Indigenous health

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

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

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

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

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

Ruth M Armstrong BMed

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

Chelsea J Bond

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

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

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

Zhiqiang Wang · Wendy E Hoy

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

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

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

Stephen R Leeder · Gavin Mooney

Shared responsibility agreements between the Australian Government and Indigenous communities are based on a concept of mutual obligation but have overtones of paternalism and imposition. The nature and extent of choice in any such agreements need to be established. In 2004, the Australian Government announced a new approach to the provision of services to Indigenous communities.1 Part of the initiative involved the forging of “shared responsibility agreements”, defined by the government as being agreements in which “both governments and Indigenous people have rights and obligations and all must share responsibility”.1 Shared responsibility agreements are based on the concept of mutual obligation. While intuitively the meaning of “mutual obligation” might appear to be clear, in practice it is not, as Aden Ridgeway, Federal Parliament’s only Indigenous member, pointed out quite forcefully in a Senate debate.2 Prominent Aboriginal leaders Pat Dodson and Noel Pearson3 describe mutual obligation as “a natural principle of human society”, which, in Aboriginal terms, is normally referred to as “reciprocity”. According to Larissa Behrendt,4 Professor of Law and Indigenous Studies at the University of Technology, Sydney, “the concept of Aboriginal reciprocity implies that those who have resources share them with those who do not, and that those who receive this generosity have the same duty to provide for and share with others”. We believe that the Australian Government’s new approach smacks of paternalism and imposition and, in the absence of both respect and equality, runs counter to the Aboriginal notion of reciprocity. We believe that there has not been adequate dialogue and negotiation between the government and Indigenous communities in relation to shared responsibility agreements. How that dialogue is initiated and how it is then used to promote policy are crucial, and there has been too little debate on these two issues. The Mulan shared responsibility agreementLate in 2004, the details of a shared responsibility agreement between the government and Mulan Aboriginal Community in the Kimberley region of Western Australia became public. Part of that agreement was that the federal government would supply the community with a petrol bowser on the proviso that members of the community meet certain standards of personal and community hygiene. These included washing children’s faces twice a day and families keeping their homes free of rubbish (see Box). Not surprisingly, the proposal provoked considerable public debate.6 On the one hand, it has been argued that the Mulan community wanted to enter the agreement with government and that the wishes of the Mulan community should be respected by those who, like us, are opposed to such contracts.3 On the other hand, we are concerned that the “choice set” that Mulan was offered was very restricted (perhaps simply “take it or leave it”). The current Australian Government appears to favour neoliberalism in the market place, the central tenet of which is freedom of choice of the consumer. But for neoliberal markets to work well, there is a need for well informed consumers and freedom of choice over a wide range. We are not proposing market solutions for Mulan, but want to draw attention to the issue of choice. What choices were the Mulan community offered? Are the “consumers” of Mulan well placed to judge whether the benefit they will get from a petrol bowser will be worth the “price” they have agreed to pay? Is the government in a position to ensure that the price is paid or even to monitor the “payment”? Our concerns about mutual obligation schemesWhile the leadership of Mulan has publicly assured the Australian community that they are comfortable with the terms of the agreement,7 we have general concerns about whether such “mutual obligation” deals respect communities’ autonomy. The literature on the social determinants of health shows strong links between autonomy and health.8,9 A community which has autonomy and self-respect is more likely to be a healthy one. Such a community is able to build trust, respect, reciprocity and, in turn, improve health standards within the community. Encouragement from the outside can foster these features, but trying to impose them will not work and may be deleterious. There are also human rights issues, and the need to avoid solutions that discriminate against Indigenous people. For example, it would be discriminatory if the “rewards” involved in mutual obligation agreements only provide Indigenous people with access to infrastructure that other Australians expect or take for granted (which, incidentally, is the case for petrol bowsers). It can also be argued that the government’s concept of mutual obligation breaches Australia’s international obligations and denies certain basic rights to Australia’s Aboriginal and Torres Strait Islander citizens. The rationale is one of social control. This, for example, breaches Article 1 of the International Covenant on Civil and Political Rights: people’s right to self-determination and the right to freely pursue their economic, social and cultural development.10 An understanding of the background to this initiative is important. The government’s mutual obligation scheme comes in the wake of, firstly, its continuing refusal to apologise, as an act of reconciliation, for the “stolen generations”. This is seen by many as a denial of the mental and spiritual havoc wreaked by colonialism and dispossession of land and culture. Instead, the government has supported “practical reconciliation” — “addressing social and economic disadvantage”.11 Mutual obligation is a natural extension of this “let’s fix it” approach. Secondly, the disbanding in April 2004 of the Aboriginal and Torres Strait Islander Commission (ATSIC),12 an organisation based on principles of self-determination, is a direct lead-in to the policy of mutual obligation. ATSIC’s successor, the new National Indigenous Council (NIC),13 is not a representative body, as the government has acknowledged: “Members of the NIC have been chosen for their expertise and experience in particular policy areas and are not representing particular regions, organisations or agencies. The NIC is not a replacement for ATSIC and not intended as a representative body.”13 The mutual obligation scheme and NHMRC guidelines for ethical research in Indigenous communities14Given that, to our knowledge, there is little evidence for the effectiveness of mutual obligation strategies in the context of improving health, it is relevant to examine such strategies in terms of the principles applied in formulating guidelines for ethical conduct of research in Aboriginal and Torres Strait Islander communities. According to the National Health and Medical Research Council guidelines,14 it is crucial to involve the relevant communities in the development of any research proposal in Indigenous health. The guidelines are based on the principles of reciprocity — in the context of research, reciprocity implies inclusion and recognition of partners’ contributions, and ensuring equitable benefits of value to communities or individuals. “. . . communities have the right to define the benefits according to their own values and priorities”14 respect — a respectful relationship induces trust and cooperation; equality — the equal value of people; responsibility — includes, among other things, “the mainten-ance of harmony and balance within and between the physical and spiritual realms”14 survival and protection — protecting culture and identity; and spirit and integrity — an overarching value binding all others into a coherent whole. “Any behaviour that diminishes any of the other values could not be described as having integrity”.14 Thus, the government’s mutual obligation scheme does not appear to comply with the principles of respect; almost certainly those of responsibility; and perhaps, most importantly, the overarching notions of spirit and integrity. To demonstrate reciprocity, the guidelines suggest the need for the researcher to show “willingness to modify research in accordance with participating community values and aspirations”. Again on this criterion, government policy would appear to be deficient. Any research proposal in health today is likely to be rejected if it cannot show how it would quantify any changes it is attempting to bring about. These standards should apply even more to policy. There needs to be some evidence-based attempt to determine whether the policy works. Our concern at this level is simple. What performance indicators are appropriate for Mulan, for example? Good policy needs to establish these in advance. There is a need to conduct research to establish whether, and if so to what extent, shared responsibility agreements work — and what “works” means in this context. It would have been useful to gather this evidence before beginning to implement the policy. It is now crucial to get that evidence as soon as possible. Alternative or complementary strategiesWe believe that the most important strategy for improving health in Aboriginal communities such as Mulan involves building up infrastructure — management, economic, social and human infrastructure.15 If a community lacks leadership and good management and does not have this infrastructure then all other efforts will fail. This aspect seems to have been neglected by government. Many Indigenous communities need help to be able to help themselves on their own terms. Secondly, respect is needed — respecting the preferences of Aboriginal and Torres Strait Islander peoples. Strategies to improve Indigenous health will only get off to a good start if the people want the strategies, and their autonomy has been respected in allowing them to make choices regarding the strategies. Thirdly, there is a need to avoid being paternalistic or patronising. If mutual obligation is an option that Indigenous communities seek, then there must be an adequate range of choices offered, respect for the preferences of the people, and ways of monitoring whether the obligations on each side are in fact carried out. Draft agreement between the government and the residents of Mulan5 Government The federal government will contribute $172 000 for the installation of fuel bowsers at Mulan. The Government of Western Australia will undertake to “monitor and review” the adequacy of health services in an area where trachoma rates are “arguably the worst in the world”. Mulan Aboriginal Community The residents will: Ensure children shower daily and wash their faces twice a day; Ensure rubbish bins are at every house and are emptied twice weekly, through the local work-for-the-dole scheme; Undertake household pest control four times a year; Act to prevent petrol sniffing. Families and individuals will also make sure children attend school, crêche and the health clinic; and they will keep their homes clean and pay rents (to ensure the local council can afford pest control and repairs like plumbing).

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

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