Indigenous health

The convergence of excessive heat, poor housing, energy insecurity and chronic disease has reached critical levels

Simon Quilty · Norman Frank Jupurrurla · Ross S Bailie · Russell L Gruen

The current lack of a national strategy for Indigenous adolescent health in Australia is a glaring gap

Seth Westhead · Quinton Appleby · Brittney Andrews · Tina Brodie · Alex Brown · Karla Canuto · Josh Cooke · Mahlia Garay · Thomas Harrington · Djai Hunter · Corey Kennedy · Jaeda Lenoy · Olivia Lester · Hannah McCleary · Odette Pearson · Lorraine Randall · Rachel Reilly · Hamish Rose · Daniel Rosendale · Jakirah Telfer · Peter Azzopardi

Increasing the visibility of Aboriginal and Torres Strait Islander peoples will ensure that the MJA enhances its commitment to inclusivity and health equity

Nicholas J Talley · Elizabeth Zuccala · Francis Geronimo · Tania Janusic · Elmer V Villanueva

Progress has been sluggish, and social factors and access to major health service schemes need much more attention

Ian T Ring · Kalinda Griffiths

Emergency department presentations are opportunities to discuss cardiovascular risk factors while the patient’s awareness of their importance is heightened

Christopher Zeitz · Angus Baumann

Our multicomponent intervention is a highly translatable primary care approach to reducing smoking by pregnant Indigenous women

Gillian S Gould · Nicole M Ryan · Ratika Kumar · Leah C Stevenson · Kristin V Carson‐Chahhoud · Christopher Oldmeadow · Joley Foster · Simon Deeming · Katherine Boydell · Christopher M Doran · Andrew Searles · Joerg Mattes · Louise Atkins · Marilyn Clarke

We need intellectual investment that prioritises Indigenous ways of knowing, being and doing, and acknowledges the historical and contemporary colonisation, dispossession and racism that continue to have an impact on health outcomes today

Michelle Kennedy · Jessica Bennett · Sian Maidment · Catherine Chamberlain · Kate Booth · Romany McGuffog · Bree Hobden · Lisa J Whop · Jamie Bryant

To the Editor: The impetigo burden for Australian Aboriginal children living in remote areas is the highest in the world, affecting 45% at any one time.1 This unacceptable public health crisis contributes to ongoing high rates of rheumatic fever and glomerulonephritis, both sequelae of Streptococcus pyogenes or group A streptococcus (GAS) infection.2 GAS infection is the key immediate driver of impetigo.3 Colonisation, social determinants and inadequate housing are overarching drivers.4 To reduce the skin infection burden, the See, Treat, Prevent (SToP) Trial (registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618000520235) was funded as a stepped wedge, cluster randomised trial in partnership with Aboriginal service providers and communities to see, treat and prevent skin infections.1 Before commencing, a situational analysis5 was performed in 2017 to describe trends, driving forces and conditions related to skin infections. The situational analysis5 identified the complex, courageous yet under‐resourced environmental health and health promotion activities in the Kimberley that could be included as prevention aspects in the SToP Trial1 and found: • a well established program of health advocacy and collaboration integrating public and environmental health which prioritises prevention; • remote Aboriginal populations remain relatively stable with predictable mobility between communities, in contrast to the high turnover of the predominantly non‐Aboriginal health workforce; and • access to household maintenance throughout Kimberley communities, necessary to prevent skin infections, remains limited and frequently under‐resourced. Despite this need, the resourcing required for this sector to deliver on these services has not occurred.6 Before the SToP Trial, prior skin infection studies focused on biomedical treatments as short term solutions to improve skin health.1 Integration of diagnosis, treatment and prevention activities in a single trial to inform skin disease control is novel and needful. Aboriginal communities and health care organisations highlighted the urgent need to incorporate prevention to reduce the inequitable burden of skin infections. The key findings of the situational analysis are as follows:5 • services are working together to combat the high burden of skin infections in the Kimberley; • the immediate environment continues to contribute to poor skin health and is an area for intervention; • addressing the social determinants of health is critical to reducing skin infections; • partnerships are required to appropriately achieve the healthy living practices; and • the Kimberley has led the way with the development of the environmental health referral form. The SToP Trial includes clinic and school staff training modules for the identification and treatment of skin infections. These include online options to overcome the logistic challenges limiting face‐to‐face professional development in isolated locations and to support continuous training of new staff. The stability of the community is a strength and community requests have led to the incorporation of family training packages. Partnerships between primary health care and environmental health service providers are allowing for the better integration of prevention measures within communities. Capitalising on the advocacy and collaboration demonstrated by Aboriginal leaders across the region has aided SToP Trial initiatives, with results expected in 2023.

Frieda McLoughlin · Vicki O’Donnell · Asha C Bowen

To the Editor: Wu and colleagues1 describe a case of congenital syphilis where the mother had no apparent risk factors and a single negative syphilis serology collected in early pregnancy. The father had an identifiable risk factor. In metropolitan Perth, Western Australia, infectious syphilis among women of reproductive age is rising, with an over 18‐fold increase from 2015 to 2021 (Box). During this period, most cases (229, 74.1%) were non‐Indigenous women. This growth has been accompanied by cases in pregnancy and, concerningly, neonates with congenital syphilis. The authors1 observed that identifying risk factors during pregnancy is challenging. They may be absent, difficult to ascertain, subject to change during the pregnancy, and are dependent on the pregnant woman and her sexual partners, whose risks she may not know. Identification relies on health care providers checking the risk throughout pregnancy and on whether the woman recognises, discloses or feels safe to discuss a risk factor. In Perth, syphilis diagnoses among pregnant women are occurring across cultural backgrounds. While some women have additional risks such as insecure housing or illicit drug use, this is not the norm. Consequently, and because we have likewise observed neonates with congenital syphilis born to women who screened negative early in pregnancy, routine syphilis serology at initial visit and at 28 and 36weeks (or delivery, if earlier) is now recommended for all pregnant women in metropolitan Perth as per the WA sexual health guidelines2 and local obstetric guidelines.3 This was achieved through the collaboration of clinical and public health staff under the Antenatal and Postnatal Working Group of the WA Syphilis Outbreak Response Group, where a decision was made that monitoring risk factors throughout pregnancy has limitations. Three‐test syphilis screening for all pregnant women minimises the risk of congenital syphilis occurring because of an unrecognised risk factor, ensures emerging risk factors are not missed, helps normalise testing and reduce stigma, and recognises that women remain sexually active while pregnant. Notably, screening is not a replacement for good history taking and clinical examination, but syphilis can present in subtle and unusual ways that can be overlooked. Routine syphilis testing at the first antenatal visit is advised by the Australian sexually transmissible infections guidelines.4 A test early in the third trimester is recommended depending on local guidelines.4 As syphilis rates grow in many parts of Australia,5 other jurisdictions should consider adopting additional routine syphilis screening for all pregnant women. Box – Infectious syphilis cases among women of reproductive age, 2015–2021 Data sources: The number of cases were obtained from the Western Australian Notifiable Infectious Diseases Database, Department of Health Western Australia (Jan 2022); and the rate of cases were obtained from the Australian Bureau of Statistics census‐derived population data from the Epidemiology Branch, Public and Aboriginal Health Division, Western Australia Department of Health (Dec 2021).

Hannah MacKenzie · Suzanne McEvoy · Michelle Porter

To the Editor: In Australia, up to 40% of women have experienced an unintended pregnancy,1 which can be associated with suboptimal pre‐conception health behaviour and reproductive health care engagement and adverse maternal and neonatal outcomes.1 Aboriginal and Torres Strait Islander women experience higher rates of pregnancy risk factors, adverse perinatal outcomes, and adolescent pregnancy compared with non‐Indigenous women.2 However, little is known about the prevalence and impact of unintended pregnancy among Aboriginal and Torres Strait Islander women. While two related national studies have been undertaken over the past decade, Aboriginal and Torres Strait Islander people were underrepresented1 or Indigeneity was unreported.3 Access to sexual and reproductive health care is a government priority,4 but without adequate data, dealing with issues or evaluating change will be impossible. This knowledge gap must be addressed. We need to better understand the prevalence, experiences and outcomes of unintended pregnancy for Aboriginal and Torres Strait Islander people (acknowledging that unintended does not necessarily mean unwanted), including issues relating to pregnancy intentions, decision making, and health care access. Meaningful engagement and collaboration with Aboriginal and Torres Strait Islander communities and researchers are required to confirm priority issues, design culturally appropriate data collection processes, and achieve a nationally representative sample. Data sources such as those held by primary health care providers and Aboriginal Community Controlled Organisations have an untapped potential to highlight the needs and priorities of Aboriginal and Torres Strait Islander people, should they be used with appropriate consultation and respect for Indigenous data sovereignty. Furthermore, knowledge gained must inform the national policy gap that exists in the area of holistic reproductive health. A national reproductive health policy and an implementation plan that address unintended pregnancy, decision making and management are urgently needed. These must be developed with due consideration to the needs of Aboriginal and Torres Strait Islander peoples from a strengths‐based paradigm and a decolonising approach that recognises historical reproductive rights violations.5 Data collection within a supportive policy framework will inform service provision, education and health promotion initiatives to improve maternal and infant outcomes and support Aboriginal and Torres Strait Islander women and families in choosing whether and when they have children.

Jessica Botfield · Emma Griffiths · Faye McMillan · Danielle Mazza

Health practitioners have the opportunity to contribute their expertise to help reduce the health consequences of climate disasters across the prevention, preparedness, response and recovery phases of disaster management

Sotiris Vardoulakis · Veronica Matthews · Ross S Bailie · Wenbiao Hu · Luis Salvador‐Carulla · Alexandra L Barratt · Cordia Chu

Life expectancy increased more rapidly for Indigenous than non-Indigenous people but the gap remains considerable

Yuejen Zhao · Shu Qin Li · Tom Wilson · C Paul Burgess

Aboriginal and Torres Strait Islander people may benefit from culturally appropriate cardiac risk factor management

Jaimi H Greenslade · Sara Berndt · Laura Stephensen · Katrina Starmer · Greg Starmer · William Parsonage · Victor Lau · Tileah Drahm‐Butler · Tania Davis · Virginia Campbell · Richard Stone · Robert Bonnin · Sarah Ashover · Tanya Milburn · Elizabeth Mowatt · Karlie Proctor · Anthony Brazzale · Louise Ann Cullen

About two in three of participating urban Aboriginal infants had mild or moderate hearing loss at twelve months of age

Tamara Veselinović · Sharon A Weeks · Valerie M Swift · Deborah Lehmann · Christopher G Brennan‐Jones

The estimated prevalence of hereditary pancreatitis in South Australia is higher than in Europe, particularly among Indigenous young people

Denghao Wu · Tristan J Bampton · Hamish S Scott · Alex Brown · Karin Kassahn · Christopher Drogemuller · Sunita MC De Sousa · David Moore · Thuong Ha · John WC Chen · Sanjeev Khurana · David J Torpy · Toni Radford · Richard Couper · Lyle Palmer · P Toby Coates

To the Editor: We congratulate Schutte and colleagues1 for their call to action for improved management of blood pressure in Australia, highlighting that 68% of people have uncontrolled high blood pressure. The burden of high blood pressure is unevenly distributed, with Aboriginal and Torres Strait Islander (hereafter referred to respectfully as Indigenous) people reportedly having a higher rate of high blood pressure than non‐Indigenous Australians in every age group.2 Reducing the prevalence of high blood pressure is one of the most important means of reducing serious circulatory diseases, which are among the leading causes of death for Indigenous Australians.3 Hence, we want to extend the call to action and report on what is happening in primary health care settings with the control of blood pressure for Indigenous people. During 2012–13, we analysed blood pressure screening and follow‐up for patients diagnosed with hypertension (n = 6523) from 123 primary health care centres across Australia using continuous quality improvement data from audits of adherence to best practice chronic illness care.4 Given there are no recently available data on follow‐up actions after an abnormal blood pressure reading at this geographic scale, and as blood pressure continues to be relatively uncontrolled, these data continue to provide unique insight. The data, aggregated at primary health care centre level (Box), tells a story of clinical inertia. Regular blood pressure screening was done well — centres on average completed blood pressure screening for about 90% of patients within the past 6 and 12 months. In this cohort, about 65% of patients recorded abnormal blood pressure (n = 4240). Most primary health care centres had documentation of a follow‐up plan for more than 70% of patients, but there was wide variation (range, 0–100%; Box). Dealing with the low levels of medication reviews and adjustments (mean, ~15%; range, 0–100%) is a vital early step in limiting the contribution of uncontrolled blood pressure to adverse health outcomes for Indigenous people. These data support the need for training on strategies to overcome clinical inertia, which was identified as a top priority by over 200 Indigenous primary health care practitioners, managers and policymakers.5 We add to the call for more attention on prevention of cardiovascular disease and suggest additional investment in evidence‐based interventions appropriate to Indigenous Australian culture and needs. The time for system‐wide action has come. Box – Boxplots showing a record of scheduled services received by patients with hypertension and follow‐up of abnormal findings within the last 12 months of audit (unless otherwise indicated) at primary health centres during 2012–13 x = mean value. More information on how to interpret box plots is available in Matthews et al.4

Jodie Bailie · Veronica Matthews · Ross S Bailie

There is a lack of data relating to all-cause concussion in Aboriginal and Torres Strait Islander peoples

Jonathan Bullen · Trish Hill‐Wall · Elizabeth Thomas · Richard Norman · Gill Cowen

A patient register and control program could help reduce the considerable morbidity and mortality caused by ARF and RHD

Jane Oliver · Myra Hardy · Joshua Osowicki · Daniel Engelman · Andrew C Steer · Katherine Gibney

It is important to establish a research culture that is embraced by the community, rather than viewed with distrust

Ella Kris · Hylda Wapau · Allison Hempenstall

Stillbirth and cancer rates are significantly elevated among Aboriginal people living near the Ranger uranium mine Stillbirth and cancer incidence rates are significantly higher among Aboriginal people living near the Ranger uranium mine than among Aboriginal people elsewhere in the Top End of the Northern Territory, with a stillbirth rate over twice as high and cancer incidence almost 50% higher.1 The NT Chief Health Officer commissioned an investigation into the excess stillbirths and cancers in 2014, but a November 2020 report found no explanatory cause.1 The Ranger uranium mine ceased operations as planned in January 2021.2 Communities expect health departments to respond to reports of clusters of adverse health outcomes such as the excess stillbirths and cancers among Aboriginal people living near the Ranger uranium mine.3 However, investigating clusters of health outcomes which have complex aetiologies rarely provides definitive answers.3 Even when associations are identified, cluster investigations cannot demonstrate that these associations are responsible for the disease cluster. Nonetheless, important environmental, public health and social problems may be identified through cluster investigations, enabling health education and promotion, and potentially, mitigation of contributing causes.3 The Ranger mine cluster investigation focused on ionising radiation as a potential cause of the excess stillbirths and cancers because this was considered the worst‐case scenario.1 There are well established causative associations between ionising radiation and increased rates of some cancers, particularly lung, head and neck, thyroid cancer in childhood and leukaemia, and fetal malformations that lead to stillbirth.1 Tobacco and alcohol consumption likewise contribute to stillbirths and cancers, and these were also examined in the cluster investigation, together with markers of poor nutrition.1 High levels of alcohol consumption by Aboriginal people in the Ranger mine region have long been a concern.4,5 The Ranger uranium mine in Kakadu National Park Uranium mining began at a location labelled “Ranger” in 1980 on land excised from the Kakadu National Park World Heritage site.6 Aboriginal rights to veto mining were overridden in legislation, and detrimental impacts on Aboriginal people were anticipated, but market prospects for uranium appeared strong and the mine was considered to be in the national interest. Mining was allowed to proceed, with recommendations to monitor and reduce harmful impacts on the region’s Aboriginal people.4,7 Health, social and ecological aspects of the Ranger uranium mine were explored in a 1984 report, whose authors recognised that their immersion into Aboriginal communities gave them deep concern about how uranium mining could affect Aboriginal people.5 They recommended that uranium mining not expand without interventions to mitigate harmful and strengthen positive effects of mining on Aboriginal people.5 Mining continued for 40 years, and the Ranger uranium mine contributed up to $388 million annually to the NT economy before its 2021 closure.2,8 During the period of mine operation, more than 200 leaks, spills and other incidents were documented.9 Five major incidents are outlined in Box 1, highlighting threats to ecosystems and employees more than radiation exposure among Aboriginal community residents.9,10 The Gundjeihmi Aboriginal Corporation represents the Mirarr people of the region and for decades has expressed grave concerns about continuing incidents and the lack of effective government response.7 While the Mirarr people maintain the right to live on their lands, their lives are disrupted by mining operations and incidents that threaten biodiversity, landscapes and livelihoods.7,9 In 2014, the mine operators lodged a proposal to expand. A submission on the proposal by the NT Department of Health noted that rates of stillbirth and cancer among Aboriginal people in the region were elevated.1 NT Department of Health investigation In 2014, the NT Chief Health Officer commissioned an investigation into stillbirth and cancer rates in long term Aboriginal residents around the Ranger mine. The investigation aimed to quantify rates and identify exposures that may have contributed to the excess stillbirths and cancers. Stakeholders including Aboriginal health and land corporations and public health and politics experts oversaw the investigation to ensure transparency, while independent epidemiologists scrutinised the investigation’s scope, design and conduct. The investigation report was released publicly in November 2020.1 The investigation identified all Aboriginal people who had spent more than half of their lives in the mine region during the 1991–2014 study period, with an exposed cohort of about 2200 people. The focus was ionising radiation because this exposure was considered the worst‐case scenario.1 The mine employed few local Aboriginal people, so occupational exposures were not considered.1,2 The comparison group comprised all other Aboriginal people in the Top End.1 Elevated stillbirth and cancer incidence rates among Aboriginal people living near the Ranger mine compared with other Aboriginal people in the Top End were confirmed. Stillbirth was over twice as common (odds ratio, 2.17; 95% CI, 1.13–3.82) and cancer about 50% more common (total cancer incidence ratio, 1.48; 95% CI, 1.17‐1.85).1 Examination of the cancer types showed that no specific cancer was responsible for the excess of total cancers. Cancers of the lip, mouth and pharynx together were the most common cancers and made up 42% of the excess: 16 cases, compared with 5.5 expected. These cancers are not considered to be caused by ionising radiation, but they are associated with tobacco smoking and alcohol consumption.1 The Aboriginal people living near the mine had higher prevalence of tobacco smoking (prevalence ratio, 1.08; 95% CI, 1.04–1.13), alcohol use (prevalence ratio, 1.21; 95% CI, 1.13–1.31) and infrequent intake of vegetables indicating poor nutrition (prevalence ratio, 1.08; 95% CI, 1.02–1.24) compared with other Aboriginal people in the Top End. Other risk factors were not statistically different between the groups. Multivariable analysis did not show that these risk factors contributed to the excess cancer incidence in the people living near the mine (Box 2). However, this analysis had low statistical power because of a lack of risk factor data.1 The investigation found “little evidence that the risk factors investigated … were associated with increased risk of cancer in study participants” in the period for which risk factor data were available.1 Despite this statistical conclusion, higher rates of tobacco smoking and alcohol use and poor diets among Aboriginal people in the mine region were highlighted in relation to the excess stillbirths and cancers. The investigation concluded by recommending that Aboriginal people follow advice about smoking, alcohol and diet.1 Discussion The Ranger uranium mine has had an impact on surrounding Aboriginal communities for over 40 years. The investigation by the NT Department of Health into the rates of stillbirths and cancers among people in the region invested significant resources and expertise in gathering data on stillbirths, cancers, ionising radiation and behavioural risk factors. It focused on cause–effect relationships between possible exposure to ionising radiation and behavioural risk factors, and the increased stillbirth and cancer rates. The investigation was not designed to consider the impact of the imposition of uranium mining on Aboriginal lands, as was recommended when the mine was proposed and developed.4,5 Development of the Ranger mine entailed nullification of veto rights, disempowering Aboriginal communities and threatening their livelihoods.7 With mining came royalty money, expensive commodities, money‐hunger and alcohol.5 Economic development from the mine has increased inequity among Aboriginal people in the region.5 Inequity may contribute to both stillbirths and cancer, although this would not be detected in a cluster investigation.3,11,12 Employment and educational opportunities associated with the Ranger mine did not promote socio‐economic development of the Aboriginal community; rather, Aboriginal wellbeing deteriorated through people relying on royalty income.2,7 Aboriginal people’s rights were ignored, and their expertise, authority and lifeways were devalued by the mine.7 Aboriginal community perspectives, knowledge and research methodologies may offer important insights into adverse Aboriginal health outcomes, while marginalising Aboriginal expertise perpetuates the impacts of colonisation.13 Excess stillbirths and cancers may be associated with a web of interrelationships between individuals, communities and wider ecological, sociological and political environments, which a biomedically focused investigation may overlook.14 Further research is needed to unravel this web, and explain the disparity in stillbirth and cancer rates between Aboriginal people in the region of the mine and the other Aboriginal people in the Top End. The NT Department of Health stillbirth and cancer cluster investigation recommended that Aboriginal people in the region reduce their tobacco and excessive alcohol consumption, although these were not considered the causes of the raised stillbirth and cancer rates.1 This response could be strengthened by a foundational approach to improve understanding and relationships between government, mining companies and Aboriginal community members.2 Conclusion The investigation by the NT Department of Health into the excess stillbirths and cancers among Aboriginal people living near the Ranger uranium mine was transparent, detailed and publicly available. High level expertise was engaged, although stronger Aboriginal contribution to the investigation’s grounding and methodology may have enhanced two‐way intercultural learning.13 Research from Aboriginal community perspectives that focuses on improving health and wellbeing may lead to possible interventions. While the mine is now closed and undergoing rehabilitation, there is an opportunity for further research to better understand and close the gap in health risk exposures and outcomes between Aboriginal people in the region of the mine and other Aboriginal people in the Top End. Box 1 – Major incidents at the Ranger uranium mine, 1979–20139,10 Date Location Incident Outcome Risk minimisation December 1995 Retention pond 2 at power station 12 000 litres of diesel fuel spilled World’s richest tropical waterbird breeding ground threatened; 40 identified waterbirds perished Office of Supervising Scientist designated this as unacceptable environmental impact. Increases in monitoring not implemented due to mine operator’s other commitments January–April 2002 Headwaters of Corridor Creek, southern side of mine Incorrect stockpiling of low grade uranium ore Water contaminated by leakage of uranium Remedial works undertaken in February 2002. No source found for ongoing run‐off identified in April March 2004 Ranger mine utility site Process water connected to drinking water, leading to water uranium levels 400 times Australian standards 159 workers potentially exposed to contaminated water for drinking and washing Mine operator prosecuted and fined $150 000 January–June 2011 Region wide Extreme wet season Risk of overflow from tailings dam Uranium mill was shut for duration of wet season December 2013 Ranger mine site Collapse of acid leach tank 1 million litres of radioactive ore slurry spilled Area was evacuated until spill contained Box 2 – Total cancer incidence rate ratios for Aboriginal people living near the mine compared with other Aboriginal people in the Top End of the Northern Territory, by selected risk factors*,1 Risk factor Cancer incidence rate ratio (95% CI) Tobacco smoking 1.53 (0.75–3.12) Alcohol use 1.54 (0.76–3.15) Infrequent vegetable intake 1.49 (0.73–3.06) * Poisson regression model adjusted for age and sex.

Rosalie Schultz

National surveillance would facilitate strategies for preventing or managing conditions that predispose people to severe streptococcal disease

Jeffrey W Cannon · Asha C Bowen

The social determinants of incidence should be addressed, and other relevant host, pathogen, and health system factors investigated

Cameron M Wright · Rachael Moorin · Glenn Pearson · John R Dyer · Jonathan R Carapetis · Laurens Manning

Cultural participation can be a buffer to racism and a tool to heal

Raymond W Lovett · Makayla‐May Brinckley