Indigenous health

The Australian Indigenous HealthInfoNet website (http://www.healthinfonet.ecu.edu.au) is the most comprehensive source of up-to-date, authoritative information on Indigenous health. Professor Neil Thomson points out features of the HealthInfoNet website to Professor Mick Dodson, Chair of the Australian Institute of Aboriginal and Torres Strait Islander Studies. To attain its goal of contributing to improving the health of Australia’s Aboriginal and Torres Strait Islander peoples, HealthInfoNet gives a wide range of potential users easy access to high quality information about health and related issues. For policy-makers, health service providers and program managers, there is an up-to-date subject review, and sections about policies, strategies and programs. For clinicians and other health professionals there are recent journal articles, theses, and clinical guidelines, and most practitioners will find the links to relevant organisations useful. For researchers, academics and tertiary students, there is a list of key references on each subject and a downloadable bibliography of relevant sources. HealthInfoNet’s overview, which is updated three times a year, is the most comprehensive summary of Indigenous health available. A shorter, plain language summary of Indigenous health is also provided. A useful section for secondary students and general readers is FAQs (frequently asked questions), which provides summary information about a wide range of issues. HealthInfoNet also aims to facilitate active sharing of information among people involved in specific areas of Indigenous health (initially, cardiovascular disease, tobacco control and road safety) by supporting “communities of practice (CoP)”. These are defined as “groups of people who share a concern or a passion for something they do, and learn how to do it better as they interact regularly”. CoP activities are supported by a listserve, an electronic discussion board, and the capacity to upload information for sharing with other people. The HealthInfoNet team also works directly with Indigenous health workers to encourage them to make use of the health resources on the Internet. This work includes running special training workshops and conducting HealthInternet cafés at relevant conferences. The HealthInfoNet’s work is undertaken by a small part-time team at Kurongkurl Katitjin, the School of Indigenous Australian Studies at Edith Cowan University, Perth, assisted by an extensive Australia-wide network of consultants. The consultants help in the essential peer-review process of the academic materials on the site. The information on the site also reflects the experience of HealthInfoNet’s Director, Professor Neil Thomson, who has worked as a doctor with Indigenous people in the Kimberley area and in Perth. His work with the Australian Institute of Aboriginal and Torres Strait Islander Studies and the Australian Institute of Health and Welfare affirmed his belief in the need for quality information to inform policy and program development and practice in Indigenous health. The core functions of the HealthInfoNet are supported by a grant from the Australian Department of Health and Ageing’s Office for Aboriginal and Torres Strait Islander Health, with funds for other activities acquired from a variety of sources. The Australian Indigenous HealthInfoNet is at the forefront of knowledge sharing in the health sector. Readers who haven’t yet used the site are invited to check it out next time they need information on Indigenous health.

Neil J Thomson MD, MPH, FAPHM

Demands for efficiency should not be met at the expense of equity Despite countless reports over decades about the health disadvantages of Indigenous Australians, attention has only recently been turned to remedying disparities in the provision and quality of health care. A report in this issue of the Journal by Coory and Walsh about access to coronary procedures (page 507)1 adds to a growing body of evidence that Indigenous Australians do not receive the same level of care as other Australians.2-4 How might clinicians be contributing inadvertently to this “treatment gap”? And how can they remedy it? The responsibility for reducing ethnic disparities rests primarily with the health care system and its providers. Clinical decisions are based on imperfect information. To each clinical encounter, doctors bring prior beliefs about the likely nature of the condition. These beliefs differ according to the patient’s age, sex, socioeconomic status and ethnicity. They influence diagnosis, investigations and treatment. With identical descriptions of pain, a doctor is more likely to diagnose cardiac ischaemia in an elderly, sedentary, obese man than in a young, active woman of normal weight. Such stereotyping is helpful — and, indeed, promotes efficient practice — when it is based on epidemiology, statistical likelihood and best evidence. However, when incorrect, inappropriate and often implicit beliefs about the behaviour or health of a particular group are applied to individuals, stereotyping can be harmful. Uncertainty increases with patients who speak a different language or belong to a different cultural group. This, in turn, can lead to unhelpful, even harmful stereotyping. The experience of an Aboriginal politician who recently underwent emergency surgery demonstrates this. “I have had problems with my stomach and my abdomen for years. They were saying it was a problem with my kidneys and now that I have had this surgery on my bowels, they have found out that my kidneys are perfect,” she said. “So when I have gone to doctors complaining about illness over many years, I suppose they have taken my genetic heritage as a Tiwi Islander and thought it was renal.”5 Delays in diagnosis and treatment caused by such stereotyping might be partly responsible for Indigenous Australians’ poorer health outcomes. In the United States, concerns about the quality of health care received by racial and ethnic minorities compared with white Americans prompted Congress to request an investigation by the Institute of Medicine (IOM). Their landmark report, Unequal treatment: confronting racial and ethnic disparities in health care, found convincing evidence that racial and ethnic disparities exist across a wide range of conditions and health services and are associated with poorer outcomes.6 The report made several recommendations relevant to Australia, including cross-cultural training, use of interpreter services, and training more health care providers from ethnic and racial minority backgrounds.6 However, this might not suffice. Doctors who treat black Americans are less likely than those who treat white Americans to be “board certified” (ie, fully qualified) specialists. They are also more likely to report difficulty in arranging access to consultants, diagnostic imaging, and non-emergency hospital admission.7 In other words, doctors who treat black patients have less power, fewer resources, and possibly less training than doctors who treat whites. Is this also true in Australia? The IOM report defined disparities as racial or ethnic differences in the quality of health care not due to clinical need, patient preference or appropriateness of intervention.6 In Australia, these three factors have repeatedly been suggested as reasons for the treatment gap. Coory and Walsh suggest that the prevalence and severity of comorbidities may have a major impact on lower rates of coronary procedures and make providers question the appropriateness of such interventions.1 They note that selection favours lower-risk patients. However, even after controlling for the presence of comorbidities, Indigenous Australians still had significantly fewer interventions. With respect to patient preference, some commentators have suggested that, because Aboriginal people treated for chronic kidney disease fare poorly, they prefer not to be treated,8 but this hypothesis is contradicted by growing community activism to secure dialysis services in remote areas.9,10 A crucial issue is the increasing conflict between “efficiency” and equity. With increasing demands on health services, doctors attempt to maximise efficient use of scarce resources. Based on the mantra of “evidence-based medicine”, doctors perform more selective procedures and strive for lower rates of complications. A recent editorial suggested that people who cannot stop smoking should be excluded from a range of therapeutic interventions because of their higher risk of postoperative complications.11 Similar exclusions could also be applied to other groups, such as obese people. While this approach might increase “efficiency”, applying such standard criteria would greatly reduce Indigenous Australians’ access to beneficial interventions. Perhaps a higher complication rate is acceptable in the overall context of Indigenous Australians’ relative need for health care. Recovery from postoperative complications might be preferable to death without surgery. The responsibility for reducing ethnic disparities rests primarily with the health care system and its providers. System-level changes are clearly required, such as adequate funding for primary care, an adequate Indigenous health workforce, and improvements in the interface between primary care and specialist services.1,6,12 Clinicians have a central role to play in advocating for such changes. Because patients should be part of the solution, the IOM report recommends the development of appropriate education for patients in areas such as when and how to access health care, and how to participate effectively in clinical decision-making.6 However, most patients, in particular Indigenous Australian patients, are relatively powerless compared with doctors and “the system”. In Australia, the political debate about Indigenous health and development is framed in terms of “mutual obligation”. If we clinicians and researchers are to fulfil our obligation, we must first understand how we might inadvertently be contributing to the problem and then take steps to bridge the treatment gap.

Joan Cunningham ScD · Alan Cass PhD, FRACP · Peter C Arnold BSc, MB BCh, BA

Objective: To compare rates of percutaneous coronary interventions (PCI) and bypass surgery after acute myocardial infarction (AMI) in Indigenous and non-Indigenous patients.Design: Cohort study of public-sector patients who were followed up for 1 year using administrative hospital data.Participants and setting: We followed up 14 683 public-sector patients admitted to Queensland hospitals for AMI between 1998 and 2002. Of these, 558 (3.8%) identified as Indigenous.Outcome measures: Rates of PCI and bypass surgery, adjusted for differences between the Indigenous and non-Indigenous cohorts according to age, sex, socioeconomic status, remote residence, hospital characteristics, and comorbidities.Results: The adjusted rate for PCI during the index admission was significantly lower by 39% (rate ratio [RR], 0.61; 95% CI, 0.38–0.98) among Indigenous versus non-Indigenous patients with AMI; the adjusted rate for subsequent PCI was significantly lower by 28% (RR, 0.72; 95% CI, 0.54–0.96). Adjusted rates for bypass surgery were similar in the two cohorts. For any coronary procedure (ie, PCI or bypass surgery), the adjusted rate was significantly lower by 22% (RR, 0.78; 95% CI, 0.64–0.94) among Indigenous patients with AMI. Diabetes, chronic renal failure, pneumonia, and chronic rheumatic fever were at least twice as common among Indigenous patients with AMI as in the rest of the cohort, and chronic bronchitis and emphysema and heart failure were at least 60% more common. If a patient had at least one comorbidity, then their probability of having a coronary procedure was reduced by 40%.Conclusions: There are likely to be several reasons for the lower rates of coronary procedures among Indigenous patients, but their high rates of comorbidities and the association of comorbidities with lower procedure rates was an important finding. As investment in primary care can reduce the prevalence and severity of comorbidities, we suggest that adequate primary health care is a prerequisite for effective specialist care.

Michael D Coory PhD, FAFPHM · Warren F Walsh FRACP, FACC

Objectives: To evaluate the impact of a community-based, collaborative, shared antenatal care intervention (the Mums and Babies program) for Indigenous women in Townsville.Design and participants: Prospective cohort study of women attending Townsville Aboriginal and Islander Health Service (TAIHS) for shared antenatal care with a singleton Indigenous birth between 1 January 2000 and 31 December 2003 (456 women; the MB group), compared with a historical control group of 84 women who attended TAIHS for antenatal care before the intervention between 1 January 1998 and 30 June1999, and a contemporary control group of 540 women who had a singleton birth at Townsville Hospital between 1 January 2000 and 30 June 2003, but did not attend TAIHS for antenatal care.Intervention: Integration of previously autonomous service providers delivering shared antenatal care from TAIHS.Main outcome measures: Patterns of antenatal visits, proportion of women undertaking key antenatal screening, and perinatal outcomes.Results: The number of Indigenous women who entered the MB program and gave birth at Townsville Hospital rose from 23.8% in 2000 to 61.2% in 2003. The number of antenatal care visits per pregnancy increased from three (interquartile [IQ] range, 2–6) in the historical control group to seven (IQ range, 4–10) in the MB group (P < 0.001). 88% of women in the MB group had at least one ultrasound. About 90% of all women attending for antenatal care were screened for sexually transmitted infections. In the MB group, there was a significant reduction in preterm births compared with the contemporary control group (8.7% v 14.3%, P < 0.01). There was no significant reduction in the prevalence of low birthweight births or perinatal mortality.Conclusion: A community-based collaborative approach to shared antenatal care services increased access to antenatal care and was associated with fewer preterm births among Indigenous women in Townsville. The model may be adaptable in other urban centres with multiple antenatal care providers and significant numbers of Indigenous people across Australia.

Kathryn S Panaretto MB BS, MPH · Heather M Lee HealthWorkerCert3 · Melvina R Mitchell EN · Sarah L Larkins MPH, FRACGP · Vivian Manessis FRACGP · Petra G Buettner PhD · David Watson FRANZCOG

Objective: To describe how a novel program of diabetic retinopathy screening was conceived, refined and sustained in a remote region over 10 years, and to evaluate its activities and outcomes.Design: Program description; analysis of regional screening database; audit of electronic client registers of Aboriginal community controlled health services (ACCHSs).Setting and participants: 1318 Aboriginal and 271 non-Aboriginal individuals who underwent retinal screening in the 5 years to September 2004 in the Kimberley region of north-west Australia; 11 758 regular local Aboriginal clients of Kimberley ACCHSs as at January 2005.Main outcome measures: Characteristics of clients and camera operators, prevalence of retinopathy, photograph quality, screening intervals and coverage.Results: Among Aboriginal clients, 21% had diabetic retinopathy: 19% with non-proliferative retinopathy, 1.2% with proliferative retinopathy, and 2.8% with maculopathy. Corresponding figures for non-Aboriginal clients were 11%, 11%, 0 and 0.4%, respectively. Photograph quality was generally high, and better for non-Aboriginal clients, younger Aboriginal clients and from 2002 (when mydriatic use became universal). Quality was not related to operator qualifications, certification or experience. Of 718 regular Aboriginal clients with diabetes on local ACCHS databases, 48% had a record of retinal screening within the previous 18 months, and 65% within the previous 30 months.Conclusions: Screening for diabetic retinopathy performed locally by Aboriginal health workers and nurses with fundus cameras can be successfully sustained with regional support. Formal certification appears unnecessary. Data sharing across services, client recall and point-of-care prompts generated by electronic information systems, together with policies making primary care providers responsible for care coordination, support appropriate timely screening.

Richard B Murray MB BS, MPH · Sue M Metcalf MPH · Philomena M Lewis AHW · Jacqueline K Mein MB BS, FACShM, MAE · Ian L McAllister FRANZCO

Objectives: To assess the accuracy of point-of-care (POC) measurements of capillary blood glucose and glycosylated haemoglobin (HbA1c) levels in a remote Aboriginal community with high diabetes prevalence.Design: Cross-sectional study comparing POC capillary glucose and HbA1c results with those from corresponding venous samples measured in a reference laboratory.Participants and setting: 152 residents aged 11–76 years (representing 76% of population aged over 11 years) had POC glucose measurement in November 2003; 88 with POC glucose level ≥ 5.0 mmol/L, or self-reported diabetes, had POC HbA1c and laboratory glucose and HbA1c measurements.Main outcome measures: POC fasting capillary levels of glucose (HemoCue Glucose 201 analyser, Medipac Scientific, Sydney) and HbA1c (DCA 2000+ analyser, Bayer Australia, Melbourne); correlation and mean difference between capillary POC and venous blood laboratory measurements of glucose and HbA1c.Results: Mean and median POC capillary glucose levels were 7.99 mmol/L and 6.25 mmol/L, respectively, while mean and median laboratory venous plasma glucose concentrations were 7.63 mmol/L and 5.35 mmol/L. Values for POC capillary HbA1c and laboratory HbA1c were identical: mean, 7.06%; and median, 6.0%. The correlation coefficient r for POC and laboratory results was 0.98 for glucose and 0.99 for HbA1c. The mean difference in results was 0.36 mmol/L for glucose (95% CI, 0.13–0.62; limits of agreement [LOA], − 2.07 to 2.79 mmol/L; P = 0.007) and < 0.01% for HbA1c (95% CI, − 0.07% to 0.07%; LOA, − 0.66% to 0.66%; P = 0.95), respectively.Conclusions: POC capillary HbA1c testing, in particular, offers an accurate, practical, community-friendly way of monitoring diabetes in rural and remote clinical settings. POC capillary glucose results should be confirmed by a laboratory test of venous plasma if the results are likely to significantly influence clinical decisions.

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 · Max K Bulsara MSc

Thirty per cent of the Northern Territory’s population are Indigenous Australians. Their cultural diversity and complexity is illustrated by the more than 50 different language groups that make up this population.1 Because of their high burden of disease, Indigenous Australians can at times occupy up to 60% of inpatient beds at Royal Darwin Hospital (RDH).2 This is particularly so in RDH’s Division of Maternal and Child Health, where the health status of Indigenous women and children is arguably the worst in the developed world. The conditions associated with Indigenous pregnancy include social issues such as high rates of smoking, alcohol ingestion, domestic violence and teenage pregnancy. Compounding these are medical problems, including hypertension, gestational diabetes and rheumatic heart disease.3 As to the outcomes of pregnancy, Indigenous neonates at RDH have not only high rates of prematurity, but also intrauterine growth retardation and a mortality rate three times that of the rest of Australia.4 The high burden of disease continues throughout childhood. For example, over the past 25 years, between 400 and 500 Indigenous children from remote communities have been admitted each year to RDH, most commonly with gastroenteritis. Associated comorbidities include malnutrition, iron deficiency, pneumonia, urinary tract infection, chronic suppurative otitis media and scabies (often secondarily infected).5 Although Indigenous people comprise 30% of the Territory’s population, less than 3% of the 1300 people employed by RDH are Indigenous Australians. There are four Indigenous people among some 700 nurses and two among 190 doctors. In 2003, the NT Health Minister, Peter Toyne, in announcing a new framework for the NT Department of Health and Community Services, laid down a challenge: “By the end of the decade, I want the world’s best practice health care for Indigenous communities in the Northern Territory. I want to see a time when we don’t have to keep talking about how bad the situation is.”6 Some 12 months later, a proposal was put to the NT Department of Health and Community Services by RDH clinicians for a Centre of Excellence for Clinical Training in Aboriginal Health (Box). The proposed centre would deliver initiatives for the professional development of Indigenous health professionals — doctors, nurses, Aboriginal health workers and other health professionals — through the centre’s proposed Aboriginal Health Professionals’ Development Unit. If established, the centre would be the first of its kind in Australia. A Centre of Clinical Research Excellence in Aboriginal and Torres Strait Islander Health had recently been funded by the Federal Government at Flinders University.7 The proposal for a centre of excellence at RDH argued that, in providing the best clinical training in Indigenous health in Australia for postgraduate staff and medical and allied health students training at RDH, the centre would provide the impetus for creating key performance measures to benchmark RDH against the world’s best, and thereby identify gaps and areas for improvement. The centre would strengthen existing professional relationships with the Northern Territory Clinical School (which accepts students from Flinders University and James Cook University), the Bachelor of Nursing course at Charles Darwin University and the Menzies School of Health Research — institutions that all are located on the RDH campus. Furthermore, the proposal fits well with other exciting local initiatives, including the proposed Flinders University Inaugural Chair in Indigenous Women’s Health, to be located at RDH, and the Postgraduate Diploma in Indigenous and Tropical Child Health currently being considered by the Royal Australasian College of Physicians. One year on, the proposal is still a dream. Barriers to its implementation have come from several sources. Firstly, some public health physicians feel that the centre would distract focus from the primary care arena, in which the major challenges to Indigenous wellbeing are to be found. However, RDH is unique in having many senior clinicians across all specialities, who have provided specialist outreach to remote communities over many years. They have accumulated an enormous depth of experience in primary through to tertiary care of Indigenous people — experience that could be better utilised for clinical training through such a centre. Furthermore, by bringing on stream such a centre, RDH would be better placed to link with cross-sectoral initiatives such as the NT preventable chronic diseases strategy. Secondly, administrators, like their counterparts in most major Australian public hospitals, are so focused on the crisis management of access block, elective surgery and budget matters that future planning is often of low priority. Thirdly, health bureaucrats newly arrived in the Northern Territory are convinced that the objective of the proposal is not unique and should have been already embedded in RDH’s core business plans. They are not inclined to commit even the modest resources necessary to make the proposal a reality. This inertia should come as no surprise. It is par for the course in initiatives involving Aboriginal and Torres Strait Islander health. Strong leadership is required to overcome the bureaucratic and financial obstacles as well as the professional rivalries that are inevitably fuelled by change. The implementation of the proposal for a centre of excellence at RDH by NT doctors and other health professionals is seen as integral to realising the NT Health Minister’s vision for dramatic improvement in Indigenous health. It remains to be seen whether there is the leadership to achieve this vision. Key components of the proposal for a centre of excellence in Indigenous health at Royal Darwin Hospital (RDH) The development of a Centre of Excellence for Clinical Training in Aboriginal Health, including an Aboriginal Health Professionals’ Development Unit An employment strategy for RDH that incorporates responsibilities to the local population and Aboriginal staff into its core functions An increase in recruitment and retention of both Indigenous and non-Indigenous RDH staff Participation of a majority of RDH’s clinical staff in initiatives designed to improve understanding of Indigenous social and cultural issues A more acceptable hospital environment for Aboriginal patients Improved communication between RDH and Indigenous communities Acknowledgement and incorporation of traditional Indigenous practices into hospital protocols (eg, maternal health and birthing, men’s health) Improved Indigenous health outcomes in the Top End within 10 years Correspondence: Dr Paul A Bauert, PO Box 42531, Casuarina, NT 0811. paulbauertATozemail.com.au AntiSpam note: To avoid spam, authors' email addresses are written with AT in place of the usual symbol, and we have removed "mail to" links. Replace AT with the correct symbol to get a valid address. ©The Medical Journal of Australia 2005 www.mja.com.au PRINT ISSN: 0025-729X ONLINE ISSN: 1326-5377

Paul A Bauert

Objective: To evaluate the role of zinc and vitamin A supplementation in the recovery of Indigenous children hospitalised for acute diarrhoea.Design: A randomised controlled 2 by 2 factorial trial of supplementation with zinc and vitamin A.Setting and participants: Aboriginal children (aged < 11 years) hospitalised for acute diarrhoea at Alice Springs Hospital, Northern Territory, April 2001–July 2002.Main outcome measures: Duration of diarrhoeal illness; re-admission for diarrhoeal illness within 120 days.Results: Our study involved 392 Aboriginal children with 436 episodes of diarrhoea. Supplementation with zinc, vitamin A, or combined zinc and vitamin A had no significant effect on duration of diarrhoea or rate of re-admission compared with placebo. Median diarrhoea duration after starting supplementation was 3.0 days for the vitamin A and zinc supplemented and placebo groups (P values 0.25 and 0.69, respectively). The number of re-admissions did not differ significantly between those receiving vitamin A or zinc and the relevant placebo groups (relative risk [95% CI], 1.2 [0.7–2.1] and 1.3 [0.8–2.1], respectively).Conclusion: Vitamin A and zinc supplementation may not be indicated for in-hospital management of acute diarrhoeal disease in Aboriginal children living in remote areas. This finding may not apply to children with malnutrition, for whom other studies suggest a benefit. Larger trials incorporating more comprehensive data on the vitamin A and zinc status as well as nutritional status of study populations might help to explain the different results in different populations.

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

Clinical records Patient 1 A 31-year-old Indigenous man from a remote Cape York community was referred for investigation of weight loss from 57 kg to 36 kg over the previous 3 years. He drank alcohol heavily and had had seizures which were probably related to this alcohol use. He had diffuse crusted scabies and there was obvious wasting. His haemoglobin level was 90 g/L (normal range [NR], 130–180 g/L) with a mean cell volume (MCV) of 97 fL (NR, 80–100 fL). His white cell count was 11.4 × 109/L (NR, 4–11 × 109/L) with an eosinophilia of 4.34 × 109/L (NR, 0.04–0.4 × 109/L). The platelet count was normal. His ferritin level was 430 μg/L (NR, 30–300 μg/L) and levels of serum vitamin B12 and red cell folate were normal. The prothrombin time was 18 seconds (NR, 11–15 seconds). The albumin concentration was 16 g/L (NR, 35–45 g/L). Upper abdominal ultrasound showed diffuse increased echogenicity of the liver. Stools had no white cells, red cells, bacterial pathogens, ova, cysts or parasites. Skin scrapings confirmed the clinical diagnosis of scabies. Results of serological testing for HIV, strongyloides and coeliac disease were negative. He was deficient in vitamin A (0.1 μmol/L; NR, 1.6–2.3 μmol/L), 25-hydroxyvitamin D (< 12 nmol/L; NR, 25–150 nmol/L) and vitamin E (6 μmol/L; NR, 11–45 μmol/L). Despite a high-protein and high-calorie diet, on Day 13 of his admission his weight was 34.4 kg. Small bowel biopsies taken at upper gastrointestinal endoscopy showed partial villous atrophy and a significant increase in inflammatory cells within the lamina propria. The endoscopic findings suggested tropical sprue, and prompted commencement of doxycycline and folate therapy. His weight improved immediately, and on discharge 10 days later he weighed 38.5 kg. Ten weeks after discharge, despite continuing to misuse alcohol, he had gained 7.6 kg. His albumin level had increased to 33 g/L and the prothrombin time was 11 seconds. His haemoglobin level was 136 g/L, and white cell and eosinophil counts were normal. Patient 2 1 Upper gastrointestinal biopsy on Day 13 of admission 2 Upper gastrointestinal biopsy on Day 24 of doxycycline and folic acid therapy A 62-year-old Indigenous man from a community near Cairns presented for investigation of weight loss, diarrhoea and macrocytic anaemia. He drank alcohol heavily and weighed only 39.5 kg. Investigations showed a haemoglobin level of 73 g/L, MCV of 97 fL, a white cell count of 3.9 × 109/L and a platelet count of 97 × 109/L (NR, 150–400 × 109/L). The blood film showed hypersegmented neutrophils and macrocytes. His serum vitamin B12 level was normal and red cell folate level was < 73 nmol/L (NR, 295–1800 nmol/L). His ferritin level was 244 μg/L. His potassium level was 2.3 mmol/L (NR, 3.4–4.5 mmol/L) and creatinine clearance was normal. His albumin level was 30 g/L, but other liver function test results were normal. Thyroid function was normal. Upper gastrointestinal endoscopy and biopsy performed on Day 13 of admission showed partial villous atrophy and increased inflammatory cells in the lamina propria (Figure 1). Therapy with doxycycline and folic acid was begun on Day 17 of admission. Follow-up endoscopy and biopsy 24 days after commencing this therapy showed a persistent inflammatory exudate, but an improvement in the villous appearance (Figure 2). By discharge, his haematological and biochemical test results were normal, his diarrhoea had stopped and his weight had improved to 47.3 kg. Patient 3 A 66-year-old Indigenous man from a community near Cairns was referred for investigation of diarrhoea and weight loss. He had previously had a hemicolectomy for diverticular disease. He had lost 15 kg over 3 months and was having significant diarrhoea. In the week before referral he had shortness of breath on minimal exertion. On examination, he weighed 42 kg and was emaciated. Investigations showed a haemoglobin level of 64 g/L with an MCV of 108 fL, a white cell count of 2.6 × 109/L and a platelet count of 40 × 109/L. A blood film showed hypersegmented neutrophils and macrocytes. His serum folate level was 3.2 nmol/L (NR, 6.6–35.3 nmol/L), vitamin B12 level was 137 pmol/L (NR, > 210 pmol/L) and ferritin level was 408 μg/L. The prothrombin time was 14 seconds. His sodium level was 129 mmol/L (NR, 135–145 mmol/L), potassium level was 1.6 mmol/L, urea level was 8.2 mmol/L (NR, 2.5–8.0 mmol/L) and the creatinine level was 0.16 mmol/L (NR, 0.05–0.12 mmol/L). Liver function test results were otherwise normal. Stool microscopy showed no white or red cells, ova, cysts or parasites, and no bacterial pathogens. Upper gastrointestinal biopsy performed on Day 4 of admission showed atrophic villi and an inflammatory infiltrate in the lamina propria. Vitamin B12 and folate supplementation were commenced on the day of admission and doxycycline therapy on Day 7. In the first week of antibiotic therapy, he gained 3 kg and his diarrhoea stopped. His white cell and platelet count became normal and haemoglobin level improved to 79 g/L. His biochemical test results normalised entirely. He was discharged home on Day 12 and booked for repeat endoscopy, but did not return. The clinical presentation, histological findings and response to tetracycline and folate therapy in our patients, seen at Cairns Base Hospital between 1998 and 2004, support a diagnosis of tropical sprue. To our knowledge, these are the first reported cases in Australia. All of our patients were Indigenous patients living in remote Indigenous communities. The alcohol use by the first patient clouds the picture, as high alcohol intake is associated with nutritional deficiencies. However, the partial villous atrophy on biopsy is more suggestive of tropical sprue. Additionally, despite being in hospital and not drinking alcohol for 2 weeks, there was no response in his weight or biochemical test results until therapy for tropical sprue commenced. Finally, his weight gain and improvement in biochemical test parameters continued despite ongoing alcohol misuse on discharge. Seeing resolution of the histological changes in all the patients as they responded to treatment would have been desirable, but their remote location and the fact that two did not attend for follow-up made this difficult. It would also have been interesting to examine the small bowel flora of the patients, but this was not prospectively considered. The absence of an agreed definition for tropical sprue has created difficulties. It has been noted that many asymptomatic people living in the tropics will have subclinical malabsorption and even abnormal small bowel biopsy results when rigorously assessed. Uncertainty in the diagnosis of tropical sprue is compounded by the condition’s incompletely understood aetiology. It is proposed that gastrointestinal infections, which occur at a higher rate in the tropics, cause mucosal injury and initiate the process. The mucosal injury leads to a disturbance in intestinal motility, allowing the overgrowth of coliform bacteria in the small bowel.1,2 Enterotoxins from these bacteria potentiate the mucosal damage which leads to malabsorption and protein loss. The resulting nutritional deficiencies hinder epithelial recovery, and a vicious circle develops. Alteration in the intestinal microflora may also lead to a change in toll-like receptor signalling and further retardation of intestinal healing.3 It seems likely that tropical sprue is not a single disease, but rather a pathophysiological process with heterogeneous manifestations resulting from subtle differences in the interplay of the initiating infection and the patient’s diet, living standards and genetics.4 A milder form of the process may lead to asymptomatic abnormalities — sometimes referred to as tropical enteropathy — while more severe expression may lead to the classical debilitating tropical sprue syndrome. The nature and the extent of the nutritional deficiencies are likely to be related to the duration of the disease and the extent of bowel involved. Admission rates for gastroenteritis in Australia are nearly seven times higher in Indigenous communities than in non-Indigenous communities. Rates are also higher in regional and remote areas than in urban settings.5 Our own analysis of hospital separation data from Queensland’s northern zone for 1996–2001 shows an age-standardised hospital separation rate for gastrointestinal infection 2.32 times higher for Indigenous patients than non-Indigenous patients (95% CI, 2.17–2.48). A number of studies of chronic diarrhoea in Indigenous Australian children have documented partial villous atrophy on small bowel biopsy.6,7 Higher colony counts and more frequent isolation of gram-negative organisms are found in duodenal aspirates from Indigenous children with chronic diarrhoea.8 Some of these studies noted a similarity with contemporary Indian studies of tropical sprue, but therapy with antibiotics and folate does not seem to have been considered in the Indigenous children. Our anatomical pathology service believes that small-bowel biopsies from Indigenous patients from remote communities do show a subtle increase in inflammatory cells (Dr M Jagusch, Anatomical Pathology Department, Cairns Base Hospital, personal communication), perhaps representing the subclinical tropical enteropathy described above. The relatively high incidence of gastrointestinal infections in these Indigenous communities may explain these histological findings and, by initiating the pathological process, may predispose these populations to tropical sprue. Dramatic presentations like those we describe are uncommon, but doctors working with remote Indigenous populations frequently encounter patients with evidence of milder nutritional deficiency. While there are many factors to consider in the assessment of poor nutrition in this population, and tropical sprue is a diagnosis of exclusion, the availability of a cheap, safe and rapidly effective treatment mandates that the diagnosis be considered in the appropriate clinical situation. Lessons from practice Tropical sprue should be considered in patients presenting with chronic weight loss, diarrhoea and nutritional deficiency. While the aetiology of the disease is by no means clear, the high rates of gastrointestinal infection in remote Indigenous communities may predispose this group to the condition. Tetracycline and folic acid therapy can be rapidly and dramatically effective, although the tetracycline course should continue for 3–6 months.

Joshua P Hanson MB BS, DTM

It takes humility to walk along the path towards better Aboriginal health Marni and her two cousins crowded together on our couch watching the Saturday footy. Like many of the Aboriginal children who regularly visited us, they laughed and chatted and found fun in almost everything. We were all still damp after a cooling swim at the nearby waterhole, and were about to tuck into a freshly baked cake from our oven. It seemed there could be nothing better. But 8-year-old Marni was unusually breathless. In fact, she was wheezing and gasping for air. With a stethoscope we could hear the crackles of pulmonary oedema. A few months earlier she had spent several weeks in hospital, and there had been talk that she might need valve replacement surgery. She narrowly avoided it then. Now her cardiac failure had worsened again. Marni has rheumatic heart disease — a disease of poverty and overcrowding. We had never seen a case before we went to work in Yambarr. However, in this small community of about 900 people, at least 25 have rheumatic heart disease. As doctors, we had sought the challenges of working in a remote Aboriginal community. Admittedly, we also found some romantic appeal in the mythical and timeless aspects of Aboriginal culture, which are said to embrace the earth, its creatures and the spirit world in what is often referred to as The Dreamtime. Inevitably, however, we found real people living lives of hardship. More than finding The Dreamtime, we were awakened to some stark realities about health in remote communities. Yambarr Aboriginal communityYambarr is hundreds of kilometres from the nearest city. From the air, the collection of tin roofs and shady trees is hardly noticeable in the rugged landscape traversed by vein-like rivers quivering in the 40 degree heat. Closer up, a permanent waterhole can be seen, flanked by scattered houses, a school, a store and a police station, and the ramshackle old clinic. The clinic’s exterior is adorned with traditional paintings of animals and birds, once radiant but now faded and peeling, weathered by years of monsoonal storms and grassfires. The doors and windows are barred, and ageing plywood inserts take the place of occasional missing panes. Standing outside, hearing only the rattle of straining air conditioners, it seems a long way from modern specialised medical centres. Inside, however, activity thrives in the relative coolness. Patients, families, and staff mill among the five consulting rooms, the drug dispensary and the emergency room. Lining the corridor are posters of Aboriginal athletes and footballers bringing health messages. This clinic has three nurses and six Aboriginal health workers — men and women who work as clinicians, interpreters and cultural aids for transient non-Aboriginals like us. Non-Aboriginal people have been in the area for a little over 100 years, a tick of the clock compared with the more than 40 000-year history of Aboriginal people. Nevertheless, white traders, missionaries and developers have left no corner untouched. Indigenous communities today are melting pots of traditional and modern ways. Coca-Cola and ice-cream go well with a meal of fresh kangaroo. Faded jeans, Nike shoes and stereos are just part of the scene at tribal dances and cultural ceremonies. Children like Marni seem to embrace both their traditional and modern worlds with an ease and simplicity that only children know. But the postcard pictures of painted faces, spears and boomerangs conceal some unspeakable suffering. Tucked away in the remote outback, communities like Yambarr are Australia’s equivalent of urban slums, where poverty, illness, illiteracy and unemployment coalesce in vicious circles. Nationally, Aboriginal people die on average 20 years earlier than other Australians, half before the age of 50 years. Rates of chronic disease and substance abuse are increasing. On nearly every social, economic and health indicator Aboriginal people are much worse off. The human faces of disadvantageLiving in Yambarr we saw these statistics in the faces of our friends, neighbours and even the clinic staff themselves. Within months of our arrival, two important Aboriginal men in the community had myocardial infarctions. One was a health worker and the other a community councillor. Both were still in their 20s. Never had we seen AMIs at such a young age. The first, Elijah, died only minutes after he had been laughing with us in the tearoom during a busy morning clinic. Then he was on the floor, his lifeless eyes staring at us, surrounded by monitors, tubes and wailing patients. We had no defibrillator, and he died amidst our helplessness. Only weeks later Bill collapsed during a football match and his team-mates carried him in, his black face pale with fear. Bill had been our chaperone when we arrived in the community, ensuring that we were welcome and safe, involving us in community activities and including us into his family. He survived his heart attack, receiving thrombolytic treatment as he lay on a trolley at Yambarr’s desert airstrip, shaded from the sun by the wing of a twin-propeller air ambulance. Such inexplicable events occurred with tragic frequency. The statistics dissolved into the faces of people we knew — at work, in the street, down at the shop, hanging around the playground. From a medical perspective, three words seemed to describe our patients’ lives (in so far as words could capture them) — “hardship”, “sufferance” and “invisibility”. Hardship refers to the struggle of daily living. In Yambarr 900 people live in fewer than 70 dwellings, lined up in neat rows and differing only in the colour of their faded exteriors. Bill’s mother, Marjorie, rents a three-bedroom, orange-painted house covered with graffiti. Its concrete floors are cracked, its window screens are broken, and the plumbing occasionally blocks. Bill lives there with his family, and so do his brother and sister and their families, usually more than a dozen people. The children play in the small yard — mud in the wet season and dust in the dry — among free-roaming, unhealthy looking dogs that pick through scraps. Both Bill and his brother have been wait-listed to rent another home for over 10 years, but a new house has not become available. Despite the popularity of hunting and fishing, families have become accustomed to shopping for food at the Yambarr store. Due to the heat and distance from markets, the supply of fresh fruit and vegetables is limited, and what is available is very expensive. Most families buy tinned produce, which may be high in fat and sugar. Most available hot food is greasy and fried. When Bill was told in hospital that he had impaired glucose tolerance, like at least 100 of the adults in Yambarr, he knew a suitable diet would be virtually impossible. Alcohol is also part of the hardship, especially for children who grow up with the impression that drinking, often excessively, is a normal part of adult life. Youth programs have been short-lived, and in the end the only established gathering place for entertainment for anyone, including kids, is the licensed club. For many Yambarr people there is simply no escape from the hardship of daily existence and few opportunities to improve their situation. Housing management, the running of the store and the activities of the club depend, to a greater or lesser degree, on externally provided non-Aboriginal contractors and administrators. Poor literacy is one of the biggest barriers to local Aboriginal people assuming real responsibility in imposed systems that are complex and unfamiliar. Bill and Elijah were quite exceptional in completing vocational training. A recent independent inquiry into Aboriginal education reported that only 4% of Aboriginal students in remote communities reach national reading benchmarks at fifth-grade level, compared with 80% of non-Aboriginal students. It also revealed that many leave school with English literacy and numeracy levels equivalent to 6 or 7 year olds and are, therefore, virtually unemployable. The fact that many are fluent in at least three or four other Aboriginal languages helps little when hunting for a mainstream job. We wondered about this as Marni (despite her breathlessness) and her cousins laughed, smiled and chatted away on the couch. They variously attended school, sometimes every day, sometimes less frequently. Their parents all had an English-speaking education, but most were now unemployed, because few jobs existed in Yambarr, and the big city was a hostile, unfamiliar white-person’s place away from family and friends. It’s easy to imagine that they had seen little value in their own education, and hence were often indifferent about their children’s school attendance. Furthermore, it is well known that good nutrition and good hearing are essential for learning. Yet, in remote areas, 20% of Aboriginal children younger than 5 years are underweight, and almost four out of five children have hearing disabilities. In some communities the prevalence of chronic otitis media has been recorded as 50%, more than 10 times that which the World Health Organization regards as a significant public health problem. Sufferance describes a resignation to illness that we found both perplexing and disturbing. We were amazed that families could quietly tolerate such sickness. Perhaps, in the context of so much disease, people grow up expecting illness as part of life. Perhaps they are unaware of available treatment. Many parents seemed unworried when pus oozed from their children’s ears. Even Bill’s cheerful 7-year-old daughter, Stephanie, had recurrent ear infections and perforated ear drums. Although Bill’s mother was a health worker, both of them seemed to be as numbed by the sheer prevalence of illness as nearly everyone else in Yambarr. Over the years they had developed no better expectations. Invisibility refers first to the level of undiagnosed and untreated illness in the community. Many chronic diseases, for example, do not become apparent to local health care providers until acute complications present. In Bill’s case, it was only after his heart attack that he was found to have rheumatic heart disease. Rheumatic heart disease provides a good illustration of the invisibility of Aboriginal peoples’ health problems to metropolitan specialist centres — despite our clinical experience, there remains a perception among some that rheumatic fever has been eradicated from Australia. Invisibility also refers to our impression that, in many ways, progress has passed by communities like Yambarr, and that many well-meaning health professionals have little understanding of Aboriginal people’s difficulties obtaining health care. Even when disease is recognised, barriers to accessing mainstream health services arise because of cultural differences, language and communication difficulties, remoteness and poverty. Forty per cent of Aboriginal communities are over 250 kilometres from the nearest hospital, most without regular public transport. From Yambarr, a simple 15-minute hospital appointment requires a day of travelling in each direction and two nights’ accommodation at crowded urban hostels. A recent survey at one hospital’s outpatient clinic showed that nearly two-fifths of people from remote communities did not keep their appointments. Non-attendees’ appointments are usually rescheduled weeks later, and their travel subsidies are often forfeited. The reasons for such non-attendance are rarely straightforward. We realised this after we sought a specialist ENT opinion for Stephanie. She and two other children waited 10 weeks for an initial appointment. Stephanie’s grandmother accompanied them in the back of a Toyota Troopcarrier to meet the public bus about 200 kilometres away. This bus service provides both public transport and occasional tourism. The non-Aboriginal driver often gives an en-route commentary about Aboriginal culture, much to the amusement of any Aboriginal passengers. This time, however, we found the old lady and the three children still at the bus stop long after the bus had departed. Embarrassed and ashamed, they asked us for a ride home. They explained that the driver had refused to let them board because they had no shoes, despite the fact that Aboriginal people in Yambarr rarely wear them. The driver had promised that he would wait while they purchased some in a nearby store. When they returned with the footwear only a few minutes later, the bus was gone. On the way home we lamented the effort that went into organising their appointments, the disruption to their families and, above all, the fact that the children would have to wait another 2 months to see a specialist. So, on top of the long-lasting health effects of poor nutrition, overcrowding, alcohol and unemployment, Aboriginal people struggle to obtain the full benefits of modern health care. Even at the Yambarr clinic, their health seemed to take one step forward while they were there and two steps back as soon as they left. Much of the clinic’s work was “band-aid medicine” — a result of both insufficient resources and overwhelming social forces. As health professionals, we were humbled by our patients’ hardship, sufferance and invisibility. A sense of humilityHumility is not often discussed in the health professions. Everyone seems much more interested in modern medical triumphs. Humility instead refers to an awareness of one’s limits. In theology, it refers to a sense of “smallness” in relation to God’s greatness, encouraging receptiveness and solidarity with all people, especially the poor, “lowly” and “sinners”. To us, in Yambarr, humility had secular relevance. A sense of smallness was evident in many ways, including our limited ability to improve the health of Yambarr’s people. It’s not that our medical knowledge didn’t provide answers to many health problems. It usually did, one person at a time. (Marni, for example, eventually had a successful valve replacement in a hospital thousands of kilometres away.) It’s more that our training provided no simple answers to preventing the enormous burden of illness that existed in Yambarr or to overcoming the difficulties of getting modern health care to the people who need it most. Furthermore, problems of housing quality, alcohol-related harm and food quality often seemed insurmountable to the overstretched clinic staff. It would take a community-wide effort to improve these things. We felt solidarity with our patients and with the community. Getting to know the people as friends and neighbours, we realised that we shared common human values and goals — things such as health, love and happiness, the centrality of family and the importance of community, and the need to imagine a bright future. With them, we experienced the pain and frustration of their medical conditions and their difficulties getting treatment. We reflected their sadness about intractable problems that made the future seem so uncertain. Eventually, we found ourselves doing things that weren’t part of ordinary medical practice, such as participating in community projects and lobbying for various hospital and community improvements. For example, the clinic staff joined with other community organisations to address scabies, a skin infection that is a risk factor for rheumatic heart disease. After developing screening, surveillance and treatment programs, and producing locally an educational video, the prevalence of scabies infections in children under the age of three fell from 33% to 8%. At other times, after Elijah’s death, we were advocates, lobbying for cardiac defibrillators in communities. After all, they are available in shopping centres, sporting venues and ambulances in many parts of the world. And the central health services agreed. By the time we left, many communities in the area had them. But solutions to many problems are not so simple. By knowing the difficulties our patients faced, however, we felt obliged to bring these to the attention of others who may be more able than we are to bring about lasting improvements in Aboriginal health and community life. Doctors and other health professionals can do a lot for people in places like Yambarr, but not all of it uses tools from the traditional black bag. Much of it is about advocating for change, highlighting problems, and refusing to be passive about hardship, sufferance and invisibility. We learned that it takes humility to walk along the path towards better Aboriginal health. And most humbling of all is that, along that path, we have changed more than our patients.

Russell L Gruen MB BS, PhD, FRACS · Theresa F M Yee MB BS, FRACGP

Twelve months ago, in announcing the inaugural Dr Ross Ingram Memorial Essay competition, we invited Aboriginal and Torres Strait Islander readers to “tell us your story”1 related to Indigenous health. We cast our net as widely as we could, and, in the fullness of time, pulled in an impressive haul of high quality essays from students, academics, nurses, Aboriginal health workers and others from all over Australia. With the help of our external judges, an essay entitled Fish traps — a significant part of our health and wellbeing, by Geoffrey Angeles, has been unanimously selected as the winner. Fish traps tells the story of a traditional fishing method, now outlawed in the author’s home town of Darwin. But it is about much more — obesity, diabetes, heart disease, delinquency, substance abuse and other health and social problems abound among his people. Angeles writes, “If we were to turn back the clock, or gather data from yesterday, the answer or solution to many of today’s chronic ailments may lie in waiting”. Geoffrey (“Jacko”) Angeles is a Kungarakan man on his grandfather’s side and a Gurindji on his grandmother’s. He is an Indigenous Research Officer at the Menzies School of Health Research, but is better known in Darwin and beyond for his passion for fishing and preparing “bush tucker” on the ABC’s Indigenous arts program Message stick. Angeles’ essay is published in this issue of the Journal (page 541), and he will receive his prize of $5000 (donated by the Australasian Medical Publishing Company) at the Australian Medical Association’s national conference to be held in Darwin in late May. Three runner-up essays will be published in the Journal later in the year: Affirmative action in Aboriginal and Torres Strait Islander health by Yin Paradies, Telling you our story: how apology and action relate to health and social problems in Aboriginal and Torres Strait Islander communities by Wendy Hermeston, and A culture of ill-health: public health or Aboriginality by Chelsea Bond. From the other finalist essays, our judges have also selected some “poignant passages”, which are published in this issue (→ Passages). We are delighted with and humbled by the response to the inaugural year of the Dr Ross Ingram Memorial Essay Competition. We also thank the members of our external panel of judges. We look forward to drawing from the expanding pool of our Indigenous colleagues’ talent and inspiration in next year’s competition and beyond.

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

In the beginning . . . Once upon a time, there was a buzz of excitement and talk that echoed through the streets and homes of Darwin. This frenzied movement of people indicated that the fish trap hunters had returned! Bush telegraph was alive and well during those times. As a result, a gathering would culminate at a well known residence and then the bartering, haggling, and negotiations would begin! The reason: fresh fish, crabs, the odd prawns and other marine edibles were on sale. The women mainly controlled this part, for they were the bargain hunters and could square a deal even with the sweetest-talking miser. Women played a significant role in the fish trap business. This was the life of good old Darwin. It was the time when fish traps were operated by local people, for local people, and when money was scarce. Money is still scarce today, but the fish traps are no longer. The government told us “they are illegal”. “They are an eyesore”, “hazardous to other fishing craft”, and “impact on the crab and barramundi industry” were other comments made in opposition to the fish trap. We asked ourselves, is it because “they” have determined that fish traps impact on “their” business? . . . nothing in . . . this Act . . . shall limit the right of Aboriginals who have traditionally used the resources of an area of land or water in a traditional manner from continuing to use those resources in that area in that manner. Fisheries Act 1988 (NT)1 Geoffrey Angeles bags a barracuda. Gumboots protect against stonefish, stingrays, crabs, blue-ringed octopus, box jellyfish and other “nasties” in our tropical waters. The tradeFish traps were made using natural resources from the land. As changing times caught up with us, other materials were used. Hence, chicken-wire became the substitute for bush string, which was used to reinforce and strengthen the trap. The chicken-wire also kept the poles together, which were straight sticks sourced from a certain tree in the bush. They were cut down with an axe to form a point for spearing into the mud. The design of the trap and the nature of its use have always been the same. A tradition, custom, cultural business, call it what you will, but this way of fishing has been used for centuries and passed down and taught to generations. The “masters” of the fish trap business have since all but passed on, although there are a couple of apprentices of the masters who can still construct and manage this age-old custom. The fish trap builders were trained and taught the same way any person would undertake an apprenticeship, except the difference is that this would last a lifetime. New learnings and adaptations in this trade were continuous and would arise at any time. Why? Because we were utilising nature and, as we know, nature is always evolving and ever-changing — it never stagnates. The fish trap business has always been a dangerous and hazardous activity with hard, hot labour — but this was expected and therefore accepted. However, this wasn’t anywhere near the hardships we later encountered with introduced biased coastal development and fishing control mechanisms. These traps were strategically placed within coastal foreshores surrounding Darwin well before the government’s narrow-minded regulations were introduced. Damage to the environs of coastal mangrove estuaries and in open sea waters was virtually nil. While commercial fishing is a major source in the seafood industry, how often do we hear of discarded netting and other debris in our seas that become fatal traps for a variety of unsuspecting sea creatures? Couple this with fuel emission and oil spillages from a flotilla of commercial sea operators, and the fish trap business is, by contrast, right at the lowest end of the scale as far as impact on the marine environment is concerned. CrocodilesOne of our main threats was crocodiles, as they too were fish-eaters. But they had challenging opposition in the form of “the true local fisherman”. We were in crocodile country, and they were in our country (from a cultural aspect), so there was an element of respect, despite the opposition. We both wanted the same thing — fish. We were both dangerous to one another, but the smartest and wisest would win the day. Thank the stars, and touch wood — the local fisherman is still the victor today! The trap would have to be serviced at every low tide, with the fish taken out of the trap caught from the previous high tide. This meant clearing the trap at night and during the early hours of the morning. Tiredness was not an excuse, nor was it acceptable. You needed to be instantly alert, extremely aware, and know your capabilities and boundaries. The more remote the fish trap location, the more crocodiles there were hanging around the trap, waiting for an easy meal. At night we would be equipped with torches and riding shotgun. If the crocodiles were too close we would fire a shot in front of them, splattering mud on to them in a bid to scare them away to keep them at a safer distance. While the distance may have been only a stone’s throw away, we were able to work swiftly enough to clear the trap, with quick glances now and again to see where they were. They seemed to cheekily edge that little bit closer every time we would turn our backs. A bit like the game we played at school, except these guys weren’t playing! But as long as we could see them we were okay. The crocodile you can’t see is the most dangerous one, which is why alertness needed to be one of our strongest senses. Community development. Aboriginal self-determination. Knowledge and wisdom. ManI guess our greatest fear was that certain kind of man. This particular species had no respect. He would tie his boat up to one of the protruding poles affixed to the trap at high tide, drop his baited line down into the trap and catch all our fish! When we would go out to clear the trap at low tide, we would find strands of line, hooks and sinkers tangled up in the trap and hardly any fish. “This one” is much craftier than any crocodile. One good thing I guess is that “he” could never get to the crabs sitting on the bottom of the trap. If the trap was raided and there wasn’t the catch we were expecting, we would have to forage around in the mangroves for a variety of shellfish and the odd crab or two. We never failed to come back with a feed. Diet and healthFish, crabs, prawns, a variety of shellfish and other inland bush tucker were being consumed on a regular basis. Without realising it at the time, we had a rather healthy lifestyle. Routinely clearing the trap, along with some maintenance, ensured a regular exercise regime, plus some of these foods consumed had medicinal qualities. Thus it is to this diet (traditional hunter-gatherer) and life style that we should turn when seeking explanations for (and solutions to) the characteristic pattern of chronic disease which emerges in all populations when they become more affluent economically and adopt a sedentary, westernized way of life.2 Today . . . unfortunately, and sadly, many of our people are suffering from an increase in a variety of chronic conditions ranging from cancers, diabetes, heart disease and stroke to other debilitating illnesses — associated with poor diet, reduced activities and exercise, and other unhealthy lifestyle habits. SolutionsMore effort and a greater level of importance needs to be directed towards strategies in practical and inexpensive prevention. 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. As a young boy growing up in Darwin, it was quite rare to see someone in a wheelchair. I remember an uncle having one leg, but he lost it as a serviceman in the war. He walked with his wooden leg and also played tricks on us as kids. Multiple amputations because of diabetes were virtually unheard of in the old days. Why was this? Could it be because of the diet back then, together with an abundance and sustainment of activities, such as sport, hunting, fishing and other regular recreational events? Australian Aborigines develop a high frequency of type-2 diabetes when they make the transition from a traditional to an urban life-style.3 If we were to turn back the clock, or gather data from yesterday, the answer or solution to many of today’s chronic ailments may lie in waiting. Donald (“Dookie”) Bonson using chicken-wire to make baskets to carry the fish. Fish trap in background. The next generationToday we have an increasing trend towards youth dysfunction associated with crime, violence, suicide and other associated factors. Is this linked to varying forms of mental illness associated with limited family connectedness, negative peer group pressure, or some early childhood abuse or neglect? Maybe it’s the hyperactivity of the “neon world” which attracts and lures them like moths to bright lights. This may momentarily help blanket out or blur the vision of a fragmented childhood, but they still have to wake up the next day. Development, tourism, a fast pace, and a “keeping up with the rest” attitude can leave a drastic legacy in its wake. If you can’t keep up or don’t fit in, you get left behind and easily forgotten. So how can we create and foster a healthier lifestyle for a healthier next generation? Our children and young people need adventure, excitement, nurturing and opportunity in all the right ways. Until such time as someone comes up with real activities for excitement-starved youth, they will be encouraged and persuaded to seek other good things in the neon world . . . but at an unhealthy price! Things like drugs, alcohol, adolescent pregnancy, aggressiveness and, eventually, low self-esteem are the result. What if . . .?Gather up all youths who work for the dole or who are on a community development employment program and ask those wanting to mow lawns, pick up rubbish, do sweeping, hedging, etc, to move to the left. Then ask those wanting to fish and learn about Indigenous coastal and land management practices, including Indigenous health and wellbeing, to move to the right. What would you pick? The fish trap business will create a feeling of achievement, pride, identity, a sense of belonging and something a bit more significant as far as contributing to community health and wellbeing is concerned. TodayNutritionists and doctors tell us today to eat at least two fish meals a week to prevent chronic conditions such as heart disease, stroke, some cancers, and type 2 diabetes. Regular exercise, other good dietary products (eg, fruits and vegies) and limited use of unhealthy substances (smokes, alcohol, other drugs, etc) increase our chances of living a longer and healthier life. It is almost as if we are being told by the new-age researchers about something we may have known all along, but yet had no control over sustaining it! Today there is a national focus on obesity, unhealthy diet, substance misuse, etc, which leads to a range of chronic illnesses, almost as if it is groundbreaking news! Well, maybe for the young, but not for many middle-aged and elderly people who once had and practised healthy lifestyles — but had them disrupted in some way. Tomorrow?The commercial fishing industry, tourist development and infrastructure, a massive gas pipeline project, mining, pollution and pumping effluent into our waterways and coastal areas have made hunting and gathering of fish and other marine edibles much harder. However, there are still some small pockets of undisturbed areas where we can resurrect some healthy traditional practices of yesterday. I am hoping that these delicate areas can remain undisturbed and protected from development. Indigenous health needs urgent attention and practical action now.

Geoffrey A Angeles BAppSc

“After several attempts at community meetings and extensive consultation with people in the communities, I returned to basics. What are the traditional ways of passing on information in Aboriginal communities? The answer came from my childhood and family environment. Information is usually passed on by family and friends at small gatherings in familiar and informal surroundings. Information passes quickly through the community by word of mouth, a ripple effect from the original gathering. This led me to develop a new format for my heart-health meetings — small gatherings of friends or family, with a meal and a talk hosted by a respected community member who was trained as a lay educator to deliver the message on the link between lifestyle and cardiovascular disease.” From: Spreading the word on cardiovascular health: report of a study aimed at developing a culturally appropriate method for delivering health messages to Indigenous Australians by Julie Owen, Finalist, Dr Ross Ingram Memorial Essay Competition "There was also the fear of the unknown. I got to thinking about the needle going into my eye. What if it went through and hit my brain somehow? What if the operating team thought that this was a stupid Aboriginal woman screaming her head off when she was out to it? What if I came out with one eye missing? Would they chuck it down the drain or keep it to show me what a diabetic eye looked like? Those were only some of the thoughts going through my mind. . . . There should be more Aboriginal health workers trained to have not only clinical skills but language skills brought to the area so that they can go into the homes or community and talk, demonstrate and teach them. They should work in schools with Aboriginal and Islander education workers.” From: Am I living in my grandmother's shoes? by Elizabeth Lockyer, Finalist, Dr Ross Ingram Memorial Essay Competition “We need to talk about such things as the words ‘health’ and ‘sickness’ that are imposed upon us as a group of people. You need to explain fully what you mean by ‘sickness’. How can I be ‘sick’ when I am still enjoying life? I can still drink, walk around, and play cards, so I can’t be sick. And what is ‘health’? . . . We as people who work in Aboriginal health become so overwhelmed by the enormity of the problems, both in and out of our work place, that we never really ‘knock off work’, so to speak. We have no avenue to debrief; we even get to the stage where we actually have to determine which is the most appropriate or highest-priority funeral to go to.” From: Indigenous health by Pamela J Hunter, Finalist, Dr Ross Ingram Memorial Essay Competition

To the Editor: We read with interest the recent cross-sectional survey of Helicobacter pylori infection in remote and urban Aboriginal populations in Western Australia.1 The prevalence of H. pylori was shown to be consistent with that in developing countries. This is not surprising, given the high prevalence of diseases such as chronic suppurative otitis media, rheumatic fever, scabies, and tuberculosis affecting Aboriginal peoples — all of which relate to poverty and overcrowding.2 Aboriginal and Torres Strait Islander people have a massively disproportionate share of the overcrowded households in Australia. In the 2001 Census, Aboriginal people in WA accounted for 53% and 93% of the two-bedroom and three-bedroom households that accommodated seven to nine and ten or more people, respectively (from 3% of the population).3 Windsor et al speculate that high H. pylori infection rates may be the result of children not wearing nappies and of poor personal hygiene — even though these matters (and housing standards, the presence of functional washing facilities and the degree of overcrowding) were not investigated. We are concerned that such conclusions reflect negatively on the Aboriginal population who took part in the survey in good faith with good will. Moreover, it is misleading to suggest that H. pylori is a cause of poor growth among Aboriginal children. There is insufficient evidence to support screening for H. pylori infection in children, as no studies have demonstrated that treating H. pylori infections improves their growth. It is expected that “some of the participants who tested positive for H. pylori have asked to be treated with antibiotics”. We assign considerable importance to research protocols that adhere to the criterion “no research proceeds without service”.4 Did those who were H. pylori positive with dyspepsia, a history of peptic ulcer complications, or a family history of gastric cancer5 receive treatment? Windsor et al do not describe what follow-up their survey participants received. Without clarity on this point (especially appropriate advice to those who were asymptomatic), we wonder what negative impacts a positive H. pylori finding had on participants’ social and emotional well-being. We are concerned by the authors’ anthropological musings: “Indigenous people may have their own H. pylori strains”. Given Australia’s heterogeneous Indigenous population, this potential research question is of no strategic relevance.4 The promotion of expanded testing for H. pylori is not supported by the evidence. Talley’s accompanying editorial prioritises a “randomised controlled trial to test the health benefits (and risks) of population-based screening and antibiotic treatment [for H. pylori] in Indigenous Australians”.5 In the absence of a clinical endpoint for an as-yet undefined health problem, there is no convincing argument for such a trial. Narrow medical answers to health problems that ignore economic and environmental solutions are not evidence-based. Both articles should have argued strongly for political commitment to these solutions to address a wide range of existing poverty-related diseases which currently affect Abori-ginal and Torres Strait Islander people on a massive scale.

Naomi R Mayers · Sophie Couzos · Richard Murray · John Daniels

In reply: We agree with Mayers and colleagues that the vexing issue of Indigenous health is a political one. We undertook this study because we thought it very strange that the prevalence of Helicobacter pylori was known in most populations on the globe, but not in Australian Indigenous people. Results from each participant in the study were forwarded to the clinicians at the test sites. These results were discussed with the participants and those who needed, or asked for, treatment received antibiotic therapy. In a previous editorial in the Journal, Mayers and Couzos state that “preventive health assessments are obviously needed earlier, given the occurrence of preventable chronic disease at younger ages and higher rates than in other Australians”.1 We agree with this, and it is to be hoped that our data will encourage further assessment and awareness of H. pylori infection in people of all ages in the Australian Indigenous community.

Barry J Marshall · Helen M Windsor

Objective: To investigate whether Indigenous Australians with cancer have more advanced disease at diagnosis than other Australians, and whether late diagnosis explains lower Indigenous cancer survival rates.Design: Retrospective cohort study.Setting and participants: Indigenous and non-Indigenous people diagnosed with cancers of the colon and rectum, lung, breast or cervix and non-Hodgkin lymphoma in the Northern Territory of Australia in 1991–2000.Main outcome measures: SEER summary stage of cancer at diagnosis (local, regional or distant spread), cause-specific cancer survival rates and relative risk of cancer death.Results: Diagnosis with advanced disease (regional or distant spread) was more common for Indigenous people (70%; 95% CI, 62%–78%) than for non-Indigenous people (51%; 95% CI, 53%–59%) with cancers of the colon and rectum, breast, cervix and non-Hodgkin lymphoma, but for lung cancer the opposite was found (Indigenous, 56% [95% CI, 46%–65%] v non-Indigenous, 69% [95% CI, 64%–75%]). Stage-adjusted survival rates were lower for Indigenous people for each cancer site. With few exceptions, the relative risk of cancer death was higher for Indigenous people for each category of stage at diagnosis for each cancer site.Conclusions: Health services apparently could, and should, be performing better for Indigenous people with cancer in the Northern Territory, and probably elsewhere in Australia. This study has demonstrated that data from cancer registers, enhanced with data on stage at diagnosis, can be used to monitor health service performance for Indigenous Australians in the Northern Territory; similar data is available in other States, and could be used to monitor health service performance for Indigenous people throughout Australia.

John R Condon MPH, FAFPHM · Tony Barnes MSc · Bruce K Armstrong DPhil · Sid Selva-Nayagam FRACP · J Mark Elwood MD

If Indigenous Australians are at high risk of H. pylori infection, the associated risks of peptic ulceration and gastric cancer may make screening and treatment necessary Interest in asymptomatic Helicobacter pylori infection seems largely to have waned in much of the developed world.1-3 It is almost universally accepted that H. pylori causes chronic gastritis and peptic ulcer disease,1-3 and the evidence that the infection also causes gastric adenocarcinoma is virtually unassailable.1-4 In high-risk populations, at least, prevention of gastric cancer by H. pylori eradication is theoretically feasible, although convincing clinical-trial evidence is lacking.2-5 However, perhaps because the incidence of gastric cancer is steadily declining in developed nations (and because H. pylori infection seems to be much less often acquired these days), interest in its prevention remains remarkably low key.1,2 Australian Aboriginals and Torres Strait Islanders are much more likely to suffer ill health and die at a younger age than non-Indigenous Australians.6 However, one health scourge that the Indigenous population seemed to have missed, despite their lower socioeconomic status, was H. pylori infection and its complications.7 For example, seroprevalence studies suggested H. pylori infection was very rare.7 The report by Windsor and colleagues in this issue of the Journal (page 210) is at variance with these earlier findings,8 and strongly suggests that H. pylori infection is as common in Australia’s Indigenous population as it is in developing countries in South America, Africa and parts of Asia.3 If confirmed, these findings may have major health implications; indeed, the high prevalence identified in children8 implies a public health risk which will continue long into the future unless this situation is rectified. Notably, the findings of Windsor et al are limited to a small and possibly unique Indigenous group, and may not be more widely generalisable — more data are needed. However, the fact that over half the population in the remote rural communities studied were tested gives some confidence that H. pylori is remarkably widespread in this community (where 91% were found to be infected by means of a “gold standard” test). On the other hand, in urban Perth, referral bias can not be ruled out as accounting for the high H. pylori prevalence (60%), although the burden of infection remains strikingly high — if bias is the sole explanation, it would have to be particularly pervasive. What are the potential implications of these findings? Gastric adenocarcinoma remains a major health problem in the developing world.2 In the developed world, the consequences of H. pylori infection have arguably been underappreciated. In the United Kingdom, it has been calculated on the basis of relatively conservative assumptions that by age 85, and allowing for competing causes of mortality, the cumulative risk of dying from gastric cancer arising because of H. pylori infection is a staggering 1 in 51 for men and 1 in 96 for women.9 Data from the Northern Territory suggest that the rate of mortality from gastric cancer among Indigenous people has not increased.10 However, gastric cancer may become a much greater burden for the Indigenous population if, as is hoped, life expectancy improves from the current unacceptable median age at death of just 51 years.6 Older studies have suggested that peptic ulcer is uncommon in the Indigenous population,8 but, if Indigenous people undergo fewer endoscopies, this impression might be driven purely by referral bias. It has been calculated that, in the UK population, 1 in 154 men and 1 in 173 women die from peptic ulcer caused by H. pylori.9 The ulcer rates may, however, be truly low in Indigenous Australians, as undernutrition and lower socioeconomic status are associated with lower gastric acid secretion. This allows H. pylori to spread throughout the stomach (causing pan-gastritis and increasing the risk of cancer if people live long enough), but protects against ulcer disease.2,3 Circulatory disease, particularly ischaemic heart disease, is a major cause of mortality in the Indigenous population.6,10 Is H. pylori an important and modifiable risk factor for ischaemic heart disease? Unfortunately, the evidence for this is mixed and, at best, equivocal.11 Overall, widespread eradication of H. pylori to try to reduce ischaemic heart disease in this population is not currently justifiable. Other health problems in the Indigenous population just might be attributable to H. pylori, at least in part. Indigenous Australians have been reported to be more likely to give birth to infants who are small for gestational age,12 and H. pylori infection has been associated with growth restriction in young children.13 A Sydney study also found (among 448 pregnant women attending for routine examinations in the third trimester) that intrauterine growth restriction was twice as common in H. pylori-seropositive women than in seronegative women.14 This association was not explained by smoking or maternal height, although these were also independent risk factors for intrauterine growth restriction.14 While the data clearly need confirmation, the general health risks of a high carriage rate of H. pylori in Indigenous people may have been underestimated and may be another antenatal risk factor. Might H. pylori offer protection from some other diseases, and, if so, might attempts at its widespread eradication lead to more ill health in the Indigenous population? Such concerns have been raised,15 but seem overexaggerated and unlikely. In particular, recent data suggest that H. pylori eradication in peptic ulcer disease neither provokes reflux oesophagitis nor aggravates symptoms of gastroesophageal reflux.16 We need large, population-based intervention trials to define any risks, but whether it is wise to wait for such results before actively intervening remains debatable. H. pylori may be very common in Indigenous Australians, particularly among those living in remote parts of Australia. Future research needs to focus on the prevalence of H. pylori (and strains of different virulence) and the burden of dyspepsia in these populations. Although the exact route of transmission of H. pylori remains controversial, close contact within families is probably at least one key risk factor, and faecal–oral spread is feasible.2,3 Thus, strong consideration needs to be given to trying to reduce the acquisition of the infection in Indigenous children by reducing family crowding, and providing adequate sanitation and clean water. Doctors need to be aware that there may be a high risk of H. pylori infection in subpopulations within Australia. They should consider testing and treating Indigenous patients who present with dyspepsia (or non-ulcer dyspepsia), have a history of peptic ulcer complications, or have a family history of gastric cancer.2,3,17 However, to reduce the disease burden of H. pylori in the next 50 years, population screening and treatment may be the only solution. Assuming the data of Windsor et al are generalisable, a randomised controlled trial to test the health benefits (and risks) of population-based screening and antibiotic treatment in Indigenous Australians should be a government research-funding priority.

Nicholas J Talley MD, PhD, FRACP

Vaccination programs can act as a paradigm for effective health programs in Indigenous people The inferior health status of Indigenous Australians has been extensively reported1 and is linked inextricably to their ongoing social and economic disadvantage.1,2 Measures to decrease this health inequity are best focused on prevention and primary care as early in life as possible.2 Infectious diseases, although accounting for only a minority of the excess disease burden in Indigenous Australians,1,3 are particularly promoted by features of their disadvantage, such as overcrowding, poor infrastructure for health and hygiene, and poor nutrition. They are also more readily and rapidly targeted for intervention than chronic diseases.3 Vaccine-preventable diseases are particularly amenable to rapid and cost-effective prevention,4 and targeted vaccination programs have been shown to reduce health disparities.5 However, delivery of these programs, like other healthcare interventions, depends on culturally appropriate health services.2 The achievements and opportunities for vaccination programs to reduce morbidity and mortality among Indigenous Australians were highlighted in a recent report from the National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases (NCIRS). This provided the first national assessment of the burden of vaccine-preventable diseases and vaccine coverage in Indigenous Australians.6 It showed that universal vaccination programs with highly effective vaccines (eg, measles, mumps, rubella, poliomyelitis, diphtheria and tetanus vaccines) have achieved excellent disease control in Indigenous people, similar to that in non-Indigenous people. Findings are similar in other countries with comparable Indigenous populations.4 In contrast, when vaccination programs are more limited (eg, hepatitis A, hepatitis B, influenza and pneumococcal disease), hospitalisation and death rates continue to be higher for Indigenous Australians than for non-Indigenous Australians.6 The report also showed gaps in vaccination coverage for both children and adults. Children identified as Indigenous had comparable coverage to other children at age 2 years, but lower coverage at age 12 months, suggesting greater delay in receipt of vaccines. Among adults aged 50–64 years (for whom influenza and pneumococcal polysaccharide vaccine have been funded since 1999 for Indigenous people alone), vaccination coverage was higher for Indigenous people than for non-Indigenous people (47% v 26% for influenza vaccine and 20% v 3% for pneumococcal vaccine), but still suboptimal. For both vaccines, Indigenous adults had higher coverage in remote areas than in non-remote areas (75% v 45% and 48% v 19% for influenza and pneumococcal vaccines, respectively). These findings highlight two key issues: the potential for expanded vaccination programs; and the need to improve delivery of current programs, especially in non-remote areas. The value of expanded vaccination programs is compellingly demonstrated by data on hepatitis A and influenza. The recognition of high infection rates and three deaths from hepatitis A in far north Queensland in the 1990s7 led to a regional vaccination program targeting Indigenous children aged under 5 years from 1999. This virtually eradicated hepatitis A in both the Indigenous and non-Indigenous population.8 Similar results after vaccination of high-incidence populations have been documented in the United States and Israel.9 Yet, the NCIRS report documented hepatitis A as an issue for Indigenous Australians outside north Queensland, with national hospitalisation rates 57 times higher in Indigenous children aged under 5 years than in non-Indigenous children the same age.6 This highlights the potential of broader national application of the strategy, which is currently being examined by the Australian Technical Advisory Group on Immunisation. In addition, deaths attributed to influenza and pneumonia are significantly higher in Indigenous Australians.6 Among age groups either not targeted for influenza vaccination (0–4 years), or where only those with risk factors such as chronic cardiac or pulmonary disease are targeted (25–49 years), the respective mortality rates are 17 times and 28 times higher for Indigenous Australians than for non-Indigenous Australians.6 In contrast, among Indigenous adults aged 50 years and over, in whom universal influenza and pneumococcal vaccination is funded, the differential mortality rate is much less (three times higher). This suggests that the vaccination program has had an impact and justifies examining more closely the expansion of universal vaccination of Indigenous people to younger age groups. As to the delivery of current programs, several presentations at the Public Health Association of Australia’s national immunisation conference in 200410 were pertinent. The conjugate pneumococcal vaccine program (introduced in 2001) provided another example of the success of appropriately targeted vaccination programs, reducing for the first time, in 2003, the national incidence of invasive pneumococcal disease in Indigenous children under 2 years of age to the levels in non-Indigenous children.11 This is similar to the impact of such a program in the United States.4 Other conference presentations highlighted the problems of vaccination delivery to Indigenous Australians in general practice. Although general practice is crucial for vaccine delivery in non-remote areas, only 27% of respondents to a national survey of GPs had a routine system for ascertaining whether their patients are Indigenous.12 Yet, Aboriginal and Torres Strait Islander people are happy to be asked about Indigenous status, provided it is done respectfully, and the reasons are explained.13 Improving GPs’ identification of Indigenous status could help increase vaccination rates of Indigenous Australians in general practice, which are lower than those of non-Indigenous Australians,14 and is vital for targeted vaccination. Improving identification is particularly important in non-remote areas, where vaccination coverage of Indigenous people is consistently lower than in remote areas,6 and where the characteristics of successful programs — accurate data on vaccination status, active promotion and outreach services, and effective collaboration across community, health authorities and providers15 — are less likely to be found. Vaccination is a safe, well accepted intervention which offers an opportunity to develop solutions in healthcare delivery that can be applied more generally. Although vaccination programs targeted only to Indigenous Australians will have less impact than universal programs, particularly in urban areas where Indigenous status may not be identified, the higher burden of disease in Indigenous people will continue to make targeting attractive. However, to translate the success shown by regional targeted programs8 to the national level requires substantial investment to improve both data collection (eg, ascertainment of Indigenous status in general practice and completeness of the Australian Childhood Immunisation Register) and service delivery (through culturally appropriate and accessible services). Provision of resources for active program monitoring and coordination equivalent to that found in successful programs in more remote areas is needed.

Peter B McIntyre PhD, FRACP · Robert I Menzies MPH

Objectives: To determine and compare the prevalence of Helicobacter pylori in an urban and a remote rural Western Australian Indigenous community.Design: Cross-sectional study of Helicobacter pylori status determined by urea breath tests between mid-January 2003 and the end of June 2004.Participants: 520 self-selected fasting participants, comprising 270 members of the Martu community at Jigalong, Punmu and Parnngurr in the East Pilbara region (129 men, 141 women; age range, 2–90 years) and 250 people from the Perth Indigenous community (96 men, 154 women; age range, 3–75 years.Results: The overall prevalence of H. pylori was 76%, but the prevalence in the remote rural community was 91%, compared with 60% in the urban community. The odds of having H. pylori were six times greater for rural than for urban participants (odds ratio [OR], 6.34; 95% CI, 3.89–10.33). Further, the overall odds of H. pylori infection in males (rural and urban combined) were greater than for females (OR, 1.61; 95% CI, 1.02–2.54). In both communities, the prevalence of infection remained relatively constant after the age of 10.Conclusions: The prevalence of H. pylori in the two Indigenous communities was two to three times higher than that in the non-Indigenous Australian population and higher than that shown in previous studies in Indigenous Australians.

Helen M Windsor PhD · Susan D Morrow BA · Barry J Marshall FRACP · Emmanuel A Abioye-Kuteyi MB BS · Jacqueline M Leber RN · Max K Bulsara MSc

Indigenous Australians with cancer are twice as likely to die from the disease than non-Indigenous Australians. Because of this stark imbalance, the Cancer Council Australia recently convened the first-ever national discussion forum to address the issue. About 120 people from around Australia gathered in Darwin in August 2004 for the forum, “Reducing the impact of cancer in Indigenous communities: ways forward”. Originally conceived by the Cancer Council Australia as an internal event, planning for the forum tapped into a ground swell of concern about the poor outcomes for Indigenous Australians with cancer. This interest, combined with financial support from the Australian and Northern Territory governments, the National Cancer Control Initiative and the Cancer Council Northern Territory, turned the meeting into a major national event. Why a discussion forum?The past two decades have seen a 30% reduction in cancer mortality rates in Australia. However, at a meeting in late 2003, the board of the Cancer Council Australia reflected on the fact that recent successes in cancer control were not shared by Indigenous Australians and that we did not fully understand why. We were familiar with the rhetoric about limited access to services, cultural barriers and coexisting health problems, but, before we could work towards improving Indigenous cancer outcomes, the problems needed to be better understood. To this end, we invited Australia’s leading oncologists and epidemiologists with an Indigenous focus, academics, Aboriginal health workers and Indigenous cancer survivors to the forum. Organisational support from the National Aboriginal Community Controlled Health Organisation (NACCHO) helped us reach Aboriginal health workers from Australia’s most remote communities. The result was an unprecedented sharing of epidemiological, cultural and anecdotal Indigenous cancer data, with consensus on ways in which stakeholders could work together to effect measurable improvements. EpidemiologyThere is no simple answer to the question of why Indigenous people with cancer die at twice the rate of other Australians with cancer, nor is there a national dataset from which to draw. The inadequacy of data itself demonstrates the extent to which the problem has been overlooked. However, information gathering on a state and territory basis is improving significantly, particularly in South Australia and the Northern Territory. David Roder (Head of Epidemiology, Cancer Council South Australia) and John Condon (Senior Research Fellow, Menzies School of Health Research) explained that the comparatively high mortality rate is partly the result of Indigenous Australians getting “more than their share” of cancers with poorer survival outcomes, such as cancers of the lung, oropharynx, oesophagus, liver, gallbladder and pancreas. Conversely, Indigenous Australians have lower rates of some of the more curable cancers, such as breast, prostate, bowel and skin cancers. Delayed diagnoses in Indigenous people also contribute to poor survival rates, along with a reduced likelihood of completing treatment. These problems may explain why Indigenous Australians die at higher rates than other Australians, even when afflicted with the same cancer type. However, the forum also revealed other, less apparent factors. Penetrating insightsNgiare Brown (an Aboriginal medical educator and child health specialist with the NT Government) cited institutionalised racism, bureaucratic inaction, and a disconnect between Indigenous and non-Indigenous Australians as the underlying reasons behind the so-called “double burden” of disease suffered by Indigenous people. Brown also reminded the forum of other statistical inequities: twice the rate of low birthweight, and an overall life expectancy 20 years less than that of non-Indigenous Australians. A penetrating cultural insight came from Jeremy Baker Balung (an Indigenous man who works as a counsellor for Aboriginal and Torres Strait Islander cancer patients at Royal Darwin Hospital). Among Baker Balung’s Yolgnu people, each part of the body represents a spiritual link to individual members of the extended family; to have a cancer in a certain organ may be the result of offending the relative whom that part of the body represents. He emphasised the need to respect such beliefs, which are underscored by a deep regard for kin. A person who believes his or her cancer is “payback” for offending a family member may not pursue treatment. Respect and understanding must be reciprocal for people with such strong spiritual convictions; medical practitioners dismissive of time-honoured traditions may be unable to gain their patients’ trust. Cultural differences go hand in hand with communication barriers. For many Indigenous people, English is the second, third or fourth language, with multiple native dialects predominating in more remote communities. NT epidemiological data show that treatment outcomes are consistently poorer for all cancers in people whose first language is an Indigenous language. Access and distanceCancer is a difficult disease to treat remotely, and many Indigenous people live vast distances from urban centres. Sid Selva (Oncologist, Royal Darwin Hospital) described treating patients for whom arduous travel exacerbated the disorientation already induced by their diagnosis. The fact that Selva is the only resident medical oncologist in the “Top End” underscores a general problem with service provision in regional Australia. Michael Barton (Deputy Director of Radiation Oncology, Liverpool Hospital), who is author of a study of radiation services in the Northern Territory, expanded on the problems of distance, a reminder about the immobile and high-maintenance nature of radiotherapy hardware. Such problems reflect overall challenges for healthcare delivery in rural and remote Australia, which are compounded by the cultural, linguistic and socioeconomic barriers unique to Indigenous communities. Jacinta Elston (Associate Professor of Indigenous Health, James Cook University), herself an Aboriginal woman undergoing cancer chemotherapy, described the practical hurdles for anyone on the cancer journey and explained how they are considerably greater for most Indigenous people: no health insurance or income protection, limited understanding of prognosis and treatment options, the absence of an informed community, unfamiliarity with a hospital environment — all of it bewildering, particularly for people already at the margins of Australian society. Ways forwardThe forum sought “ways forward”, and the discussions and workshops mapped out paths towards improving the poor cancer outcomes for Indigenous people. Consistent throughout was the need for allied health agencies to form collaborative partnerships with Indigenous organisations and individuals. Our ignorance of complex yet imperative cultural and linguistic issues was laid bare at the forum and supported by the latest data. Only by engaging with people like Jacinta Elston and Jeremy Baker Balung in interface roles will we be able to break down these barriers. In response, the Cancer Council Australia is inviting Indigenous representatives to join its principal committees, is seeking to co-opt an Indigenous Australian onto its board, and is discussing a memorandum of understanding with NACCHO. Options will be examined to boost research on cancer in Indigenous people, ensuring it is undertaken with liaison officers and developed in ways that will give ownership of the data to Indigenous people, many of whom have reason to be sceptical about research given the history of European paternalism. Increased collaboration should be enhanced by efforts to build the capacity of the Aboriginal health workforce. Much will depend on government funding, and improved cancer control in Indigenous communities has now become a key cancer council advocacy goal. The signs are encouraging: the Coalition’s pre-election cancer policy included a national bowel cancer screening program, targeting Australians aged from 55 and Indigenous Australians aged from 45, indicating a shift towards policy adjustments consistent with the poorer health outcomes of Indigenous people. Cancer councils and their allies will also work towards factoring Indigenous issues into policy development and promotion at every step in the cancer journey, from prevention to palliation. There is no better example of the challenges of cancer prevention than smoking prevalence: 50% of the Indigenous population smoke, compared with about 20% of non-Indigenous Australians. To reduce this figure, again we must connect with Indigenous people and involve their organisations and communities in spreading the public health messages. The need to formally involve Indigenous people in service design and delivery also applies to cancer screening programs. Already there are signs of improvement, with targeted Pap smears contributing to a 50% fall in Indigenous cervical cancer mortality in the late 1990s. Palliation is also critical, particularly among people with such high rates of mortality and premature death. The Cancer Council Australia will look at educational tools to assist in the management of pain, dying and death among Indigenous communities. Our commitment is already well supported at state and territory level. The Cancer Council New South Wales’ recent employment of an Aboriginal liaison officer based in Dubbo and the release of a cancer information kit for Aboriginal health workers are excellent initiatives that could be applied nationally. These are all small steps towards a distant destination. But only through setting and achieving shorter-term goals will we be able to make an impact on the appallingly poor state of cancer outcomes for Indigenous Australians. The discussion forum reiterated the overarching themes of dispossession, hopelessness, grieving, racism, paternalism and abject socioeconomic status — seemingly insurmountable problems, but not when addressed with the sense of purpose, cooperation and strategic thinking evident at the recent national forum.

Ray M Lowenthal MD, FRCP, FRACP · Paul B Grogan · Ellen T Kerrins BNur

Fiona M Wood,* Bess V Fowler,† Daniel McAullay,‡ Jocelyn R Jones§ * Plastic Surgeon and Director, † Epidemiologist, Burns Service of Western Australia, Royal Perth Hospital, GPO Box X2213, Perth, WA 6847; ‡ Senior Policy Officer, § Manager, Office of Aboriginal Health, Health Department of Western Australia, Perth, WA. FionawATmccomb.org.au To the Editor: People with major burn injuries (50% total body surface area or more) now have an improved likelihood of survival with the implementation of aggressive treatment regimens, including supportive therapy, nutrition, and advances in the control of sepsis. Technological developments and treatments, particularly expedient wound closure, early surgical debridement, covering of large burn wounds, early skin repair,1 use of cultured epithelial autograft2 and ventilation,3 have also contributed to improved outcomes for people with these injuries. In Australia, there are inequities in access to health services which may particularly affect Aboriginal people.4 We therefore undertook a retrospective, observational study to compare the incidence of major burn injuries, clinical and demographic characteristics of patients with burns, as well as treatment and outcomes between Aboriginal and non-Aboriginal children and adults in Western Australia between 1992 and 2002. Potential cases were identified using data linkage from the Western Australian Department of Health. Raw data came from clinical records. Of the 84 people identified with major burn injuries, nine were Aboriginal (11%) and 75 were non-Aboriginal (89%). The incidence of major burn injury among Aboriginal people is greater than expected, as data from 2001 show that 3.5% of the WA population are Aboriginal. Aboriginal people with major burn injuries were younger than non-Aboriginal people with those injuries (mean, 21 v 35 years). Eight of the nine Aboriginal people (89%) had flame-only burns, compared with 33 of 75 non-Aboriginal people (44%). No statistically significant difference was seen between the groups in the percentage of total body surface area affected, provision of treatment (including number of operative procedures, applications of cultured epithelial autografts, units of blood products used, nasogastric feeds, and antibiotic doses) or length of hospital stay. We found that, although a greater percentage of Aboriginal people sustained major burn injuries, after this group entered the hospital system they experienced comparable levels of service and outcomes to non-Aboriginal people. Further research into burn care is warranted, from culturally and environmentally appropriate prevention through to critical appraisal of outcomes.

Fiona M Wood · Bess V Fowler · Daniel McAullay · Jocelyn R Jones

Objective: To determine the extent to which the Framingham function predicts the risk of coronary heart disease (CHD) in Aboriginal people.Design and setting: Cohort study in an Aboriginal community in the Northern Territory.Participants: 687 Aboriginal people aged 20–74 years were followed up from a baseline examination in 1992–1995 through to 31 December 2003.Main outcome measure: First CHD events were identified through hospital and death records during the follow-up period.Methods: An original Framingham function was used to predict CHD risk according to the duration of follow-up and the values of traditional risk factors, which included age, sex, total cholesterol level, high-density lipoprotein (HDL) cholesterol level, blood pressure, the presence of diabetes, and smoking status. The predicted CHD incidence using the Framingham function was 4.4 per 1000 person-years, while the observed incidence was 11.0 (95% CI, 8.7–13.9) per 1000 person-years. The observed number of CHD events (68) was 2.5 times the number predicted (27) using the Framingham function. The observed incidence was about four and three times the predicted incidence for age groups < 35 and 35–44 years, respectively, and about twice the predicted incidence for those over 45 years of age. The Framingham function was a particularly unreliable predictor for women, especially younger women, in whom the observed CHD rate was 30 times the predicted rate.Conclusions: The Framingham function substantially underestimates the actual risk of CHD observed in Aboriginal people in a remote community, especially for women and younger adults. This implies that traditional risk factors have different degrees of impact and/or that other factors are contributing to risk. A population-specific risk function is needed.

Zhiqiang Wang PhD, MSc, MB · Wendy E Hoy MB BS, BScMed, FRACP

We have a fabulous country out there, with lots of people who will benefit from our skills I was tired of seeing myself in my patients — white, middle-aged, middle-class, menopausal women — the “worried well”. It was time for a change. Time to leave my renovated terrace in inner Sydney. Time to put down the glass of champagne, cancel the subscription to the opera, put in storage my five pairs of boots from the Manhattan winter sales, and head off to “the bush” for a seachange. The bush was not an unknown entity for me. Although I’ve lived most of my life in cities, mainly Sydney, I was born in rural Wagga Wagga, the daughter of the first university-trained vet to practise west of the Blue Mountains. I spent my preschool days with my father, flying in a Tiger Moth to attend cows in obstructed labour, and delighting in watching his whole arm disappearing inside the birthing cow. So, my idea of what it would be like working in rural and remote Australia was partly based on these early experiences. Nonetheless, some of my friends were a little sceptical, viewing this decision as a whim, a blip in my middle-class, ABC Classic FM-saturated life. How wrong they were! I have ended up embracing wholeheartedly this wonderful life, committed to spending the rest of my working days facing the challenges of being a doctor in remote Aboriginal communities. It’s not all fun and games, of course. For a multitude of reasons, the health of Aboriginal people, as we all know from media reports and journal articles, is much worse that that of other Australians. In remote areas, the people often do not seek help until the advanced stages of an illness. A person with a toothache may first present with a huge dental abscess and a fever; another, with an unchecked ear infection, may be first diagnosed with a cerebral abscess; a pregnant woman may wander in for her initial check-up at 38 weeks’ gestation; painful joints are more likely to be lupus or rheumatic fever than osteoarthritis; and chest pain in a 26-year-old man must be treated as a myocardial infarction until proved otherwise. Flying over Arnhem Land. Photo courtesy Dan Armstrong. But medicine in the Northern Territory has grown up with an infrastructure geared to remote communities and to Aboriginal health. Having always believed in a public health system in which treatment priority is determined by illness severity (as in emergency departments in public hospitals), I was thrilled to find that the Northern Territory delivers the type of healthcare I believe in. Requests for outpatient appointments are faxed to the specialist in charge of that department and “triaged”. A woman with cervical intraepithelial neoplasia (CIN) grade III will be seen before one with grade I, and a woman with a history of breast cancer with recent weight loss and low back pain will be seen within a week. No preferential treatment linked to income or social standing. Just the sickest are seen first. Exactly how public medicine should be. Working in Aboriginal health in the Northern Territory is like working in a big cooperative family. I have never known such a sense of collegiality, and a lack of competition between healthcare providers. Help is always at the end of a phone. An emergency evacuation is organised via the district medical officer on duty for that day or night. There may be some input from a registrar or specialist to fine tune the patient’s treatment before air evacuation, and, if the patient’s condition is unstable, a registrar may accompany the nurse on the flight and perform the necessary resuscitation procedures before evacuation. Each time I have accompanied a patient to the airstrip for a medivac, I have watched the plane take off with tears in my eyes and an embarrassingly “proud to be Australian” lump in my throat. Not just the feeling that at last the patient is in safe(r) hands, but the feeling that not many countries provide such a fabulous service. But what of the communities I have worked in, the life I now lead, and the medicine I now practise. My favourite community is in western Arnhem Land, and I will return to this community in January 2005 to take up a 12-month contract. My first job there was in the “Wet”, that time of year when the skies become more ominously black as the day progresses, and the thunderstorms and lightning displays make the 1812 Overture and the Sydney Harbour New Year’s Eve fireworks display seem like child’s play. When the heavens open, the rain buckets down and the temperature drops a welcome 10°C. And, in the “Top End”, this is the time when tropical diseases blossom, and any person with symptoms of pneumonia or explosive fevers with skin lesions is diagnosed as having melioidosis until proved otherwise. This disease has a reasonably high fatality rate (the books say 17%), and the causative organism lives in the soil in the rainy season, so anyone with a cough and high fever is pumped with intravenous ceftriaxone and immediately evacuated. On a single day in this community during the Wet, our patients included a man with suspected melioidosis (which turned out to be septicaemia from a staphylococcus pustule on his leg); a 9-year-old with a huge, hard tonsillar lymph node and a massive cavity in a nearby tooth (I suspected osteomyelitis); and a 21-year-old girl who, as a child, had miraculously survived a gigantic brain abscess that developed from mastoiditis (which in turn developed from an untreated ear infection). She presented with headaches and vomiting, probably associated with a blockage in the shunt extending from her brain to her belly. And to top it off, there was a 17-year-old girl with active (treated) tuberculosis that appeared to have spread to her kidneys. All these people had to be either evacuated (with limited places on the Aerial Medical Service plane) or flown on a charter plane to Jabiru and then taken by bus to Darwin. A nightmare to organise, but somehow it gets done. One of my most memorable experiences involved visiting an outstation that, in the Wet, could only be reached by a small twin-engine plane. I had asked the outstation nurse what supplies to bring — lunch? water? stethoscope? “Just water and stethoscope”, she said. “Keep it light. Forget about the lunch. Rebecca and Samuel [at the outstation] have a pack of about 60 dogs, and they’ve become unmanageable. In fact, Rebecca and Samuel have moved out into the humpy outside, as the dogs have taken over the house. If you bring your lunch, they’ll smell it and eat you and your lunch for starters.” “Righto”, I said, always casual in the face of impending disaster. And she wasn’t far wrong. We flew over the Arnhem Land escarpment, some of the most beautiful wilderness country I have ever seen, and as the plane skidded to a halt on the very short airstrip we were prevented from getting out by a mob of about 20 ferocious dogs, who obviously thought the pilot, nurse and doctor were their breakfast, lunch and dinner by air express. Rebecca finally managed to call them off and we set up the clinic on the veranda, tending to the needs of eight people with a variety of disorders — chronic obstructive airway disease, rheumatic heart disease (requiring monthly penicillin injections and regular echocardiography and cardiology review), newly diagnosed hepatitis B, a child with anaemia, hypertension, as well as the usual smattering of hypercholesterolaemia, worms and diabetes. For all those urban GPs out there who are feeling sluggish and jaded, I thoroughly recommend considering a seachange to rural and remote Australia. If your emergency medicine skills are somewhat rusty (mine were totally obsolete), head off to your local ED and spend a few months eating humble pie while interns and residents show you the latest ropes. Book into a few courses, such as emergency life support (ELS) and early management of surgical trauma (EMST). If you’ve decided that remote Aboriginal communities might be your cup of tea, practise communicating with your neighbours from non-English-speaking backgrounds. Or, better still, travel to a country whose language and culture is totally different from your own, get ill (but not too seriously), and experience at first hand how difficult it is to describe your symptoms to a doctor or nurse who doesn’t speak your language. We have a fabulous country out there, with lots of people who will benefit from our skills. My best advice to anyone who wants to see Australia, and is ready to experience new challenges and work with some of the most disadvantaged people in the world, is to pick up the ball, run with it, and, in the words of a famous running shoe company, JUST DO IT!

Glynis A Johns MB BS, DPH, MPhil

An important Australian initiative that sets an international precedent We’ve got major problems at a really early age . . . to do these elderly health assessments, are they going to dig us up? We’re dead and buried by then. We might as well set up a clinic next to the cemetery.1 These poignant words were spoken by Dr Puggy Hunter, recipient of the Human Rights and Equal Opportunity Commission’s Human Rights Medal in 2001 and former Chair of the National Aboriginal Community Controlled Health Organisation (NACCHO), who passed away at the age of 50 years in 2001. He made these observations after the federal government’s launch of the Enhanced Primary Care Package in November 1999. Among other things, the package was designed to assist general practitioners to provide preventive care for Australians over the age of 75 years through Medicare Benefits Schedule rebates. For Aboriginal or Torres Strait Islander people the age limit was lowered to over 55 years.2 As 53% of Aboriginal men and 41% of Aboriginal women die before reaching the age of 50 years,3 representatives from NACCHO,4 general practice groups and the Australian Medical Association expressed concern that relatively few Aboriginal people would benefit from these rebates. Moreover, an evaluation in 2003 found that few Aboriginal and Torres Strait Islander people over 55 years had accessed the Enhanced Primary Care rebates.5 In this population, preventive health assessments are obviously needed earlier, given the occurrence of preventable chronic disease at younger ages and higher rates than in other Australians.6 Preventive healthcare can both reduce costs to the health sector and enhance health equity for Aboriginal peoples and Torres Strait Islanders, as most of the factors underpinning health disparities relate to social disadvantage (Box). For example, if renal disease is detected early, end-stage renal failure can be avoided and treatment will reduce mortality by 50%.12 However, during 1997–2002, Aboriginal and Torres Strait Islander Australians (compared with non-Indigenous Australians) were twice as likely to be referred late for dialysis treatment. (Late referral is defined as first attending a renal unit or being seen by a nephrologist less than 3 months before the initiation of dialysis.) In the intervening years, NACCHO has lobbied hard for the Medicare Benefits Schedule to make preventive health checks accessible to younger Aboriginal people.4 On 5 May 2004, the Federal Minister for Health launched a new Medicare Benefits Schedule rebate for an adult health check of Aboriginal and Torres Strait Islander people aged 15–54 years (Item 710).13 The challenge now is for GPs to make use of this rebate. Firstly, they need to understand what comprises an effective preventive health assessment for this population. In 2001, NACCHO led an alliance of eight non-government organisations — the Chronic Disease Alliance — to undertake a review of the evidence for preventive interventions, with the support of the Royal Australian College of General Practitioners and the Australian Government Department of Health and Ageing. The outcome — The national guide to a preventive health assessment in Aboriginal and Torres Strait Islander peoples — was completed in 2004,6 and a pilot study has been conducted with over 40 GPs. The guide lists a range of health problems and risk factors that are amenable to prevention, and supplements the “red book” of the Royal Australian College of General Practitioners.14 It takes into consideration the differing demographic and epidemiological factors that influence the development of disease in Aboriginal and Torres Strait Islander populations and was the basis for the descriptor for the new rebate. Secondly, changing practice to align with the evidence requires more than guidelines. Multifaceted strategies are needed, including decision-support systems, clinical audit, feedback, and support from opinion leaders.15 A health system that relies on free market provision of preventive healthcare can perpetuate inequity, as those who need the interventions are least able to afford and access the provisions. Proactive encouragement of preventive health assessments requires incentives and penalties, as well as removal of administrative and legislative barriers. Even with the rebate, implementing adult health checks in general practice may not be easy. According to 2001–02 data from the BEACH study (Bettering the Evaluation And Care of Health), at least 70% of GPs in Australia have, to their knowledge, not provided care for a single Aboriginal or Torres Strait Islander person in that period.8,9 Thus, changing practice to maximise the uptake of adult health checks for this population will require a range of supportive activities, such as: Distributing the guide to every GP; Promoting a suite of resources to assist GPs to better identify Aboriginal or Torres Strait Islander people and to improve cross-cultural communication;13 Developing ancillary resources such as case studies; Upskilling GPs using the expertise of Aboriginal community-controlled health services through coordinator positions established within NACCHO affiliates; Enhancing and supporting the role of Aboriginal health workers; Developing a communication strategy for the broader Aboriginal and Torres Strait Islander population to increase the demand for adult health checks;8,10 and Introducing clinical audit points for professional development. Bulk-billing for these assessments is critically important given the significant socioeconomic disparity between Aboriginal and Torres Strait Islander people and the broader Australian population.16 Mechanisms for improving access to medications under the Pharmaceutical Benefits Scheme for Aboriginals and Torres Strait Islanders are also required. This has been proposed by the Australian Pharmaceutical Advisory Council, NACCHO, the AMA and the Pharmacy Guild in a series of new reforms.17 2004 is the final year of the United Nations International Decade of the World’s Indigenous Peoples, and the development of this Medicare Benefits Schedule rebate removes a significant cost barrier from the delivery of preventive healthcare to Australian Indigenous people. The adult health check is an important Australian initiative that sets an international precedent. A total of 1977 services were claimed against Item 710 (Health Insurance Commission data18) from May to August 2004. This appears slower than the initial claim rate of elderly health assessment items (Enhanced Primary Care) for which an extensive implementation strategy was funded by the government. It is now time to finance an appropriate implementation strategy for the adult health check. General practice groups, including Divisions, should assist GPs to use the new adult health-check rebate for the identification and timely management of unrecognised health problems among Aboriginal and Torres Strait Islander Australians — the populations in which this is most urgently needed. Justification for a Medicare Benefits Schedule rebate for adult health checks for the Aboriginal and Torres Strait Islander population Aboriginal people and Torres Strait Islanders: have lower participation rates in preventive health programs (eg, cervical screening and breast cancer detection).7 have high rates of undetected risk factors and chronic disease.6 are referred late for end-stage disease, making treatment options more expensive (eg, if renal failure develops).6 are less likely to ask for preventive health assessments (significantly lower rates of requests for check-ups).8 have unequal access to Medicare (rate of use of the Medicare Benefits Schedule by Aboriginal people and Torres Strait Islanders is less than half that of other Australians, yet their overall health needs are about three times greater).9 General practitioners: miss opportunities for prevention (eg, significantly lower rates of vaccination by GPs in encounters with Aboriginal and Torres Strait Islander people10), leading to higher rates of hospital admissions for preventable diseases.11 find the preventive assessment process complex (comorbidity, sociocultural considerations).6 experience difficulties in delivering preventive healthcare to the Aboriginal and Torres Strait Islander population (inadequate remuneration for the time required, lack of knowledge of relevant health issues and inability to identify Indigenous Australians).6

Naomi R Mayers · Sophie Couzos MPH

To the Editor: While the article by Henry and colleagues provides food for thought and possible action,1 do they exhibit the fairness they exhort to solve the problem they perceive? There appears to be a distinct lack of logic in some of their deductions in the Box on page 517. “Body part funding” is not confined to Aboriginal health. For the 43 years I was associated with NSW Health, it was an integral part of the system and, together with its variations, increased as the years passed. The authors claim that as only $80 per head being spent on medical and pharmaceutical benefits in a remote Aboriginal community compared with the $900 spent in Double Bay is an example of racism. Surely, it is only a reflection of the lack of both a pharmacy and doctor in the remote community compared with the easy access to both in the inner-Sydney suburb. Comparison between the remote Aboriginal community and an all-white community of similar characteristics would have more validity.

Raymond S Hyslop