Indigenous health

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

To the Editor: I am responding to a recent editorial by Jamrozik1 commenting on a study proposed by Sibthorpe and colleagues to assess a brief intervention for hazardous use of alcohol by Indigenous people in an urban setting.2 After two unsuccessful attempts to recruit participants, the study was discontinued and funds returned to the National Health and Medical Research Council (NHMRC) in 1998. Sibthorpe et al identified their difficulties as primarily the result of having overestimated the number of suitable participants, for a number of complex reasons. Jamrozik's criticisms rest disproportionately with the NHMRC and are based on procedures and processes in effect in 1996 and 1997, yet they are informed by contemporary knowledge and wisdom. This seems somewhat anomalous. In 2000, the NHMRC revised its system for assessing research applications. This involved several developments which would have had a direct impact on the assessment of this application had they been instituted in 1996. Some of these include: the introduction of panels comprising 11 experts in the domain of the application; the introduction of the Indigenous Health Research Panel (IHRP), which provides advice on cultural appropriateness, community consultation and methods in applications with an Indigenous component (most members are Indigenous people); and the opportunity for IHRP to make stipulations upon which funding is contingent. Also of significance was the establishment of the Research Agenda Working Group (RAWG), which oversaw the formulation of intervention-based criteria. Colloquially known as the "Darwin criteria", these principles ensure that all Indigenous research design has: sufficient Indigenous community consultation and participation; transferability (of the methods to other settings); and sustainability (of resulting changes). The NHMRC was disappointed that the study by Sibthorpe et al did not proceed and did not result in usable data to inform a significant problem. However, it is also important to recognise that unanticipated outcomes, which can often lead to other, very positive results, are an integral part of the learning process. The NHMRC has supported Australian health and medical research since 1936. It has a strong commitment to ensuring the continuing evolution of its procedures and practices. The new systems implemented in 2000 were designed to ensure the continuing tradition of funding high quality, relevant and applicable research.

Beverly M Sibthorpe BA(Hons), PhD · Ross S Bailie MD, FAFPHM · Maggie A Brady MA, PhD · Sandra A Ball BCom, GradDip Public Administration · Polly Sumner-Dodd DipManagement · Wayne D Hall BSc, PhD · Alan Pettigrew BSc, PhD · Tom Gavranic MB BS, DPH, FRACGP

To the Editor: The recent article by Sibthorpe et al1 and the accompanying editorial2 on the issue of the failure of an alcohol intervention trial in an Aboriginal Health Service deal with problems facing all primary care practitioners in the field of "alcohol misuse" and should not be seen as a peculiarly Aboriginal problem. Firstly, despite what the academics may tell us, administering an Alcohol Use Disorders Identification Test (AUDIT) questionnaire in general practice as a screening measure meets with huge resistance, no matter where you practice. Denial of the disease-inducing potential of alcohol is certainly not peculiar to Aboriginal society. Secondly, I find that the bulk of the medical profession reinforces this community denial by diagnosing conditions such as diabetes, hypertension, obesity, anxiety, depression and schizophrenia instead of seeing these problems as being a manifestation of alcoholism or other "alcohol misuse" until proven otherwise. Indeed, the denial is so extreme that they tend to avoid the term "alcoholism" altogether. Specialists are in even greater denial and are more often a hindrance than a help to general practitioners in this regard. As a consequence, community leaders and affected families are unable to develop effective strategies for dealing with their problems. What they get instead is increasing healthcare costs, hospital bed shortages, increasing domestic violence, more "drug problems" and more prisons. So "GP reluctance or inability to follow through . . ."2 is not surprising. Indeed, denial of alcohol is so strong in the medical profession that it is harder, in my experience, to get doctors and even medical students (let alone healthcare workers) to attend open meetings of Alcholics Anonymous and Al-Anon than it is to persuade affected people to do so. Thirdly, general practice throughout Australia has been organised for episodic, fast-throughput care. People have become so accustomed to this that they see any attempt at a comprehensive preventive approach to illness as odd, out of place, time-consuming and even intrusive, especially so where alcohol and family histories are concerned. That Aboriginal people are no different from the rest of us in this regard should cause no surprise.

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

Objective: To compare hospital costs of Aboriginal and non-Aboriginal patients having haemodialysis treatment and forecast the future treatment cost.Methods: The costs of patients with HD in the "Top End" of Australia's Northern Territory were estimated for the financial years 1996/97 and 1997/98 using a hospital costing model. We used an Autoregression Integrated Moving Average model to predict future demand.Results: 165 patients (101 Aboriginal and 64 non-Aboriginal) were treated at a total cost of $12.4 million in this two-year period. These 165 patients represented 0.7% of inpatients, 8.8% of total inpatient costs and 31.6% of total inpatient episodes of care in the Top End region. $9.5 million (77%) was spent on routine haemodialysis treatment and $2.9m (23%) on other hospitalisations. The average cost per routine haemodialysis treatment over the two-year period was $527, or $78 600 per patient treatment year. Hospitalisations for comorbidities occurred in 86% of Aboriginal and 39% of non-Aboriginal patients. Average cost per patient, number of admissions and length of hospital stays were all significantly greater for Aboriginals. We predict an average increase in the number of treatments of 12% each year over the next five years and a five-year cost of $49.8m.Conclusions: A multipronged strategy designed to reduce the prevalence and costs of renal failure is required.

Jiqiong You MSc, MBA, MB BSc · Yuejen Zhao PhD · Carol Beaver MSc · Wendy Hoy FRACP · Kathy Eagar PhD

Objectives: To identify factors limiting the effectiveness of communication between Aboriginal patients with end-stage renal disease and healthcare workers, and to identify strategies for improving communication. Design: Qualitative study, gathering data through (a) videotaped interactions between patients and staff, and (b) in-depth interviews with all participants, in their first language, about their perceptions of the interaction, their interpretation of the video record and their broader experience with intercultural communication. Setting: A satellite dialysis unit in suburban Darwin, Northern Territory. The interactions occurred between March and July 2001. Participants: Aboriginal patients from the Yolngu language group of north-east Arnhem Land and their medical, nursing and allied professional carers. Main outcome measures: Factors influencing the quality of communication. Results: A shared understanding of key concepts was rarely achieved. Miscommunication often went unrecognised. Sources of miscommunication included lack of patient control over the language, timing, content and circumstances of interactions; differing modes of discourse; dominance of biomedical knowledge and marginalisation of Yolngu knowledge; absence of opportunities and resources to construct a body of shared understanding; cultural and linguistic distance; lack of staff training in intercultural communication; and lack of involvement of trained interpreters. Conclusions: Miscommunication is pervasive. Trained interpreters provide only a partial solution. Fundamental change is required for Aboriginal patients to have significant input into the management of their illness. Educational resources are needed to facilitate a shared understanding, not only of renal physiology, disease and treatment, but also of the cultural, social and economic dimensions of the illness experience of Aboriginal people.

Alan Cass FRACP · Anne Lowell PhD · Michael Christie PhD · Paul L Snelling FRACP · Melinda Flack Grad Dip Renal Health · Betty Marrnganyin · Isaac Brown BAppSci

To the Editor: We were disappointed with the article by Bailie and Runcie on household infrastructure in Aboriginal communities.1 It has major methodological and ethical problems that, in our view, should have precluded its publication. The data were not collected by a process which allows meaningful scientific analysis. In determining the state of health hardware, the authors did not outline the testing methods or how functioning of different items was assessed. No standardised procedure is evident within the process, no formalised training of those conducting the assessment is indicated, and there is no evidence that supervision or auditing of consistency was performed. In fact, these problems are acknowledged by the authors in a publication on the same project, in which they state: "There was no protocol for a number of steps in the data collection process. There was no protocol for what type of information was gathered by interviewing residents, nor for which resident was the most appropriate interviewee. "The way data was collected varied between field officers, and the way an individual officer collected data varied between houses. Firstly, the items might be observed. Secondly, but not always, items may be tested for functionality (eg, by turning a tap on). Whether items were physically tested sometimes depended on how "clean" the house was. If it was clean, then the items were sometimes assumed to be functioning . . .".2 No amount of analysis can correct for such inadequacy in primary data. The authors dismiss this problem by referring to consistent patterns of data across different communities. This in no way addresses the problem of identifying the true level of hardware functioning. It simply suggests that measurement omission or error was widespread. Even if the items tested did not require maintenance, this does not indicate that they were functioning adequately, as no defined and standardised tests were applied (see Appendix B, page 38, in reference 2).2 The article's ethical problems are masked by discussion about community confidentiality. The authors described an audit and assessment of health hardware without any attempt at intervention and improvement. This is in a setting where a method that links assessment and intervention has not only been established, but is now performed by different groups across a wide range of communities. In fact, this process is referenced by the authors.3 The article by Bailie and Runcie reinforces what is widely known — that Aboriginal housing is generally poor. There can be only two reasons for trying to assess the actual state of Aboriginal housing and health hardware. The first is to enable intervention to rectify the problem at the same time. The second is to enable future housing and infrastructure programs conducted by government to be technically targeted and subsequently assessed to determine whether improvement really is occurring. Unless the baseline status is accurately and reproducibly determined, then we will have no way of knowing whether such programs are actually making a difference.

Paul J Torzillo · Paul Pholeros

In reply: A primary objective of our evaluation1 was to identify methodological deficiencies for the purpose of improving data quality in subsequent surveys. These deficiencies, described in detail in our evaluation report and referred to by Torzillo and Pholeros, are also described in our Medical Journal of Australia article.2 Our assessment (reinforced by reference to subsequent survey findings) was that the data were of sufficient quality to be useful for the purpose for which they were collected — to guide and monitor a substantial maintenance and building program. Torzillo and Pholeros appear to have missed this point. Their analogy with a clinical therapeutic trial where the survey is equated with a placebo is absurd, all the more so for the reference to the HealthHabitat work as being "an effective agent [that] is already licensed". This "effective agent" has, to my knowledge, never been subjected to external evaluation or peer review — some licensing process! With regard to ethics, a fundamental aim of the survey was to identify areas of greatest need, and allow the allocation of resources on an equitable basis to improve Aboriginal housing standards across the Northern Territory. In an environment of massive need and limited resources, this is arguably a more ethical approach than that of HealthHabitat, where, in 2001, intensive input was delivered to only four out of hundreds of Aboriginal communities in the NT. Runcie M, Bailie R. Evaluation of environmental health survey data – Indigenous housing. Darwin, Northern Territory: Menzies School of Health Research, July 2000. Bailie RS, Runcie MJ. Household infrastructure in Aboriginal communities and the implications for health improvement. Med J Aust 2001; 175: 363-366. <eMJA Full text> <PubMed> (Received 21 Mar, accepted 25 Mar 2002)

Ross S Bailie

To the Editor: Cunningham has shown that in Australian public hospitals patients identified as Indigenous are significantly less likely than other patients to have a principal procedure recorded.1 This finding is based on data collected by the Australian Institute of Health and Welfare using the coding scheme of the International classification of diseases, 9th revision, clinical modification (ICD-9-CM). No information was available about the clinical indications for conducting a principal procedure. Despite this crucial omission, Cunningham speculates about the reasons for the disparity in the rate of procedures between Indigenous and non-Indigenous patients. These speculations include alarming suggestions such as the possibility of systematic discrimination against Indigenous patients of both an institutional and personal nature. She then concludes that "Work is urgently needed to characterise more fully the nature, level, sources and consequences of institutional and interpersonal discrimination so that we can reduce unfair treatment, ensure equitable care and improve outcomes for the most disadvantaged Australians". These speculations and conclusions are simply unjustified by the data. In addition, such comments may cause more harm than good — Indigenous people have become extremely sensitive about medical and social research and may reject future investigations that are essential to their welfare. There are reasons other than adverse discrimination which may explain the data. These include the common rejection by Indigenous patients of medical advice to have a procedure (they may well be adopting the wisest action), and their more frequent admission to hospital (rather than outpatient care), as they may have travelled from remote communities (ie, there are social criteria for admission without the need for medical procedures). Furthermore, the quality of the data must be questioned, as many Indigenous patients are admitted to hospitals where the data forms are completed by unskilled personnel who do not understand the meaning of a "principal procedure". Cunningham J. Diagnostic and therapeutic procedures among Australian hospital patients identified as Indigenous. Med J Aust 2002; 176: 58-62. <eMJA Full text> <PubMed> (Received 1 Mar 2002, accepted 25 Mar 2002)

James S Lawson

In reply: Lawson suggests that my conclusions1 are not justified, and that they may "cause more harm than good". I strongly disagree. He suggests a number of alternative explanations, including "social" admissions for remote patients, and poor coding, but these do not account for the differences observed. Over half of the separations identified as Indigenous were of urban (19%) or rural (33%), rather than remote, area residents. Disparities in procedures for Indigenous and other patients were evident for each area. Almost half (46%) the separations identified as Indigenous were in principal referral or major hospitals, where coding should be of a high standard. Indigenous–non-Indigenous disparities existed within each hospital category. The results presented in my report1 were adjusted for area of residence, hospital category, as well as several other factors, and large differences in procedures remained. Lawson also suggests that rejection of medical advice by Indigenous patients may play an important role. Rejection of advice certainly occurs on occasion, by both Indigenous and non-Indigenous patients. I question whether it is "common", as Lawson suggests, but that is not really the point. It would be far more productive to ask why and how this occurs, and how interactions between healthcare providers and Indigenous patients can be improved. Lawson takes exception to my raising the possibility of systematic discrimination in the Australian healthcare system, referring to it as "alarming". In that we are in complete agreement. I, too, find it alarming. However, unlike Lawson, I choose not to deny it, but to accept it as an important challenge. My aim is not to make medical practitioners defensive, but to invite them to participate in finding ways to reduce disparities. Systematic discrimination can occur even when well-meaning people are trying to do the right thing. The systems in which we work can defeat our best intentions, even when we don't realise it. The reasons why a procedure was not performed on a particular patient may be perfectly sound given the circumstances. What we must ask ourselves is how those circumstances came to be, and what we can do to change them. I agree with Lawson that some Indigenous people are sensitive about research, but I do not accept that they will "reject future investigations that are essential to their welfare". On the contrary, I expect that many Indigenous people would be happy to participate with healthcare providers in the development and implementation of creative solutions to improve the healthcare system. Cunningham J. Diagnostic and therapeutic procedures among Australian hospital patients identified as Indigenous. Med J Aust 2002; 176: 58-62. <eMJA full text> <PubMed> (Received 21 Mar 2002, accepted 25 Mar 2002)

Joan Cunningham

To the Editor: I wish to commend the Journal for publishing the article by Cunningham1 and the analysis of her findings in the accompanying editorial.2 Both articles stress the need for improved communication between Indigenous patients and hospital staff. The Kimberley Interpreting Service provides accredited Aboriginal language interpreters for six Kimberley languages, and is involved in training other interpreter candidates. We have been operating since November 2000 and are currently looking for funding to continue offering our service into the future. To date, we have been working primarily in the legal sector and are quite perplexed as to why we do not receive bookings from the health services. In 2002, the Kimberley Interpreting Service is targeting the health sector through a number of strategies, including the production of a promotional poster for use in hospitals and clinics, articles in medical publications, and face-to-face meetings with health professionals. I encourage your readers to find out more about our service and to pass the message on to colleagues. We can be contacted at kisATwn.com.au, or please visit our website at http://members.westnet.com.au/mirima/

Tea C Dietterich