substance use service, crisis accommodation and child protection services. The medical unit at TAIHS provides comprehensive primary health care, with a staff of 36, including nine general practitioners, four registered nurses (three Indigenous), six Aboriginal health workers, a dietitian and a psychotherapist. In addition, visiting specialists (general physician, endocrinologist, ophthalmologist and psychiatrist) and allied health professionals (podiatrist, child health nurse, psychologist and midwife) complete a team able to provide a range of health care and lifestyle modification programs. WuChopperen in Cairns is another large Aboriginal community controlled health service. It has a staff of around 90, with five full-time equivalent GPs, three registered nurses, seven Aboriginal health workers and sessional allied health providers. WuChopperen has developed two other, now autonomous, Aboriginal community controlled health services in Far North Queensland, Mulungu (in Mareeba) and Mamu (in Innisfail), and currently has a satellite clinic at Atherton. The range of programs provided is very wide, including a social health and youth health service, and health services for illicit/licit drug use, family violence and prison health. Visiting specialists are called on when available. 1. Australian Bureau of Statistics. Population distribution, Indigenous Australians, 2001. Canberra: ABS, 2002. (Catalogue No. 4705.0.)

Helping patients sort out the complexities of life, even if in small steps, can be a source of great satisfaction Aboriginal community controlled health services (ACCHSs) across Australia are supported by predominantly non-Indigenous doctors. As of 2005, there were between eight and ten Indigenous doctors working in ACCHSs. For many non-Indigenous doctors, working in an Aboriginal health service has been a choice to do something different and to try to make a difference. One of us (K S P) moved to Townsville from Sydney. Working for the Townsville Aboriginal and Islanders Health Services (TAIHS) provided an opportunity to combine general practice with interests in maternal and child health and clinical research. For Indigenous doctors, the reasons for working in an ACCHS are varied, but generally centre on wanting to work closely with their community. The other author (M W) is one of two Aboriginal GPs working at WuChopperen Health Service. Communities and family members, but also the medical community and government, expect Indigenous doctors to work directly in primary health care. In taking on this role, Indigenous doctors need to be able to respond to a variety of community, leadership and role-model pressures, but their value to the local community is measured not only by their natural cultural communication skills, but by the capacity development among Indigenous people that they represent. OpportunitiesIndividual level: the art of medicineThe practice of medicine in an ACCHS challenges even the most highly trained clinician. The number, complexity and interaction of problems presenting in any one consultation1 require listening skills, a depth of clinical knowledge, familiarity with evidence-based medicine, and the ability to formulate feasible management plans2 — and all these skills are needed all the time. A constant challenge is to tease out the subtleties in communication. Inherent in this is the ability of the practitioner to engage in empowerment strategies with Indigenous patients, and a big part of the job is advocacy on behalf of patients, helping them to negotiate parts of the health system compromised by institutionalised racism.3 Diseases such as impetigo, diabetes, and chronic obstructive airway disease are well recognised, but often not only their prevalence but their severity at initial presentation is overwhelming. There is also the need to rapidly acquire the knowledge to manage less familiar diseases, such as rheumatic fever (and its sequelae), syphilis and tuberculosis. Working with teamsACCHS doctors work in multidisciplinary teams. Aboriginal health workers’ and registered nurses’ knowledge of both the cultural and social aspects of a patient’s background are vital to patient management, and they often work independently on aspects of the care plan. ACCHSs are often well supported by visiting specialists and allied health professionals, allowing GPs to work within a truly multidisciplinary primary health care team. Outreach work It is unlikely when working in an ACCHS that the whole week will be spent in the same office. Visits to “parkies” and “grass camps” (people living in town parks and fringe dwellings), sessions in jails, and visits to outlying communities are just some of the possible outreach scenarios. Quality improvement, population health and research programsThe futility of practising medicine only on an individual level quickly becomes apparent and, once an ACCHS doctor is established within a community, it is possible to branch out into quality improvement and population health programs. This requires working with the community and the myriad funding bodies to develop, for example, programs for Pap smear screening, smoking cessation or diabetes care. This not only benefits the community and enhances service capacity, but also allows GPs to develop skills that may prolong their involvement in Indigenous health. It is relatively common to conduct research in larger ACCHSs, and opportunities exist for GPs to access research funding and training. DifficultiesCultural safetyThere are two relevant aspects of cultural safety. The first is the more traditional view of cross-cultural communication;4 the second concerns the culture of being a doctor. In the ACCHS setting, doctors will often have a different cultural background to their patients, and English may not be the first language of the patient or the doctor. Consequently, cross-cultural training programs provide orientation in cultural background, language concepts, communication and relationships within the local Indigenous community. Cross-cultural education outlines the history of white colonisation of Australia, the effect of subsequent government policies on the local community, the cycle of poverty, local communication issues, and local customs for births, deaths and illness. Not all cultural awareness programs are alike, so, while education provides an important introduction, cultural awareness accumulates with experience, but only develops fully if the doctor is prepared to respect and learn from the community and, importantly, if the community will mentor and assist the doctor. The second aspect of cultural safety is the culture of medicine that many doctors are used to and have been trained in. This can cause difficulties coping with the unfamiliar clinic environment — its very high workloads, poor infrastructure, multiple and chaotic medical records, lack of structured clinical sessions with no appointment systems, patients arriving en masse in bussed transport, and apparently poor patient compliance (which often can be explained by difficult dosing regimens, and a lack of common reality and priorities). While these issues may appear insurmountable to a new GP, leadership and a quality improvement approach can result in more controlled working environments. Trauma and griefThe recent history of Queensland Aboriginal and Torres Strait Islander communities, like those in Townsville, is one of loss of land (often accompanied by violence), forced removal, and detention of differing clans in missions and reserves, with consequent loss of culture, autonomy, identity and life skills. Many patients come from such traumatised family backgrounds.5,6 Dealing constantly with traumatised patients and the resulting problems of unemployment, poor education, substance misuse and violence can become a threat to the wellbeing of the ACCHS staff, especially the GPs. The high mortality rates in Indigenous populations become starkly evident. In any context, it is difficult for GPs to see relatively young patients die of preventable diseases, but the monotonous regularity of community funerals can become depressing. Indigenous doctors, who may also be from the local community, can experience this from both a medical point of view as well as from family involvement. It is important that GPs are able to recognise their own reactions to trauma and grief and take appropriate action. While counselling is available, regular periods of leave are probably necessary for survival in the job. Lack of autonomyThe stressors of mainstream general practice — job demands, time pressures and perpetual change — are well known. These also affect GPs working for ACCHSs, but the strongest predictor of job satisfaction has been identified as being in control of the job.7 The major stress for GPs working for an ACCHS is the loss of autonomy in practice management. ACCHSs are governed by community-elected boards, who make many of the decisions GPs in mainstream practices would ordinarily make themselves. Some board members are highly trained in the health field, others are not, and their decisions may or may not be in line with GPs’ perceptions of how a medical clinic should operate. This lack of autonomy can make the implementation of change difficult when the ultimate decision for acquisition of equipment, recruitment, conference attendance, or participation in research and population health programs lies with the board. The stress is minimised if GPs enjoy good working relationships with their senior managers, chief executive officers and boards. Community politics may also influence some decisions, which can be difficult to comprehend until an understanding of the broader context of Indigenous control and empowerment has been gained. RemunerationWhile remuneration levels in some centres are improving, through support from, for example, the Rural Incentive Payments Scheme,8 GPs in the larger urban ACCHSs are often not as well paid as their mainstream colleagues. This reinforces the perception that the work they are engaging in is less valuable and has led to a high turnover of doctors and difficulty in attracting Australian-trained GPs. To attract and retain more Australian-trained doctors, a review of remuneration is needed. Career paths and ongoing trainingThe better supported ACCHSs are an ideal environment for training, not just in general practice, but also in specialties such as public health, general medicine and cardiology. This would provide a new source of doctors for the Indigenous community. The burden of disease encountered on a daily basis would, with remote supervision, provide excellent training for registrars. While there is growing support from the Royal Australian College of General Practitioners in cultural safety, peer networks and mentoring, in many areas GP registrars are not allocated to ACCHSs as a priority. If the Colleges could develop training paths that encompass terms in ACCHSs, it would not only enrich the pool of doctors trained in caring for Indigenous people, but also enhance the quality of medical care for Indigenous communities. Public health registrars, with their population health skills, could be a valuable asset to the larger ACCHSs. There have been some moves to offer integrated general practice and public health training, but this has left many GPs in the ACCHS sector faced with the decision of whether to stay or leave when they reach an advanced stage of their training. ConclusionWhile every GP will have a different experience within an ACCHS, a few will truly become part of the community. Many doctors will develop close friendships with both staff and families that can be especially rewarding. Sharing the highs and lows of the Indigenous community, especially with respect to sport and music and their role in mainstream Australian culture, strengthens the bonds some doctors have with their roles in ACCHSs.

Kathryn S Panaretto MB BS, MPH · Mark Wenitong BMed

Working in one’s own community can be rewarding but stressful; there is a perception that you are “everything to everyone” Aboriginal health workers (AHWs) have usually lived in the community they work in and have developed lasting relationships with the community and with the various government agencies. One of us (M M) has lived in Townsville for 12 years and the other (L H) for 4 years (having grown up in the town of Hughenden, 370 km west of Townsville). These ties to the community and health networks provide us with a real sense of what is going on and what is needed at a grassroots level. There are many reasons for AHWs choosing to work in an Aboriginal community controlled health service (ACCHS). The opportunity to work with their community, as mentioned, is a strong motivation. Others may be “head-hunted” (as we were) or may have practical reasons for wanting to move to larger centres. One of us (M M) gained a great deal of experience working as an enrolled nurse in a small regional hospital for 10 years and was looking for a new challenge. Working with the Townsville Aboriginal and Islanders Health Services (TAIHS) provided an opportunity to participate in a holistic health service planned by the community. For others, it may be the opportunity to participate in research projects and community development projects. Some health workers at TAIHS have moved down from more remote areas, such as the Torres Strait, to be near their family and further their education. OpportunitiesClinical experienceHealth workers at ACCHSs, unlike those in mainstream services, are free to use their clinical skills and are called on to perform a wide range of procedures. For example, we are able to administer childhood vaccinations under the supervision of a doctor, take Pap smears, take blood, and perform health checks. Opportunities exist to experience a broad clinical program or pursue an area of interest, whereas health workers in the government sector are often tied to specific clinical areas or to non-clinical work, such as transport and social assistance. Empowerment and autonomy It has been very empowering as Aboriginal women to be involved in the many programs run through TAIHS. The ACCHS setting allows more autonomy in setting up and implementing health programs. At TAIHS, we have planned and successfully run programs such as a breastfeeding peer support program, a smoking cessation project, a human papilloma virus project (which has increased the number of women having Pap smear screening), and a walkabout project (increasing physical activity). These programs also allow for innovative approaches to raise awareness within the community. For example, at TAIHS, the health workers have initiated a community breakfast for breast cancer week, and participate in a weekly local radio health segment. DiversityHealth workers in ACCHSs also deliver outreach services to the wider community, including prisons, fringe camps and youth detention centres, and have the opportunity to travel to workshops and conferences to expand their knowledge and skills as well as build professional networks. Community controlInevitably, working in Indigenous health, there will be cultural clashes, but these are easier to mediate in the ACCHS setting. The state health system’s mainstream perspective, less flexible management, and lack of cultural sensitivity can make dealing with cultural clashes more difficult. DifficultiesRole definition and recognitionACCHS health workers carry a great load of community expectation. We are asked to take on many roles at once, and are seen as being “everything to everyone”. Older staff members may not respect the contribution of younger workers; they may carry their role as elders into the workplace, and this can cause problems. Working in the community sector involves working with multidisciplinary teams. Some professional staff — both nurses and doctors — can be ignorant of the AHWs’ skills and abilities, opting to work with a registered nurse instead. Difficulties in teamwork can be frustrating and can affect service delivery. A continued source of stress is the lack of national qualifications and recognition of competencies of AHWs. For example, those trained in taking Pap smears and giving vaccinations can only use these skills in an ACCHS setting because their training is not recognised in other heath sectors in Queensland. Although AHWs are accepted into training courses, sit the same exams and develop the same level of competence, only registered nurses gain formal recognition across all sectors. RemunerationThe health service union award, under which AHWs work, has not been updated since 1992. In the past decade, there have been significant changes to education for AHWs and increased levels of responsibility in the clinical environment. Remuneration in the community sector is not progressing in line with government-employed health workers. ACCHS health workers have higher levels of clinical skills and responsibilities than our colleagues in state health. Service delivery in the two sectors is very different, with state health focusing on a disease-model approach while the ACCHS approach is broader, encompassing a social model of health. There are a number of enrolled nurses working as AHWs. This is because the training is short and hospital-based (and in remote areas it is more likely there will be a hospital than an ACCHS). When enrolled nurses move into ACCHSs, both parties are disadvantaged because, although enrolled nurses participate in care-planning activities, they are not issued with provider numbers and are unable to bill under Medicare. Living and working in the communityBearing the load of community expectation can be very tiring when combined with the responsibilities of work and family. We cannot go out after work and relax, as community members may want to unload their problems on us. When there is family conflict in a community, people can distance themselves from the ACCHS if the health worker belongs to a different clan. There may be concerns that confidentiality is not adhered to, despite health workers being committed to professional codes of conduct. These issues can be frustrating and may damage health workers’ sense of their own professionalism. The community grapevine can add to the pressure by exaggerating things out of all proportion. The futureWe are hopeful that we will finish our studies, complete our Bachelor of Nursing Science degrees and one day work as chief executive officers of TAIHS. As joint CEOs, we would strongly advocate for improving the recognition of AHWs and for more equitable pay structures, while continuing our work with the community.

Melvina Mitchell EN · Lynette M Hussey EN

As Indigenous CEOs, we train non-Indigenous doctors in cultural safety, and rely on them to integrate Aboriginal health workers into the multidisciplinary team Aboriginal community controlled health services (ACCHSs) are generally managed through an elected board of directors and an appointed chief executive officer (or equivalent). In taking on such roles, managers face competing professional, community and political demands and requirements. The CEO is a member of the Aboriginal or Torres Strait Islander community in which he or she lives, and is also managing a major health service for their community. The demands placed on individuals in these circumstances, as well as the expectations to achieve outcomes often beyond their immediate control, are significant. The CEO is constantly balancing individual clients’ needs with community expectations for an accessible high quality health service. The reasons for choosing to work in this area are varied and are driven by personal, organisational and community goals. This is consistent with the findings of a report based on interviews with 41 Aboriginal and Torres Strait Islander health managers.1 The report revealed that the distinctive features of the managers include: a very strong personal motivation to assist the Aboriginal and Torres Strait Islander community; a willingness to take on a leadership role and initiate change within the community; a direct sense of responsibility and accountability to the community; and a desire to work outside the bureaucratic processes that often create barriers to success. Meeting the community’s needs Although ACCHSs were set up primarily to deliver comprehensive primary health care services, the responsibility of many of them now extends to child protection services, drug and alcohol programs, aged care, and housing and infrastructure and schools-based programs. This has significant management implications in terms of the multiple funding sources, the need to administer a wide range of programs, the increased staff size and skill mix, the physical infrastructure required, and the complex reporting requirements. The accessibility of health services for Aboriginal and Torres Strait Islander peoples is affected by a number of factors, including the distance to and availability of health professionals. The employment of Aboriginal and Torres Strait Islander staff has long been recognised as an important factor in accessibility of services. Unpublished data from the Department of Health and Ageing and the National Aboriginal Community Controlled Health Organisation suggest that in 2000–01, 67% of full-time equivalent positions in federally funded Aboriginal primary health care services were held by Aboriginals and Torres Strait Islanders. However, examination of the workforce composition shows that most Indigenous staff (97%) were employed as health workers or field workers, while non-Indigenous staff were more likely to be employed in professional positions. Most doctors (98%), nurses (87%), allied health professionals (89%) and dentists (88%) were non-Indigenous.2 Therefore, in the Aboriginal medical services, there may be three strata of employees. Tsey has described the pyramid structure of most of the services, with a small group of Aboriginal managers at the top of the pyramid, a middle stratum occupied by predominantly non-Aboriginal professional staff, and a bottom stratum of predominantly Aboriginal workers who occupy semi- or non-professional roles.3 Thus, the CEO is faced on the one hand with the need to train their non-Indigenous staff in cultural safety, and on the other hand must rely very heavily on them for service provision and integration of Aboriginal health workers into the multidisciplinary team. Similarly, the CEO might be obliged to act as a manager for an Indigenous relative or close community member. Prioritising needs and resourcesThe explosion of activity in relation to new policy initiatives and program development in Aboriginal and Torres Strait Islander health has resulted in increased opportunities to access funding, but it has also created many vertical programs within the services. As a result, a large amount of new money has been allocated on a short-term basis or for pilot programs, making it difficult to sustain any gains made. The management challenges associated with such growth include future planning (when there is a high dependence on “soft” money), the accountability requirements of multiple funding sources, and the inefficiency of having to maintain systems to achieve this. Other challenges relate to managing staff in a climate of uncertain job security, and the workforce implications of funding new positions with ill-defined skills levels, training needs and career pathways. Finally, to access the additional funds, staff resources are needed for writing funding submissions and fulfilling the requirements of the granting bodies, a task that usually has to compete with clinical priorities. An area in which services often struggle is obtaining access to specialist and allied health services. To address this, we are trying to improve linkages with mainstream service providers and foster relationships that allow for some flexibility in how and where services are delivered. For example, considerable barriers to accessing maternal and child health services were overcome in Townsville by arranging for a child health nurse to work four mornings per week at Townsville Aboriginal and Islander Health Services. The importance of Indigenous community controlThe ACCHS model essentially requires that ownership and management of the health agency are vested in the local Indigenous community, generally through a local Indigenous board of management. This arrangement allows the local community to decide on its priorities, policies, management structure, staff and service profile, within government funding guidelines. The model has features in common with the community controlled primary health care services that have contributed to health gains in other indigenous peoples. International comparative analyses4,5 demonstrate the success of community controlled models of health care, when governments have been engaged in the development of effective and efficient systems. For example, through the 1976 Indian Health Care Improvement Act in the United States, appropriated resources were used to expand health services, build and renovate medical facilities, provide safe drinking water and sanitary disposal facilities, and establish programs to increase the number of Native American health professionals.4 The future of Aboriginal community controlled health servicesThe first of a series of reports on expenditure on Indigenous health identified the specific areas in which spending inequities have occurred.6 As a result, major reforms and changes have been implemented. However, achieving a balance between time allocation for strategic initiatives and meeting acute clinical care needs remains a major challenge within many services. While Aboriginal medical services only represent one sector of the health system with responsibilities in Indigenous health, they tend to attract the most attention when the government is seeking to explain the relative lack of progress in health outcomes. We need to recognise that while ACCHSs are an essential component of the health system, they do not have exclusive responsibility for Indigenous health. It is time for the entire system to embrace and respond to its responsibilities for the health of Indigenous Australians. The ACCHSs are well placed to support such an integrated approach.

Cindy Shannon DSocSc, MBA · Adrian Carson · Rachel C Atkinson MBA, BSocWk

To the Editor: The Ear, Nose and Throat Department at the Royal Darwin Hospital services an area of about 550 000 km in the Northern Territory. As part of our remit involves dealing with conditions affecting the organs of speech and hearing, a proportion of our patients have communication handicaps. We have frequently encountered the use of “Hand Talk” among Indigenous patients with communication handicaps, and we feel this merits highlighting to your readership. Hand Talk is an established sign language within and between Aboriginal groups in the NT. Although various groups have different signing systems, there are enough similarities between them to enable inter-group communication. Its existence is thought to date as far back as other spoken Aboriginal languages that have now been lost. Theories about its conception include a means of overcoming language barriers between different language groups, a silent form of communication during hunting expeditions, a means of conversation for women during long periods of mourning when speech is prohibited, and a means of communication for deaf or aphonic individuals.1 While completely separate from established Western sign languages, Hand Talk is a sophisticated and intricate means of communication that allows complex interactions to take place and proficient individuals to integrate into their society.2 In the course of our service delivery in Darwin and to outlying districts, we have been struck by both the frequency with which Hand Talk is used in an impromptu manner and the proficiency users exhibit in communicating with it. The significance of this requires an appreciation of the difficulties of applying Western-type communication rehabilitation to Indigenous Australians in remote regions. For example, providing hearing aids, a basic and standard form of communication rehabilitation in urban areas of Australia, can face numerous obstacles in a remote setting. These include lack of a service provider and technical and maintenance support, poor compliance, and logistical problems (something as simple as running out of hearing aid batteries can be a major problem for those in remote areas). While no data are available on the ubiquity of Hand Talk, it clearly represents a valuable part of Aboriginal culture with an important practical function in a situation where Western models of communication rehabilitation are difficult to apply. While attempts to improve conventional communication rehabilitation should continue, these should be combined with efforts to foster Hand Talk through education and facilitating its dissemination by existing users so it does not suffer the fate of other lost Indigenous languages.3

Patrick Jassar · Garrett F Hunter

Each year up to a quarter of all young Aboriginal men have direct involvement with correctional services, and Aboriginal prisoners currently represent 22% of the total Australian prisoner population. The high rates of repeated short-term incarceration experienced by Aboriginal people in Australia have a multitude of negative health effects for Aboriginal communities and the wider society, while achieving little in terms of increased community safety. Well identified health and social priorities for Aboriginal people affected by incarceration include housing and tenancy support; mental health and wellbeing, including family violence, grief and loss support; substance misuse support; general health services, including hepatitis C management; and social inclusion, including the need for family and community integration, skills development and employment. The post-release period is a crucial time for the provision of integrated health and social services to address these priorities and to break the cycle of incarceration. To achieve significant health gains for Aboriginal people, there is a need to develop a broader collaborative approach to primary health care, incorporating social health and justice perspectives as fundamental components of health care planning. Health and human services have a critical role to play in developing community-based solutions to reduce excessive incarceration rates for Aboriginal people.

Anthea Susan Krieg BM BS, BSc, MPH

As shared responsibility agreements between Indigenous communities and the Australian Government become more prevalent, where their goal is health improvement we need to consider whether the rewards and obligatory behaviours are acceptable, whether communities have real freedom of choice, whether the arrangements can be implemented and evaluated, and whether they will improve health. The Howard Government’s New arrangements in Indigenous Affairs have seen 76 shared responsibility agreements (SRAs) signed between leaders of 64 Indigenous communities and the Australian Government.1 The first SRA publicised, in December 2004, entailed community leaders in Mulan in the East Kimberly ensuring that children were given showers daily in return for funding for a new petrol bowser and health programs. The main rationale for the agreement presented in the media was improving child health, particularly reducing the incidence of trachoma.2 The near-silence of health commentators on this issue was, thankfully, broken last year by Collard and colleagues in this Journal.3 These authors questioned the morality of the government in placing conditions on the provision of basic rights to Indigenous communities. However, behind both the government’s enthusiasm and Collard et al’s criticism lie enduring public health dilemmas. Below, I present five questions that may help readers consider these issues as they relate to the Mulan SRA in particular, and to incentives and obligations in general. But first, we need a working definition. In the context of health, let us say that “mutual obligation” means obligating people to adopt healthy behaviours in return for a reward. While the Mulan agreement incorporated a number of obligations and rewards (see Box), here I focus on the obligation of parents and children to maintain hygienic behaviours and the reward of a petrol bowser. The key questions presented here refer only to obligations placed on communities, rather than on governments. Furthermore, for the purposes of this discussion, it is assumed that community members are in a position to fulfil the obligations (for example, they have access to a functioning water supply). Is the reward acceptable?For many, this question hinges on the distinction between a right and a privilege. Is it the right of a small, isolated community to be provided with a petrol bowser by the government, or is it a privilege? Most would agree that it is unfair to offer something as a reward if it is a human or civil right, such as the provision of health care. If it is a privilege, however, it may be considered acceptable to use it as an incentive. This distinction is highlighted by “no school, no pool” programs (in which children who do not attend school may not use the community pool), which share features with mutual obligation arrangements, and also use improved child health as their rationale.4 There has been no prominent criticism of the government providing swimming pools to remote communities conditionally, perhaps because swimming pools are seen as a privilege, not a right. In making these judgements, the special status of Indigenous peoples must be taken into account. Their historical status as Australia’s first peoples, their current position of extreme social disadvantage, and their cultural distinctiveness all mean that the government has special responsibilities towards them.5 For instance, if it is shown that swimming pools hold long-term benefits for child health, it may be argued that they should be provided to remote communities as part of their right to health-promoting infrastructure. Is the obligatory behaviour acceptable?Is it acceptable to ask parents to ensure their children are clean? Some people would consider it an intrusion into the family unit, an affront to personal autonomy, or dangerously close to the paternalism of the assimilation era. Others would argue that the grave situation of child health means that we should explore any approach that can improve it, including addressing basic health behaviours such as hygiene. The issue of who is obliging the behaviour is clearly important. If it can be shown that the community itself wants to dictate the behaviour of community members, there may be less basis for concern. For instance, when community councils enact alcohol restrictions, obliging people not to drink, they are celebrated by many as effective public health interventions.6 Is it acceptable that people adopt the behaviour in order to obtain the reward?Public health science has long wrestled with the problem of changing behaviour, including whether and when education, incentives or compulsion are the best strategies.7 Economic incentives and disincentives for healthy behaviour are generally acceptable in some forms, such as taxes on tobacco and alcohol, and health insurance rebates for spending on healthy activities such as gym membership and yoga classes. The question is whether it is acceptable for people to adopt healthy behaviours in order to obtain the reward (a petrol bowser or saving money), or whether sustainable behaviour change must stem from genuine belief in the related health benefits. This question is partly one of effectiveness: some argue that once a behaviour is adopted it becomes habitual, regardless of why the behaviour was adopted, while others question this reasoning.8 But the question is also one of ethics: is the reward an inappropriate inducement, despite the “healthiness” of the obligation? This relates to the issue of autonomy I now turn to. Do communities freely choose to participate?This is the key issue for Collard and colleagues,3 and others for whom community autonomy and self-determination are central concerns. They suggest that the Mulan community was not “well placed to judge whether the benefit they will get from a petrol bowser will be worth the ‘price’ they have agreed to pay”,3 implying an element of exploitation or coercion in the government’s approach. The proponents of the agreements, however, argue they enhance community autonomy by allowing the community to deal directly with government, rather than through intermediaries in multiple bureaucracies.9 Some would consider that the substantial power difference between a small, isolated Aboriginal community and the Australian Government means that a community can never freely participate, even if community representatives truly believe they are making an autonomous choice. Others think that to dismiss the choices communities make as “false” is paternalistic.10 Can the arrangement be implemented?It is concerning that there are no formal evaluative mechanisms built into SRAs, as there are numerous questions surrounding the implementation of these agreements. How would the cleanliness of children be assessed? Would the government take the bowser away if people stopped showering their children? If one family in the community didn’t comply, would they be barred from using the bowser? These are but a few of the immediate questions that would need to be addressed in the implementation of the Mulan SRA — questions that remain unanswered. Will it improve health?The public health literature indicates that incentives and obligations that promote healthy behaviours have a role in improving health.7 The lack of attention to the implementation and evaluation of these agreements on the government’s part suggests that they, at least, are not taking the potential health benefits seriously. A more serious approach to the potential health benefits of SRAs would employ public health expertise and an evidence-based approach. For instance, face-washing programs need to be integrated with screening and treatment programs and environmental health programs to have maximum impact on trachoma rates.11 It is also difficult to judge how genuinely Indigenous communities themselves are engaging with the health-related obligations of SRAs. A pessimistic view might be that, to access much-needed resources, communities are agreeing to obligations they have no intention or ability to meet. This may have the inadvertent effect of focusing the public health gaze on individual behaviours and distracting us from necessary structural change. An optimistic view would welcome the opportunity for community leaders to voice their concerns about health and adopt novel health promotion approaches, in a similar vein to alcohol restrictions and “no school, no pool” policies. There may also be potential to use the agreements to hold the government accountable for the provision of basic infrastructure and services necessary for good health. The political reality of SRAs is complex and fraught. However, the current focus on incentives and obligations provides an opportunity to reflect on the variety of methods available for practising public health, and the factors that may affect the application of SRAs in Indigenous contexts. Draft agreement between the government and the residents of Mulan Government The federal government will contribute $172 000 for the installation of fuel bowsers at Mulan. The Government of Western Australia will undertake to “monitor and review” the adequacy of health services in an area where trachoma rates are “arguably the worst in the world”. Mulan Aboriginal Community The residents will: Ensure children shower daily and wash their faces twice a day; Ensure rubbish bins are at every house and are emptied twice weekly through the local work-for-the-dole scheme; Undertake household pest control four times a year; and Act to prevent petrol sniffing. Families and individuals will also make sure children attend school, crêche and the health clinic; and they will keep their homes clean and pay rents (to ensure the local council can afford pest control and repairs like plumbing). Source: Collard, et al. Med J Aust 2005; 182: 502.3

Emma Kowal MB BS, BA(Hons)

Objectives: To compare the injury profiles of the Indigenous population in New South Wales with that of the non-Indigenous population.Design and setting: Descriptive analysis of NSW Health data obtained from the Health Outcomes Information and Statistical Toolkit (HOIST) database. Hospitalisation data were collected for the period 1 July 1999 to 30 June 2003. Mortality data were collected for the period 1 January 1999 to 31 December 2002.Main outcome measures: Hospitalisation and death rates due to injury by age, sex, injury mechanism and Indigenous status. Rate ratios for comparison between Indigenous and non-Indigenous populations.Results: Rates of death from injury were higher for all age groups in the Indigenous population, except people older than 65 years. Indigenous people aged 25–44 years were twice as likely to be hospitalised as their non-Indigenous counterparts (rate ratio [RR], 2.09; 95% CI, 2.03–2.14), and five times as likely to be hospitalised for interpersonal violence (RR, 5.19; 95% CI, 4.98–5.40).Conclusion: The higher rates of injury-related hospitalisation and death in the Indigenous population in NSW are consistent with data reported for other parts of Australia. Of particular concern is the number of Indigenous deaths and hospitalisations due to interpersonal violence.

Kathleen F Clapham PhD · Mark R Stevenson PhD · Sing Kai Lo PhD

Graham Simpson,* Paul Clark,† Trevor Knight‡ * Director of Thoracic Medicine and Regional TB Control Unit, † Resident Medical Officer, ‡ Nurse Unit Manager, Department of Thoracic Medicine, Cairns Base Hospital, Cairns, QLD 4870. fgsimpsonATiig.com.au To the Editor: Australia has a low incidence of tuberculosis (TB), which has remained constant for over a decade.1 However, the incidence is not uniform across the population; immigrants and Indigenous Australians have higher rates. An audit of all cases of TB in Far North Queensland over 5 years showed an incidence of 35.9/100 000 per annum in Indigenous Australians, and poor outcomes in this group.2 This finding led to a number of policy changes, including an increase in directly observed therapy (DOT), made possible by increased use of Aboriginal health care workers in remote communities, and more aggressive and prolonged treatment of relapses. A follow-up audit was undertaken to assess the effect of these changes. The results are shown in the Box for both time periods. New cases of TB in Indigenous Australians were significantly reduced (P < 0.0001 by Fisher’s exact test), and DOT had increased significantly (P < 0.0001). The number of deaths from TB had declined, as had relapses, but these falls were not statistically significant. There were no deaths among Indigenous Australians during the second 5-year period. Of the people who died in this period, three were elderly men suspected of having cancer, and one was a patient from Papua New Guinea (PNG) who had HIV co-infection with TB. The most striking finding was the dramatic increase in cases in people from PNG (P < 0.0001). The outer Australian islands in the Torres Strait are only 3 kilometres from the PNG coast, and there is free movement of people across the border under a treaty arrangement. Although there are no precise figures,3 it is clear that there are epidemics of both TB and HIV in PNG, and that these have extended to rural areas. Specialist outreach clinics with x-ray facilities have been established on the outer islands, but numbers have continued to rise. In 2005, of 38 cases of TB in Far North Queensland, 26 were from the Torres Strait including seven cases of multidrug resistant TB. This represents a significant public health threat and highlights the importance of local audits of TB control, as state and national data may not be adequate to identify emerging local problems. Findings of two 5-year audits on tuberculosis in Far North Queensland Findings 1993–1997 1998–2002 Total cases 87 92 Indigenous Australians 50 22 Non-Indigenous 30 26 Papua New Guineans 7 44 Pulmonary tuberculosis 54 57 Sputum smear positive 67% 47%* Directly observed therapy 18 (21%) 67 (73%) Death from tuberculosis 10 4 Deaths in Indigenous Australians 7 0 Total early relapses 7 2 Indigenous Australians 7 0 Drug resistance 6 7 Multidrug resistant tuberculosis 1† 3‡ HIV co-infection 0 2‡ * Queensland average, 48%. † Patient from the Philippines. ‡ All in Papua New Guineans.

Graham Simpson · Paul Clark · Trevor Knight

Elizabeth May Pepper,* Dominique A Cadilhac,† Dora C Pearce,‡ James Burrow,§ Tarun S Weeramanthri¶ * Neurology Registrar, John Hunter Hospital, Newcastle, NSW. † Manager, Public Health Division; ‡ Biostatistician; National Stroke Research Institute, Melbourne, VIC. § Neurologist; ¶ Physician, Royal Darwin Hospital, NT. hornblowerATinternode.on.net To the Editor: Although the age-standardised stroke mortality rates among Australia’s Indigenous people is more than twice that of the non-Indigenous population,1 the medical literature contains only one audit of Indigenous stroke patients in Perth metropolitan hospitals.2 No review of hospital care has been reported. Royal Darwin Hospital (RDH) is the referral centre for Australia’s “Top End”, where 8.7% of Indigenous Australians reside; 40% of RDH inpatients are Indigenous. In 2002, while planning for the RDH stroke service, we audited stroke admissions from the previous year. Among 121 eligible patients admitted between 1 July 2001 and 31 June 2002 with International classification of diseases, 10th revision, Australian modification (ICD-10-AM) codes 160–164 (haemorrhages [subarachnoid, intracerebral, other non-traumatic intracranial] and cerebral infarction), records for 116 (96%) were available, but six patients were excluded because of incorrect coding. Box 1 outlines patient characteristics, while Box 2 examines risk factors and medication use for ischaemic stroke (because haemorrhages were few). Despite the observed differences between subgroups, there were no significant differences in mortality (4/36 for Indigenous v 7/42 for non-Indigenous; P = 0.204) or stroke severity at admission or discharge. Box 3 highlights differences in risk factors between Indigenous males and females. Retrospective data, particularly from a sample identified by medical record coding, should be interpreted with caution. In addition, the potential for random error due to small numbers, and the referral bias inherent in tertiary hospital admissions, mean our results may not truly represent the “Top End” Indigenous population. However, our data corroborate findings that Indigenous Australians suffer premature cerebrovascular disease, and have higher rates of vascular risk factors than other Australians,1 with some risk factor differences between males and females. Further, recent evidence suggests differences in standards of stroke care in regional (Queensland) hospitals.3 We found disparity in hospital care of Indigenous patients, and this requires further detailed investigation. A prospective, community-based study is urgently needed. 1 Baseline characteristics for 110 patients admitted to Royal Darwin Hospital with subarachnoid, intracerebral, and other non-traumatic intracranial haemorrhages and cerebral infarction in 2001–02 Baseline characteristics Indigenous Other P Number of patients 45 65 Female sex 22 (49%) 19 (29%) 0.018 Mean age (years) 54 61 0.005 Rural dwelling 41 (91%) 22 (34%) < 0.001 Ischaemic stroke 36 (80%) 42 (65%) 0.081 2 Risk factors and medication use for the 78 patients who had ischaemic stroke Risk factors and medications Indigenous Other P All patients 36 42 Smoking 23 (64%) 11 (26%) 0.001 Diabetes mellitus 16 (44%) 10 (24%) 0.030 Rheumatic heart disease 8 (22%) 1 (2%) < 0.001 Males 19 (53%) 30 (71%) 0.089 Smoking 14 (74%) 12 (40%) 0.017 Diabetes mellitus 10 (53%) 7 (23%) 0.030 Females 17 (47%) 12 (29%) 0.089 Smoking 9 (53%) 0 0.002 Rheumatic heart disease 6 (35%) 0 0.026 Antiplatelet therapy Before admission 11 (31%) 19 (45%) 0.078 Admission 20 (56%) 38 (91%) < 0.001 Discharge 18/32 (56%) 29/35 (83%) 0.013 Anticoagulant therapy Before admission 4 (11%) 1 (2%) < 0.001 Discharge 4/32 (13%) 6/35 (17%) 0.235 3 Risk factor differences between Indigenous males and females who had ischaemic stroke Males Females P Number of patients 19 17 Hypertension 16 (84%) 6 (35%) 0.003 Non cerebral vascular disease 6 (32%) 1 (6%) < 0.001 Excessive alcohol intake 7 (37%) 1 (6%) < 0.001

Elizabeth May Pepper · Dominique A Cadilhac · Dora C Pearce · James Burrow · Tarun S Weeramanthri

Objective: To evaluate the efficacy of supplementation with zinc and vitamin A in Indigenous children hospitalised with acute lower respiratory infection (ALRI).Design: Randomised controlled, 2-by-2 factorial trial of supplementation with zinc and vitamin A.Setting and participants: 187 Indigenous children aged < 11 years hospitalised with 215 ALRI episodes at Alice Springs Hospital (April 2001 to July 2002).Interventions: Vitamin A was administered on Days 1 and 5 of admission at a dose of 50 000 IU (infants under 12 months), or 100 000 IU; and zinc sulfate was administered daily for 5 days at a daily dose of 20 mg (infants under 12 months) or 40 mg.Main outcome measure: Time to clinical recovery from fever and tachypnoea, duration of hospitalisation, and readmission for ALRI within 120 days.Results: There was no clinical benefit of supplementation with vitamin A, zinc or the two combined, with no significant difference between zinc and no-zinc, vitamin A and no-vitamin A or zinc + vitamin A and placebo groups in time to resolution of fever or tachypnoea, or duration of hospitalisation. Instead, we found increased morbidity; children given zinc had increased risk of readmission for ALRI within 120 days (relative risk, 2.4; 95% CI, 1.003–6.1).Conclusion: This study does not support the use of vitamin A or zinc supplementation in the management of ALRI requiring hospitalisation in Indigenous children living in remote areas. Even in populations with high rates of ALRI and poor living conditions, vitamin A and zinc therapy may not be useful. The effect of supplementation may depend on the prevalence of deficiency of these micronutrients in the population.

Anne B Chang MPHTM, FRACP, PhD · Paul J Torzillo FRACP, FFICM · Peter M Stewart FRCPA · Naomi C Boyce BNurs · Andrew V White FRACP · Gavin R Wheaton FRACP · David M Purdie BSc(Hons), PhD · John Wakerman MB BS, MPH · Patricia C Valery MD, MPH, PhD

Alan R Clough,* Bart J Currie,† Maymuna W Yunupingu,‡ Katherine M Conigrave§ * Postdoctoral Fellow, Institute of Advanced Studies, Menzies School of Health Research, Charles Darwin University, PO Box 1479, Nhulunbuy, NT 0881; † Professor, and Head, Tropical and Emerging Infectious Diseases Division, Menzies School of Health Research, Charles Darwin University, and Northern Territory Clinical School, Flinders University, Royal Darwin Hospital, Darwin, NT; ‡ Senior Aboriginal Health Worker, NT Department of Health and Community Services, Yirrkala, NT; § Specialist in Drug Health Services, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW. Alan. CloughATbigpond.com To the Editor: We are concerned that the Northern Territory’s regulations on kava have not succeeded in controlling its availability in Arnhem Land (the north-eastern region of the NT). Under the Kava Management Act 1998 (NT), one wholesaler is licensed to supply kava (Piper methysticum Forst. f.) to four licensed retailers in Arnhem Land Aboriginal communities.1 “Kava Management Plans” in “Kava Licence Areas” permit retailers to supply 600–800 g per week of kava powder to each purchaser1 — more than double the known harmful consumption levels (240–440 g per week).2 Legal kava supplied will reach 26 tonnes in 2005 (worth $3.6 million), with a persistent illegal trade adding 8 tonnes, worth perhaps $2 million (Box). Two proposed additional retail licences1 will increase kava’s availability. Kava’s social and economic effects remain an ongoing concern. The region’s community-controlled health service attributes to kava abuse an accelerated decline in participation in traditional ceremonies and mortuary rites in some localities. Kava is the psychoactive substance with greatest impact on the financial resources of communities and individuals in Arnhem Land.2 Kava’s health effects include seizures and extreme weight loss in heavy users (up to 20% of body mass), similar to that seen in anorexia nervosa.4 Extreme weight loss, evident during the 1980s, has re-emerged in the region’s kava users (M W Yunupingu, unpublished observations). Raised total and low-density lipoprotein (LDL) cholesterol levels4 add to unresolved concerns that heavy kava use may be a risk factor for cardiovascular disease and sudden cardiac deaths. Potential immunosuppressive effects are suggested by relative lymphocytopenia in heavy kava users4 and by increased risk of melioidosis.5 Raised levels of liver enzymes (alkaline phosphatase and γ-glutamyltransferase), which reverse after ceasing moderate kava use, should be monitored because of fatal hepatotoxicity documented in users of manufactured kava products available as natural therapies.6 Given the scarcity of substance misuse treatment services in the region, with no effective treatments for kava misuse, controlling supply is the only practical measure to reduce kava-related harms. Tighter controls on kava supply are urgently required while licensees implement promised demand-reduction and harm-minimisation strategies.1 We recommend that: no further retail licences be granted until kava supply is reduced; retail licensees supply no more than 440 g per week to individual kava consumers; quantities permitted to be imported by the wholesaler and supplied to retailers be limited; kava selling prices be reviewed in the light of trade-offs between higher prices to reduce demand and minimal financial drains on communities; rigorous enforcement be continued to eliminate illegal kava dealing; and the Kava Management Act be reviewed to facilitate these changes. History of kava use and retail value ($ million) on the legal and black markets in Arnhem Land, Northern Territory, since 1982, extrapolated to the end of 2005* * Data on kava supplied were obtained from d'Abbs (for 1982–1993);3 were estimated from population surveys of kava use (for 1994–1997); were estimated from kava seized by Police and Licensing Inspectors (for illegal use, 1998–2005) (seizures were estimated to account for 14% of the illegal kava supplied, based on correlation with population surveys in 1999 and 2000); and were based on the licensed wholesaler’s monthly figures, extrapolated to the end of 2005 (for legal use from May 2002). Retail value was calculated from data on kava supplied and regulated values of $100 per kg (1990–1993), $140 per kg (2002–2004) and $150 per kg (2005), or a black market value of $250 per kg.2 † Approval required from Minister for communities to supply kava. pa = per annum.

Alan R Clough · Bart J Currie · Maymuna W Yunupingu · Katherine M Conigrave

CorrectionRe: “Long-term trends in cancer mortality for Indigenous Australians in the Northern Territory”, by John R Condon, Tony Barnes, Joan Cunningham and Bruce K Armstrong, in the 17 May 2004 issue of the Journal (Med J Aust 2004; 180: 504-507). Box 1 on page 505 of this article inadvertently included some incorrect data. The corrected table is shown with the changes in bold text. The html and pdf versions of this article were corrected on 1 December 2005. In summary: for oesophageal cancer, the corrected mortality rate ratios (NT Indigenous to total Australian) are higher than the published results in all age categories; for stomach cancer, the corrected rate ratio for the 0–64 age group is lower than the published figure, and the all-ages result is now reported because the difference between the younger and older age groups is no longer statistically significant (P = 0.06); for cancer of the liver and gallbladder, the corrected rate ratios are lower in the 0–64 years and all-ages groups; and there are also very slight changes for breast and lung cancers. These changes do not alter the inferences that might reasonably be drawn from the results in the table, or the overall findings of the study and their interpretation. Cancer mortality rate ratios* (NT Indigenous population compared with the total Australian population), by age group, 1991–2000 Site/type of cancer 0–64 years 65 years and over All ages† Interaction P value† Oropharynx 8.0 (5.5, 11.6) 2.0 (0.8, 4.8) — < 0.01 Oesophagus 2.9 (1.5, 5.6) 1.2 (0.5, 2.9) 1.9 (1.1, 3.2) 0.11 Stomach 1.4 (0.6, 3.0) 0.2 (0.0, 1.2) 0.7 (0.3, 1.4) 0.06 Colon and rectum 0.9 (0.5, 1.4) 0.2 (0.1, 0.6) — 0.01 Liver and gallbladder 5.5 (3.6, 8.6) 5.8 (3.9, 8.6) 5.7 (4.2, 7.6) 0.88 Pancreas 4.1 (2.7, 6.3) 1.1 (0.5, 2.2) — < 0.001 Lung 3.6 (2.9, 4.5) 1.4 (1.0, 1.9) — < 0.001 Melanoma 0.0 0.0 0.0 na Breast 0.8 (0.5, 1.3) 0.9 (0.4, 1.8) 0.8 (0.6, 1.3) 0.86 Uterus‡ 3.4 (1.1, 10.7) 2.5 (0.8, 7.6) 2.9 (1.3, 6.4) 0.68 Cervix 8.0 (5.2, 12.4) 10.1 (5.4, 19.1) 8.6 (6.0, 12.3) 0.56 Ovary 1.0 (0.4, 2.6) 1.3 (0.5, 3.5) 1.1 (0.6, 2.2) 0.67 Prostate 0.9 (0.2, 3.6) 0.3 (0.1, 0.8) 0.4 (0.2, 0.8) 0.23 Bladder 1.5 (0.4, 6.1) 0.5 (0.1, 1.9) 0.7 (0.3, 1.9) 0.24 Kidney 0.3 (0.0, 2.2) 0.0 0.1 (0.0, 1.0) 1.00 Thyroid 12.9 (4.8, 34.7) 6.1 (1.5, 24.7) 9.4 (4.2, 21.1) 0.40 Unknown primary 3.2 (2.1, 4.7) 1.7 (1.0, 2.6) — 0.04 Non-Hodgkin’s lymphoma 1.1 (0.5, 2.2) 0.7 (0.2, 1.7) 0.9 (0.5, 1.6) 0.40 Leukaemia 1.5 (0.9, 2.5) 0.8 (0.3, 2.0) 1.2 (0.8, 1.9) 0.25 * Mortality rate ratio estimated by negative binomial regression. † Mortality rate ratios are reported separately for age groups 0–64 and 65 years and over; the rate ratio for all ages combined is reported only where the P value of an interaction term testing for difference in mortality rate between younger and older age groups was > 0.05. ‡ Not including cervix. na = not applicable because rate ratio was zero (no NT Indigenous deaths from this cancer in 1991–2000).

John R Condon MPH, FAFPHM PhD · Joan Cunningham ScD · Tony Barnes MSc · Bruce K Armstrong DPhil

Binan Goonj. Bridging cultures in Aboriginal health. A K Eckermann, T Dowd, E Chong, et al. Sydney Churchill Livingstone, 2005 (xvi + 216 pp). ISBN: 0729537714 I clearly remember what a strong impression the first edition of Binan Goonj. Bridging cultures in Aboriginal health made on me at the outset of my career in Indigenous health research. This second edition retains much of the balanced and erudite style of the feted first edition. With Binan Goonj meaning “hearing but not listening”, cross-cultural communication is the raison d’être of this book. The text begins with an excellent introduction to the historical and sociopolitical context of Aboriginal health (something notably absent from many other texts in this field). A conversational style blends with challenging questions, activities and case studies to make the book an ideal teaching aid. Poignant narratives of continuing Indigenous disadvantage and marginalisation are accessibly combined with sophisticated social, psychological and anthropological concepts; and an emphasis on cultural adaptability/vitality and Indigenous diversity transcends both anachronistic myths of Aboriginality and the “deficit model” that continues to trouble public health. The remedies presented in this book focus on comprehensive primary health care, community participation, holism, trust, cultural safety and empowerment. Although recognising the social determinants of Indigenous health, the book would be better subtitled Bridging cultures in Aboriginal healthcare, as it is primarily aimed at non-Indigenous health care providers rather than professionals in other sectors that have an enormous influence on Indigenous health. The text is also blemished by a smattering of avoidable inaccuracies and careless assertions that may mislead the unfamiliar, and irritate the advanced, reader. These include a definition of scientific racism that encompasses any scientific research undertaken about Indigenous people (p. 9), and the erroneous claim that Aboriginal life expectancy has not improved for generations (p. 65). Overall, this book eschews much of the tired rhetoric of the Aboriginal health arena for an unflinching account of the facts, fallacies and future directions of health for Indigenous Australians. Yin C ParadiesPhD Student, Menzies School of Health Research, NT and University of Melbourne, VIC

Yin C Paradies

With the demise of the Aboriginal and Torres Strait Islander Commission in 2004 after a long and painful 8-year illness, a new council to represent the views of Indigenous people, the National Indigenous Council, has been chosen for us. One of the first viewpoints expressed by one of the new council members concerned the “Sorry” debate.1 The council member stated that an apology for past injustice was important, “but does not address domestic violence in our homes”, and went on to say that the need to address poverty, poor health and lack of education were a higher priority than statements of regret. In my view, this comment was a disappointment, not only because of the leverage this kind of statement gives to the “anti-bleeding heart” brigade, but also because a true apology — and, more importantly, the actions that go with it — would address exactly these conditions in our communities. Genuine measures would go some way towards making holistic health gains and dealing with health inequities experienced by Aboriginal and Torres Strait Islander people. To be truly effective, any actions taken should be based on the existing framework of the recommendations of the Human Rights and Equal Opportunity Commission’s report, Bringing them home.2 A little background: the Bringing them home inquiry traced the history of the forcible removal of Aboriginal and Torres Strait Islander children from their families from the earliest days of colonisation to contemporary removals that took place in the 1990s. In New South Wales, the Aborigines Protection Act 1909 allowed the Aboriginal Protection Board (APB) to “assume full custody and control of the child of any Aborigine”. Intimidation and influence hadn’t been effective in getting families to hand their kids over, so the law was brought in. The justifications for removal included claims that children would receive a better education or that it would help them gain good employment (the reality was that education was often discouraged and adolescents were sent off to do menial domestic and farm or labouring jobs). However, what isn’t so well known is the reasoning at the time, which was simple, and may explain why many who were connected personally and professionally with the issue called the policies and practices “genocide”. The architects of the Aborigines Protection Act had an aim of making the Aboriginal race cease to be a problem to settlers and townspeople: In the course of a few years there will be no need for the camps and stations; the old people will have passed away, and their progeny will be absorbed in the industrial classes of the country.3 An amendment to the Act came into force when the APB desired the power to remove children without having to go through a court and without having to establish neglect (Aborigines Protection Amending Act 1915). Reasons for removal found on files in the NSW state archives include “to send to service”, “at risk of immorality”, “to get her away from surroundings of Aboriginal station/removal from idle reserve life” and “being Aboriginal”.2 Mostly, children were sent to institutions such as the Bomaderry Childrens Home, Cootamundra Girls Home or Kinchela Boys Home. The experiences of these children were often brutal, with assimilation into white society the main aim. Experiences such as that recounted below are detailed in the Bringing them home report. Most of us girls were thinking white in the head but were feeling black inside. We weren’t black or white. We were a very lonely, lost and sad displaced group of people . . . We didn’t know anything about our culture. We were completely brainwashed to think only like a white person. When they went to mix in white society, they found they were not accepted [because] they were Aboriginal. When they went and mixed with Aborigines, some found they couldn’t identify with them either, because they had too much white ways in them. So that they were neither black nor white. They were simply a lost generation of children. I know. I was one of them.”2 The APB evolved into the Aboriginal Welfare Board, and the amended Act became the Child Welfare Act 1939 (NSW), which had one system of regulation for Aboriginal children and another for non-Aboriginal children. While the Child Welfare Act returned removal matters to the court system, most parents were excluded from procedures because of physical isolation from the towns where children’s courts were located and a lack of money to pay for legal representation. Added to the legislation at this stage were the terms “neglected” and “uncontrollable”, with all the race and class subjectivity that goes along with interpreting the definitions. The Aboriginal Welfare Board finally ceased to exist in NSW in 1969, but not before the institutionalisation of removed children had been slowly phased out over the years in favour of adoption and fostering into non-Aboriginal family homes. By this time, the fine art of coercion by Welfare staff had been honed — much more “civilised” than driving in and rounding up kids with a truck while their parents tried to hide them in flour bags. This trend, reinforced by adoption laws, gave children little chance of finding out who they were and where they were from or even that they were Aboriginal, unless they were fortunate enough to be told by caring adoptive families. Even today, Aboriginal children are placed in out-of-home care at rates up to 13 times greater than those for non-Aboriginal children.4 Contrary to recent claims made in public discourse and media reports, Aboriginal children, unlike other children, are removed for neglect more often than they are for abuse.4 The well publicised high rates of incarceration also bear witness to the continued institutionalisation of Aboriginal and Torres Strait Islander people, well after the shift away from assimilationist policies. If the seeds of future ill health are indeed present before birth,5 what could be the cumulative consequences of several generations’ worth of control by the government? I would suggest you need look only as far as your Aboriginal patients who present for treatment. The likelihood is that these policies, or their equivalents in other states, have affected them in some way. The Bringing them home inquiry estimated there would barely have been a family untouched by these practices. If your patient was not taken, he or she may have parents, siblings, aunts, uncles, cousins, grandparents or great grandparents who were taken. The patient’s own children may have been removed or temporarily separated. Or the patient’s family may have lived in fear after witnessing friends’ children being taken and grown up denying their own Aboriginality to avoid the same fate. How could these removal policies have had such an effect on such a great number of individuals across Australia, and could that explain the poor health, educational and socioeconomic status and the social problems of Indigenous people so visible today? The effects of the policies are numerous and include: The grief of parents and family for the child or children removed; The interruption to family and community structure when children have been taken; The loss of identity, of rightful place in family, of ties with family, community and culture of the children removed; The anxiety of the search for family and identity; The turmoil, for all, of trying to fit each other back in each other’s lives; and The pain and anger when this doesn’t happen as it was hoped, or if it can’t happen at all. Each of these effects manifests itself in various ways, leaving its impact on relationships, physical and mental health, family structure, parenting skills and social and criminal behaviour. Perhaps here it’s best to let one of the many hundreds of people who submitted evidence to the Bringing them home report tell you her story in her own words: After the kids had gone to the home Mum and Dad hit the grog hard as they had done everything in their power and in their hearts to keep us away from . . . the Welfare. But they sniffed us out of the bush like dogs. My parents couldn’t handle the trauma of not having the closest warmth loving caring family we were. They separated. My Mum went one way; my Dad went his way . . . Eventually I got married when I was 21 years old. I thought maybe I could get my brothers and sisters and give them the home that the Welfare said my parents had to do . . . After about 14 years my [eldest] brother came to live with us. One sister found us through the Salvation Army about 16 years later. Then my brother [the baby] who died last year, who was caught up in the System was like a lost street kid and was bashed by the police in Melbourne a couple of years ago, ended up with a tumour on the brain and was never the same again. My second sister who I or my family didn’t see for 27 years. What could anyone do now to make up for those 27 years of not having their sister a part of their life? A terrible big hole in my heart that will never be filled. We all are in contact with each other now and we try to make up for all those lost years. But something’s missing. Could you put yourself in the situation that we were put through?2 The view that an apology for past injustice is important “but does not address domestic violence in our homes” is mistaken. The impact of removal policies goes on down the line and will continue to do so for as long as child welfare policies are directed at removal rather than prevention, with Indigenous families bearing the brunt. Professor Beverly Raphael spoke to the Inquiry of the reaction people had to the kind of trauma described above. She described it as: . . . a high level of arousal . . . that heightened arousal can stay on a heightened level with physiological responsiveness for the rest of one’s life . . . And one reason they take alcohol and other substances is often to dampen this down and they don’t know its cause.2 The Bringing them home report also discussed research into the effects of adoption on relinquishing parents and the impact of bereavement on mortality and morbidity. The researchers stated that there were a number of matters affecting recovery: Perceived social support facilitates adjustment; The opportunity for free expression of feelings facilitates adjustment; The ability to find meaning in the outcome facilitates adjustment; and The presence of other life stressors impedes adjustment.6 If this is a framework upon which to base the healing of those affected, it surely can be seen how genuine apology and practical support (or lack thereof) for survivors could have an impact on health and wellbeing. When families have been torn apart and parenting and familial roles undermined, damage is done and lives continue to be interrupted. Aboriginal people can grow up with emotional scars and cultural identity issues, leading to deep and highly visible “practical” problems such as family violence, social and emotional wellbeing issues, and substance and alcohol abuse problems. Many people affected have shown great resilience to overcome such problems and emerge with their families safe and intact, but many more have not and are still trying. There are services to help, such as Link-Up7 and the many “Bringing Them Home” counsellors, Aboriginal social and emotional wellbeing workers, Aboriginal health workers and many other concerned professionals. These positions, their integrity, and the existence of these organisations must be assured. * While state governments around the country made apologies around the time of the release of the report, the federal government has failed to do so. Furthermore, if the cycle of trauma that the “Stolen Generations” has created is to be halted, there are numerous recommendations from the Bringing them home report that must be put into action. The proposals range from acknowledgement and apology* to guarantees against repetition, implementation in federal legislation of the Genocide Convention,8 restitution and rehabilitation (including medical and psychological care, legal and social services), to parenting skills training and health professional training regarding the effects of removal. Unfortunately, until the underlying problems are appropriately addressed, existing services guaranteed and the required new services implemented, the cycle will continue and we’ll struggle to deal with the important issues such as poverty, poor health and lack of education that this new National Indigenous Council member rightly spoke of.

Wendy A Hermeston BA(Psych)

This state-wide Aboriginal community child health survey, the first of its kind in Australia, describes physical and mental health and their antecedents in Western Australian Aboriginal children and young people. Aboriginal young people had significantly more physical and mental health problems and were more likely to engage in lifestyle risk factors than non-Aboriginal young people. Aboriginal young people tend to be caught up in a cycle of disadvantage that includes family and community factors as well as recent history, facilitating their making less optimal life choices, thereby perpetuating the cycle. A coordinated approach will be required to break this cycle, in which appropriately and sympathetically provided medical attention is necessary but not sufficient.

Eve M Blair PhD · Stephen R Zubrick PhD · Adele H Cox DipAppSci

Objective: To evaluate the effect of appointment reminders sent as short message service (SMS) text messages to patients’ mobile telephones on attendance at outpatient clinics.Design: Cohort study with historical control.Setting: Royal Children’s Hospital, Melbourne, Victoria.Patients: Patients who gave a mobile telephone contact number and were scheduled to attend any of five outpatient clinics (dermatology, gastroenterology, general medicine, paediatric dentistry and plastic surgery) in September (trial group) or August (control group), 2004.Main outcome measures: Failure to attend (FTA) rate compared between the group sent a reminder and those who were not.Results: 2151 patients were scheduled to attend a clinic in September; 1382 of these (64.2%) gave a mobile telephone contact number and were sent an SMS reminder (trial group). Corresponding numbers in the control group were 2276 scheduled to attend and 1482 (65.1%) who gave a mobile telephone number. The FTA rate for individual clinics was 12%–16% for the trial group, and 19%–39% for the control group. Overall FTA rate was significantly lower in the trial group than in the control group (14.2% v 23.4%; P < 0.001).Conclusions: The observed reduction in failure to attend rate was in line with that found using traditional reminder methods. The ease with which large numbers of messages can be customised and sent by SMS text messaging, along with its availability and comparatively low cost, suggest it may be a suitable means of improving patient attendance.

Sean R Downer MBA · John G Meara FRACS · Annette C Da Costa BA, GradDip(Psych), GradCert(AppSc)

In late 1995, a treatment program for renal disease and hypertension was introduced into a remote Aboriginal community. Over the next 3.5 years, mean blood pressure levels were markedly reduced, renal function stabilised, and rates of both renal and non-renal deaths declined significantly. In 1999–2000, responsibility for the program was passed to the community’s local Health Board, which subsequently faced deficiencies in clinical information systems and a shortfall in funding. After the handover, the intensity of the program declined, and compliance with medicines fell. Blood pressures in the treatment cohort increased, renal function deteriorated, and rates of deaths from natural causes subsequently rose. From 2002 to mid-2003, the adjusted risks of renal and non-renal deaths in the treatment cohort were three and 9.5 times the respective risks of people during the first 18 months of treatment in the systematic phase of the program. Sustained vigorous activity, both in treatment of people already identified and in community screening for treatment eligibility, is required to maintain good results in any chronic disease program. Adequate resources and well supported staff are essential, and constant evaluation is needed to follow outcomes and modify strategies as necessary.

Wendy E Hoy FRACP · Srinivas N Kondalsamy-Chennakesavan MB BS, MPH · Jennifer L Nicol BSc(Hons), MSc(Stats)

As Indigenous Australians, our health lags behind that of indigenous groups in other settler colonial nations such as the United States, Canada and New Zealand.1 Similarly, we are far behind these nations in relation to Indigenous participation in the health workforce and the professions generally. A compelling illustration of this is the fact that the first indigenous doctors in North America and New Zealand graduated in 1889 and 1899, respectively, while the first Indigenous doctor in Australia graduated almost a century later, in 1984.2,3 It is undeniable that our poor health and our low participation in the health workforce are related. Increasing recognition of this has led to a situation in which there are now over 80 qualified Indigenous doctors and almost 100 Indigenous medical students in Australia.4 This achievement has only been possible because we live in the era of “self-determination” that was born, as was I, during the 1970s. I am a multiracial Australian, with Aboriginal, Anglo and Asian ancestry. Because my grandmother (being my only Indigenous ancestor) was a member of the “stolen generations”, and because I am fair-skinned, I started life with an ambivalent Indigenous identity which has been profoundly shaped by the policies of affirmative action (or positive discrimination) that epitomise the era of self-determination. My first experiences with affirmative action occurred in high school, when I was showcased as a role model for other Indigenous students. I went on to gain a degree in science and start a career in health research through an Indigenous cadetship. Affirmative action also provided me with the financial means to complete a Master of Medical Statistics — the first Indigenous Australian to do so — and with preferential access to scholarships, which allowed me to complete a Master of Public Health and to undertake a PhD. In return for this assistance, I have spoken at Indigenous youth summits and school career days, tutored, taught, and donated prize money to Indigenous tertiary students, and conducted research and teaching in Indigenous health on topics of importance to Indigenous people (such as the health effects of racism).5 In addition, I have brought an “Indigenous” perspective to a range of committees, forums, round tables, community groups, conferences, colleagues and students. These experiences are in keeping with the goals of affirmative action, which are to create equality of opportunity and outcome for Indigenous Australians and, for the benefit of all Australians, to promote diversity through equitable representation of Indigenous people in society. Affirmative action is achieved, in practice, by assisting individual Indigenous people to become more “successful”. In addition, there is often an implicit assumption that the Indigenous recipients of affirmative action will themselves strive to reduce social inequities, promote opportunities for and enhance representation of Indigenous people, and act as role models. While medicine has made some progress towards these goals, and the role played by Aboriginal and Torres Strait Islander health workers has been crucial, other areas of health have not fared as well. There has been little government support for increasing the number of Indigenous nurses or allied health professionals,2 with the notable exception of the recent Puggy Hunter Memorial Scholarships.6 Health research is a particularly lonely field. I knew of no other Indigenous person studying at my institution in the same degree program as me. Also, milestones such as the first Indigenous doctor and the first Indigenous clinical psychologist to gain a PhD have only been achieved in the 21st century. Clearly, there is still considerable scope for applying affirmative action in health and other sectors in which Indigenous people continue to suffer from disadvantage. However, I believe there are complexities inherent in both the aims and practice of affirmative action that need to be considered in order to improve social outcomes for Indigenous Australians and allow our diversity to contribute to Australia’s future. In this essay, I will share with you what I have learnt about the benefits and pitfalls of affirmative action as an Indigenous health professional during the past decade. The most obvious difficulty faced by Indigenous people who are beneficiaries of affirmative action is the self-doubt stemming from accusations that we do not merit such support. Unfortunately, it appears that many Australians still think Indigenous people get “too many benefits”. In one survey, almost a third of participants believed that car loans are paid for us by the government, and almost two-thirds thought that we receive more social security benefits than non-Indigenous people.7 In another survey, more than half of respondents believed Indigenous people were “treated over generously by the government”.8 The hostility to affirmative action programs, which is compounded by these misconceptions, can only be reduced through education that explains the benefits of diversity and the need to remedy historical injustice.9 There is also an urgent and profound need to tackle systemic racism in Australia, which, in its most extreme form, led to the death of Private Damien Palmer. After entering the army through an affirmative action policy, he committed suicide following racist taunts and intense ridicule from fellow soldiers and instructors.10 Systemic racism is something that white Australians, as those who benefit most from the system of racial oppression, are in the best position to combat. Indigenous people, in contrast, face anguish and rapid “burnout” when leading the fight against this insidious form of racism. The intense doubt of our self-worth which some Indigenous people experience as a result of affirmative action can be reduced by ensuring that Indigenous people are only placed in positions and given training or learning opportunities for which they have the appropriate commitment, skills, abilities and qualifications. If we cannot do a job or don’t have the capacity to benefit from a program, this is no doubt due to a legacy of oppression and colonisation. However, this situation is not remedied by the tokenism being engaged in by far too many organisations around Australia. Not only are those caught up in tokenism unable to effectively advance the goals of affirmative action, but they are also being set up to fail or, worse, set up as ever more prominent “tokens”, whose increasing visibility as such severely hampers ongoing efforts to redress Indigenous disadvantage. It is clear that affirmative action, no matter which segment of the Indigenous population is targeted, is most helpful to those who are most advantaged to begin with.11 It is easiest, and perhaps most appropriate, for those who have the most capacity to benefit to take up whatever opportunities are on offer. However, there is still a tendency for both Indigenous and non-Indigenous people to assume that being Indigenous is synonymous with a certain “marginality or victimage”.12,13 This misconception can leave Indigenous recipients of affirmative action not only doubting their self-worth but also being seen as threatening “tall poppies”2 and having their Indigenous identity questioned. I have certainly been accused of taking positions that should have been given to “real blacks” who weren’t as acculturated to white society as me and/or who had darker skin. These issues need to be brought into the open, so that Indigenous people who are beneficiaries of affirmative action can share these difficult experiences and learn from each other about effective coping strategies. In implementing affirmative action policies, we need to stop simply seeing “Indigenous people” as a single entity and instead see individuals with multiple personal and professional identities, including Indigeneity. We need to believe in and respect Indigenous people as individuals who have their own goals, principles, flaws and foibles and who may or may not be interested in, capable of, or suitable for a specific affirmative action policy or program. Despite what is often assumed, some Indigenous people — just like some non-Indigenous people — are not effective role models or interested in working towards emancipatory goals. Therefore, it is vital to consider, in every case, whether, and to what degree, affirmative action is aimed at helping an individual become more successful, at increasing diversity, or at aiding recipients who will then contribute to the goals of affirmative action themselves. These questions need to be addressed by all Australians and will require us to grapple with the historical baggage that accompanies the stereotyped Indigenous identity we have inherited as a nation.14 All of us need to truly come to terms with the diversity of Indigenous people in Australia, rather than just paying lip service to this notion. To do this, non-Indigenous Australians must overcome their reluctance to engage in debate about Indigenous affairs,15 and Indigenous Australians must stop acting as if dissenting views are nothing more than simplistic attacks on Indigenous people.2 If there is one thing that most people agree on, it is that there is no simple solution to the complex problems in Indigenous health.2 In relation to our history as a nation, the struggle to improve the lives of Indigenous people in Australia has only just begun and has a long way to go before equity is achieved. In the field of Indigenous health research, in which I work (and, I suggest, in many other fields), we require a greater clarity of purpose and increased patience in relation to affirmative action if we are to avoid jeopardising our efforts at improving the plight of Indigenous people. Not all health research can involve Indigenous researchers, because those with sufficient training and experience are few and far between. We are not well served by setting up Indigenous people as “researchers” when they are not, or by prioritising affirmative action to such an extent that the very research we do is compromised. Let us hope that the spectacular rise in the number of Indigenous doctors continues until equity in medicine is reached and that we can match this achievement in Indigenous health research. In working towards these goals we need to recognise that the era of self-determination, like those before it, won’t last forever. What could perhaps be called the “partnership era” may already be replacing it, as exemplified by policy approaches such as shared responsibility agreements.16 The role of affirmative action in this new era is not assured and will only be maintained by addressing the difficult issues now, so that Australia may one day become an inclusive nation where, as Indigenous people, we can maintain our unique identity while playing a full role in society and enjoying the same level of health as other Australians.

Yin C Paradies BSc, MMedStats, MPH

Diane A Longstreet,* Deanne L Heath,† Robert Vink‡ * Dietitian, † Research Scientist, Townsville Aboriginal and Islander Health Services, 57–59 Gorden Street, Garbutt, QLD 4814; ‡ Head, Department of Pathology, University of Adelaide, SA. dlongstreetATtaihs.net.au To the Editor: Diabetes in Indigenous Australians occurs at a younger age and at almost four times the rate in non-Indigenous Australians. The age-adjusted prevalence of diabetes among Indigenous people is 16% in remote areas and 9% in non-remote areas, with the actual prevalence estimated to be between 20% and 25%, and possibly higher than 30% in some remote areas.1 The cause for this disparity in diabetes incidence is multifactorial, and recent evidence suggests that nutrition — particularly magnesium intake — may play a role. Although central obesity remains a major risk factor, magnesium deficit has been posited to be an underlying common mechanism for the insulin resistance found in type 2 diabetes, as well as in metabolic syndrome, hypertension, and impaired glucose tolerance.2 The clinical correlations between low magnesium and diabetes have been well documented,3 with serum magnesium deficits being reported in 25%–39% of diabetic outpatients in the United States and Switzerland, and up to 73% of diabetic outpatients in Mexico. With magnesium deficits being observed in diabetes, studies examining the effects of magnesium-rich foods on diabetes risk become relevant. The Nurses’ Health Study and the Health Professionals’ Follow-up Study, which included 85 060 women (18 years follow-up) and 42 872 men (12 years follow-up), demonstrated that, after adjusting for confounding variables, a magnesium-rich diet reduced the relative risk of developing diabetes by 34% in women and 33% in men.4 A similar inverse correlation between magnesium intake and diabetes risk was shown in the Iowa Women’s Health Study with a cohort of 35 988 older women,5 and in the Honolulu Heart Program and the Women’s Health Study with cohorts of 8006 men and 39 345 women, respectively.6,7 Despite this growing body of evidence supporting the involvement of magnesium in diabetes, consideration of magnesium status has not been integrated into Australian medical care for diabetes, and more specifically, for Indigenous Australians. It is known that the traditional diet of hunter-gathers such as Indigenous Australians was much more nutrient- and magnesium-rich than the current estimated Australian intake.8 Nonetheless, there remains a lack of information about current magnesium status, including dietary intake, in Indigenous Australians. It is possible that dietary magnesium intake may be too low to maintain normal serum magnesium homoeostasis, and that this might contribute to the development of type 2 diabetes. Further research into this issue may provide this information.

Diane A Longstreet · Deanne L Heath · Robert Vink

We know what to do, but doing it is the challenge In 1992, the late Fred Hollows warned of the catastrophic effects that HIV would have in remote Indigenous communities. His trademark candour caused considerable stir, and a number of important initiatives were implemented, such as the Tri-state HIV/STI Project in Central Australia and the National Indigenous Australians’ Sexual Health Strategy. However, it would be hard to argue that HIV is widely believed to be a priority in Indigenous health 13 years later. Health-seeking behaviour based on the presence of genital symptoms or awareness of risk is limited in many Indigenous communities . . . Until now, the prevalence of HIV in the Indigenous community has been considered similar to that in the non-Indigenous community.1 In this issue of the Journal (page 124), Wright et al present evidence of a higher rate of HIV among Indigenous people in Western Australia than in the non-Indigenous population.2 They report that, while the rate of HIV notifications in the non-Indigenous population declined between 1985 and 2002, it increased in the Indigenous population. The difference in risk for Indigenous women was striking — 39% of all female HIV notifications in WA since 1994 have been for Indigenous women, giving an Indigenous : non-Indigenous age-standardised rate ratio of 18. In contrast, the rate ratio for Indigenous males was 2. Wright et al also confirmed the marked differentials in risk of other sexually transmitted infections (STIs) in the Indigenous population — with Indigenous : non-Indigenous age-standardised rate ratios of 242 for syphilis, 77 for gonorrhoea and 16 for chlamydia. The data in this study are likely to predominantly reflect the situation in rural and remote regions of WA, and the authors acknowledge the difficulties of interpreting surveillance data. Nevertheless, the findings demand attention. Health-seeking behaviour based on the presence of genital symptoms or awareness of risk is limited in many Indigenous communities: the concept of “sexual health” is a construct usually confined to well-resourced urban populations. Few Indigenous children in remote areas complete high school and, as a result, there are few reliable means of informing young people about health risks. Although many Aboriginal Health Services have instituted local programs of distribution, condom use appears to be uncommon,3 and there is anecdotal evidence of an increase in injection drug use in remote areas. In settings of social disruption and dislocation, such as among individuals who congregate on the fringes of major urban areas, sex is often exchanged for favours, alcohol and other substances. Not surprisingly, reinforcement and maintenance of health messages and wide implementation of interventions are difficult to achieve in these settings. It is not entirely clear why the prevalence of HIV has remained low in remote Aboriginal Australia; however, this might be explained by the structure of local sexual networks. In simple terms, the sexual network identifies who is having sex with whom, how often and where. Individuals in a sexual network operate in a social space, not necessarily a geographic space. Because of the sensitivity surrounding this issue, there has been very little published on the complex sociocultural factors that determine the structure of Indigenous sexual networks in remote Australia. It is known that Indigenous people living in remote areas may travel extensively across the country, but are likely to choose partners they already know and who share the same background. This has been termed “assortative” partnering, and has been observed in other populations.4 The absence of HIV from a network protects all its members — it is only when an HIV-infected individual enters the network that transmission occurs. Such individuals may have travelled to large urban areas and contracted HIV through injection drug use or homosexual contact. As a result, a substantial proportion of the members of the sexual network will become infected, although in small communities the absolute numbers will remain low. This implies that control of HIV in the Indigenous population will require multiple small interventions that target individual sexual networks, as well as reflecting the local sociocultural conditions. In the 1990s, the rates of curable STIs (chlamydia, gonorrhoea and trichomoniasis) were found to be many times higher in the Indigenous population in the Northern Territory, compared with the non-Indigenous population. However, the rate of a non-curable, viral STI (human papillomavirus) was higher in the non-Indigenous than in the Indigenous population. This suggested that a major reason for the disparity in rates is the limited access to and use of clinical services in remote areas, rather than differences in average rates of partner change.5 Health professionals who have worked in remote health settings know how hard it is to do more than simply react to the patients who walk through the clinic doors with an acute problem. Maintaining population health programs, such as immunisation, health promotion and risk factor modification, is always difficult in these settings, and these programs are first to suffer when a medical crisis occurs. The opportunity costs of a local HIV epidemic are considerable: HIV does not just affect the individual who is infected — sexual partners are also at risk, and transmission can occur antenatally and during breastfeeding. Ongoing risk behaviour after a diagnosis of HIV is documented, driven by psychiatric and substance abuse-related factors. The medical system is compelled to react to the presence of HIV infection in a particular community. In one remote community, this required an increase in the staff of the local public health unit from three to eight, and other programs fell by the wayside (unpublished data). This migration of resources may be one of the major costs of an HIV epidemic in remote Indigenous Australia. Evidence from Africa suggests that STI control early in an HIV epidemic may be effective in limiting the spread of HIV,6 but this strategy is less useful once the HIV epidemic is established. Good STI control requires a coordinated program that addresses health promotion, diagnostic and screening services, rapid access to appropriate treatment and locally appropriate contact tracing. This is not easy, nor cheap, but it is possible — as seen with a successful program in Central Australia.7 Others have also implemented relatively effective programs.8 Primary care providers can use a new Medicare rebate item (item 710) to screen for STIs in Indigenous people as part of a broader preventive health assessment. The new National Aboriginal and Torres Strait Islander Sexual Health and Blood Borne Virus Strategy, to be announced later in the year, will provide a useful review of existing programs, and recommendations for specific action. HIV testing is central to HIV control: it determines the extent of the epidemic and helps plan local interventions. Antenatal screening and antiviral treatment of an HIV-infected mother can almost eliminate the risk of transmission of HIV to the neonate; appropriately timed therapy has obvious benefits for the individual in terms of morbidity and mortality, and successful treatment reduces the viral load and decreases the risk of transmitting HIV through sexual contact. There is no need to reinvent guidelines for testing in Indigenous settings — they already exist. Sustainable implementation is the challenge that faces primary care providers. The data from Wright et al provide a compelling reason for meeting this challenge now.

Francis J Bowden FRACP, MD