Indigenous health

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

Objective: To compare trends and rates of HIV and sexually transmitted infections in Indigenous and non-Indigenous people of Western Australia.Design and setting: Analysis of WA notification data for chlamydia, gonorrhoea, and primary and secondary syphilis in 2002, and for HIV infections from 1983 to 2002.Main outcome measures: Rates of HIV and sexually transmitted infection by Indigenous status.Results: In 2002, there were 3046 notifications for chlamydia, 1380 for gonorrhoea and 64 for syphilis. When information on Indigenous status was available, Indigenous people accounted for 41% of chlamydia and 76% of gonorrhoea notifications, with Indigenous : non-Indigenous age-standardised rate ratios of 16 (95% CI, 14–17) and 77 (95% CI, 67–88), respectively. Indigenous people accounted for 90.6% of syphilis notifications (age-standardised Indigenous : non-Indigenous rate ratio, 242 [95% CI, 104–561]). From 1985 to 2002, HIV notification rates for non-Indigenous people in WA declined and rates for Indigenous people increased. From 1994 to 2002, there were 421 notifications of HIV infection in WA residents, 52 (12.4%) in Indigenous people and 369 (87.6%) in non-Indigenous people. Indigenous people accounted for 39% and 6.2% of all notifications in WA females and males, respectively. The Indigenous : non-Indigenous rate ratios were 18 (95% CI, 12–29) for females and 2 (95% CI, 1–3) for males.Conclusions: Indigenous Western Australians are at greater risk of HIV transmission than non-Indigenous people. Strategies to prevent further HIV infection in Indigenous Australians should include control of sexually transmitted infections.

Michael R Wright BSW, MAE(IH) · Carolien M Giele RN, BSc(Hons), MPH · Phyll R Dance BA, PhD · Sandra C Thompson FAFPHM, PhD

No single voice nor one perspective can claim to represent the whole of bioethics “Deep listening: bridging divides in local and global ethics” was the theme of the 7th World Congress of Bioethics, held in Sydney in November 2004. Preceded by the 5th Feminist Approaches to Bioethics Congress and followed by the 10th Australasian Bioethics Association Conference, the conference had 550 registered attendees from 35 different countries.1 The three conferences, running over 8 days, provided the biggest event in bioethics thus far in Australia and the Asia–Pacific region and demonstrated the breadth and heterogeneity of bioethics. The theme of the Congress — suggested by the word “dadirri”, meaning “deep listening”, from an Australian Aboriginal language — expressed the intention of the Planning Committee to explore a wide range of approaches to ethics in relation to health care and to provoke vigorous and productive discussion of the issues from different perspectives. The approaches ranged from those with a traditional focus on local issues in a clinical setting to broader reflections on bioethics at a global level. Emphasising the central importance of the indigenous theme, the keynote address of the Congress was delivered by Marcia Langton (Professor of Australian Indigenous Studies, University of Melbourne) on “Aboriginal intellectual and property rights”. Speakers at major plenary sessions included Thomas Pogge (Professor of Philosophy, Columbia University) on “World poverty”; Daniel Wikler (Professor of Public Health, Harvard University) and Daniel Brock (Professor of Social Medicine, Harvard University) on “Ethical issues in population health”; and Catriona MacKenzie (Associate Professor of Philosophy, Macquarie University) on “Conceptions of the body and autonomy”. There were 15 special symposia presented by specialist groups covering a wide range of subjects, including equity, refugees, torture, genetics, stem cells, biopolitics and HIV/AIDS, in addition to over 200 individual oral and poster presentations. The Congress program covered many topics of intense current interest — most notably cloning and stem cell research — and included many styles of presentation, such as talks, debates, panel presentations and group discussions. There was a program of Australian Indigenous dance and music, storytelling, poetry and art. There were also events for the general public that were well attended and aroused considerable interest, such as an open forum on biotechnology, stem cells and cloning and a debate between George Annas (Professor of Health, Law and Bioethics, Boston University) and Alex Capron (Director, Department of Ethics, Trade, Human Rights and Health Law, World Health Organization) on human rights and bioethics.2,3 A broader view of bioethicsThe Congress deliberately sought to extend the focus of bioethics discussions from traditional and important concerns about problems arising between doctors and patients to issues of wider compass, such as the broad social, cultural and political contexts that affect health and shape health care delivery. Also on the agenda were concerns about public health programs and the responsibilities of developed countries to contribute to health care in the developing world, as well as feminist and indigenous perspectives on bioethics. This combination of approaches precipitated some trenchant critical reflections on the philosophical assumptions on which bioethics itself has been based and revealed some tensions between differing views. Feminist perspectiveMany feminist writers have been critical of a prevailing assumption that individuals are autonomous decision-makers. From this perspective, Catriona MacKenzie argued that bioethics developed with a narrow, highly individualistic conception of personhood and autonomy. As an alternative, she outlined a “relational” approach to autonomy, according to which individuals and the decisions they make are understood as constituted within relationships of interdependence and embedded in complex social situations. Such a model necessarily draws attention to power relations within intimate and familial relationships and to oppressive or unequal social structures.4 Responsibility for health in the developing worldSome speakers built on this critique of power relations by drawing attention to power inequalities at a global level. For example, Solomon Benatar (Professor of Medicine, University of Capetown) proposed that HIV/AIDS be viewed not in isolation but as symptomatic of problems of poverty and injustice afflicting the developing world.5 Thomas Pogge argued that trade agreements between affluent countries disadvantage poorer countries and lead to systematic impoverishment and poor health of many people living in the developing world. As a result of this, he claimed, citizens in Western countries are not just innocent bystanders, but carry an unavoidable responsibility.6 One practical measure he proposed was to establish a system of financial incentives to encourage pharmaceutical companies to develop effective and inexpensive treatments for the major illnesses afflicting these countries. Tension between population health and individual perspectivesIn a controversial presentation that stimulated vigorous and sometimes heated debate, Daniel Brock and Daniel Wikler, using a rights-based framework, drew attention to the particular concerns of population health (rather than health care) and argued for a shift of emphasis away from managing disease to promoting health. While those who responded accepted the importance of a population perspective, they suggested that it did not go far enough in dealing with the problems of impoverished countries, and challenged those who engage in bioethical debates to become personally and politically engaged. One participant expressed concern that the proposed new focus on public and population health would lead to a diminished appreciation of the importance of issues affecting individuals. This brought to the surface a tension between those concerned with issues of individual freedom (including individual autonomy and human rights) and those who emphasise the role of society and culture in establishing ethical conduct and relationships. Human rights and bioethicsA further tension, expressed in the public debate, was between a human rights approach and more traditional approaches to topics in bioethics. In essence, the question became whether bioethics can (and should) be properly understood and addressed entirely in its own language and concepts, or whether it needs to be supplemented (or even replaced) by a human rights perspective. Indigenous ethics Aboriginal dancer: Clarence Slockee, Mindgingbal Clan of the Bundjalung Tribe, Northern NSW. There were also tensions evident in discussing the experiences of indigenous people in relation to majority cultures within their countries, and tensions surrounding issues of cultural difference. In her address, Marcia Langton adopted a broad approach to these issues and raised fundamental questions about knowledge and its dependence on culture, power and economic forms of relationship.7,8 Speakers from India, Sri Lanka, South Africa, New Zealand and Australia showed that indigenous populations face challenges in the delivery of health care that are in common across the world, such as disenfranchisement, lack of control over health programs and research, imposition of programs from outside, displacement from the land, prejudice and poverty. Nonetheless, there was a recognition of irreducible differences between cultures that require effective responses to be based on specific local needs and conditions. The discussion of indigenous issues, perhaps more than any other topic, made evident the need for openness to multiple perspectives. The challenge of accommodating diversityWhat can be concluded from this Congress, with its emphasis on listening across broad divides? One obvious conclusion is that there is no single voice nor one perspective that can claim to represent the whole of bioethics. There is no predominant theory or homogeneous position, nor is it constituted by just one focus. There are many areas of bioethical interest, including issues in the clinic, issues arising from new understandings in medicine (such as genetics) or possibilities presented by new technologies (such as stem cell research), and issues arising from feminist (and other) theoretical perspectives. Moreover, different levels of approach, ranging from a focus on individuals to a focus on populations (such as public health and indigenous health) raise different sets of ethical interests and concerns. In this context, “deep listening” can be understood as listening to each other, listening to different groups and listening to those with different voices. It implies an openness to a multiplicity of approaches. In drawing on a variety of perspectives on a health care issue, it is possible that some central concerns may rise above and be strengthened by this multiplicity, leading to an outcome that is recognised as ethical by all interested parties. It is also possible that some views will be incommensurable, some voices discordant, and decision-makers will have to determine that one set of values needs to take precedence over another. Nevertheless, we believe that many perspectives are needed to provide a wide vista and adequate understanding in preparation for informed, appropriate and nuanced decisions in health care. Human rights, population health and indigenous ethics can complement traditional perspectives. There is a need, both within health care education and in policy development, to consider issues from individual as well as wider social and cultural perspectives and to address disparities in power as part of a broader understanding of bioethics. The Congress demonstrated that diverse views can be accommodated, even when they are held passionately and discussion is vigorous. Listening for, and openness to, differences and commonalities worked well as a theme for the Congress. It is a capacity that remains to be encouraged in bioethics and applied in health care more generally.

Paul M McNeill MA, LLB, PhD · Ruth Macklin PhD · Angela Wasunna LLM · Paul A Komesaroff MB BS, PhD, FRACP

From left: Bill Glasson, Geoffrey Angeles, Ruth Armstrong, Martin Van Der Weyden. The 2005 Dr Ross Ingram Memorial Essay Prize was presented to Geoffrey Angeles (Indigenous Health Researcher, Menzies School of Health Research, Northern Territory) at the national AMA conference in Darwin in May. Outgoing AMA president Bill Glasson presented the award, with Martin Van Der Weyden and Ruth Armstrong present from the Journal to hand over the $5000 prize money on behalf of the Australasian Medical Publishing Company. Geoffrey Angeles emerged from a strong field to win the competition with his essay Fish traps — a significant part of our health and wellbeing, which was published in the 16 May 2005 Indigenous health issue of the Journal. In accepting his prize, Geoffrey thanked Dr Ross Ingram and his family, and the Journal, for providing him (and many others across the nation) with the inspiration to share their stories. He also thanked his own family and community in Darwin for their wisdom and support. We wish him all the best with his work, his writing and his fishing. Entries for the 2006 Dr Ross Ingram Memorial Essay Competition close on 16 January 2006. The competition is open to any Aboriginal or Torres Strait Islander person who is working, researching or training in a health-related field. See the eMJA for details (http://www.mja.com.au/public/issues/180_10_170504/arm10277_fm.html).

Ruth M Armstrong BMed

My career in Indigenous health was first ignited in my teenage years as part of an overall desire to “work among my own people”. At that point in my life, I never really felt “Aboriginal”, owing, in part, to my being of “mixed descent”, light-skinned and having been raised in a predominantly white neighbourhood in an urban area. My claim to Aboriginality somehow felt a little inauthentic in light of the public imaginings of Aboriginality that I had been exposed to growing up. My perception of the “real” Aboriginal people were those who possessed dark skin, occupied the remotest parts of our country, and had retained a “pure” and “uncontaminated” Aboriginal culture. Rather naively, I had imagined that I would graduate from university and work with those people, sharing my expert wisdom of health knowledge and, in return, finding a connection with my “true” self — my Aboriginality. Funnily enough, I did achieve my goal of finding myself and my sense of Aboriginality. It was just not in the place, and not in the form, that I had first anticipated several years earlier. Commitment to family and community among Indigenous people (quotes from a study by Brough et al4) “My wife’s cousin rings up from Cairns, said, oh some fellas come down for hospital and they want a place to stay. . . . They all say [name’s] daughter, down there in Brisbane, you go stay with her anytime. Because dad was always taking in the homeless up in Cairns.” “To me, being involved in the community is something that, if you identify as being Aboriginal, then that’s part and parcel of what you give back to it by being involved in your community.” “Weddings, sporting events, NAIDOC Week. Sometimes it can be as little as a performing arts thing. People will turn up . . . especially if it’s got some Indigenous input in there . . . they’ll turn up to those events. They’re good events because usually people are feeling high in spirit because it’s something that . . . because there’s an Indigenous input (might be Indigenous actors), so they feel proud and good about themselves. This person put on a good play and there’s lots of white people there too, so that this white person can see black fellows from a different side and it makes black fellows proud and feel good.” NAIDOC = National Aboriginal and Islander Day Observance Committee. The chronicling of this journey is not meant to be a purely narcissistic endeavour. It revolves around two plights — one personal and one professional — which together describe the disjuncture between the lived experience of being an Aboriginal person and the described experience of Aboriginality that is manifest within public health practices and hampers our ability, as health professionals, to have a meaningful and positive impact on Indigenous health. It was upon undertaking a degree in Indigenous health that my romanticised ideas of a noble people quickly came crashing down. I soon learnt that Aboriginal communities were fraught with appalling levels of ill health, disease, despair and dysfunction, a situation that would invoke moral indignation from even the most casual and distant observer. Spurred on by the desire to “save my people”, I successfully obtained a rural health scholarship, which (I imagined) would see me stationed within a rural or remote Aboriginal community upon graduation from university. As it turned out, my placement was in a large rural community just 3 hours west of Brisbane. I was initially a little discouraged, as I didn’t view that placement as capable of providing me with the personal and professional prestige of having proven myself in a more “authentic” Aboriginal community in some far-flung region of the state. Nonetheless, I still found myself in a place with a sizeable Aboriginal population and a sense of community that I thought had eluded me in all my years growing up in Brisbane. Upon starting there, I threw myself into the role of Aboriginal health worker, conducting hospital visits to clients, assisting the community medical centre, liaising with non-Indigenous health providers in a cultural brokerage role, and uncritically, week after week, churning out the employer-sanctioned Aboriginal and Torres Strait Islander cultural awareness program. As each workshop went by, I began to notice that there were increasing numbers of local Indigenous community members in attendance, who were interested not so much in teaching others about specific Aboriginal cultural practices and protocols as in learning, sharing and reflecting upon their own experiences as Aboriginal people. Ironically, the task of educating white health professionals about the local Aboriginal community was inadvertently replaced by an ever more important task of connecting local Indigenous people with their own experiences, their own histories and their own cultures. Similarly, most community members appeared less interested in engaging in the traditional health education campaign of our health service, and instead were much more enthused about cultural revival in the form of NAIDOC Week* celebrations, cultural programs for young people, and sharing their own stories of strength and survival. At the time, I was a little troubled by this because, as a health worker, I was meant to be talking up health, not culture. The two seemed to lie in opposition to each other. My supervisor — a non-Indigenous nurse who had never engaged with the local Aboriginal community outside of a nurse–patient relationship at the local hospital — appeared annoyed and concerned about my inability to persuade the community to engage in the “real” health work. Rather than reflect upon the failings of our health service, she, and many of my non-Indigenous colleagues, saw this predicament as just further “evidence” of the passivity, dependency, and non-compliant nature of our mob, which in turn could be explained away as the “real” cause of our ill health. Any efforts on my part to celebrate Aboriginal culture and community were considered a contradiction within our health service, because of the assumed unhealthiness of the Aboriginal experience. I began to reflect upon the reasons for the Indigenous community’s disengagement with health education and started to question the way in which our communities had been constructed within this practice. Within the health care system, no value or worth was attached to being Aboriginal, as the success of the system was measured solely by its ability to bring the health of Indigenous people up to the same level as that experienced by non-Indigenous Australians. Underlying the quest to reduce health inequalities lay first the assignment of inferior status to Aboriginal people within health education programs. Is it actually any wonder, then, that we’d have to beg “Aunty” to come along to a presentation where she was depicted as nothing more than a subset of problems and unhealthy afflictions that could be remedied by simply telling her to eat better and exercise more? I remember feeling shame about having enticed community members to a workshop for a free feed, only to have them subjected to the paternalism of visiting health professionals, who, by virtue of their occupation alone, assumed they could completely disregard cultural and community protocols and that they were instantaneously authorised to speak to our old people as a parent would to a child. As time went by, I began to feel that health promotion in the form of health education was not empowering, but rather disempowering, to our mob. Under this system, we are seen as nothing more than a group of people who just don’t know what is good for us. And herein lay a strong contradiction between what I had been taught as a health professional and what I had learnt and experienced as an Aboriginal person. Health promotion was, I thought as a health professional, meant to empower people.1 Aboriginality, I thought as an Aboriginal person, was about pride, strength, determination and survival — survival of our people, our communities and our cultures. Why then does Indigenous health discursively reverberate around the inadequacies, impairment and hopelessness of our people, families and communities? Yes, sure, the status of Indigenous health is “appalling”. We have countless reports, studies, investigations and inquiries to remind us and reinforce the nature and breadth of these problems.2,3 But my question remains — so then what? What is left of us that we can draw from to make some improvement to our lot in life? I find it hard to just passively accept, as both an Indigenous person and as a health professional, that Indigenous communities have nothing to bring to the table in efforts to improve our own health. A few years after I began my rural placement, on returning home to Brisbane, I continued working in the field of Indigenous health, this time in the role of project officer for an urban Indigenous health promotion project that critically challenged these assumptions. It was through this project that I was able to realise how health promotion could equate to more than just health education. Here I was able to work in a manner that sought to uncover and support the true assets of our communities. Perhaps one of the most conspicuous strengths, which community members continually spoke of, was strength in identity — the persistence of Aboriginality within ourselves, our families and our communities.4 Here identity was not simply a label or name, a series of health issues, or even a stereotypical depiction, but a very complex, dynamic and fluid entity that provided a resource for everyday living. For instance, a vast number of social resources were derived from large family and community networks, and the values attributed to one’s Aboriginal identity produced a reciprocal exchange whereby individuals felt a strong sense of commitment to their community (Box). The result of this participation, such as community organisations and community events, was a source of strength and pride for many of the respondents. It should hardly be surprising, however, that there is something resourceful about Aboriginal identity, given that it has endured over 200 years of active attempts to remove, deny and delegitimise it. It was here that I made my connection. What resonated most with me was the persistence and diversity of our Aboriginality, which I had witnessed and experienced myself as an Aboriginal person, having lived and worked in both rural and urban Aboriginal communities. All this time, I had been seeking a version of Aboriginality that was simply not mine. So, exactly whose version of Aboriginality was it? My search for answers has led me to undertake a PhD in Indigenous health, to examine how the concept of Aboriginality has been constructed within public health practice. As I’ve reflected on my own culture as an Aboriginal person, I’ve been forced to examine the professional culture of public health that I am also a part of. In so doing, I have realised that my own naive and romanticised understanding of the “authentic Aboriginal” was not unique to me. In fact, I have found that these very images are supported and reproduced within much of Indigenous public health practice. For instance, there has to be some explanation for why the epidemiological gaze in Indigenous health research still disproportionately focuses on rural and remote Aboriginal communities,5 when the majority of Aboriginal people reside in urban centres.6 One must also question the practice of continually highlighting the health inequalities facing Aboriginal people without explaining the precise causal pathways — thus perpetuating assumptions about “innate characteristics related to ‘ethnic’ or ‘racial’ difference”.7 The perception of Aboriginality as nothing more than a label, a health risk, and predicator of unhealthy behaviours within Indigenous public health practice reinforces stereotypical ideas of Aboriginality, demonises those who possess it, and disconnects Aboriginal people from their own identities in a manner similar to past oppressive policies of colonisation, assimilation, segregation and integration. Critically examining such practices is not just a matter of “political correctness”, but a vital step that will have profound and meaningful implications for the health of Aboriginal people. Such depictions fuel the very racism that creates and compounds health inequality,8-10 and may also result in Aboriginal people internalising such negative depictions.11 Internalised racism has been linked to increased drug use, behavioural problems,12 increased rates of depression and obesity, and lower academic aspirations.13 Numerous studies have also demonstrated the association between social status and health inequality,14 the relationship between community integration and health,15 and the influence of factors such as social exclusion, support, isolation, participation and autonomy.16 It has been argued that notions of identity and culture are an important resource for empowering minority or marginalised communities — a goal that accords with the broader global health promotion agenda.17 It is not the quantification or authentication of culture by the dominant group, but rather the process of enabling such communities to define, express and represent themselves that is empowering and conducive to better health outcomes. Bearing this in mind, I have sought to develop my research agenda around examining and validating the way in which Aboriginal people define themselves, without the distraction of a predetermined health agenda guiding or hijacking every activity that I engage in. Importantly, despite my apparent rejection of the way public health is practised and health care delivered to Indigenous people, I do not view my current journey as contradictory to the overall goal of public health practice — which is to improve the health and wellbeing of Aboriginal people. All that differs is the construction of meanings around our own notions of health and Aboriginality. Public health and medicine are themselves cultural practices that have been influenced heavily by the politics of colonialism.18 Rather than claiming to be neutral, objective observers of the cultural domain occupied by Aboriginal people, we, as health professionals, need to be prepared to place our own cultural practices under the microscope and examine their effect on the health of Aboriginal people. For Aboriginal people, health is “not just the physical well being of the individual, but the social, emotional and cultural well being of the whole community . . . [and] a matter of determining all aspects of their life, including control over their physical environment, of dignity, of community self esteem and of justice. It is not merely a matter of the provision of doctors, hospitals, medicines or the absence of disease and incapacity.19 I am currently conducting my fieldwork, the chosen site of which is itself somewhat poignant. It is not in some far-off exotic location, but just a few suburbs over from where I grew up. Through my journey so far, I have found the strength in my identity as an Aboriginal person, in all of its “inauthenticity”, and the strength in my community, in all of its unhealthiness, to see a way forward to improving the health of our people. For me, inherent in the task of improving Indigenous health and in achieving wellbeing as an Indigenous person is providing a space within public health practice and in our own minds that allows us, the “public”, to define and redefine our experiences of our identity.

Chelsea J Bond

CorrectionRe: “Point-of-care testing of HbA1c and blood glucose in a remote Aboriginal Australian community” in the 16 May 2005 issue of the Journal (Med J Aust 2005; 182: 524-527). The authors of this article have requested that Max K Bulsara (School of Population Health, University of Western Australia; and Centre for Child Health Research, University of Western Australia, Telethon Institute of Child Health Research, Subiaco, WA) be included as an author. The corrected list of authors is David D Martin, Mark D S Shephard, Hayley Freeman, Max K Bulsara, Timothy W Jones, Elizabeth A Davis, Graeme P Maguire. The online version of this article (html and pdf) was corrected on 27 May 2005.

David D Martin MB BS, PhD · Timothy W Jones DCH, FRACP · Elizabeth A Davis FRACP · Mark D S Shephard MSc, MAACB · Hayley Freeman RN · Graeme P Maguire MPHTM, FRACP, PhD

In reply: We agree with Kinlay that it is important to prevent risk factors at the population level (a population strategy). However, there is also a need to properly identify high-risk individuals who require immediate medical intervention (a high-risk strategy) and to understand the full spectrum of factors that determine such risk. The primary focus of our study was to assess whether the widely used Framingham risk functions were applicable to Aboriginal people in remote communities. Our data show that the Framingham functions significantly underestimated the risk of coronary heart disease (CHD). 1 The high CHD risk in Aboriginal people cannot be fully explained by traditional risk factors. Some major risk factors such as abnormal total cholesterol level and obesity in the study population are actually not as prevalent as those in the general Australian population. 2 Evaluation of traditional risk factors and identification of novel factors in this population are useful for the development of intervention strat-egies. Novel factors such as infection, inflammation, albuminuria and low birthweight have been suggested as predictors of CHD risk in this population. 3,4 Kinlay suggests that Framingham functions should be used to predict CHD risk in Aboriginal people. We disagree. Guidelines for the management of Aboriginal people need to recognise the serious underestimation of risk that the Framingham formulas provide. We agree that some high-risk groups, such as patients with established CHD, do not need additional risk estimates. With our current knowledge, however, we can not say whether the whole Aboriginal community should be treated as a very high-risk population.

Zhiqiang Wang · Wendy E Hoy

The past 12 months have brought considerable changes that affect the lives of Australia’s Indigenous people Five years ago, we began to deliberately cluster the publication of research reports on Aboriginal and Torres Strait Islander health in the second issue of the Journal in May, to coincide with National Sorry Day (26 May) and Reconciliation Week (26 May – 3 June). In the years that followed, the quantity and quality of papers related to Indigenous health grew, culminating this year in the inaugural MJA Indigenous Health issue. Some readers might question this initiative, considering that Indigenous Australians account for less than 3% of our population. However, we would counter that the social, economic and health disparities between Indigenous and non-Indigenous people in Australia are worse than in any other comparable country in the world,1 and that the MJA remains the only high level Australian research forum to regularly report these issues. Engaging with Indigenous people, and coping with our own feelings of impotence, guilt, frustration and fear as health professionals, must play a role in the healing process. The past 12 months have brought considerable changes that affect the lives of Australia’s Indigenous people. The Australian Government has completely overhauled its approach to Indigenous affairs:2 The Aboriginal and Torres Strait Islander Commission has been abolished, and a ministerial taskforce and a National Indigenous Council have been convened to advise on Indigenous affairs; Shared responsibility agreements are being forged with Indigenous communities; and, recently, Prime Minister John Howard has suggested changes to Aboriginal land rights, which would favour individual over communal ownership.3 In announcing the new arrangements for Indigenous affairs, Amanda Vanstone, the Minister for Immigration and Multicultural and Indigenous Affairs, promised,4 We will work with states and territory governments and Indigenous communities to find the best mechanism for input at the local and regional level. Our focus will continue to be on better service and better outcomes for Indigenous people. Despite widespread recognition that there were problems with the previous arrangements, some Indigenous leaders believe that the government’s move to “mainstreaming” threatens Indigenous Australians’ right to self-determination.5 Concerns have also been expressed that it will be more difficult for Aboriginal and Torres Strait Islander voices to be heard in health policy development.6 Disquiet about the place of shared responsibility or “mutual obligation” agreements in improving Indigenous health7 is echoed by Collard et al in this issue of the Journal (page 502). National Sorry Day was initiated in 1998, a year after the Bringing them home report focused public attention on the experiences of the Indigenous Australians who had been removed from their families. It was set aside as a day for acknowledging these people’s suffering and committing to assist them on their “journey of healing”. But this too has changed. The National Sorry Day committee has decided that the day will now be known as a “National Day of Healing — for all Australians”. In explaining the change, committee chairs Ray Minniecon and Gillian Brannigan noted:8 . . . the stolen generations cannot heal in isolation. Their healing depends on, and contributes to, healing among the wider Indigenous community. And healing among Indigenous Australians depends on, and contributes to, healing in the non-Indigenous community. This emphasis on the need for healing among all Australians should take us, as health professionals, beyond the usual perspective that the poor health of Indigenous Australians is about “them” — to look at ourselves, our society and our health care system. According to the National Sorry Day committee:8 If healing is to come, it will come through a grass-roots movement of people who feel each other’s pain across the gulfs which divide us, and commit themselves to work for justice. This was the experience of Gruen and Yee (page 538) after working for some time in a remote Aboriginal community. Engaging with Indigenous people, and coping with our own feelings of impotence, guilt, frustration and fear as health professionals, must play a role in the healing process. Some of the stories, pictures and vignettes in this special Indigenous Health issue may provide an avenue for such engagement. Health system problems also feature in this issue. A study published in the Journal in 2002 noted that Indigenous patients were less likely to receive diagnostic and therapeutic procedures in Australian hospitals.9 While the reasons for this differential treatment are complex, a similar shortfall has since been reported in the management of cancer patients,10 and, as reported by Coory and Walsh in this issue, in the rates of patients receiving percutaneous intervention or coronary artery bypass surgery after acute myocardial infarction (page 507). Whatever we make of these sobering findings the need for change is apparent. One of the reasons advanced by Coory and Walsh for their findings is the high prevalence of comorbidities in Indigenous patients, which, in turn, reflects social, economic and health care deficiencies in Indigenous communities. In a recent discussion paper Healing hands — Aboriginal and Torres Strait Islander workforce requirements, the Australian Medical Association identified lack of access to high quality primary health care as one of the major impediments to improving Indigenous health.11 The report revealed that these services were underfunded by $400 million per year, and there was a workforce shortfall of 430 doctors and 450 other health professionals. It also called for a commitment to increase the number of Indigenous people in the health workforce to levels proportionate to those of the general population — a project which requires training and support for an additional 928 doctors and 2570 nurses. An additional 2000 Aboriginal health workers are also required. Full resourcing of primary care for Indigenous people makes good sense, and should be achieved both through mainstream measures, such as the newly funded primary care item, Aboriginal and Torres Strait Islander health check,12 and via community-based projects achieved by partnerships with Aboriginal-controlled health organisations. An addendum to the AMA discussion paper included five “good news stories” of community-based clinical research projects that have achieved meaningful on-the-ground outcomes. Several such reports are also published in this issue: a decade-long retinal screening project in the Kimberley (Murray et al, page 520), point-of-care diabetes monitoring and feedback in a remote community (Martin et al, page 524), and a collaborative shared antenatal care project for urban Indigenous women (Panaretto et al, page 514). Such projects might seem at times like drops in an ocean of despair, but they are proof that an adequately resourced and carefully designed primary health care system for Indigenous people can make inroads into health inequity. So what do we make of Sorry Day, the National Day of Healing, and Reconciliation Week in 2005? Geoffrey Angeles, the winner of the first Dr Ross Ingram Memorial Essay Competition (page 541) should have the last word. There is nothing wrong with some of the old and a little bit of the new. Reconciliation comes in many forms, but basically it is about bringing together, compromise, resolution and understanding. Shaking hands and saying sorry is surface stuff. Examples of partnerships that work are more real. The Australian Government has adopted the rhetoric of partnership in Indigenous health. It now remains to be seen if rhetoric becomes reality, and whether we can come together as individuals, as a society and as a health system to form true and equitable partnerships. These partnerships should be based on hearing and understanding each other’s stories, healing relationships and an ongoing willingness, both personally and politically, to work together on upskilling, motivating and funding a health workforce that has Indigenous parity and is fit for the task. Editor, The Medical Journal of Australia, Sydney, NSW medjaustATampco.com.au

Ruth M Armstrong BMed · Martin B Van Der Weyden MD, FRACP, FRCPA

Crossing the line [video recording]. Kaye Harrison (director). Change Focus Media Pty Ltd, 2005. 56 mins. Video available from Ronin Films, phone (02) 6248 0851 or email orders@roninfilms.com.au. Amy McCormack (medical student) and Louise Roughsey Silhouette of youth on street (photo: Paul Joffe) Hector Thomas and Paul Joffe (medical student) Crossing the line is a 1-hour video that charts the paths of two Tasmanian medical students, Amy and Paul, during an 8-week placement on Mornington Island in north-west Queensland. Kaye Harrison wrote, directed and co-produced the video for ABC-TV, which screened it earlier this year in two parts on the Indigenous program Message stick. Amy and Paul come across as delightful young people. They are affluent and idealistic. After a week’s briefing in Mt Isa, the flight to Mornington Island teleports them to another world, where the health and social needs of the Indigen-ous people are vast and often unmet. Eight short weeks is all they have, and their instructors have urged them to maintain their professional stance and distance, and not to “cross the line”. The video examines whether this advice is realistic and how adequately prepared they are for this culturally shocking experience. After arriving at the Mornington Island Community Hospital, life expands for the two students. They cannot avoid the experiences of the people served by the hospital. After several weeks, Paul encounters a young girl who is brandishing a rope, threatening suicide. He intervenes. Should he? His local Aboriginal mentor explains how her son shot himself and how important she considers early intervention to be. The Mt Isa supervisors, in their weekly tele-conference with Amy and Paul, perceive that Paul has crossed the line and that suicide is an issue he should not touch on. He is further criticised for interviewing community members without a health professional being present to supervise him and without ethical clearance. One supervisor cautions Paul against “building up an expectation that you’re going to make a change”. Amy attends a church service at a time when many funerals are being held for young men. She weeps with the people, wrestling with the meaning of her Christian faith as she listens to stories of missionaries who removed children from their families and disciplined the people. The folk of Mornington Island demonstrate a warm-hearted resilience in the face of their history, but to Amy it is appalling. Without seeming to consult the community, Paul and Amy’s supervisors in Mt Isa pull them out for debriefing a week early — almost before they can say goodbye to the people they have come to know and begun to love — because they have become too involved. Two Aboriginal colleagues watched the video. They despaired at the “offensive” lack of attention given to the community’s wishes and at what they perceived to be an element of voyeurism in the placements themselves. Australia remains stuck in a trench in relation to Aboriginal health. The spent cartridges of bright ideas litter the ground. There is a need for new thinking. Certainly it must be born of Aboriginal culture. It would address reculturation and the rejuvenation of Aboriginal identities. Given the emphasis on social capital, mutuality and reciprocity in Aboriginal culture, building on that may be the way forward. Awakening the minds and sensitivities of future doctors to the needs and wishes of Aboriginal people makes sense if there is to be participation of each in the other’s future. If medical students are to “go in at the deep end at the Top End”, there needs to be strong support from a partnership of medical educators and the communities involved. We believe that educating students of all disciplines relevant to Aboriginal people is part of our obligation to improve the way we respond to and interact with Aboriginal people in the future. Crossing the line should remind medical educators to harness, rather than suppress, the welling energies of youth to cross the line. At the same time, for Aboriginal communities to cross the line puts their cultural identity at risk. Better ways than those shown in this video would combine the wisdom of the elders with the idealistic energies of youth.

Stephen R Leeder · Gavin Mooney

Shared responsibility agreements between the Australian Government and Indigenous communities are based on a concept of mutual obligation but have overtones of paternalism and imposition. The nature and extent of choice in any such agreements need to be established. In 2004, the Australian Government announced a new approach to the provision of services to Indigenous communities.1 Part of the initiative involved the forging of “shared responsibility agreements”, defined by the government as being agreements in which “both governments and Indigenous people have rights and obligations and all must share responsibility”.1 Shared responsibility agreements are based on the concept of mutual obligation. While intuitively the meaning of “mutual obligation” might appear to be clear, in practice it is not, as Aden Ridgeway, Federal Parliament’s only Indigenous member, pointed out quite forcefully in a Senate debate.2 Prominent Aboriginal leaders Pat Dodson and Noel Pearson3 describe mutual obligation as “a natural principle of human society”, which, in Aboriginal terms, is normally referred to as “reciprocity”. According to Larissa Behrendt,4 Professor of Law and Indigenous Studies at the University of Technology, Sydney, “the concept of Aboriginal reciprocity implies that those who have resources share them with those who do not, and that those who receive this generosity have the same duty to provide for and share with others”. We believe that the Australian Government’s new approach smacks of paternalism and imposition and, in the absence of both respect and equality, runs counter to the Aboriginal notion of reciprocity. We believe that there has not been adequate dialogue and negotiation between the government and Indigenous communities in relation to shared responsibility agreements. How that dialogue is initiated and how it is then used to promote policy are crucial, and there has been too little debate on these two issues. The Mulan shared responsibility agreementLate in 2004, the details of a shared responsibility agreement between the government and Mulan Aboriginal Community in the Kimberley region of Western Australia became public. Part of that agreement was that the federal government would supply the community with a petrol bowser on the proviso that members of the community meet certain standards of personal and community hygiene. These included washing children’s faces twice a day and families keeping their homes free of rubbish (see Box). Not surprisingly, the proposal provoked considerable public debate.6 On the one hand, it has been argued that the Mulan community wanted to enter the agreement with government and that the wishes of the Mulan community should be respected by those who, like us, are opposed to such contracts.3 On the other hand, we are concerned that the “choice set” that Mulan was offered was very restricted (perhaps simply “take it or leave it”). The current Australian Government appears to favour neoliberalism in the market place, the central tenet of which is freedom of choice of the consumer. But for neoliberal markets to work well, there is a need for well informed consumers and freedom of choice over a wide range. We are not proposing market solutions for Mulan, but want to draw attention to the issue of choice. What choices were the Mulan community offered? Are the “consumers” of Mulan well placed to judge whether the benefit they will get from a petrol bowser will be worth the “price” they have agreed to pay? Is the government in a position to ensure that the price is paid or even to monitor the “payment”? Our concerns about mutual obligation schemesWhile the leadership of Mulan has publicly assured the Australian community that they are comfortable with the terms of the agreement,7 we have general concerns about whether such “mutual obligation” deals respect communities’ autonomy. The literature on the social determinants of health shows strong links between autonomy and health.8,9 A community which has autonomy and self-respect is more likely to be a healthy one. Such a community is able to build trust, respect, reciprocity and, in turn, improve health standards within the community. Encouragement from the outside can foster these features, but trying to impose them will not work and may be deleterious. There are also human rights issues, and the need to avoid solutions that discriminate against Indigenous people. For example, it would be discriminatory if the “rewards” involved in mutual obligation agreements only provide Indigenous people with access to infrastructure that other Australians expect or take for granted (which, incidentally, is the case for petrol bowsers). It can also be argued that the government’s concept of mutual obligation breaches Australia’s international obligations and denies certain basic rights to Australia’s Aboriginal and Torres Strait Islander citizens. The rationale is one of social control. This, for example, breaches Article 1 of the International Covenant on Civil and Political Rights: people’s right to self-determination and the right to freely pursue their economic, social and cultural development.10 An understanding of the background to this initiative is important. The government’s mutual obligation scheme comes in the wake of, firstly, its continuing refusal to apologise, as an act of reconciliation, for the “stolen generations”. This is seen by many as a denial of the mental and spiritual havoc wreaked by colonialism and dispossession of land and culture. Instead, the government has supported “practical reconciliation” — “addressing social and economic disadvantage”.11 Mutual obligation is a natural extension of this “let’s fix it” approach. Secondly, the disbanding in April 2004 of the Aboriginal and Torres Strait Islander Commission (ATSIC),12 an organisation based on principles of self-determination, is a direct lead-in to the policy of mutual obligation. ATSIC’s successor, the new National Indigenous Council (NIC),13 is not a representative body, as the government has acknowledged: “Members of the NIC have been chosen for their expertise and experience in particular policy areas and are not representing particular regions, organisations or agencies. The NIC is not a replacement for ATSIC and not intended as a representative body.”13 The mutual obligation scheme and NHMRC guidelines for ethical research in Indigenous communities14Given that, to our knowledge, there is little evidence for the effectiveness of mutual obligation strategies in the context of improving health, it is relevant to examine such strategies in terms of the principles applied in formulating guidelines for ethical conduct of research in Aboriginal and Torres Strait Islander communities. According to the National Health and Medical Research Council guidelines,14 it is crucial to involve the relevant communities in the development of any research proposal in Indigenous health. The guidelines are based on the principles of reciprocity — in the context of research, reciprocity implies inclusion and recognition of partners’ contributions, and ensuring equitable benefits of value to communities or individuals. “. . . communities have the right to define the benefits according to their own values and priorities”14 respect — a respectful relationship induces trust and cooperation; equality — the equal value of people; responsibility — includes, among other things, “the mainten-ance of harmony and balance within and between the physical and spiritual realms”14 survival and protection — protecting culture and identity; and spirit and integrity — an overarching value binding all others into a coherent whole. “Any behaviour that diminishes any of the other values could not be described as having integrity”.14 Thus, the government’s mutual obligation scheme does not appear to comply with the principles of respect; almost certainly those of responsibility; and perhaps, most importantly, the overarching notions of spirit and integrity. To demonstrate reciprocity, the guidelines suggest the need for the researcher to show “willingness to modify research in accordance with participating community values and aspirations”. Again on this criterion, government policy would appear to be deficient. Any research proposal in health today is likely to be rejected if it cannot show how it would quantify any changes it is attempting to bring about. These standards should apply even more to policy. There needs to be some evidence-based attempt to determine whether the policy works. Our concern at this level is simple. What performance indicators are appropriate for Mulan, for example? Good policy needs to establish these in advance. There is a need to conduct research to establish whether, and if so to what extent, shared responsibility agreements work — and what “works” means in this context. It would have been useful to gather this evidence before beginning to implement the policy. It is now crucial to get that evidence as soon as possible. Alternative or complementary strategiesWe believe that the most important strategy for improving health in Aboriginal communities such as Mulan involves building up infrastructure — management, economic, social and human infrastructure.15 If a community lacks leadership and good management and does not have this infrastructure then all other efforts will fail. This aspect seems to have been neglected by government. Many Indigenous communities need help to be able to help themselves on their own terms. Secondly, respect is needed — respecting the preferences of Aboriginal and Torres Strait Islander peoples. Strategies to improve Indigenous health will only get off to a good start if the people want the strategies, and their autonomy has been respected in allowing them to make choices regarding the strategies. Thirdly, there is a need to avoid being paternalistic or patronising. If mutual obligation is an option that Indigenous communities seek, then there must be an adequate range of choices offered, respect for the preferences of the people, and ways of monitoring whether the obligations on each side are in fact carried out. Draft agreement between the government and the residents of Mulan5 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; 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).

Kim S Collard · Heather A D’Antoine · Barbara R Henry · Gavin H Mooney · Dennis G Eggington · Carol A Martin