Indigenous health

To the Editor: In their challenging article, Henry and coauthors assert that the poor health of Australian Aboriginals is the result of the “divided, divisive, racist, socially unjust society” of “this Australia”.1 I cannot agree. The health standards enjoyed by “white Australia” are not an isolated phenomenon, but rather a part of the fabric of an advanced technological society. Efforts to bring Australian Aboriginal health to the same standard without the Indigenous Australians being fully part of this 21st-century society will never be successful, even with limitless resources and endless goodwill. It is possible to maintain cultural identity and remain cognizant of past hurts while playing a full, if not leading, role in this technological society. If the Aboriginal elders were to lead their people into mainstream society they would find, I’m sure, an inclusive, tolerant, exciting and advancing society where they could play a full role, enjoy the same health as the rest of Australia, while still maintaining their unique identity.

Christopher R Strakosch

Objective: To describe the impact of a hepatitis A vaccination program for Indigenous children in north Queensland.Design: Enhanced surveillance of all notified cases of hepatitis A in north Queensland from 1996 to 2003.Setting: North Queensland; population, 596 500 people, including about 6900 Indigenous children aged under five years.Interventions: Hepatitis A vaccine was provided to Indigenous children in north Queensland from February 1999; two doses were recommended (at 18 months and 2 years of age), as was catch-up vaccination up to the sixth birthday.Results: In the 4 years 1996–1999, 787 cases of hepatitis A were notified in north Queensland, 237 (30%) of which were in Indigenous people. The average annual notification rates in Indigenous and non-Indigenous people during this period were 110 and 25 cases per 100 000 persons, respectively. In the first 4 years after introduction of the vaccination program (2000–2003), 66 cases of hepatitis A were notified. Only nine of the 66 (14%) were in Indigenous people. The average annual notification rates in Indigenous and non-Indigenous people in 2000–2003 were 4 and 2.5 cases per 100 000 persons, respectively.Conclusion: Hepatitis A seems to have been eradicated from Indigenous communities in north Queensland very soon after the vaccination program began. The rapid decline in notifications in non-Indigenous as well as Indigenous people suggests the program quickly interrupted chains of transmission from Indigenous children to the broader community. To our knowledge this is the first evidence that a hepatitis A vaccination program targeting a high-risk population within a community can reduce disease in the broader community. Hepatitis A vaccine should be provided to other high-risk Indigenous children elsewhere in Australia.

Jeffrey N Hanna MPH, FAFPHM · Susan L Hills MTH, FAFPHM · Jan L Humphreys

Kim Hoe Chan,* Murugasu Segasothy† * Medical Registrar, † Associate Professor of Medicine, NT Clinical School of Medicine of Flinders University, Alice Springs Hospital, PO Box 2234, Alice Springs, NT 0871 m.segasothyATnt.gov.au To the Editor: A recent review suggests that acute rheumatic fever, osteoarthritis and systemic lupus erythematosus account for most rheumatic disease in Australian Aboriginals, and comments on the rarity of gout.1 Although the increased prevalence of hyperuricaemia in Aboriginals compared with non-Aboriginals has been described,2 clinical attacks of gout in Aboriginals have so far been extremely rare.1,3 This is in sharp contrast to various Polynesian and other indigenous populations, including Mäori in New Zealand, Filipinos in Hawaii and Alaska, Chamorros and Carolinians in the Marianas Islands, and Taiwanese aborigines. In these populations, increased prevalences of both hyperuricaemia and gout have been documented.4,5 In an extensive literature search, we found only one report of confirmed acute gouty arthritis in an Australian Aboriginal with normal renal function,3 although there have been several Aboriginals in the “Top End” with crystal-confirmed gout in association with chronic renal impairment.1 Between January 2001 and April 2004, we identified seven new cases of acute gouty arthritis in Aboriginals (Box), confirmed by joint aspiration revealing monosodium urate monohydrate crystals. Three of these patients had confirmed acute gouty arthritis without renal impairment. This series also includes the first reported cases of gouty arthritis in Aboriginal women. Our findings suggest that the prevalence of acute gouty arthritis in Australian Aboriginals is much higher than previously reported. Discussion with physicians at Alice Springs Hospital revealed that they too have encountered gouty arthritis in Aboriginals, but whether this was confirmed by joint aspiration is not known. It appears that gout has been misdiagnosed or under-reported, or both. Further epidemiological studies should be undertaken to confirm this hypothesis, and we must have a higher index of suspicion for gout when an Aboriginal patient presents with an arthropathy, as gout is a potentially disabling and yet easily treatable condition. Aboriginals with acute gouty arthritis, Alice Springs Hospital, January 2001 – April 2004 Age (years) Sex UA level (mmol/L) Site of joint aspiration Possible precipitating factors Joints involved 46 M 0.37 Right knee Alcohol Right knee 44 M 0.45 Right knee Acute renal failure, alcohol Right knee, left first metatarsophalangeal joint, left ankle 65 M 0.23 Right knee Renal transplant, cyclosporin Right knee, right foot 64 F 0.50 Right knee Chronic renal impairment Both ankles and first metatarsophalangeal joints, right knee 61 F N/A Right knee Acute-on-chronic renal failure, alcoholism Right knee 51 M 0.48 Left knee None identified Left knee 35 M 0.54 Right knee None identified Both ankles, right knee UA = uric acid. Reference range, 0.20–0.45 mmol/L. N/A = not available.

Kim Hoe Chan · Murugasu Segasothy

Announcing the Dr Ross Ingram Memorial Essay Competition (entry details below) Not so long ago, we at The Medical Journal of Australia realised that, when it came to Indigenous health, we were great at publicising the problems. Most of the articles we publish are observational studies confirming that, yes, in health, as well as in almost every other area, Indigenous Australians are worse off than other Australians and, indeed, Indigenous populations worldwide. Ross Ingram (16 Feb 1967 – 15 May 2003) Ross Ingram was an Indigenous doctor who died last year, aged 36, of cardiovascular disease. At the time of his sudden death he was working as a GP in the New South Wales rural town of Leeton. Ross grew up in the Leeton area, where he was educated at the local primary and high schools. In 1984 he was named Young Citizen of the Year for Leeton, and in 1985, while vice-captain of Leeton High School, he received a Rotary Citizenship Award. In 1987 he was awarded a National Aboriginal Islander Day Observance Committee (NAIDOC) Award for Aboriginal Youth of the Year. Ross was the first Indigenous person from NSW to be accepted into the University of Newcastle’s Medical School. He enrolled in 1986 and graduated in 1993, the first Wiradjuri person to become a doctor. Life and medicine took him to an internship and residency in Gosford, then general practice on the NSW central coast and in Tasmania, and finally back to practise in Wiradjuri Country (central western New South Wales). His death is the first among the small community of Indigenous doctors who have been graduating from Australian medical schools since 1984. A keen practitioner of softball, football and cricket, as well as medicine, Ross was proud of his achievements both as a man and an Indigenous man. He is remembered by a loving family, including his wife, Julie, three children and three stepchildren. We also realised that the Journal was missing an important “voice”, telling us the story of Indigenous health. Many of the people working in Indigenous healthcare do not publish in academic journals. Also, more than in some other sectors of the population, social, cultural, political and economic issues influence the health and wholeness of Indigenous people. Some of these factors cannot be explored in strict academic style. Essays, on the other hand, leave room for the writer to analyse and interpret, often from a personal perspective and possibly including some form of narrative — “telling a story”. With this in mind, we are delighted to announce the annual Dr Ross Ingram Memorial Essay Competition for the best essay relating to Indigenous health. The competition is open to any Indigenous person who is working, researching or training in a health-related field; we are looking for essays that present original and positive ideas aimed at promoting health gains and health equity for Australia’s Indigenous peoples. After all, real insights and solutions come from within, not from without. The essays should be no more than 2000 words long, and must be submitted by Monday, 10 January 2005. A panel, including external experts and MJA editorial staff, will judge finalist essays, and judges will be blinded to the identities of the authors. The judges’ decision will be final. The winning entry will be published in the 2005 Indigenous Health issue of the Journal (the second issue in May), and the author will receive $5000. Other essays of high merit may also be published. We asked the members of the Australian Indigenous Doctors’ Association (AIDA) to help us name the prize and they chose to name it after Dr Ross Ingram (see Box). Ross’s story of premature death from natural causes is not an unusual one. More than half the deaths in Indigenous men occur before they reach the age of 50, compared with 13% of deaths among non-Indigenous men. The members of AIDA chose Ross not just because he was the first known Indigenous doctor to die, but because his plight typified that of many of the people currently working in Indigenous health. The human reality of statistics like those mentioned above is that Indigenous Australians inhabit a world of sickness, death and tragedy. Many of the seeds of future ill health are present from before birth. To a greater extent than most of their non-Indigenous colleagues, Indigenous doctors risk becoming a part of the problem they are trying to treat. “As Indigenous doctors, the fraternity of medicine has always accepted us wholly, and without question, and yet we are very different from so many of our non-Indigenous colleagues. Many doctors, when they look into the eyes of an Indigenous child, get a glimpse of a world they never knew existed; when we look into the eyes of that child, we see ourselves, and are reminded of the toll taken by unending stress and anxiety, and cycles of grief. For Indigenous doctors, the loss of our dear brother Ross reminds us that the privilege we enjoy as doctors does not remove our responsibilities to our people.” — Louis Peachey, President, AIDA We are hoping that the Dr Ross Ingram Memorial Essay Competition will provide a forum for some of the stories and ideas of Indigenous people working in Indigenous healthcare. Ross Ingram will not be able to contribute in this way, but he is a silent reminder of both the problem and the struggle of those who are working to find a solution. We look forward to receiving your entries.

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

Objective: To quantify the burden of disease and injury for the Aboriginal and non-Aboriginal populations in the Northern Territory.Design and setting: Analysis of Northern Territory data for 1 January 1994 to 30 December 1998 from multiple sources.Main outcome measures: Disability-adjusted life-years (DALYs), by age, sex, cause and Aboriginality.Results: Cardiovascular disease was the leading contributor (14.9%) to the total burden of disease and injury in the NT, followed by mental disorders (14.5%) and malignant neoplasms (11.2%). There was also a substantial contribution from unintentional injury (10.4%) and intentional injury (4.9%). Overall, the NT Aboriginal population had a rate of burden of disease 2.5 times higher than the non-Aboriginal population; in the 35–54-year age group their DALY rate was 4.1 times higher. The leading causes of disease burden were cardiovascular disease for both Aboriginal men (19.1%) and women (15.7%) and mental disorders for both non-Aboriginal men (16.7%) and women (22.3%).Conclusions: A comprehensive assessment of fatal and non-fatal conditions is important in describing differentials in health status of the NT population. Our study provides comparative data to identify health priorities and facilitate a more equitable distribution of health funding.

Yuejen Zhao BMed, MBiostats, PhD · Steve Guthridge MB BS, MTH, FAFPHM · Anne Magnus BEc, BEd · Theo Vos MD, MSc

Objective: To examine long-term trends in cancer mortality in the Indigenous people of the Northern Territory (NT) of Australia.Design: Comparison of cancer mortality rates of the NT Indigenous population with those of the total Australian population for 1991–2000, and examination of time trends in cancer mortality rates in the NT Indigenous population, 1977–2000.Participants: NT Indigenous and total Australian populations, 1977–2000.Main outcome measures: Cancer mortality rate ratios and percentage change in annual mortality rates.Results: The NT Indigenous cancer mortality rate was higher than the total Australian rate for cancers of the liver, lungs, uterus, cervix and thyroid, and, in younger people only, for cancers of the oropharynx, oesophagus and pancreas. NT Indigenous mortality rates were lower than the total Australian rates for renal cancers and melanoma and, in older people only, for cancers of the prostate and bowel. Differences between Indigenous and total Australian cancer mortality rates were more pronounced among those aged under 64 years for most cancers. NT Indigenous cancer mortality rates increased over the 24-year period for cancers of the oropharynx, pancreas and lung, all of which are smoking-related cancers.Conclusions: Cancer is an important and increasing health problem for Indigenous Australians. Cancers that affect Indigenous Australians to a greater extent than other Australians are largely preventable (eg, through smoking cessation, Pap smear programs and hepatitis B vaccination).

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

Objective: To assess primary care processes and clinical characteristics of adults with diabetes in remote northern Australian Indigenous communities.Design: Clinical audit from diabetes registers in 21 remote primary healthcare centres in the Torres Strait Health Service District (n = 921), three in Cape York, Queensland (n = 252), and three in the Northern Territory (n = 194), between September 2002 and February 2003.Participants and setting: Aboriginal and Torres Strait Islander adults with diabetes who were receiving their routine diabetes care in these 27 centres.Main outcome measures: Provision of regular checks for weight, blood pressure, glycaemia (HbA1c), proteinuria, lipid levels, renal function, eyes and feet, influenza and pneumococcal vaccination. Weight, blood pressure and glycaemic control.Results: Most routine diabetes checks were delivered according to recommended schedules, except for eye and foot checks in the NT. There were uniformly high rates of appropriate treatment for hypertension and albuminuria, but low rates of insulin treatment and self-monitoring despite a high mean HbA1c level (8.9%). Vaccination rates were low in the NT. Torres Strait Islanders with diabetes were significantly heavier than Aboriginals, but had lower mean diastolic blood pressure (77.3 mmHg compared with 79.5 mmHg) and lower prevalence of albuminuria and smoking.Conclusion: A high proportion of Aboriginals and Torres Strait Islanders requiring treatment for high blood pressure and proteinuria are receiving it. However, there is dissonance between the relatively high rates of routine checks and apparent lack of therapeutic action on glycaemia. More intensive management of glycaemia, including improved nutrition, exercise and (probably) insulin, is required to reduce microvascular complications.

Robyn A McDermott FAFPHM, PhD · Fiona Tulip AssocDipMRA · Barbara Schmidt BSc, MBA

During the 1950s and 1960s, there was a dramatic explosion in the number of letters to the editor about Indigenous health published in the MJA, reflecting increased reader interest. The letters from Barry Christophers were part of the Federal Council for Aboriginal Advancement’s largely successful campaign for equal civil rights for Aboriginal and Torres Strait Islander people. His letters not only drew attention to discriminatory legislation and policies, but also emphasised the structural (especially economic) determinants of Indigenous ill-health, and the negative impact on Indigenous people of racist medical representations. There was little interest in the health of Aboriginal and Torres Strait Islander peoples in the MJA before 1950. Early research portrayed Aboriginal people as being from an inferior and primitive race, the demise of which was thought to be inevitable. For example, in 1924, a case series of Aboriginal psychiatric patients was introduced by stating that: Contact with civilization, phthisis and other diseases, mixed breeding and general racial decay are the order of the day. In a few years this line of research will be closed for ever. Whatever may be one’s sentimental views on the passing of the primitive peoples, from the scientific or even the utilitarian aspect it will be more than unfortunate if our records are not completed before they vanish.1 Any research on Aboriginal and Torres Strait Islander peoples before the 1960s was not primarily about improving their health. It was about using Indigenous health research to improve understanding of the health problems of white Australians, and about collecting information about Aboriginal people for science before the race became extinct.2 Letters to the editor are the voice of the readers of the MJA. Letters do not have the same academic status as journal articles, but three readership surveys in the 1950s and 1960s showed that the letters pages were the most read section of the MJA.3-5 An editorial marking the 50th anniversary of the MJA in 1964 described the number of letters to the editor as a barometer of the interest of readers in a journal.6 Most letters received by the MJA were published.7 Before 1950, there were only 13 letters about Indigenous Australians published in the MJA. Readers did not write more than a single letter to the editor in response to any MJA publication about Indigenous people until 1952, when an editorial announced that a new university scholarship for an Aboriginal student marked a change from the brutal past of the colonial encounter, and decried the obstacles caused by “the monstrous fiction of racial superiority and inferiority”.8 Writers of editorials had much greater freedom of language and freedom to express opinions than writers of scientific articles. Letter writers had even more freedom, and were often those with the strongest opinions. Four letters were published in response to the editorial: one claimed that it was possible to discuss Aboriginal people’s inferiority (but did not assert a biological basis for this inferiority); the others replied that doctors should treat “aborigines as our equals” and that their problems were due to racism.9-12 A dramatic increase in letters to the editor about Indigenous health began in the 1950s (Box 1). This increase occurred before a large increase in the number of all letters later in the decade. Letters to the editor accounted for a quarter (48/200) of the publications on Indigenous health in the MJA in the 1950s and 1960s, increasing to more than a third in the 1980s and 1990s (76/204 and 108/203).2 Barry Christophers’ letters to the MJA editorBarry Christophers (Box 2) wrote 25 letters to the MJA about Indigenous health between 1956 and 1969. He wrote half the letters to the editor about Indigenous health in this period (and a similar number of letters not about Indigenous health), but he did not write any longer articles about Indigenous health. At the time, Christophers was a general practitioner in the inner-city Melbourne suburb of Richmond, and an activist in the Federal Council for Aboriginal Advancement (FCAA) (in 1964 the name was changed to the Federal Council for the Advancement of Aborigines and Torres Strait Islanders [or FCAATSI]) (Box 3). His letters may not have reflected the views of the majority of MJA readers, but they draw attention to one doctor’s role in events that led to great changes in the relationship between Indigenous and non-Indigenous Australians. In 1957, Christophers drew MJA readers’ attention to claims of starvation in the Warburton Ranges made by Pastor (later Sir) Doug Nicholls and Western Australian members of parliament William Grayden and Stan Lapham.16,17 He often sent similar versions of his MJA letters to various newspapers, but he saw a special role for doctors. He explained to me that he wrote to the MJA because doctors were “important folk in the community” who influenced people’s views and attitudes (Dr Barry Christophers, personal communication). Christophers was always careful to not criticise the work of individual doctors; his targets were governments and bureaucrats, and their discriminatory policies and legislation. He did not choose to either alienate his audience or undermine the authority of the medical voice, which could continue to be used for other activities. In contrast, other writers in the MJA questioned the capacity of non-medically trained activists like Nicholls to speak authoritatively on Indigenous health matters.18 Christophers wrote many letters to the MJA about FCAA and FCAATSI campaigns to highlight and then remove discriminatory legislation and policies affecting Indigenous people. He wrote about the restriction of the movement of Aboriginal people in Western Australia by the “leper line”.19,20 He wrote four letters to the MJA, and many more to newspapers, supporters, bureaucrats and politicians, about the exclusion of Queensland Aboriginal patients with tuberculosis from the generous allowance paid to other TB patients to encourage convalescence and treatment.21 He explained that the exclusion was “understandable”, even if abhorrent, only because it was much higher than the very low wages then being paid to Aboriginal people in northern Australia.22 Christophers was secretary of FCAA’s Equal Wages Committee and, in the MJA and elsewhere, he repeatedly emphasised economic causes (and solutions) for Indigenous people’s suffering and ill-health. While many of his contemporaries blamed Aboriginal behaviour, just as their predecessors had blamed Aboriginal people’s inferior racial characteristics, Christophers focused on deeper structural causes of ill-health. In response to a claim that alcohol restriction needed to continue and citizenship to be opposed, he argued that Aboriginal alcohol abuse was merely a “symptom” of the “disease” of “lack of citizenship, low wages and colour prejudice”.23 In spite of his attention to structural determinants of health, he did not portray Indigenous people as passive victims; their actions were constrained, but not entirely determined, by racist, white institutions; nor did they just drift or follow biological urges, as others had claimed. His concern with the WA “leper line” was due to its interference with the attempts by Aboriginal “liberators” to “assist some of their not so fortunate friends”.20 Aboriginal people could be their own liberators and the liberators of other Aboriginal people, not just a problem to be solved by others. In the Northern Territory, he complained about withholding of blood transfusions from Aboriginal patients, inferior medicine chests required to be kept by employers of Aboriginal labour (compared with those at Royal Flying Doctor Service outposts), and legislation about Aboriginal people dying intestate.24-28 He was concerned that this legislation about the estates of Aboriginal people had been taken directly from the Mental Defectives Act: “The psychological trauma inflicted upon aborigines by regarding them and treating them as mental defectives and bankrupts must be immeasurable”.27 He similarly suggested that writers should avoid certain words, used by earlier conventions to describe Aboriginal people, that might inadvertently cause similar “psychological trauma” because of their negative metaphorical associations, or because he thought they were inaccurate or no longer acceptable.29 Christophers did not just promote positive over negative words and representations of Indigenous people, he investigated the portrayal of power in these representations and their colonial context. But no one questioned the fact that these representations of Indigenous people were created in their absence by non-Indigenous doctors. Enormous social changes since the 1950s in Australia make this omission seem obvious today. No longer can doctors expect to be unchallenged as the only authoritative voice on health matters. No longer can non-Indigenous people remain untroubled about the colonial context of their position when they speak about Indigenous people’s lives — or if they try to speak for Indigenous people. After the 1967 referendumFCAATSI’s 10-year campaign successfully led to 90.77% of voters in the 1967 referendum approving the deletion of the two discriminatory references to Indigenous people in the Constitution (Box 3). FCAATSI folded 10 years later after a decade of internal divisions concentrated on concerns about non-Indigenous control of the organisation.13 In part due to FCAATSI’s successes, attention had turned from equality to special Indigenous rights, like land rights, and Indigenous control of Indigenous lives. In the decades since the referendum, hundreds of Indigenous-controlled organisations, including health services, have been established and become successful. In more recent times, however, a new official and grassroots coalition promoting “reconciliation” between Indigenous and non-Indigenous Australians has emerged with prominent Indigenous and non-Indigenous leaders and members. While clearly lobbying in a different time and for different causes, this present-day coalition or social movement evokes memories of FCAATSI. This reconciliation movement has proved to be extraordinarily popular among both non-Indigenous and Indigenous Australians and very effective in spite of the considerable early and continued scepticism of many Indigenous people.30 With time, many people have forgotten or not heard of the activism and achievements of FCAATSI and its members like Barry Christophers. The dramatic changes in Indigenous lives and health that began in the 1950s and 1960s facilitated greater changes in the following decades. Joe McGinness, a Kungarakan man who lived in Cairns, was the President of FCAA (and FCAATSI) for most of its 20-year history. Christophers nominated him for the position in 1961 when he was first elected, and worked closely with him on many campaigns; they remained friends many years later. Sadly, Joe McGinness died in July last year. 1: Number of letters to the MJA editor about Indigenous health, 1914–1999 2: Barry Christophers in Melbourne, August 2000 Photograph: David P Thomas. 3: The Federal Council for Aboriginal Advancement (FCAA) and the 1967 referendum The first meeting of the FCAA declared its goal as equal civil rights for Aboriginal people (equal living conditions and pay and the removal of discriminatory legislation). In the 1960s, FCAA began to assert the need for different Indigenous rights (like land rights), not just equal civil rights.13,14 Torres Strait Islanders were acknowledged when the organisation changed its name to the Federal Council for the Advancement of Aborigines and Torres Strait Islanders (or FCAATSI) in 1964. Historian Peter Read has asserted that there were two dominant groups in the FCAA in its early years: the unions (and associated leftists, such as Christophers) and the churches. These groups included Aboriginal pastors like Doug Nicholls and Aboriginal unionists like Bert Groves and Joe McGinness, but these men had no special status as Indigenous people. FCAA and FCAATSI were “multi-racial” (or anti-racial) organisations, not Indigenous organisations — all people involved were treated “equally”—although, in practice, they were largely run by non-Indigenous people.13 The emphasis on the equality of Indigenous and non-Indigenous members reflected the organisations’ campaign goals for equal rights for Indigenous Australians. FCAATSI’s greatest public acclaim came with the success of its campaign for the 1967 referendum. The Australian Constitution had stated in Section 51 that the Commonwealth Parliament had the power to make “special laws” for the “people of any race, other than the aboriginal race in any State”. Section 127 stated that “aboriginal natives shall not be counted” in the populations of the states. While the referendum merely removed these two discriminatory references to Aboriginal people in the Constitution, FCAATSI’s campaign for the referendum was part of the larger social movement towards other, more significant equal rights. The referendum is now publicly and fondly (even though legalistically incorrectly) remembered for finally granting equal rights to Aborigines, including “citizenship” and the right to vote, as well as being associated with equal rights to drink alcohol.15

David P Thomas PhD, FAFPHM

Addictions and healing in Aboriginal country. Gregory Phillips. Canberra: Aboriginal Studies Press, 2003 (xix + 210 pp). ISBN 085575408. This is not the first book documenting the problems of addiction and healing in Aboriginal communities. It is, however, the first written by an Indigenous academic. It is also important because it puts forward a methodology for an Indigenous science that seeks to provide a theoretical and practical basis for Indigenous ways of knowing and working. The study is based on ethnographic research in an Indigenous community in north Queensland. Phillips first discusses his own role and responsibilities as an Indigenous academic working in an Aboriginal community. He articulates an Indigenous-defined methodological theory and culturally appropriate knowledge production, an issue that has received very little discussion in research among Indigenous Australians. Interweaving the voices of the community of “Big River” with a range of historical, anthropological and medical material, the experience of trauma and substance misuse is explored. Arising from these explanations, the author reflects on some of the ways the Big River community talk about addressing addiction problems. One fascinating chapter explores approaches to treating addictions among Native Canadians, where the author, together with a suicide prevention officer from Big River, made a number of visits to different communities and treatment programs. Through these experiences the author provides a provisional approach to the treatment of addictions, one that acknowledges the importance of culture and spirituality, but which also incorporates a number of other approaches, such as harm reduction, Alcoholics Anonymous and residential treatment. One criticism would be that the approaches to an Indigenous science outlined at the beginning are not clear in the following chapters. How would the Indigenous methodologies be replicated elsewhere? Do they rely on identification as an Indigenous person and in what ways can non-Indigenous academics and health professionals engage with this approach? In order for such important ways of knowing to be transferred elsewhere, it is important that such methodologies be clearly formulated. Nevertheless, this is an important book on a difficult subject, and one that successfully conveys the individual and social traumas of substance misuse and the ways communities are addressing them. Richard D ChenhallResearch Fellow Menzies School of Health Research, Darwin, NT

Richard D Chenhall

Reading doctors’ writing: race, politics and power in Indigenous health research 1870-1969 David P Thomas. Canberra: Aboriginal Studies, 2004 (xvi + 209 pp). ISBN 0 85575 458 3. This is an apt title for this book. Race, politics and power in Indigenous health research have, not surprisingly, mirrored race, politics and power in Indigenous affairs generally. In order to tackle these subjects, Thomas has provided an interesting history of the development of medical associations and medical journals in Australia. The notion of Aboriginal people as primitive and a dying race who needed to be studied before they became extinct permeated much of the early research — “smoothing the pillow of a dying race”. But it was not simply a matter of Aboriginal people needing to be studied while the opportunity was still there. It was also an issue of the health of Aboriginal people potentially impacting on the health of non-Aboriginal people, and of the potential to learn things of value to the non-Aboriginal population by studying the health of Aboriginal people. This was all caught up with power relationships between Aboriginal people as research subjects and non-Aboriginal people as researchers and administrators. The concept of Aboriginal people being research subjects because they were considered to be more “primitive” was pervasive, and this belief led to a variety of wider paternalistic and repressive policies. In 1961 Sir Paul Hasluck, then Federal Minister for Territories, felt obliged to write that “I myself am not disposed to direct that wards can be sampled like a herd of cattle[.] Personal willingness of native people to assist is essential.” This statement is an interesting reflection on the tenor of the times. The sad part of all of this is that, with few exceptions, little research appears to have been done in that period with the explicit aim of helping to improve the health of Aboriginal and Torres Strait Islanders. Most researchers reflected the prevailing mood, but there were occasional exceptions, continuing the tradition of individual doctors arguing for a wholly different viewpoint against the mainstream, and perhaps with more than a little effect. There is much in this book for those with an interest in doctors’ role over a 100-year period in one of the major unresolved issues in Australian public health. Ian T RingEpidemiologist Health Information Centre Queensland Health, Brisbane, QLD

Ian T Ring

Objectives: To study the relationship of blood pressure to birthweight and current body mass index in a population with high rates of low birthweight (< 2.5 kg).Design: A cross-sectional population screening program conducted between 1992 and 1998, with retrospective retrieval of birthweights.Setting: A remote coastal Australian Aboriginal community with a high prevalence of diabetes, cardiovascular and renal disease.Participants: Eighty-two per cent of the community members (1473/1805) were screened. Birthweights were available for 767 (71%) of the screened participants aged 7–43 years.Main outcome measures: The association between birthweight and current blood pressure, accounting for current body mass index.Results: Mean birthweights were low, and 18% of children and 35% of adults had been low-birthweight babies. In children (7–17 years), blood pressure was not correlated with birthweight, but in adults there was an inverse correlation — a 1 kg increase in birthweight was associated with a 2.9 mmHg (95% CI, 0.3–5.5 mmHg) decrease in systolic blood pressure, after adjusting for age, sex and current weight. Overweight adults with low birthweight had the highest blood pressures.Conclusions: Low birthweight is significantly associated with higher blood pressure in adult life, and the effect is amplified by higher current weight. Given the high rates of low birthweight in Aboriginal people in remote areas, and the detrimental effect of higher blood pressures on chronic diseases (currently present in epidemic proportions), interventions should focus on improving birthweights and on weight control in adolescents and adults. Special attention should be paid to children with low birthweight to avoid their becoming overweight in adult life.

Gurmeet R Singh MB BS, MD, MPH · Wendy E Hoy MB BS, BScMed, FRACP

Zhiqiang Wang,* Wendy E Hoy† * Senior Research Fellow, † Professor, Centre for Chronic Disease, School of Medicine, University of Queensland, Herston, QLD. zwangATccs.uq.edu.au To the Editor: In a recent article, Thompson and colleagues provided useful information on the prevalence of cardiovascular risk factors in urban Aboriginal people.1 Using the Sheffield table of absolute risk,2 the authors estimated that “15% men and 6% women had an absolute risk > 15% of a cardiovascular event within 10 years”. The Sheffield risk table was developed for assessing the risk of coronary deaths rather than the risk of cardiovascular events.2 Moreover, the validity of applying the Sheffield table and other risk assessment tools based on the Framingham risk functions to Aboriginal people is yet to be assessed. The lower risk estimate in women reported by Thompson and colleagues may simply reflect the higher cholesterol concentration cut-offs for women in the Sheffield table. The true risk difference between sexes in Aboriginal people may not be as dramatic as Thompson and colleagues suggest. Firstly, data in Box 1 of their article show that there was little difference between men and women as regards past history of cardiovascular disease. Secondly, Aboriginal women experience a higher prevalence than men of some cardiovascular risk factors such as diabetes,1,3 abnormal HDL cholesterol level and overweight.3 Thirdly, our own research suggests that there may be a substantial difference between estimated and observed risks. Using data from a cross-sectional study of 681 Australian Aboriginal people in a remote community,3 we performed a similar analysis to that of Thompson et al. Based on the Framingham functions,4 we estimated that 10-year risks of coronary heart disease for women were much lower than those for men in all age groups (a finding similar to that of Thompson and colleagues). However, in a related study of the same Aboriginal community (as yet unpublished), when we analysed cohort data from 838 participants with 13 years of follow-up, the observed coronary disease rates for women were as high as those for men (Box). The discrepancy we found between estimated and observed risks is a warning that researchers and clinicians need to be cautious when applying existing risk assessment tools to Aboriginal people. Incidence rates per 1000 person-years of coronary heart disease (95% CI), by age and sex (based on a cohort study of 838 Aboriginal people in a remote community) Age (years) Women Men 20–34 4.1 (1.8–9.1) 3.2 (1.4–7.0) 35–44 15.6 (9.4–25.9) 8.6 (4.5–16.5) 45–54 19.3 (10.9–33.9) 26.5 (15.0–46.7) ≥ 55 50.2 (32.4–77.9) 31.9 (16.6–61.2)

Zhiqiang Wang · Wendy E Hoy

Peter L Thompson,* Pamela J Bradshaw,† Margherita Veroni,‡ Edward T Wilkes§ * Cardiologist, † Clinical Research Coordinator, ‡ Epidemiologist, Western Australian Heart Research Institute, Sir Charles Gairdner Hospital, Nedlands, WA 6009; § Senior Research Fellow, Centre for Developmental Health, Telethon Institute for Child Health Research, Subiaco, WA. peter.thompsonAThealth.wa.gov.au In reply: We appreciate the commentary by Wang and Hoy on the problems of the use of risk scores for assessing cardiovascular risk in Aboriginal people. In general, we agree that caution is essential in using tables that predict absolute risk of cardiovascular events. However, despite their limitations, absolute risk estimates are being encouraged by Australian, European, New Zealand and US authorities as a practical aid to targeting coronary disease preventive measures.1 An estimated risk of > 15% of a fatal cardiovascular event within 10 years, based on the Sheffield or Framingham scores, is now recommended as an indication for active treatment. Our prime purpose in providing an estimate of absolute risk in the Perth urban Aboriginal population was to demonstrate that a program of cardiovascular risk assessment with strong Aboriginal community support is capable of detecting high-risk people who will benefit from intensive risk-lowering strategies. Wang and Hoy’s caution about applying absolute risk estimates based on the Framingham population to unrelated populations is of particular importance in the case of Australian Indigenous people, in whom diabetes and the related metabolic syndrome may be the predominant risk factors. We have recently completed an analysis of the determinants of carotid atherosclerosis in the same population described in our earlier study.2 Our results confirm that, while the Framingham estimates (based on sex, age, LDL cholesterol and blood pressure) are indeed predictors of carotid atherosclerosis, their predictive value is significantly enhanced by the addition of markers of diabetes status and obesity. The 13-year follow-up study of the Aboriginal cohort referred to by Wang and Hoy will provide unique data to help identify reliable risk predictors specific to Aboriginal people, and we look forward to its publication.

Peter L Thompson · Pamela J Bradshaw · Margherita Veroni · Edward T Wilkes

All Indigenous communities in Australia have a common heritage of loss. Indigenous death rates are much higher than those for white Australians. Indigenous people use healthcare services reluctantly, and palliative care services rarely. Cultural considerations that need to be respected include Indigenous understandings of disease causation, attributions of blame for sickness, the performance of ceremonies after death and the importance of dying on traditional lands. The involvement of Indigenous health workers in clinical care increases confidence in the healthcare system as a whole.

Ian Maddocks MD, FRACP, FAChPM · Robert G Rayner FRACGP, FAChPM

Donna B Mak,* Alastair MacKendrick,† Max K Bulsara,‡ Sharon Weeks,§ Lewis Leidwinger,¶ Harvey Coates,** Francis J Lannigan,** Deborah Lehmann†† * Public Health Physician, ¶ Audiologist, Kimberley Public Health Unit, Derby, WA; † Ear, Nose and Throat Surgeon, Southern Corridor ENT Services, South Fremantle, WA; ‡ Biostatistician, Biostatistical Consulting Service, School of Population Health, University of Western Australia, Crawley, WA; § Audiologist, Disability Services Commission, West Perth, WA; ** Ear, Nose and Throat Surgeon, Department of Otorhinolaryngology – Head and Neck Surgery, Princess Margaret Hospital for Children, Subiaco, WA; †† Senior Research Fellow, Centre for Child Health Research, University of Western Australia, Telethon Institute for Child Health Research, Subiaco, WA. Correspondence: Dr Donna B Mak, 189 Royal Street, East Perth, WA 6000. makhoATbigpond.com To the Editor: Chronic suppurative otitis media is very common among Australian Aboriginal children, resulting in hearing loss and educational and social disadvantage.1 Reconstructive middle-ear surgery has been part of the accepted treatment for decades. However, there are no publications about long-term outcomes in Aboriginal populations.2 We report here the results of a study of long-term postoperative outcomes in Aboriginal children following reconstructive middle-ear surgery. We studied all Aboriginal children aged ≤ 15 years who underwent middle-ear surgery for a tympanic membrane perforation (excluding cholesteatoma) in the Kimberley region of Western Australia between 1 October 1986 and 31 December 1995. Data had been collected prospectively during a previous study, and long-term follow-up was undertaken as part of a recent study of middle-ear surgery outcomes.2,3 Ethical approval was obtained from the WA Aboriginal Health Information and Ethics Committee. The study population consisted of 93 children (57 girls, 36 boys), aged 5–15 years (mean, 10 years; median, 10 years) at the time of operation. Preoperative air–bone gap (ABG) measurements ranged from 8.75 to 58.75 dB (mean, 36.7 dB; median, 36.25 dB). The operations were performed by nine surgeons at three hospitals and included tympanoplasty using temporalis fascia (73%), dura (13%), and other graft materials (8%), and mastoidectomy (6%). Sixty-four children (69%) underwent early postoperative review (median follow-up interval, 11 months) and 73 children (78%) underwent late postoperative review (median follow-up interval, 103 months). More of the patients had a late review because, at the time, additional resources were available to actively locate the patients for follow-up. At late postoperative review, 56/93 (60%) patients had a successful outcome (intact tympanic membrane and normal hearing) and 17/93 (18%) did not (20/93 [22%] did not undergo late postoperative review). Of the 32 patients who had a successful outcome at the early postoperative review (median follow-up interval, 5 months), 26 (81%) underwent late postoperative review; 24/26 (92%) still had an intact tympanic membrane and ABG ≤ 25 dB at late postoperative review (median follow-up interval, 109 months) (Box). These findings indicate that successful tympanic membrane closure with hearing improvement after middle-ear surgery in Aboriginal children is probably longlasting. The major limitation of our study is the absence of clinical information in the time period (mean, 8 years) between the early and late postoperative reviews. An unknown (but likely to be small) number of patients may have had further operations and/or conservative management, which may have influenced their ear health status at late postoperative review. Collection of these data would have been extremely difficult given the nomadic lifestyle of many patients and the logistical realities of remote-area healthcare. Our findings support the current recommendation of the Office of Aboriginal and Torres Strait Islander Health that Aboriginal children should be offered tympanoplasty if conservative management of chronic suppurative otitis media is unsuccessful.4 Postoperative review status of 93 Aboriginal children who underwent middle-ear surgery for a tympanic membrane (TM) perforation* in the Kimberley region of Western Australia between 1 October 1986 and 31 December 1995† * Excluding cholesteatoma. † If a patient had more than one operation, the first ear operated on during this time period was included in the analysis. If a patient had operations on both ears on the same date, the ear with the largest preoperative hearing loss was included. If hearing loss was the same on both sides, the right ear was chosen.

Donna B Mak · Alastair MacKendrick · Max K Bulsara · Sharon Weeks · Lewis Leidwinger · Harvey Coates · Francis J Lannigan · Deborah Lehmann

Objectives: To compare the effectiveness of ototopical ciprofloxacin (0.3%; CIP) with framycetin (0.5%), gramicidin, dexamethasone (FGD) eardrops (5 drops twice daily for 9 days) together with povidone-iodine (0.5%) ear cleaning as treatments for chronic suppurative otitis media (CSOM) in Aboriginal children.Design and participants: Aboriginal community-controlled, community-based, multicentre, double-blind, randomised controlled trial in eight Aboriginal Community Controlled Health Services across northern Australia, involving 147 Aboriginal children with CSOM.Main outcome measures: Resolution of otorrhoea (clinical cure), proportion of children with healed perforated tympanic membrane (TM) and improved hearing, 10–21 days after starting treatment.Results: 111 children aged 1–14 years (CIP, 55; FGD, 56) completed treatment. CSOM cures occurred in 64% (CIP, 76.4%; FGD, 51.8%), with a significantly higher rate in the ciprofloxacin group (P = 0.009, absolute difference of 24.6% [95% CI, 15.8%–33.4%]). TM perforation size and the level of hearing impairment did not change. Pseudomonas aeruginosa was the most common bacterial pathogen (in 47.6%), while respiratory pathogens were rare (in 5.7%).Conclusions: Twice-daily ear cleaning and topical ciprofloxacin is effective at community-level in achieving cure for CSOM. Healthcare providers to Aboriginal children with CSOM should be given special access to provide ototopical ciprofloxacin as first-line treatment.

Sophie Couzos FRACGP, FACRRM, FAFPHM · Traven Lea MAEIH, DipPHTM · Margaret Culbong · Reinhold Mueller MSc, PhD · Richard Murray FRACGP, MPH

Objective: To describe the results of a program for detecting high cardiovascular risk in an urban Aboriginal community.Design: Cardiovascular risk assessment program conducted between January 1998 and October 1999. Participants completed a questionnaire and underwent a physical assessment and biochemical tests.Participants: 738 self-selected members of the Perth Aboriginal community (332 men, 406 women; age range, 18–79 years).Results: The participants represented approximately a fifth of the Perth Aboriginal population aged 25–64 years (those aged 18–24 years comprised < 5% of Aboriginals aged 15–24 years in Perth). Eighty-four per cent fell within National Heart Foundation “high risk” or “highest risk” categories for cardiovascular disease; 15% of men and 6% of women had an absolute risk of a cardiovascular event of over 15% within 10 years. A high proportion of participants reported diabetes, hypertension, smoking, overweight and obesity. A fasting plasma glucose level indicative of diabetes or impaired fasting glucose was found in 8.6% (95% CI, 6.2%–11%) of people not previously known to have diabetes. Obesity and smoking were twice as prevalent in study participants as in the general population. Less than a third of subjects with hypertension and diabetes had attained recommended target levels for blood pressure reduction or glycaemic control, and only a third of those at high risk and one in six of those at highest risk had attained recommended lipid-level targets.Conclusions: A cardiovascular risk assessment program with strong community support in an urban Aboriginal population can identify a significant number of people with high cardiovascular risk who are candidates for intensive risk-factor reduction strategies.

Peter L Thompson MD, FRACP · Pamela J Bradshaw RN, MSc · Margherita Veroni MSc · Edward T Wilkes BA

Graeme H Johnson*, Donna B Mak†; *Acting Public Health Medical Officer; †Former Public Health Medical Officer, Kimberley Population Health Unit, Derby, WA 6728. graeme.johnson@health.wa.gov.au To the Editor: In their study of a SAFE-style trachoma control program (which included Antibiotic treatment, Facial cleanliness, and Environmental improvement, but not Surgery) in a remote Australian community, Ewald et al suggest that no systematic SAFE trachoma control program exists in Australia.1 In the Kimberley region of Western Australia, the Kimberley Public Health Unit (KPHU) has coordinated a trachoma control program since 1989. The World Health Organization SAFE strategy has been implemented since 1996, as described in the Kimberley regional trachoma control guidelines and a peer-reviewed publication.2,3 The trachoma control program in the Kimberley has been delivered by a variety of environmental health, health promotion, community and clinical health professionals employed by State and local governments, and by community-controlled and other non-government organisations. We believe a coordinated regional approach is mandatory, because of the numerous organisations involved in program delivery. The trachoma control program in the Kimberley continues to achieve good results. The prevalences of follicular trachoma during annual screening of school-aged children in the Kimberley have been published annually in the KPHU Bulletin.4 Since 1996, in accordance with the WHO SAFE strategy, communities with trachoma prevalences of less than 5% were not screened in subsequent years and did not contribute to regional prevalence data. Thus, the observed decrease in trachoma prevalence between 1996 and 2001 is likely to be greater than that shown in the Box. We believe the Kimberley region is well placed to achieve the WHO aim of eradicating blinding trachoma by 2020.5 However, it is a concern that other regions of Australia with endemic trachoma infection may not conduct disease control activities in a coordinated manner because of lack of leadership in trachoma control or insufficient resources, or both. The community described by Ewald et al borders the Kimberley region and has strong cultural links with several Kimberley groups. The achievements in trachoma control in the Kimberley cannot be sustained in the long term without a nationally coordinated approach. We believe that it falls within the statutory responsibilities of State and Territory departments of health to ensure that environmental and clinical health services are coordinated to achieve trachoma control in Australia. Trachoma in Kimberley children Point prevalence of follicular trachoma among children in the Kimberley region aged 5–15 years at annual trachoma screening, 1991–2002

Graeme H Johnson · Donna B Mak

Andrew C Laming,* Bart J Currie† * Advisor, Federal Minister for Health and Ageing, Parliament House, MG 48, Canberra, ACT 2600; † Professor in Medicine, Northern Territory Clinical School and Menzies School of Health Research, Darwin, NT. andrew.lamingAThealth.gov.au To the Editor: The important article by Ewald et al shows that offering azithromycin treatment to 70% of a remote community may be inadequate to control hyperendemic trachoma, even when combined with a health promotion campaign.1 Yet, significant short-term gains in similar locations have been achieved with as little as 20% of the population receiving azithromycin, where administration to children with trachoma and their household contacts was directly observed by health staff.2 In that study,2 we reported a 6-month follicle resolution rate in schoolchildren of 72%, followed, however, by a return of trachoma prevalence towards baseline levels over 12 months. The critical factors for short-term success with azithromycin appear to be appropriate selection of cases and contacts, plus, where possible, directly observed therapy to minimise reinfection from untreated cases. Sustainability of initial reduction in trachoma prevalence is problematic, and issues of how extensively and how often to screen and/or treat need to be determined in the Australian context. Similar sustainability considerations have arisen in community scabies programs.3 Ewald et al are correct to identify population mobility as a major issue, with trachoma likely to be reintroduced by untreated children entering a community where a treatment program has occurred. Hence the need for a coordinated regional approach. However, a regional approach to trachoma control does not necessarily mean a uniform approach, and it is vital to tailor programs to suit the capacity of communities and their degree of commitment to labour-intensive treatment and health promotion. Our study suggested that directly observed twice-yearly azithromycin therapy, with a health promotional component, is likely to be preferable to an annual program.2 Mathematical modelling supports this more frequent dosing and, unlike in Africa, the cost of azithromycin should not be a constraining factor in Australia.4 Regardless of the strategy selected, if, after treatment, the prevalence remains hyperendemic (> 20%), then the outcomes from concurrent health promotion are compromised. Appropriately targeted and directly observed azithromycin therapy can help create conditions favourable for health promotion campaigns, which in turn prolong those gains by reducing trachoma transmission.5 Major issues for trachoma control in Australia are (i) who to screen and treat (with directly observed azithromycin therapy); (ii) how often to screen and treat; (iii) how to plan trachoma programs as regional initiatives; and (iv) who will fund, coordinate and implement trachoma programs.

Andrew C Laming · Bart J Currie

Dan P Ewald,* Gillian V Hall,† Christine C Franks‡ * Senior Research Fellow, Centre for Remote Health, Flinders University, PO Box 4066, Alice Springs, NT; † Lecturer, National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT; ‡ Educator, Health Development, Health and Community Services, Alice Springs, NT. dan.ewaldATflinders.edu.au In reply: These letters reinforce a number of important points about control of trachoma (and other endemic infections) in Australia. The questions of whom and how often to treat need refining through Australian experience. Long-term control needs multifaceted, intersectoral collaboration to alter environmental and behavioural conditions against disease transmission. Strategies should be sustained, regional (large as practicable); acknowledging, and guided by, Aboriginal kinship networks; and recommend observed drug treatment (which was negotiated for the final treatment in our study). A non-uniform approach could include more frequent treatment in hyperendemic communities, probably leading to less net use of antibiotic treatment. Reports from the Kimberley Population Health Unit show a very mixed picture, with wide year-to-year fluctuations in prevalence in many communities. While hyperendemic communities remain in a region, the prevalence of trachoma may increase unnoticed in communities no longer screened because their prevalence has dropped below 5%. If not looked for, it is unlikely to be noticed. Further analysis, such as the graph provided by Johnson and Mak, is to be applauded in the context of a thorough analysis. When this happens, it will greatly strengthen the case for active trachoma control in other regions. For trachoma prevention, and for many other reasons, we believe environmental health interventions are critical. These remain difficult to evaluate given the high mobility of people in Aboriginal communities. Reliable, long-term, regional environmental health and mobility data are needed as part of this broad issue.

Dan P Ewald · Gillian V Hall · Christine C Franks

Objectives: To describe the short-term outcomes in Aboriginal children admitted to hospital with radiological alveolar lobar changes; and determine whether predischarge chest radiography can predict respiratory morbidity found at follow-up.Design, participants, setting: Prospective cohort study of Aboriginal children admitted to Alice Springs Hospital between October 2000 and April 2001 with alveolar lobar abnormalities (area of consolidation, ≥ 1 cm) on chest radiographs. Participants were to have a predischarge radiograph and be followed up for 12 months.Main outcome measures: Comorbidities, follow-up rate, and new respiratory disease found at follow-up.Results: Of 113 children hospitalised with radiological alveolar lobar changes, 109 were Aboriginal. Their median age was 1.8 years (range, 0.2 months–13.3 years), and 124 episodes were recorded. Comorbidities were common in these children (anaemia, 51.5%; suppurative otitis media, 37.3%). The follow-up rate one year after admission was 83.1% of episodes. New treatable chronic respiratory morbidity was found in 20 (25.6%) of the 78 children with completed follow-up. Predischarge chest radiographs were predictive of all chronic respiratory morbidity when they showed no or minimal resolution (0–20% resolution) (relative risk, 7.43; 95% CI, 2.07–26.60).Conclusions: Central Australian Aboriginal children admitted to hospital with alveolar changes on chest radiographs have a substantial burden of chronic respiratory illness, and should be clinically followed up for early detection and management of chronic respiratory morbidity. A predischarge radiograph is useful, and patients whose radiograph shows no or minimal resolution should have a follow-up x-ray film.

Anne B Chang MPHTM, PhD, FRACP · John P Masel MB BS, FRACR · Naomi C Boyce BNursing · Paul J Torzillo MB BS, FRACP, FFICM

Objective: To describe the levels of inflammation and vascular endothelial activation in an Aboriginal community, and the relationship of these factors to coronary heart disease (CHD) risk factors and markers of nutritional quality.Design and participants: A cross-sectional survey of 95 women and 76 men participating in a chronic-disease prevention program.Setting: A remote Aboriginal community in Western Australia in 1996.Main outcome measures: Concentrations of markers of inflammation (C-reactive protein [CRP]) and vascular endothelial activation (soluble E-selectin [sE-selectin]); presence of metabolic syndrome; concentrations of diet-derived antioxidants.Results: Participants exhibited very high plasma concentrations of CRP (mean, 5.4 mg/L; 95% CI, 4.6–6.3 mg/L) and sE-selectin (mean, 119 ng/mL; 95% CI, 111–128 ng/mL). Both CRP and sE-selectin concentrations were significantly higher in the presence of the metabolic syndrome. There were significant inverse linear relationships between concentrations of CRP and plasma concentrations of the antioxidants lycopene, β-carotene, cryptoxanthin and retinol. Even stronger inverse associations were evident between concentrations of sE-selectin and lycopene, β-carotene, cryptoxanthin and lutein.Conclusions: Vascular inflammation and endothelial activation may be important mediators of elevated CHD risk in Aboriginal people. Inadequate nutrition and physical inactivity may contribute to this process.

Kevin Rowley BAppSci PhD · Jacob Cohen BSc · Alicia J Jenkins FRACP FRCP · David O'Neal MB BS, MD, FRACP · James D Best FRACP FRCPath · Karen Z Walker PhD MND · Qing Su MSc PhD · Kerin O'Dea BSc PhD

No Australian Indigenous doctor has previously chosen a surgical career Medical training is an arduous task in optimal circumstances. When also confronted by myriad social issues, the task can be quite daunting. I hail from the Worimi mob, located north of Newcastle in the Port Stephens area, and I am currently in my first year of advanced training in otolaryngology, head and neck surgery. I am extremely fortunate in the support I have been given, to help me make the most of the opportunities afforded to me. However, despite the support, there have been many difficulties, and here I will attempt to outline some of my experiences as my career has unfolded. From an early age, I was interested in the field of health. My mother comes from a solid family of 12, and I was lucky enough to grow up among what I call my nuclear family — this includes all of my mother's family and a plethora of cousins. My mother, as the eldest in her family, didn't have the opportunity to finish secondary school; rather, she was given the task of helping to raise her siblings in very poor socioeconomic circumstances. The demands and stress imposed on our family are not new to most Aboriginal families, who confront these on a daily basis. Despite my mother's situation and lack of opportunity, her determination allowed her to successfully attain registered nursing qualifications. With the myriad health problems that face us, and the reluctance of Aboriginal people to seek medical help, it was very common to see family and friends seek help from mum. Naturally, as a curious child, I was always keen to assist in a range of basic first aid. The greatest reward was seeing the appreciation and smiles that came with improvement in their wellbeing. It wasn't until I was older that I questioned why my family would seek help from mum and not from the medical system. More intriguing was why it seemed to be Indigenous people, and not my non-Indigenous counterparts, who frequently were afflicted. With my twin sisters who led the way. It is only now that I can discuss with my sisters the humorous side of our upbringing and how it has affected us. Simple things like bed arrangements, and our desire to have our own bed instead of sharing it with our cousins; the wish to have a doona instead of a bundle of crocheted blankets; and the longed-for luxury of an indoor toilet or simple heating for the house in the winter months. By no means am I trying to embellish a hard-luck story, but, rather, to illustrate the closeness and appreciation of family life that I experienced. The greatest quality that I have gained from this experience is to be humble and non-judgemental. My acceptance into university created a "mixing pot" of emotions. On the one hand I was elated — fancy me, going to university to study medicine! Of course, to enter the health profession had long been an ambition, but it had been an unlikely prospect, particularly as I was actively discouraged from pursuing tertiary education, both covertly and overtly, by people who thought the idea of a Koori studying medicine was incredible. There was also pressure to get a job to help bring in money, rather than create an extra financial burden by going to university — tertiary education is a daunting expense for already strained family finances. Apart from two very recent exceptions, none of my family had finished Year 12, and anything beyond that was a far cry from their world. What I did have on my side were my amazing twin sisters. They had always shown the way by example, and have given me so much encouragement. They both completed Year 12, and both were accepted into medicine at Sydney University. In fact, they were the first Indigenous medical graduates from the oldest university in Australia. Now, for this to occur first in the 90s is a modern-day example of institutionalised inequality. Their acceptance into medicine also cast some doubts on my medical career, as there was resentment from the non-Indigenous community, even though my sisters' academic merit spoke for itself. To counter this, they gained strength from a belief in themselves and the big smiles of pride emanating from our community. In my final year of high school, I was without my sisters' physical presence for the first time. But their words of encouragement and pride in me had strengthened my determination to succeed. I was still fortunate to have the support of my mother, who always believed in all of us. It is easy, in retrospect, to realise why she saw our education as such a high priority, particularly when you hear of the battles she went through at a similar age. She always kept me grounded in reality and enlightened me on the journey ahead, but, most importantly, she impressed on me, and instilled in me, pride in our heritage. No one would ever take that away. Many instances of institutionalised racism occurred — unless you are on the receiving end, you often don't see it. It can be as subtle as being the only black face in a sea of white faces; to schoolyard taunts; to double standard treatment (eg, being checked when purchasing items on a credit card as a "routine" security check); to hearing other people speak slightingly of your family; and to hearing media stories denigrating your culture. But my mother never wavered in her support for our culture, and explained the importance of our ancestry. My mixed emotions included intimidation — the medical culture was a daunting thought. I was leaving my comfort zone. I had felt the emptiness at home when my sisters ventured to medical school, but now I was to follow. As I was not accepted at Sydney University, I could not follow exactly in their footsteps. I entered the medical course at the University of New South Wales (UNSW), and, initially, it took me quite a while to settle in. Today, as an ENT registrar. It was hard to leave the friends I had grown up with, who accepted me for who I was and what I represented. They knew my background and my family, and I considered them to be family. I envisaged medical students as all upper class, private school boarders, with no idea about the realities of life as I knew them. I thought my colleagues would be my opposites: had never left the city, had never met a Koori, had their own rooms, owned cars, and had always been comfortable financially. I also wondered how my lecturers and seniors would treat me. Needless to say, entering university was terrifying. Leaving my family behind was extremely difficult. As a Koori, family is extremely important to me — looking after cousins, big family gatherings, and being able to support one another in difficult times. I really wanted them all to move with me. I was terrified of becoming an "outer" in the family; to be rejected for following what, until recently, was a non-Indigenous career path; to lose my identity that I had finally grasped (from teenage years); to become lost in the system; and to fail (when my sisters had led the way and the community had high expectations). I am happy to say all my fears were ill founded, and studying at UNSW was a delight. It is true it took me a while to adjust. The new social surroundings were initially difficult, but I was fortunate enough to reside at a university college, and met many new people and formed long-lasting, inspirational friendships. This also gave me an avenue for meeting people outside the medical course, so I could appreciate the diversity of opportunities the university had to offer. The university environment is dynamic as well as diverse, and I strongly feel that being immersed in this ambience was equilibrating. I learnt a great deal from other people's experiences, as they learnt from mine. I acquired a better understanding of other cultures and how other people lived. This provided a great opportunity to learn to treat different people. I have made wonderful friendships with the very people I was initially afraid of, and I soon realised that the majority of medical students are pleasant and open. Sure, there were a lot of mixed impressions, and ignorance sometimes reared its ugly head. But, talking to other Indigenous medical students made me realise that my experience was not unique, and the strength that had been instilled in me helped me to rise above any adversity. I also realised the magnitude of help and assistance that was available to students, and that most lecturers were readily available and willing to help. Although I had become comfortable among my new friends, I felt alone in my studies. I realised this when a dear Aboriginal friend transferred from another university halfway through my training. Instantly, I didn't feel alone any more. It was a feeling of someone else understanding my predicament without having to explain it myself. Newcastle University had always had strength in numbers of Indigenous students, and at Sydney University my sisters had each other. This inspired the instigation of a premedical program at UNSW for Indigenous students wanting to study medicine. I was passionate about creating an environment that supported, rather than discouraged, the aspirations of Indigenous students, while at the same time not creating unrealistic dreams. A small group of us set about formalising a program. We received lots of strong support, mixed with a small amount of resistance. Rallying the support of the Faculty, making a presentation at a medical deans' conference and providing a realistic business plan were all worthwhile and achievable. My graduation highlighted the pride of my family. A strong family contingent attended my graduation, many of whom had never set foot in a university. In their words, it "charmed" them to attend and be part of it. And, in many ways, it was their graduation — my accomplishment is a testament to my family, my mother, my community and my ancestors and to the incredible fight they have endured, and the struggle that we as a race continue to endure. This aspect was really brought home to me when, as an intern, I first treated an Indigenous patient. My worst fear was upsetting the elder, as being able to treat Indigenous patients was my reason for being there. After a thorough history and examination, the patient began to cry. My heart sank and I felt I had failed. My smile proudly appeared again when she explained that her tears were tears of joy, as she never thought she would ever be treated by an Indigenous doctor. The importance of professional equality hit home, and it reaffirmed my desire to give back to my community. Residency was hard work, but fun and rewarding. It seems, though, no matter what you go through, you always come across poorly managed Indigenous patients. What surprised me most was that their first contact with a medical institution seemed to have a profound effect on how these patients responded, not medically, but rather in their compliance and willingness to attend follow-up. I continued to come across racism, but again it was more institutionalised. For example, there was the reaction and misunderstanding of medical staff when confronted by an Indigenous patient, at the same time claiming they were not racist — their actions obviously stated otherwise and they didn't have the insight to recognise their inbuilt perceptions and prejudice. I decided to pursue a career in surgery because it appealed to me and suited my persona. I was fortunate to have the great benefit of support from my surgical mentors at St Vincent's Hospital, although the surgical exams were my toughest exams to date! The major difference was being able to create a suitable study environment, and the greater appreciation of my desire to better equip myself for my future role. Although my mentors were wonderful, again I felt isolated, given that no Australian Indigenous doctor had previously chosen a surgical career. This is understandable, given the demands of surgical training and the small number of Indigenous doctors Australia has, as yet, produced. I passed my surgical primary examination and have gained great experience in general surgery. With the Third World status of ear disease in Indigenous Australians, I had always had a desire to pursue a career in ENT. After gaining some experience in ENT, I realised the scope of the specialty beyond ear disease, and the great professional opportunities available. I am back where my passion originated, but now I am on the professional side. The understanding and support from the otolaryngology community has been overwhelming. As I embark on my advanced training, it seems almost surreal to be where I am now, and I am even more proud of my culture.

Kelvin M Kong MB BS, BSc

How to heal the festering sore of Indigenous health? In Australia, Indigenous health remains a blot on the nation's collective consciousness. There has been little, if any, improvement in the last quarter of a century.1 Although an association between health and socioeconomic status has been described in many different societies, in Australia we seem to avoid taking this connection into account when considering Indigenous health. The First Nation's people of Australia still do not have the same access to housing, education and employment as those who are relative newcomers; thus, it should not be surprising that their health status is worse. Senator Aden Ridgeway, in his address to the United Nations Human Rights Commission,2 summarised the root of this problem as: Non-Indigenous Australians are keen to embrace the rhetoric of reconciliation, so long as it doesn't require them to take effective action to share the country's abundant resources and political power. Most are not prepared to make any significant adjustments in how they live their lives or how they see their future. Few are prepared to really look within themselves to challenge their beliefs and values, for fear of what they might find and for fear of what they think they might lose. So, what might it be that non-Indigenous Australians are so fearful of finding? Possibly, that the entire basis of land ownership in Australia, and therefore our economy, is based on the lie of Terra Nullius — that is, that no one owned the land claimed by others.3 And, what might non-Indigenous Australians be so fearful of losing? All their benefits, including health benefits, that they may have derived from this lie. At a recent National Health Summit in Sydney (held at Merchant Court Hotel, Sydney, 18–19 February 2003; hosted by Terrapinn), speakers outlined Australia's achievements in health, most notably that we can boast the second highest longevity among OECD countries. But little of what was said had any bearing on Indigenous health — it was almost as though Indigenous health had to be annexed so that the mood could remain positive. However, it is neither moral nor ethical for Australia to continue to ignore the deplorable state of Indigenous health. For too long, too many of the issues have been relegated to the too-hard basket. The festering sore of Indigenous health will not go away by ignoring it, but rather needs direct action — the active promotion of opportunities for Indigenous Australians in mainstream professions and services, health or otherwise. The medical profession has long recognised its social contract to Indigenous Australians, and we can easily start to fulfil this contract by attending to our own backyard. For proportionate racial representation in the medical profession in Australia, we should have about 1260 Indigenous doctors; however, there are no more than 55. All have graduated since 1983 and more than half from the one medical school. Had the other nine medical schools made the same effort to recruit and train Indigenous doctors, we would now be much closer to the racial equity goal of 1260 doctors. The presence of Indigenous Australians within the student body of our medical schools does more than just help to meet a target. It enriches the profession and enables other medical students to access something of the Indigenous experience — many Indigenous medical students and doctors have been the first Indigenous Australians that our non-Indigenous colleagues have met. The presence of Indigenous Australians in our medical schools also keeps the focus on Indigenous health active and honest. And it can provide a shining example and model for other professions who should recruit, support and graduate Indigenous students. In fact, it is important for our Indigenous students in primary and secondary school to see that all professions are accessible and supportive, so they can confidently consider tertiary education as a reality rather than a fanciful dream. Many of our medical postgraduate clinical colleges are already seeking to actively recruit Indigenous doctors into their training programs; we will also need to see the introduction of compulsory Indigenous health curricula into each of the postgraduate training programs. Beyond incorporating Indigenous health and health workers into our ranks, we need to actively encourage appropriate access to health services. For example, as a profession we need to call for the introduction of a Medicare safety net that will make a discernible improvement to the health status of Indigenous Australians. Real gains in Indigenous health are attainable by incorporating Indigenous health provision (albeit with additional benefit or consideration) into our mainstream delivery of health services, rather than, or at least in addition to, setting up more and more services specifically for Indigenous Australians. Beyond healthcare delivery, more of our profession should consider taking leadership in issues related to sovereignty and treaty, and ensure that satisfactory access to housing, education and employment is pursued. What benefit can Australia expect to receive from such a radical change in approach? As Senator Ridgeway said, much of Australia may avoid self-examination for fear of what will be found and what will be lost. This apparent milieu of fear is a poor legacy to leave to future generations of Australians. In confronting these issues, we can offer a better future for our nation and bring healing to the festering sore that is Australia's Black history (and health). The medical fraternity can play a leading role in this process — after all, healing is the prime concern of our profession.

Louis G Peachey BMed, FACRRM

To the Editor: As practitioners in a community-controlled Aboriginal and Torres Strait Islander primary healthcare centre, striving to better meet the healthcare needs of our community, we would like to offer some thoughts on a recent article by Coory et al.1 In reporting on cervical cancer screening participation rates in Indigenous communities in Queensland, Coory et al identified the communities but did not inform them that the study was being conducted. We feel that such an approach is unhelpful and reflects a paternalistic attitude. The accompanying editorial2 rightly drew attention to the lack of direct consultation with the communities involved and the consequences of this in terms of future interventions. Without a true partnership with the women and their communities, the authors were unable to do more than imply that participation rates were better in centres with a primary-healthcare approach to screening. Information about the types of services and choice of Pap smear providers available in each community, in addition to the Pap smear screening participation rate, would be of great interest. It would, in part, answer the question the authors themselves posed about the role of primary healthcare in improving Pap smear participation rates. Already scarce funds could then be committed to improving access to quality primary healthcare rather than to conducting further trials. A further factor, which was not explored in either the study or the editorial, was health promotion. The cornerstone of health promotion in the Indigenous community remains the "kit-video" model, comprising posters, leaflets and a video. In contrast, mainstream health promotion often involves expensive multimedia campaigns promoted by national celebrities. Such campaigns have been shown to increase Pap smear screening in the wider community.3,4 To date, these campaigns have rarely had an Indigenous focus, and it might be argued that a consequence of this is the low Pap smear participation rate documented by Coory et al. In our experience,5 the Indigenous community does respond to culturally appropriate holistic primary healthcare. The study by Coory et al demonstrates a lack of commitment, collaboration and innovation — essential features for the delivery of quality primary healthcare — that is all too common in the current approach to Indigenous health.

Katie S Panaretto · Sarah Larkins · Vivienne Manessis