Topics
Indigenous health
Routine ear health and hearing checks for Aboriginal and Torres Strait Islander children aged under 6 years attending primary care: a national consensus statement
New recommendations for primary care assessment of ear health and hearing status of young Aboriginal and Torres Strait Islander children
Samantha Harkus · Vivienne Marnane · Isabel O'Keeffe · Carmen Kung · Meagan Ward · Neil Orr · John Skinner · Kelvin Kong · Lose Fonua · Michelle Kennedy · Mary Belfrage
Lung cancer screening for Aboriginal and Torres Strait Islander peoples: an opportunity to address health inequities
A commitment to culturally appropriate codesign processes will shape the development of an equitable lung cancer screening pathway
Alison Brown · Gail Garvey · Nicole M Rankin · Claire Nightingale · Lisa J Whop
The MJA supports an Aboriginal and Torres Strait Islander Voice to Parliament
New approaches, which place Aboriginal and Torres Strait Islander communities at the heart of discussions and decision making about their futures, are clearly needed; on this basis, the MJA supports an Aboriginal and Torres Strait Islander Voice to Parliament
Virginia Barbour
Aldosterone and renin concentrations and blood pressure in young Indigenous and non‐Indigenous adults in the Northern Territory: a cross‐sectional study
Screening test results for primary aldosteronism were positive for about one-quarter of urban Indigenous and non-Indigenous participants
Elisabeth Ng · Stella M Gwini · Michael Stowasser · Morag J Young · Peter J Fuller · Gurmeet R Singh · Jun Yang
Training pathways back to Country
The burden of disease in Aboriginal and Torres Strait Islander people is stark, occurring at two to three times the rate of non‐Indigenous Australians.1 The provision of culturally appropriate and safe health care is imperative in addressing this imbalance.2 One strategy to enhance cultural competency of health care services is to increase the representation of Aboriginal and Torres Strait Islander people working within the services.1 I have personally witnessed a cultural shift in the provision of health care services and the increased number of Aboriginal people who access health care when they are being cared for by an Aboriginal doctor. I am a Gija woman, born in Derby and raised in Halls Creek, less than four hours’ drive from my current home in Kununurra, in the East Kimberley region of Western Australia. I am a general practitioner who has worked at Kununurra District Hospital since 2011; first as a GP registrar (having completed all my training in Kununurra) and then as a District Medical Officer, having attained a Fellowship in General Practice in 2013. My role as a District Medical Officer gives me the opportunity to provide culturally safe and appropriate health care to my family and “countrymen” in the two largest First Nations communities in the East Kimberley in various clinical settings, including emergency, inpatient, palliative care, and remote clinics via the Royal Flying Doctor Service. In 2013, I commenced working for the Rural Clinical School of Western Australia as a Medical Coordinator and then as Lead Medical Coordinator. These roles complement each other and align with my personal and professional belief that the disparity between the number of rural medical practitioners and community needs will be addressed by enhancing the pathways of education and training, which assists in growing our own workforce. This workforce may come from people originating in rural and remote areas, or from city residents, who have an opportunity to immerse themselves in a rural/remote community while completing a clinical placement. Since working in Kununurra, I have supervised and mentored many medical students from both rural/remote and urban backgrounds, and have seen the transition students undertake, from one of reluctance or apprehension in working in rural/remote communities, to being able to see themselves returning to the country to practise medicine once qualified. I attended the special Aboriginal school in Halls Creek. Recognising the importance of a good education, my parents then sent me to boarding school in Perth, 3000km away. I was 11 years of age and I still consider that year one of my most challenging. Missing my big, close family in Halls Creek was tough, but learning to navigate this new world was daunting. The success of my secondary education was principally due to my parents providing me with the love, support and encouragement needed, while remaining steadfast in their resolve that I remain at boarding school to complete my education. On leaving high school, I completed a Diploma of Nursing at Edith Cowan University and graduated in 1991. I returned home and worked at Halls Creek Hospital before returning to Perth to convert my qualification to a Bachelor of Nursing in 1992. Although I loved working in the hospital setting as a registered nurse, I felt my need to contribute to addressing the health disparities of my community would be best achieved working within the community, so I embarked on a Graduate Diploma of Community Health Nursing. I had given up the idea of becoming a doctor way back in primary school because I thought those who studied medicine were far more intelligent than I! I also completed a Postgraduate Diploma in Clinical Nursing – Midwifery, which gave me the opportunity to move to Kununurra in the Kimberley, where I undertook consultancy work with Dr David Atkinson, who was developing the Kimberley Aboriginal Health Plan. On our many trips, we talked about a career in medicine for me. I respect, trust and admire David, and his belief, advice and support was instrumental in my embarking on my journey to become a doctor. I did not act on his advice and encouragement immediately, but over the next two years conversations about a career in medicine kept coming up. One day my husband said I should do it but forewarned me that I needed to really want to do so, because I would be the one doing all the hard work. The decision to apply to the School of Medicine at the University of Western Australia in 2002, with two children under two, at the time seemed reasonable. On reflection, I think we must have been a little nuts! In 2003, I was accepted and survived with the help of a scholarship and cadetship, my husband working full time, and with support from beautiful family and fellow students. The Medical Rural Bonded Scholarship assisted with our day care costs and thus my attendance at university. Without this financial support, my medical journey would not have started, despite my husband working full time. A cadetship offered through the Princess Margaret Hospital (now Perth Children's Hospital) also assisted us greatly. I was their first cadet and this was made possible by another one of my distinguished mentors, the late Dr Paul Carmen. Dr Carmen was a brilliant clinician, an amazing academic, and a kind and caring person, and to have had his unwavering support and belief in my ability to become a doctor was invaluable. The Centre for Aboriginal Medical and Dental Health at Shenton House is the Aboriginal student support program at the University of Western Australia and its support was excellent. For me, studying at home with two small children was challenging, so on the weekends I would retreat to Shenton House, leaving home at 5.30 am and returning around lunchtime to spend the weekend with my family. With my circumstances, there were periods of self‐doubt, but at Shenton House there was always someone to say, “Sure, the going is not easy – and yes, with two young children, your background and lifestyle are different from others, but that's OK”. I had a safe environment where I could go, somewhere I could have time out, and somewhere I could speak to other students and staff and receive reassurance. Although I had the opportunity to apply to the Rural Clinical School during my undergraduate degree, I did not do so, as I always intended returning to the Kimberley and felt my time was best spent gaining valuable experience and exposure in the tertiary settings in Perth. I remained in Perth for my internship and postgraduate training, despite having been accepted into the GP training program. Aware of the areas where I needed additional clinical knowledge and experience, and in readiness to return to the Kimberley, I spent my second postgraduate year gaining this experience. I completed a Diploma of Child Health while working at Princess Margaret Hospital, followed by working in a tertiary emergency department. In addition to acquiring sound clinical knowledge, I also developed an understanding of how tertiary hospitals function, which has been essential in my navigating and accessing health care services while advocating for and preparing patients who need these specialty services. Soon after returning to the East Kimberley in 2011, I began working for the WA Country Health Service at Kununurra District Hospital, where I have been since then. No two days are the same, and having the opportunity to provide health care that is tailored to meet the specific needs of the patient, in collaboration with the patient in a culturally safe environment, is why I work where I do. An example of this success was the rollout of the COVID‐19 vaccination program in Warmun Community at the end of 2021, where 83% of the eligible community members were vaccinated over two days, and then providing the clinical lead in the rapid response team when COVID‐19 arrived in the community in early 2022. The highlight of my journey has been returning home, armed with my medical degree and a steadfast resolve to help abate the burden of disease in my community and the region. The goal of providing best practice, with my ongoing education keeping me abreast of changes, places me in a unique position. My inherent knowledge assists in enhancing the health literacy of Aboriginal people by bridging the language, knowledge and cultural gaps of my Aboriginal patients, their families and the community, thereby ensuring the provision of culturally appropriate and safe health care.
Catherine Engelke
Upholding our rights in research: calling for urgent investment in Aboriginal and Torres Strait Islander health research ethics
Growth in Aboriginal and Torres Strait Islander health research requires urgent investment in Aboriginal and Torres Strait Islander ethical governance
Michelle Kennedy · Janine Mohamed
Bloodstream infection rates in Aboriginal and non‐Aboriginal people in Central Australia, 2014–2018
Bloodstream infection rates in Aboriginal residents of Central Australia remain extremely high, and risk factors must be remediated
Alice Coe · Richard J Woodman · Rob Baird · Lloyd Einsiedel
Reducing the burden of group A streptococcal disease in the Northern Territory: the role of chemoprophylaxis for those at greatest risk
To the Editor: We thank Gibney and Steer for their editorial1 in response to our research letter,2 supporting further public health action and research into invasive group A streptococcal (iGAS) disease. However, we are concerned about the statement that the 30‐day risk of iGAS disease for contacts of someone with an index infection is about 2000‐fold higher than background risk. This figure is derived from an English population‐based study3 and cannot be universally applied across circumstances varying in background incidence of GAS‐related disease, which is driven predominantly by socio‐environmental factors. Applying this 30‐day secondary attack rate of iGAS infection in Northern Territory household contacts would translate to about 177 cases per 1000 population (18%) in Indigenous Australian contacts and 2738 per 1000 population (274%) in people receiving haemodialysis.2 In contrast, rates of iGAS infection in household contacts were 3.2 per 1000 population in Canada4 and 0.7 per 1000 population in the United States.5 As described in the NT public health guidelines for iGAS, previous NT and Queensland studies have demonstrated large diversity of iGAS genotypes,6 with less clonality and a greater proportion of sporadic cases rather than transmission directly from another case of iGAS infection. This reflects the stark contrasts in iGAS and other consequences of GAS infection between central and northern Australia and southern states, as seen with so many other health issues linked to socio‐economic disadvantage. Gibney and Steer also note that some authorities recommend antibiotic prophylaxis for close contacts, and others do not.1 We wish to highlight that the NT guidelines for the public health response to iGAS include specific guidance around antibiotic prophylaxis for close contacts (for mother–neonatal pairs, contacts of severe iGAS disease cases, and in other special circumstances), informed by a literature review in the Appendix.6 National guidelines for iGAS are currently being developed and these need to include advice tailored for the vastly different epidemiology seen across Australia, reflecting a contrasting diversity of endemicity of GAS‐related disease. This has also been necessary for the Australian guidelines for diagnosing acute rheumatic fever, with low risk and high risk populations defined.7
Johanna M Birrell · Bart J Currie · Vicki L Krause
Challenges for Medicare and universal health care in Australia since 2000
More effective, coordinated approaches are needed to improve and secure the universality of public health care
Mary Rose Angeles · Paul Crosland · Martin Hensher
Clinician alert: toxigenic diphtheria cases across North Queensland are on the rise
To the Editor: Until recently, detection of locally acquired tox gene carrying diphtheria in Australia was rare. Toxigenic diphtheria had almost disappeared from the Australian landscape, with the widespread uptake of the diphtheria toxoid vaccine. Diphtheria is predominantly caused by toxigenic Corynebacterium diphtheriae and can present as both respiratory and cutaneous diphtheria disease. There have been increasing reports internationally of diphtheria outbreaks primarily in vulnerable migrant populations.1 In Australia, there were 46 diphtheria cases between 1999 and 2019 (eight respiratory diphtheria and 38 cutaneous), with C. diphtheriae accounting for 87% of these cases.2 Since 2020, a genomically linked clone of tox gene carrying diphtheria bacteria has spread across North Queensland. Cases described here are from the Queensland Health's Notifiable Conditions Register. The Townsville Hospital and Health Service Human Research and Ethics Committee provided an ethics exemption (EX/2022/HREC/88895) for this study. Of the 29 linked cases identified between 2020 and 2022, all have had epidemiological links to North Queensland and 23 were notified in 2022. Three of these cases were detected interstate. Clinically, three cases presented with classic diphtheria, four with mild respiratory diphtheria, and 22 with cutaneous diphtheria. The median age was 21 years (range, 2–59 years). Of the 29 cases, 34% (10/29) were aged 11–20 years and 45% (13/29) were older than 20 years. Further, 38% of cases (11/29) were fully vaccinated, 48% (14/29) were partially vaccinated and 10% (3/29), including two of the classic diphtheria cases, were unvaccinated for their age according to the National Immunisation Program Schedule. All were acquired in Australia, and 86% of patients (25/29) identified as Aboriginal and/or Torres Strait Islander. Isolates in the cluster are closely genomically linked, with between zero and 20 single nucleotide polymorphism differences found on whole genome sequencing. All cases were managed with penicillin or azithromycin, vaccination, and diphtheria antitoxin administered when deemed appropriate by infectious disease physician assessment. Azithromycin was given in most cases, as higher minimum inhibitory concentrations to penicillin have been observed with this clone. Household contacts were screened for symptoms, administered chemoprophylaxis with penicillin or azithromycin, and offered a diphtheria‐containing vaccine if due. A North Queensland public health working group has recently been established to develop a consensus on further public health management. This diphtheria outbreak, almost exclusively in Aboriginal and Torres Strait Islander communities, highlights the continuing impact of social determinants on disease in vulnerable populations. We recommend clinicians be aware of these cases and consider diphtheria among their differentials in patients from, or who recently travelled to, North Queensland. Classic diphtheria is characterised by a sore throat, fever, and membrane on the back of the throat, which may cause difficulty in breathing and swallowing. Cutaneous diphtheria usually presents as a non‐healing ulcerative lesion.2 The toxoid vaccine protects against the toxin effects rather than the infection itself. Unvaccinated individuals are therefore at highest risk of severe disease, including classic diphtheria, myocarditis, and neuropathies. Vaccination remains imperative and timely vaccinations are essential. The National Immunisation Program Schedule currently recommends a diphtheria‐containing vaccine for children at two, four, six and 18 months, and four years, and adolescents at 11–13 years. A diphtheria‐containing vaccine booster is recommended for adults at 50 years.3 Clinicians across the state and nation should be vigilant for future cases.
Allison Hempenstall · Jay Short · Tonia Marquardt · Valmay Fisher · Janice Johnson
Mitigating the impacts of racism on Indigenous wellbeing through human rights, legislative and health policy reform
System-wide racial discrimination and inequitable access to justice impedes Indigenous rights to health and wellbeing
Pat Dudgeon · Abigail Bray · Roz Walker
The Mobile Outreach Boomerang van: taking care to the community
Indigenous-specific mobile clinics improve access to health care by delivering care to underserviced communities
Deborah A Askew · Ethan Kettyle · Kim Passante · Tamika Campbell · Maree R Toombs
Beyond the intensive care unit: ensuring the long term health of critically ill Indigenous people
An important aim after critically ill Indigenous people return home is to avoid the need for re-admission to hospital
Dianne P Stephens
Aboriginal and Torres Strait Islander health research leadership
When will we see Indigenous Australians move from being the examined to being the examiners?
Candice McKenzie · Lilon G Bandler
Supporting Indigenous health equity strategic planning: a Queensland perspective
Queensland’s approach to Indigenous health equity planning and implementation should align with existing international frameworks
Maree R Toombs · Caitlin Curtis · Claire E Brolan
Where should we offer mass drug administration for trachoma?
Elimination programs should be guided by the prevalence of markers of infection, not of disease
Jaki Adams · Sung Hye Kim · Anthony W Solomon
Reducing the burden of group A streptococcal disease in the Northern Territory: the role of chemoprophylaxis for those at greatest risk
The unacceptably high prevalence among Indigenous people and people who need dialysis warrants a clinical trial of prophylactic antibiotics
Katherine Gibney · Andrew Steer
Twelve‐month mortality outcomes for Indigenous and non‐Indigenous people admitted to intensive care units in Australia: a registry‐based data linkage study
After adjusting for age and other factors, survival outcomes are poorer for Indigenous than non-Indigenous people admitted to ICUs
Paul J Secombe · Alex Brown · Michael J Bailey · Sue Huckson · Shaila Chavan · Edward Litton · David Pilcher
Ethics guidelines use and Indigenous governance and participation in Aboriginal and Torres Strait Islander health research: a national survey
Barriers that limit the oversight of and participation of Indigenous people in Indigenous health research should be overcome
Luke J Burchill · Aneta Kotevski · Daniel LM Duke · Jeanette E Ward · Megan Prictor · Karen E Lamb · Michelle Kennedy
Invasive group A streptococcal disease in the Northern Territory and the impact of melioidosis antibiotic prophylaxis
An intersectoral response to improving the social determinants of skin health is needed, particularly in remote communities
Johanna M Birrell · Rowena Boyd · Bart J Currie · Nicholas M Anstey · Asanga Abeyaratne · Sandawana William Majoni · Vicki L Krause
Clinical signs of trachoma and laboratory evidence of ocular Chlamydia trachomatis infection in a remote Queensland community: a serial cross‐sectional study
Assessing progress to trachoma elimination in Australia and elsewhere should therefore incorporate laboratory testing
Kathleen D Lynch · Wendy Morotti · Garry Brian · Lenore Ketchup · Kozue Kingston · Mitchell Starr · Robert S Ware · Beth Everill · Nazihah Asgar · Anne O'Keefe · Lisa J Whop · John M Kaldor · Stephen B Lambert
Improved life expectancy for Indigenous and non‐Indigenous people in the Northern Territory, 1999–2018: overall and by underlying cause of death
To the Editor: Zhao and colleagues1 recently published an article highlighting the improved life expectancy for Aboriginal and Torres Strait Islander men in the Northern Territory over the past 20years.1 This is both important and welcomed. It reflects consistent and concerted work of countless individuals and organisations that are contributing to the improved health and wellbeing of Aboriginal and Torres Strait Islander men in the NT, despite limited resources to do so. It makes sense that we are beginning, albeit slowly, to see these inroads. One example of contributing to the positive outcomes for Aboriginal and Torres Strait Islander men’s health in the NT is the evolution of the Darwin Men’s Inter‐Agency Network (DMIAN). DMIAN is a network of men from across government and the non‐government organisation sector to collaboratively advocate for Aboriginal and Torres Strait Islander men in Darwin.2 DMIAN has enabled men’s health researchers to better understand and act on the wants and needs of the Aboriginal and Torres Strait Islander men in the community from the perspective that matters most: their own. As Zhao and colleagues1 point out, there is still a long way to go with improving the life expectancy of Aboriginal and Torres Strait Islander men, which sits 15.4years behind non‐Indigenous men. In addition, as the life expectancy of Aboriginal and Torres Strait Islander men increases, so too does that of non‐Indigenous men.1 So if we are to close the gap, we cannot afford to lose momentum on targeted action, particularly that relating to Aboriginal and Torres Strait Islander male health and wellbeing.3,4 There is still a need for this to be a recognised priority in the NT and nationally, and for primary health care and social services in the NT to be resourced appropriately. In particular, the Aboriginal Community Controlled Health Services and Aboriginal medical services have a key role to play and should be funded to develop, implement and evaluate health and social and emotional wellbeing programs for male clients, as this is severely lacking and is ultimately hampering progress in Aboriginal and Torres Strait Islander male health and wellbeing outcomes.4 While the National Men’s Health Strategy identifies Aboriginal and Torres Strait Islander men as a priority population,5 we also need substantially more investment in research and evaluation to find new innovate solutions.6 We hope the important work being done by individuals in health, justice, education and other social services sectors continues to be enabled to support Aboriginal and Torres Strait Islander men for the benefit of their communities and future generations.
Kootsy Canuto · Karla J Canuto · Jason Bonson · James Smith
Roadmap to incorporating group A Streptococcus molecular point‐of‐care testing for remote Australia: a key activity to eliminate rheumatic heart disease
Strep A POCT is a critical element in preventing acute rheumatic fever and will contribute to the elimination of rheumatic heart disease in Australia
Dylan D Barth · Gelsa Cinanni · Jonathan R Carapetis · Rosemary Wyber · Louise Causer · Caroline Watts · Belinda Hengel · Susan Matthews · Anna P Ralph · Janessa Pickering · Jeffrey W Cannon · Lorraine Anderson · Vicki Wade · Rebecca J Guy · Asha C Bowen
Doing “deadly” community‐based research during COVID‐19: the Which Way? study
An Indigenous-led study aims to empower and support Aboriginal and Torres Strait Islander women to be smoke-free
Michelle Kennedy · Hayley Longbottom
