Indigenous health

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

Nicholas J Talley MD, PhD, FRACP

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

Peter B McIntyre PhD, FRACP · Robert I Menzies MPH

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

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

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

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

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

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

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

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

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

Glynis A Johns MB BS, DPH, MPhil

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

Naomi R Mayers · Sophie Couzos MPH

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

Raymond S Hyslop

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