Indigenous health

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

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

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

Graeme H Johnson · Donna B Mak

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

Andrew C Laming · Bart J Currie

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

Dan P Ewald · Gillian V Hall · Christine C Franks

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

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

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

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

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

Kelvin M Kong MB BS, BSc

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

Louis G Peachey BMed, FACRRM

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

Katie S Panaretto · Sarah Larkins · Vivienne Manessis

In reply: Black has argued that the role of evidence in policy development is to create concern and set agendas.1 This was the aim of our article. Although there has been a national, organised approach to preventing cervical cancer since 1991, our study found that screening rates for Indigenous women still lag well behind those of non-Indigenous women. Workers in Indigenous health might have suspected as much, but valid data have not previously been available for a wide geographical area. As Murray and Lopez point out, the lack of good data on a health issue is often taken to mean that the problem is not important.2 We agree that the development of effective programs should be done in consultation and partnership with Indigenous communities. However, there is an additional need to influence decision-makers and budget-holders at national, State and regional levels. An evidence base that identified effective interventions would facilitate this process. Such evidence need not come from randomised controlled trials. On the other hand, case reports of successful interventions in a single community that cannot be sustained when key personnel leave are not very persuasive. It is also useful to demonstrate that the situation is not hopeless. The encouraging finding from our study was that the participation rate in cervical cancer screening was more than 50% in three of the 13 communities studied.

Michael D Coory · Patricia S Fagan · Jennifer M Muller · Nathan AM Dunn

To the Editor: We welcome Ring and Brown's editorial comment1 on the Public Report Card 2002 No More Excuses,2 produced by the Australian Medical Association's Task Force on Indigenous Health. We hope that drawing attention to the poor outcomes of Indigenous Australians will catalyse Federal and State governments to take action, particularly as international comparisons demonstrate the likelihood of success. Australia's poor performance in relation to its Indigenous people is a complex phenomenon, involving political, sociocultural and historical factors, as well as health factors. Levels of ill health among Indigenous communities in post-colonial Australia, Canada and New Zealand are particularly disturbing from a global health perspective, as they persist despite the relative affluence and excellent health status enjoyed by the general population in these nations. One of the difficulties in assessing progress is the lack of high-quality data for comparative purposes. The types of indicators of Indigenous health in common use in Australia, Canada and New Zealand range from central indicators (such as the age-standardised rate ratios for Aboriginal people) to secondary indicators (such as change in the prevalence and incidence of chronic diseases, like diabetes, in Aboriginal communities). It would be useful to develop additional indicators that more closely reflect Aboriginal community knowledge models and values.3 Existing indicators emphasise outcomes rather than opportunities for early intervention, such as early childhood development and youth resilience. Finally, there need to be greater attempts to explore how to use and compare international experiences to help Indigenous people most effectively. The Memorandum of Understanding between the Canadian Institutes of Health Research, the Medical Research Council of Australia, and the Health Research Council of New Zealand may provide a framework for international collaboration.4

Paul Bauert · Elizabeth McMaugh · Carmel M Martin · Janet K Smylie

Objectives: To describe the prevalence of markers of growth, chronic and infectious disease in peripubertal Aboriginal children living in the Darwin Health Region in the "Top End" of the Northern Territory, and to compare prevalence between children living in urban and remote areas.Design: Cross-sectional survey nested in a prospective birth cohort.Subjects: 482 children living in the region who were recruited at birth (Jan 1987 to Mar 1990) and were followed up between 1998 and 2001, when aged 8–14 years.Main outcome measures: Selected parameters of growth and nutrition, infectious disease and potential markers of chronic adult disease were compared between children living at follow-up in suburban situations in Darwin–Palmerston (urban) and those living in rural communities with an Aboriginal council (remote).Results: Remote children were shorter than urban children (mean height, 141.7 v 146.3 cm; P < 0.001), lighter (median weight, 30.3 v 37.1 kg; P < 0.001) and had lower body mass index (median, 15.3 v 17.9 kg/m2; P < 0.001) and haemoglobin level (mean, 125.1 v 130.9 g/L; P < 0.001). Some potential markers of adult chronic disease were higher in urban than remote children: systolic blood pressure (mean, 109.6 v 106.2 mmHg; P = 0.004), and levels of total cholesterol (4.3 v 4.0 mmol/L; P < 0.001), high-density lipoprotein cholesterol (mean, 1.4 v 1.2 mmol/L; P < 0.001) and insulin (median, 7 v 4 mU/L; P = 0.007). Diastolic blood pressure, levels of red cell folate, serum glucose and low-density lipoprotein cholesterol, and urinary albumin–creatinine ratio did not differ by location. The prevalence of visible infections was also higher in remote than urban children (P < 0.05).Conclusion: As some markers of health differ between peripubertal Aboriginal children living in urban areas and those in remote areas, results of surveys in remote areas cannot be generalised to urban Aboriginal populations.

Dorothy E M Mackerras MPH, PhD · Alison Reid MSc · Susan M Sayers FRACP, PhD · Gurmeet R Singh MD · Kathryn A Flynn BNurs · Ingrid K Bucens FRACP

Objectives: To evaluate the effectiveness of a trachoma control program in a remote community before and after major environmental health improvements.Design: Before-and-after cross-sectional design. The control program was in three rounds — each consisting of community census, screening of children < 13 years, health promotion activities and antibiotic treatment. There were two housing and infrastructure surveys.Interventions: Treatment of affected children and their households with azithromycin at baseline, 7 and 21 months, and health promotions. Housing and sewerage infrastructure improvements were completed at 12 months.Setting: Large, remote Central Australian Aboriginal community, 1998–2000.Participants: All community residents.Main outcome measures: Prevalence of active trachoma among children under 13 years; community population changes; and adequacy of housing facilities for healthy living practices.Results: The prevalence of trachoma among children was 40% (95% CI, 32%–46%) at baseline, 33% (95% CI, 26%–40%) at 7 months' follow-up and 37% (95% CI, 29%–46%) at 21 months. These proportions were neither clinically nor statistically significantly different. There was a high degree of population mobility over the study period, with only 32% of residents appearing in all three censuses. The proportion of houses with completely adequate facilities increased from 0 to 16%.Conclusions: Population mobility (both within and between communities), inadequate housing and continued crowding (despite improvements), as well as uncertainty about compliance with antibiotic treatment, are the likely factors contributing to the lack of effect of this trachoma control program. Because of high population mobility, a region-wide approach is needed for effective trachoma control.

Dan P Ewald MAppEpid, FAFPHM · Gillian V Hall MB BS, PhD · Christine C Franks GradDipIndHealth, MAppEpid

Chronic HBV infection is common in remote Aboriginal and Torres Strait Islander communities, where resources are scarce and patients may have several concurrent illnesses. The management of chronic HBV infection has changed over recent years, with greater application of serological and radiological investigations and new, more acceptable treatments for chronic liver disease, cirrhosis and hepatocellular carcinoma. Optimal follow-up procedures for patients with chronic HBV infection are still being debated, but may not be applicable to Aboriginal and Torres Strait Islander communities where factors such as endemicity, remoteness, frequent comorbidities, shorter life expectancy and cultural differences in health priorities must be taken into consideration. We have defined an algorithm to assist primary care providers caring for patients with chronic HBV infection in Aboriginal and Torres Strait Islander communities. Patients are divided into one of three categories for follow-up and referral based on clinical features, and results of liver enzyme and serological tests.

Dale A Fisher FRACP · Sarah E Huffam FRACP

The recent pioneering Public Report Card 2002 — Aboriginal and Torres Strait Islander health, entitled No more excuses,1 outlines where we are today and how the health of our Indigenous population compares with that of other similar countries — New Zealand, Canada and the United States. Produced by the Australian Medical Association, it is a "warts-and-all" assessment which is designed to show what is working and where we need to do better. Where do we stand on health?There have certainly been some gains. The health of Indigenous infants has improved dramatically, although from a low baseline, and most of the gains occurred 20–30 years ago.2 The current infant mortality rate for the Aboriginal and Torres Strait Islander population is almost three times that of the general Australian population, twice that of the Maori, and 50% higher than the mortality rate of US Indigenous infants.3 This is some improvement on previous rates, but we can and should do better. Death rates overall for Indigenous people in Australia are still three times as high as for the rest of the population: diabetes death rates are eight times as high, respiratory deaths four times as high and circulatory conditions almost three times as high.4 These are unacceptable statistics for treatable and preventable conditions. On the other hand, there are number of recent good news stories. Programs in the Northern Territory and elsewhere have shown that birthweight, the critical factor in the survival of newborn infants, can be improved.5,6 More dramatically, death rates from pneumonia have dropped by around 40% since 1996 (derived from Australian Bureau of Statistics data). This is important, because this reduction is likely to be due, in part, to recent government initiatives for promoting pneumococcal vaccination. This is a real indication of the kind of rapid and substantial gains that can be achieved through application of knowledge we already have. (Well done, even if long overdue.) Progress in providing access to health services for Aboriginal and Torres Strait Islander communities is much too slow. There is a gross shortage of doctors working in Indigenous health, with an estimated 60% increase required (ie, at least 500 doctors). The number of nurses also needs to increase by 25%, and there are sizeable deficits in all the other health professions.7 There has been some improvement in basic services and facilities to some areas, but too many Aboriginal and Torres Strait Islander communities still lack adequate water, electricity and sewerage services.8,9 In other fields influencing health, there has been some modest improvement in educational benchmarks, but still only a third of Aboriginal and Torres Strait Islander children reach Year 12 at school.10 Most tellingly, however, are the data for the most reliable overall measure of health — median age at death, currently 51 years for the Aboriginal and Torres Strait Islander population. There has been no improvement at all in this measure in the last 10 years.3 In this same period, the median age at death for the total Australian population increased by three years, so that the gap in median age between Indigenous people and the rest of the population has now increased to a staggering 26 years. Median age at death is much higher for the Indigenous populations of New Zealand (59 years), Canada (65 years) and the United States (63 years) and, in contrast to the situation in Australia, has been progressively increasing for the last 25 years,11 and probably for much longer. What about health spending?Spending on Aboriginal and Torres Strait Islander health is increasing, but, incredibly, the Commonwealth Government, through programs under its direct control, still spends less per capita on Indigenous people than it does on the rest of the Australian population — 74c on Indigenous Australians for every $1 spent on the rest of the population! The real increase in spending on Indigenous health between 1995–96 and 1998–99 was 15%.12 This is worthwhile, but nowhere near enough to cater for the higher levels of illness among Indigenous people. There has been a major new initiative, the Primary Health Care Access Program, with three key features: needs-based funding, funds pooling and community control. However, the funding for the program is totally inadequate, and at this stage only selected communities can participate in a program which is needed for Indigenous people throughout Australia.13 The consequences of the funding shortfall are major deficiencies in the crucial prevention and early treatment services required to break the cycle of ill-health. Why do we do so much worse than other countries?What is it about Australia that stops us from achieving the gains seen in the health of the Indigenous populations in other Western democracies, or, for that matter, in developing countries around the world? There is, after all, nothing absolutely unique either about the disease pattern or the history and circumstances of the Australian Indigenous population. Heart disease, respiratory conditions, injuries and diabetes are also the major conditions for the Indigenous populations of other countries. Dispossession, forcible relocation, removing children from their families, and heavy-handed paternalism are certainly not unique to Australia. Nor is Australia incapable of doing well with health and health services. Depending on which measurement you take, Australia is arguably the second- or third-healthiest country in the world, with a proud record in confronting difficult and complex issues such as AIDS and cancers in women.14 Why is the government not doing more?It is symptomatic of our lack of progress that this report card, and its call for action, comes not from the government, but from health professionals. Surely one would hope that some response, some soul searching, some rethinking would be evoked by the fact that over the last 10 years, despite some good news, the overall mortality of the Australian Indigenous population, alone among Western nations, has not improved, is much worse than for the Indigenous populations of New Zealand and North America, and that the gap between the mortality rate of the Indigenous population and that of the rest of the Australian population is becoming wider. But no, there is simply a deafening silence; a case of industrial deafness. Shortfalls in medical services for rural areas have produced major government programs and initiatives, and a massive injection of funds. Where is the response to the huge shortage of doctors and nurses to work in Indigenous health, and the major gaps in the workforce of all the other health professions? For any other section of the population there would be a massive outcry and appropriate remedial action. In fact, for Aboriginal and Torres Strait Islander health, the Commonwealth Government seems to be tied up with a curious logic that requires "good news" from spending less on people with worse health before it will fully rectify the health service deficiencies needed to address the worse health! Australia is locked into a cycle of endless consultation, policy and strategy formulation and measurement. Report after report is produced showing that Indigenous health is poor, improvement patchy at best, and that, overall, the gap between Indigenous and non-Indigenous health is widening. These reports reach the highest levels of Australian public and political life and are simply noted, or evoke defensive bureaucratic responses. We must act on the reports, not just note them. Flat-lining for 10 years is not good enough! Many worthwhile activities are under way, but would any informed observer really claim that current or planned prevention and treatment services, staff provision and training plans, and environmental improvements, will do the job, or are anywhere near sufficient to bring about the Indigenous health gains seen in other countries most like Australia? What do we need to do?We don't need new solutions, new strategies, some magic bullet. We need to implement strategies, like the National Aboriginal Health Strategy,15 that have been around for more than a decade. The Report Card reinforces previous calls for a national program to build up the necessary community-controlled health services for prevention and treatment; for the Primary Health Care Access Program to be given the funds required to provide those services; for a National Training Plan to train the staff, particularly Indigenous staff, required to deliver those services; and for a National Infrastructure Plan to rectify the continuing deficiencies in water supply, sanitation, education and other basic services. Australia spends over $50 billion per annum on health for its total population.16 It isn't that the modest funds required for adequate health services for Aboriginal and Torres Strait Islander people are out of reach, or that the services required are beyond our technical capacity. It is ultimately a commitment to implement the recommendations of the endless reports, and this is what the AMA, in support of Aboriginal and Torres Strait Islander organisations, is urging on the nation. Straws in the wind?Despite the general lack of progress, there are straws in the wind. The appointment of a new Health Minister and a new head of the Commonwealth Department of Health provides a fresh opportunity for dealing with the issues highlighted in the Report Card. Death rates of the NZ Maori and the Indigenous peoples of Canada dropped by 30% in the 1970s.17 Over a 40-year period, the health of the Indigenous populations of the United States improved twice as rapidly as that of the non-Indigenous population.14 Australia can do the same, and that should be our aim. Summary of the AMA Report Card on Aboriginal and Torres Strait Islander health Status Comment Infant mortality rate Indigenous rates are 2 times the total population rate Rapid fall in the 1970s. Rates in Indigenous Australians almost twice as high as those of the NZ Maori and US Indigenous populations Low birthweight Indigenous babies are twice as likely to have low birthweight. Little overall improvement since 1991, but effective programs developed and implemented in the Northern Territory and South Australia Expectation of life The gap between Indigenous and non-Indigenous people is 20 years In North America and New Zealand, the life expectancy gap (Indigenous v non-Indigenous) is 5–7 years Median age of death For Indigenous people this is 25 years less than for non-Indigenous people There has been no improvement in the median age of death in the Indigenous population in Australia in the past 10 years Standardised mortality ratios Indigenous rates are three times those of the total population High rates for diabetes, respiratory, circulatory and other conditions in the Indigenous population Mortality from pneumonia A dramatic decline in Indigenous rates since 1996 Pneumoccocal and influenza vaccines may be contributing to the decline in mortality from pneumonia Health workforce Estimated at least 59% increase in doctors required, and a 25% increase in nurses Required increase related to difficulties in accessing preventive and early treatment services Infrastructure 21 communities lack water, 80 lack electricity and 91 sewerage Some improvement, but significant gaps Education Year 12 retention rates are 36% for Indigenous people v 73% for the total population Some improvement, but significant gaps Health funding 15% real increase in government funding between 1995–96 and 1998–99 Level of health spending is 22% higher for Indigenous people but a needs index of 200% is required Aboriginal Community Controlled Health Services (ACCHS) OATSIH funding of community-controlled services increased by 50% between 1995–96 and 1999–2000 ACCHS with a network of culturally appropriate healthcare services provides a model for Indigenous health services OATSIH = Office for Aboriginal and Torres Strait Islander Health.

Ian T Ring MB BS, FAFPHM · Ngaire Brown B Med, MPHTM

Christmas Eve, a couple of years ago. I was on call for the birth suite until 8 am the next, Christmas, morning but was hoping to be able to stay at home with my family. At 6 pm, I did a festive round with the registrar on duty. Good — only three women in the suite, and two delivered, both delighted with themselves for getting it over before Christmas Day. In the corner room, one woman in early labour — Grace, aged 34. Elderly for a first baby, especially for an Aboriginal woman, the registrar observes. I say hello to Grace, but don't examine her — that's why the midwives and junior staff are here. Surprisingly, no partner or family is with her. Then I realise that I have seen Grace about our town. She is one of the "park people". Virtually homeless, living mostly outdoors, drifting back and forth between town and some of the more remote communities of the region, the park people are frequently subjected to the ire of some of the town's better-heeled residents. Recently, these residents have demanded more stringent "move-on" laws, to keep the park people out of the sight of the tourists and restaurant patrons along the town's seashore. So far, the State's Anti-Discrimination Commissioner has successfully opposed such laws, but for the park people — rather like those people back in Bethlehem whose birth experience we are celebrating tonight — it seems there is no room at the inn. In her time, like other park people, Grace has had many visits to the hospital's emergency department. At every admission, the same comments appeared: "poor historian"; "C2H5OH"; "lacerations"; "bruises". She'd been sutured many times, with the new and old stab wounds noted. A large scar on her throat and another on her left breast were recorded. Unfortunately, no-one noted the scar on her lower abdomen. Longitudinal and midline. A laparotomy scar. Grace hasn't attended any formal antenatal clinics, but thankfully, during one of her visits to casualty a while back, someone did do an ultrasound scan, so we know she is labouring close to term. Routine antenatal blood tests are being done now. She is in established labour, progressing, and all appears well. I leave it to the registrar to check the results, wish everyone a Merry Christmas, and go home. Two hours later, I am rung by an agitated registrar and, on the strength of what I am told, go back to the birth suite. In conversation with one of the midwives on duty, an elderly Aboriginal woman, visiting another patient, remarked of Grace: "Long time since that girl had a baby!". "Oh no," replied the midwife, "this is her first". "No," the woman was firm. "Had the baby when she was 13. A caesarean. At . . . " — and she named a former mission station some hundreds of kilometres away. The midwife hastened to question Grace. Did she ever have a baby before? It was difficult for her to answer; she is indeed a poor historian. For a start, she has no teeth. Those that weren't knocked out in fights have rotted away. Also, chronic middle ear disease since childhood has made her rather deaf. But she does know that, yes, she did have a baby. A girl. Nobody in the hospital had ever asked her before; she didn't know it was important. Did she have a caesarean? Grace is unsure. It was a long time ago. Did the baby come out through that scar on her tummy? Yes, maybe. It was a long time ago. Where is her daughter now? Grace does not know. Obstetric dilemma: is the abdominal scar longitudinal because Grace had a classical caesar, in which case, because of the risk of uterine rupture, caesarean section should be repeated forthwith? Or — and more likely — was the longitudinal incision merely the route to a standard lower-segment operation, allowing Grace the possibility of a successful vaginal birth this time? For the moment, all seems well. Grace is contracting regularly, has accepted pethidine, and is making progress in labour. She now lies in a clean hospital bed, surprised to be — for perhaps the first time in her life — the centre of concerned attention. We try ringing the hospital near the former mission for more information. It's 9.30 pm on Christmas Eve! We're told: "You want records from more than 20 years ago? You must be joking! Ring back next week." An hour later, a further complication arises. Grace's blood has shown unusual antibodies and it will take some hours to find and crossmatch blood if we need it. We decide to ask for the crossmatch and hope that she delivers vaginally soon and that she won't need surgery or blood. Regularly, anxiously, we watch Grace's vital signs and the fetal monitor. Another two hours later, we have blood, Grace's cervix is 8 cm dilated and the fetal heartbeat has been fine. And then, she begins to bleed. Torrentially. Everyone swings into action. After all, this is what we do best. Acute care. Three wise men appear — anaesthetist, paediatrician and theatre porter — bringing not frankincense, myrrh and a manger but ropivacaine, oxygen and a trolley. In five minutes, Grace is on the operating table; another five, and a spinal block is in place. Soon, a rapid repeat caesarean section is under way. The old scar — in fact, a classical — has ruptured and is bleeding profusely, but it's repairable and the baby is alive. On the stroke of midnight, a baby boy arrives. He is small and scrawny, covered in meconium. But when he gives a feeble cry, Grace smiles and reaches out one arm for him (a blood transfusion is running into the other) and she names him, appropriately, Joseph Christopher. Joseph spends that night and the next in the special care unit. He starts to breastfeed. Grace is eating three meals a day, including turkey and plum pudding. But it's Christmas time, the hospital is short of staff and many beds are closed, so even at this inn Grace cannot stay too long. On Day 5 post-op, Grace and Joseph are discharged "home". As Grace has no home, a place is found for her in a hostel, with domiciliary visits planned. On the first visit, the domiciliary midwife finds things are OK; the next day, Grace and her baby have gone. A few days later — in fact, on New Year's Day — Grace presents to the emergency department again, this time with Joseph. He isn't feeding well and is bringing up feeds; and, he has a fever. But we can deal with all that. It's another acute problem, not one of those complicated social issues that, in hospital practice, just have to be put into the "too-hard" basket. The paediatric registrar arrives, Joseph is admitted and a drip is put up. And so the cycle of disadvantage starts all over again — unto a new generation.

Caroline M De Costa FRANZCOG, FRCOG

When asked about features of women's health services that would best meet their needs, specific groups of Aboriginal and Torres Strait Islander women, despite their diversity, have given very similar responses.1-3 They want women's healthcare that takes a holistic rather than a narrow "single-disease" or biomedical approach; services that are accessible, flexible and supportive; and providers they can trust, who are respectful and who can communicate well. For many Aboriginal and Torres Strait Islander women, having access to a female provider is critical to their acceptance of women's healthcare services. The higher cervical cancer incidence and mortality for Aboriginal and Torres Strait Islander women compared with other women, and the available evidence about screening effectiveness, provide a strong imperative for healthcare providers and funders to listen carefully and respond to what women say they want.4 The article by Coory and colleagues in this issue of the Journal (page 544) quantifies and compares women's participation in cervical screening by analysing data from the Queensland Health Pap Smear Registry.5 Participation for women living in rural and remote Aboriginal and Torres Strait Islander communities in Queensland was generally lower than for women living in other areas. Proportions of women in these communities who had had a Pap smear over a two-year period ranged from 19% to 63%. These results suggest women's needs for women's health services are being better met in some communities than others. In interpreting their analysis, Coory et al used residence in a community where most people were Aboriginal and/or Torres Strait Islander as a proxy for Indigenous status. We believe this is a resourceful and reasonably valid way around Indigenous status not being identified on the Pap smear register. However, one limitation is that we can learn nothing about Aboriginal and Torres Strait Islander women living in other localities (ie, the majority of Aboriginal and Torres Strait Islander women in both Queensland and Australia more generally). It is important that the needs of these women are not neglected because of the lack of quantitative data with which to measure them. We commend the researchers for acknowledging the sensitivities of identifying data from individual Aboriginal and Torres Strait Islander communities in their research. However, rather than only obtaining permission to do so from a government department, we believe consulting directly with members of the communities concerned at an early stage of the project may have been beneficial. Although such a practice is uncommon in this type of research, and may be challenging and more time-consuming, it may also create or strengthen trust, links and understanding, which could be useful when implementing and evaluating subsequent interventions. Coory et al suggest that the higher cervical screening participation rates in some communities are an indication of what is achievable, and express support for a strategy of strengthening primary health care. We agree with these conclusions, but disagree that an intervention study where communities are randomised would be an ideal next step. Although randomised-community intervention trials have been implemented in other settings,6 for Aboriginal and Torres Strait Islander communities the barriers to delivery of women's health services are likely to be highly location-specific and the means to overcome them not amenable to random allocation. We believe any available resources would be better spent on (i) exploring in more detail the factors contributing to high and low levels of participation, and (ii) responding actively to identified issues in communities with lower levels of participation. Barriers to Aboriginal and Torres Strait Islander women accessing women's cancer screening services, and ways of responding to them, have been reviewed — most recently in the context of considering how to support the roles of general practitioners.1,4 We would like to highlight the need to also support the roles of Aboriginal Health Workers (AHWs). Because of their key role in providing primary health care for Aboriginal and Torres Strait Islander people, the need for improved clarity, recognition and support of AHW roles has been identified as a national priority.7 We have worked with many female AHWs who have had personal experience of the impact of cervical cancer on Aboriginal and Torres Strait Islander women and their communities, and are keen to be involved in women's health education and promotion activities. Some AHWs also want to provide women's clinical care, including taking Pap smears. Some of the specific areas needing attention are the provision of better training for AHWs in women's health, and issues of accreditation, legal cover and quality assurance for those wanting to take Pap smears. Finally, we urge caution about evaluating cervical screening programs solely on the basis of participation rates. Recent commentaries have begun to question a primary aim for screening programs of maximising participation, arguing that this may lead to the positive effects of screening being overstated, and the limitations and possible negative effects of screening and its sequelae being ignored or downplayed.8,9 These commentators acknowledge that providing more balanced information about screening may have a negative impact on participation rates, but stress the importance of individuals being informed about screening and being able to choose for themselves whether or not to participate.8 Qualitative research conducted with women in one rural Aboriginal community with high rates of participation in cervical screening found that many of the women had little understanding of cervical screening or its implications.10 For programs successful in terms of participation, questions may remain about the extent to which women are making an informed choice about screening. In many localities, providers' attempts to consistently give adequate information to Aboriginal and Torres Strait Islander women can be constrained by many factors, including lack of time, and language and cultural differences. These barriers, combined with a high level of concern about cervical cancer and evaluation criteria based mainly on participation rates, may lead to an emphasis on persuading women to have a Pap smear rather than on providing information and an opportunity for informed choice. We strongly advocate that evaluators of cervical screening programs take into account not only participation rates, but also Aboriginal and Torres Strait Islander women's views about available health services and their understanding of screening-related issues.

Jennifer M Hunt MB BS MPH FAFPHM Public Health · Lynore K Geia BN, RM, MPH

Objective: To investigate the extent of participation in cervical cancer screening among women who live in discrete rural and remote Indigenous communities in Queensland.Design: Descriptive analysis of data from the Queensland Health Pap Smear Registry for the period March 1999 to February 2001.Subjects: Women aged 20–69 years who had given their address of usual residence as one of 13 discrete rural and remote Indigenous communities in Queensland.Main outcome measures: Proportion of women who participated in cervical screening over a two-year period ("biennial participation percentage") and variation in participation across the 13 communities.Results: Overall, the biennial participation percentage in the Indigenous communities was 41.1%. This was 30% lower (risk ratio, 0.70; 95% CI, 0.67–0.72) than that for the rest of Queensland. There was statistically significant variation among communities, with biennial participation percentage ranging from 19.9% to 63.5%.Conclusions: The variation in participation across the communities suggests that the problem of low participation among Indigenous women is not intractable. Achieving participation rates similar to the highest rates found in our study would be of major benefit to Indigenous women.

Michael D Coory MB BS, PhD · Jennifer M Muller MEnvCommHealth, GradDipHealthProm · Nathan A M Dunn BSc(Hons) · Patricia S Fagan MB BS, FAFPHM

In October 2000, a 10-year-old Aboriginal boy from the Darwin region of the Northern Territory was referred to hospital with a 24-hour history of abdominal pain, initially generalised, but then localising to the right iliac fossa. The pain was accompanied by occasional vomiting, but no fever or diarrhoea was noted. At laparotomy, a gangrenous, unruptured appendix was removed. Postoperatively, the patient made a good recovery. Neither he nor any family members had travelled outside the Northern Territory. Histological sections of the surgical specimen showed changes typical of acute suppurative appendicitis. Closer examination, however, revealed numerous round-to-oval structures resembling trophozoites (see Box). When the possibility of invasive amoebiasis was raised, staining of the section with Entamoeba histolytica-specific sera confirmed the diagnosis. E. histolytica serology was negative. DiscussionE. histolytica is a protozoan parasite of humans that causes infectious colitis and amoebic liver abscess. It has recently been recognised that invasive disease is caused exclusively by the species E. histolytica, while the morphologically identical species E. dispar exists in the colonic lumen as a harmless saprophyte.1 Patients with invasive amoebiasis living in Australia and other developed countries generally acquire the infection outside their country in a region where the pathogenic species is known to be endemic. While cases of amoebiasis in Australians who have not travelled overseas have been reported,2-6 all except one pre-date the recognition of pathogenic and non-pathogenic species, and in none was the primary source identified. Isolated appendicitis due to E. histolytica is a rare condition. Even in regions where the organism is endemic, it causes less than 1% of cases of appendicitis.7 The diagnostic method of choice for amoebic colitis is testing for parasite antigen in stools.1 In this case, for the first time, the species-specific antibody normally used in the stool antigen test was adapted for immunohistochemistry and confirmed E. histolytica infection. Possible alternative methods for confirming the diagnosis include the polymerase chain reaction (PCR) or detection of E. histolytica-specific antibodies or parasite antigen in patient serum.1 However, PCR is not readily available outside research laboratories. The sensitivity of the E. histolytica antibody test in intestinal disease is 52%, a likely explanation for the negative serological test. It is curious that no outbreaks of the readily identified and much more common manifestations of this infection, namely amoebic colitis and amoebic liver abscess, have been recently reported in northern Australia. The potential public health significance of a case of proven autochthonous infection in an Australian population is reinforced by its high transmissibility in settings where hygiene may be suboptimal.8 Furthermore, there is a well documented possibility of prolonged latency between infection and the development of invasive disease.1 Both these factors support the merit of selective screening and appropriate treatment of at-risk contacts if invasive disease is detected. The use of new diagnostic techniques, such as the adapted staining method we used, will enable a more accurate determination of the endemicity of E. histolytica in Australia. Entamoeba histolytica in an inflamed appendix A: Periodic acid–Schiff stain, showing trophozoites (arrowed) within an inflammatory infiltrate. B: Immunoperoxidase stain of trophozoites (arrowed) using E. histolytica-specific sera. Note the surrounding necrotic tissue.

James S McCarthy FRACP MD · David Peacock MB BS · Kevin P Trown FRCPA · Patrick Bade FRACS · William A Petri Jr MD · Bart J Currie FRACP

To the Editor: We write to alert policy makers and clinicians to the challenge presented by rising cannabis use in north-east Arnhem Land, in the Northern Territory, given that many current cannabis users were previously petrol sniffers. In the past five years, there has been a rise in cannabis use and evidence of expansion of supply links in the Miwatj region.1 There are concerns that rising cannabis use is associated with social effects: increased family violence, drug–alcohol psychosis, self-harm and suicide, and community disruption. Policy makers seeking to foster initiatives to minimise harmful outcomes must develop general policies that can have local effects in a varied Northern Territory population. NT police have targeted cannabis in remote communities. A Substance Abuse Select Committee and Illicit Drugs Task Force, each with Indigenous representation, will report to the NT government during 2002. We recently began collecting baseline data to allow us to evaluate the effects on patterns of use of cannabis (and related harm) of community-wide interventions. These interventions will be similar to those implemented for petrol sniffing,2 but with a focus on improved availability of appropriate drug education. We have selected a random sample of about a third of the residents (aged 13–34 years) from two communities. From this sample, current cannabis users (at least weekly) and past petrol sniffers have been identified by using health worker consensus classification, supported by data from review of the health clinic chart and self-report, if available. These data for 145 males and 141 females are presented in the Figure. Among males aged 20–34 years, 74% are current cannabis users and, of these, 60% are former petrol sniffers. To date, 57 cannabis users have agreed to interview (34 males and 23 females) and, of these, 38 met DSM-IV criteria for cannabis dependence.3 A particular health concern is that persistent cannabis use may compound any residual cognitive impairment from petrol sniffing. Current cannabis users among people aged 13–34 years in northeast Arnhem Land Results for samples from two remote communities in the Miwatj region, assessed by using health worker consensus classification, self-report data, and supporting data from health clinic chart review.

Alan R Clough · Sheree Cairney · Paul Maruff · Robert Parker

In 1990, while the Royal Commission into Aboriginal Deaths in Custody was in progress, a group of Aboriginal women requested a meeting with the Federal Minister for Aboriginal Affairs so they could talk with him about issues of deep concern. They were granted 10 minutes. Two minutes into the meeting, as they told the Minister of the escalating incidence of violence within our communities, the Minister interrupted: "I know the problem. You tell me some solutions."1 Most Indigenous Australians regard research and researchers with cynicism and suspicion. We have good reason. We have been researched to death and beyond. Research does have an important role in helping find solutions. It can uncover what is happening and why. If designed and implemented appropriately, it can navigate a way forward and show what is, or is not, working. An accurate description, analysis and understanding of "problems" determines the actions of activists, workers in the field, policy-makers and service providers. Research therefore has a vital role to help inform both Indigenous peoples in their pursuit of appropriate services and non-Indigenous policy makers as we work together. In this issue of the Journal, Williams et al (page 300), reporting on assault-related admissions to hospital in Central Australia, conclude: ". . . assault-related admissions to hospital in the proportions we describe suggest a significant public health problem that requires attention."2 Their article is important, if only to strengthen the voices of Aboriginal women, who have been saying for some time that violence, in its many forms, is escalating at an alarming rate within our communities.3 But more is needed. Williams et al present their results from a reductionist research focus on morbidity and mortality. These parameters represent only the end-result of a vicious cycle of violence — a cycle that has had profound and lasting impacts on Indigenous families and communities across generations.4 No reference is made to the context, which embraces where, why and how such violence is occurring. A reference is made to "many resources . . . developed to assist healthcare workers, communities and individuals with alcohol and violence", but these are not discussed. Research into the health status of Indigenous peoples must begin to focus beyond statistical data. For research to have value and to be of benefit, we must try to find out if the strategies referred to are working or not, and why. Some researchers have observed that "there is abundant evidence that psychosocial factors have a profound impact on health", but that "little research to date has targeted the possible biopsychosocial pathways by which social, environmental and contextual conditions of living affect health".5 Indeed, the Australian Institute of Health and Welfare, while recognising the multiplicity of factors that might account for poor health status, relies predominantly on biomedical indicators of health.9 This fails to embrace the less easily measured aspects of community living and wellbeing, now deemed to be of prime importance by Indigenous peoples and public health researchers alike.7 The 1986 Ottawa Charter of Health Promotion outlines the fundamental conditions and resources for health: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity, which requires, among other things, equity in housing, education, income, and social power.8 Its principles resonate strongly with punyu. The word punyu, from the language of the Ngaringman of the Northern Territory, explains that concepts and functions of health or wellbeing must be considered from an interdisciplinary and multidisciplinary approach. Punyu encompasses person and country, and is associated with being strong, happy, knowledgeable, socially responsible (to "take a care"), beautiful, clean, and safe — both in the sense of being within the law/lore and in the sense of being cared for.9 Being well would therefore be an "achieved quality, developed through relationships of mutual care".10 We do not have peace in Indigenous communities, and all the other prerequisites listed here for health and wellbeing are also left wanting. The Ottawa Charter and the subsequent Sundsvall Statement bring into sharp focus the connectedness between human beings, their physical and social environments and their health and wellbeing. They emphasise that "Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love. Health is created by caring for oneself and others, by being able to make decisions and have control over one's life circumstances and by ensuring that the society one lives in creates conditions that allow the attainment of health by all its members."11 This view echoes the same beliefs that underpin the quest for equality in health, which ensures all people have a right to be part of the process that impacts on their wellbeing at both personal and professional levels within the health service, education and research industries. As we reflect on this major public health problem, we must also consider our potential for doing things differently. There is an appealing reciprocity about the Indigenous punyu and the Western new public health movement, with its strong ecological framework. There exists an opportunity for strong partnerships between Indigenous and non-Indigenous healthcare professional educators and practitioners in shaping or reshaping the future education of healthcare professionals and meaningful health research, even research that focuses on violence. The Minister was right. We do need to focus on solutions. Some Indigenous Australians have argued for process evaluation research, looking at the application and outcomes of interventions and services within our communities. The search for solutions will have to involve greater discussion between Indigenous and non-Indigenous researchers in consideration of the more ecologically grounded interpretation of health promoted by Indigenous peoples, the Ottawa Charter and the Sundsvall Statement. We must develop ways of thinking about and engaging with problems, such as assault-related injuries, as we work together to find better tools for changing the wellbeing of Indigenous communities.

V Judy Atkinson BA, PhD · Jenny Graham DipOT, MSc(Ed), AFCHSE · Gloria Pettit BA, MA · Liz Lewis BA

Objective: To determine the number of assault-related admissions to hospital in the Central Australia region of the Northern Territory over a six-year period.Design and setting: Retrospective analysis of all patients admitted to Alice Springs Hospital (ASH) and Tennant Creek Hospital (TCH) from July 1995 to June 2001, where the primary cause of injury was "assault".Main outcome measures: Frequency of assault-related admission to hospital; demographic characteristics of the victims.Results: In the six years, there were 2449 assault-related admissions to ASH and 545 to TCH. Adults aged 25–34 years were most frequently hospitalised for assault, in a proportion greater than their proportion in the NT population. Females represented 59.7% of people admitted to ASH and 54.7% to TCH, greater than their proportion in the NT population. Aboriginals comprised 95.2% of ASH and 89.0% of TCH admissions, and were admitted in a significantly greater proportion than their proportion in the NT population (P < 0.001). The age-adjusted hospital admission rate resulting from assault has increased (P = 0.002) at an average rate of 1.6 (SE, 0.2) per 10 000 people per year. The proportion of assault-related admissions associated with alcohol has also increased significantly (P < 0.001).Conclusion: The frequency of assault-related admissions to hospital, especially among the Aboriginal population, suggests that this major public health issue is escalating.

Ged F Williams RN, FRCNA · Wendy P Chaboyer RN, PhD · Philip J Schluter MSc(Distinction), PhD

Otitis media — definitions Acute otitis media without perforation: Presence of middle-ear fluid with symptoms or signs of suppurative infection. Bulging of the tympanic membrane is the most reliable sign in Aboriginal children. Acute otitis media with perforation: Acute suppurative infection with recent discharge from the middle ear (within the last 7 days). Otitis media with effusion: Presence of middle-ear fluid without symptoms or signs of suppurative infection. Chronic suppurative otitis media: Persistent discharge from the middle ear through a tympanic membrane perforation for more than 6 weeks. Chronic suppurative otitis media (CSOM) (see Box) is very uncommon in First World countries and is best regarded as a disease of poverty. The World Health Organization has indicated that a prevalence rate of CSOM greater than 4% in a defined population of children is indicative of a massive public health problem requiring urgent attention.1 That CSOM affects up to ten times this proportion of children in many Aboriginal communities is an indictment of the poor living conditions in these communities.2 The associated hearing loss has a life-long impact, as it occurs during speech and language development and the early school years. Why is chronic suppurative otitis media so recalcitrant?Many factors contribute to poor health outcomes. In biological terms, the greatest risk factor for the early onset and persistence of otitis media is nasopharyngeal colonisation by multiple bacterial species and subtypes.3 In Aboriginal communities with overcrowded households, infants are frequently exposed to siblings whose nasopharyngeal carriage rates are almost 100% for each of the major otitis media bacterial pathogens.3 In non-Aboriginal children, the host response to a low-dose infection usually eradicates pathogens, which, in turn, down-regulates inflammation and limits tissue damage. In contrast, we believe that early exposure of very young Aboriginal infants to a large bacterial inoculum (or frequent exposures to immunologically distinct pathogens)4 provides constant stimulation of the inflammatory cascade, which damages mucosal tissue yet fails to eradicate pathogens.5 This begins a vicious cycle that may persist throughout childhood: early exposure, persistent bacterial colonisation, and chronic mucosal disease. Furthermore, such infants themselves become chronic carriers and pose a risk to other, younger infants. This cycle is facilitated by overcrowded and poor living conditions, lack of appropriate washing facilities,6 and limited access to appropriate healthcare services. Bulging of the tympanic membrane is the best diagnostic predictor of perforation.7 Other signs and symptoms of acute otitis media (such as pain, fever, irritability or redness of the tympanic membrane) are frequently absent in this population. The implications of this lack of signs or symptoms are clear — parents do not see their child as unwell and thus children remain untreated. Together, this biological model and clinical pattern help us to understand the intractable nature of otitis media in Aboriginal children. Currently, failure to apply existing knowledge is a more important problem than lack of knowledge. Aboriginal children have poorer access to therapy, hearing aids, special teachers, classroom soundfield systems and other rehabilitative programs.2 Furthermore, there is inequitable distribution of funds from the Commonwealth Hearing Health Services Program, with evidence that the hearing health needs of Aboriginal children are not being met.8 What strategies have worked?A systematic review of existing evidence and primary care guidelines for the management of otitis media in Aboriginal and Torres Strait Islander people2 identified effective primary prevention strategies: improving nutrition and the home environment, increasing breastfeeding, and reducing passive smoking. A small but important role was noted for vaccines (the polysaccharide, polyvalent pneumococcal vaccine and the new pneumococcal conjugate vaccine). Controversies remain regarding the effectiveness of antibiotics in primary prevention and the impact of maternal pneumococcal vaccination on infant disease.2 High doses and prolonged courses of antibiotics are often required for the treatment of acute otitis media and CSOM,7 but the optimal use of topical ear preparations remains uncertain.2 Where appropriate primary healthcare interventions have failed, timely referral to otolaryngologists for assessment and surgical interventions can improve hearing outcomes.2 However, access to such specialist care for children in remote Aboriginal communities is suboptimal. Audiological rehabilitation is critical, requiring the provision of ongoing education about effective communication strategies and appropriate use of devices to assist hearing. These include standard hearing aids and bone conductors, as well as classroom devices such as soundfield amplification systems (which provide a uniform soundfield throughout the classroom and increase the speech-signal : noise ratio), and FM systems (a form of personal amplification whereby an FM signal from a microphone worn by the teacher is picked up by a receiver worn by a child with hearing loss).9 What needs to happen in the future?Greater community control over improvements to education, employment opportunities, housing infrastructure and primary healthcare services is long overdue. To realise these improvements requires substantially increased resources, linked to community responsibility. In the meantime, initiatives that increase access to primary healthcare for the detection and management of ear disease and facilitate access to other services should continue. An example is the Office for Aboriginal and Torres Strait Islanders Health Hearing Health Program.10 Realistic expectations about the benefits and harms of evidence-based healthcare interventions should be incorporated into updates of currently available clinical guidelines, and the information made accessible to families. The Commonwealth needs to reform the provision of rehabilitative services and coordinate approaches to soundfield amplification in schools. The research priority is to determine the best use of preventive strategies and interventions (including educational, medical, surgical and audiological initiatives). Multidisciplinary research in the areas of diagnosis, new antibiotics, the role of biofilm and vaccines is also appropriate. Bacterial biofilm is a community of interacting bacteria attached to a surface and encased in a protective matrix of exopolysaccharide. Formation of biofilm in the middle-ear mucosa of Aboriginal children with CSOM may explain the recrudescence of bacterial otorrhoea after viral upper respiratory tract infections.11 Pneumococcal conjugate and innovative protein-based vaccines are aimed at inducing a mucosal immune response. Several Australian trials are currently examining the impact of pneumococcal conjugate vaccine on nasopharyngeal carriage rates and perforation of the tympanic membrane. Only with urgent attention to improving housing and access to running water, nutrition and quality of care, and giving communities greater control over these improvements, will this massive public health problem be solved so that Aboriginal children can take their rightful place in this, the century of communication.

Harvey L Coates MS, FRACS · Peter S Morris PhD, FRACP · Amanda J Leach PhD · Sophie Couzos FRACGP, FACREM, FAFPHM

The rates of bronchiectasis for Indigenous children from remote Australian communities are unacceptably high, with one study showing 14.7/1000 Aboriginal children. Children with bronchiectasis need to be identified early for optimisation of medical treatment. Under-reporting of cough is common. Bronchiectasis should be suspected in children with recurrent bronchitis or pneumonia, and when, despite appropriate therapy, pulmonary infiltrates or atelectasis persist 12 weeks beyond the index illness. During acute infective episodes, oral antibiotics and chest physiotherapy to clear the airways should produce prompt resolution; otherwise, hospitalisation is necessary. Management follows the cystic fibrosis model of regular review, encouragement of physical activity, optimising nutrition, maintenance of immunisation and avoidance of environmental toxicants, including passive smoke exposure. Successful management and prevention of bronchiectasis will require improvements in housing, nutrition, and education, as well as access to comprehensive healthcare services, with coordination between primary and hospital-based healthcare providers.

for the Working Group on Indigenous Paediatric Respiratory Health

To the Editor: Jamrozik's editorial1 about our report of a failed randomised controlled trial (RCT)2 in an Aboriginal medical service helps to explain why researchers might be reluctant to submit articles describing unsuccessful trials, thus limiting potential for the scientific community to learn from such experiences. The main point of our article was to describe the manifest difficulties of implementing an RCT — the evidence "gold standard" — in this type of setting. Interestingly, Jamrozik largely attributes these difficulties to incompetence or naivety (or both) on the part of the researchers and funders, rather than to complexities inherent in the study design, the setting and the intervention. A separately funded pilot study is, in principle, a good idea, but extremely difficult to get funding for in today's environment. Of course, we did conduct a pilot — that, in fact, was what we reported on — but it is unclear how this would have helped us better estimate absolute prevalences and effect sizes for intervention and control groups, as a substantial number of participants, followed up for six months, would have been needed to do this. Nor is it clear how taking a population approach and distributing guidelines to all drinkers rather than offering personalised advice to hazardous drinkers would have helped — firstly, because we were specifically trialling the internationally validated brief intervention, and secondly, because the effect size of the alternative approach would have been so small that we would have needed very much larger numbers to test its effectiveness. We had no intention of "stumbling down something like this path". Nor do we agree that the blood tests were "medicalising a social problem". They were intended not only to provide robust outcome measures (a mark of a good trial), but also tangible evidence to clients of the health effects of alcohol, shown from previous research to be well received by Aboriginal people.3,4 They were not a requirement for participation. Further, that we should have got around the potentially off-putting business of seeking informed consent by bypassing this step almost defies comment. While trials of some therapeutic interventions can be undertaken blind with patient consent by using placebos, this does not mean that where blinding is not possible patient consent should be done away with in order to avoid a Hawthorne effect! However, we do agree with Jamrozik on one point — nothing about this study or our report could reasonably "compound any negative perceptions about Aboriginal Medical Services and Aboriginal patients".1

Beverly M Sibthorpe · Ross S Bailie · Maggie A Brady · Sandra A Ball · Polly Sumner-Dodd · Wayne D Hall · Alan Pettigrew · Tom Gavranic