Indigenous health

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

Objectives: To examine associations between community cultural connectedness indicators and suicide mortality rates for young Aboriginal and Torres Strait Islander people. Study design: Retrospective mortality study. Setting, participants: Suicide deaths of people aged 10‒19 years recorded by the Queensland Suicide Register, 2001‒2015. Main outcome measures: Age‐standardised suicide death rates, by Indigenous status, sex, and age group; age‐standardised suicide death rates for young First Nations people by area level remoteness and Index of Relative Socioeconomic Advantage and Disadvantage, and by cultural connectedness indicators (at statistical area level 2): cultural social capital index score, community Indigenous language use, and reported discrimination. Results: The age‐specific suicide rate was 21.1 deaths per 100 000 persons/year for First Nations young people and 5.0 deaths per 100 000 persons/year for non‐Indigenous young people (rate ratio [RR], 4.3; 95% CI, 3.5‒5.1). The rate for Aboriginal and Torres Strait Islander young people was higher in areas with low levels of cultural social capital (greater participation of community members in cultural events, ceremonies, organisations, and community activities) than in areas classified as having high levels (RR, 1.8; 95% CI, 1.2‒2.7), and also in communities with high levels of reported discrimination (RR, 2.7; 95% CI, 1.7‒4.3). Associations with proportions of Indigenous language speakers and area level socio‐economic resource levels were not statistically significant. Conclusion: We found that suicide mortality rates for Aboriginal and Torres Strait Islander young people in Queensland were influenced by community level culturally specific risk and protective factors. Our findings suggest that strategies for increasing community cultural connectedness at the community level and reducing institutional and personal discrimination could reduce suicide rates.

Mandy Gibson · Jaimee Stuart · Stuart Leske · Raelene Ward · Robert Tanton

To the Editor: The article by Giuseppin,1 Chair of the Australian Medical Association Council of Rural Doctors, published in MJA InSight+, on ending geographic narcissism, overcoming metro‐based policy making, and instituting health self‐determination by rural practitioners and communities echoes the feedback we have received from health practitioners and consumers attending our workshops throughout northern Australia. The HOT NORTH (Improving Health Outcomes in the Tropical North) program (Box), funded by the National Health and Medical Research Council, aims to address inequitable health coverage across northern Australia through more widespread implementation of locally designed research and practice. Epidemiological and health service data indicate a higher disease burden and risk profile in northern Australia compared with the rest of the country, with health disparity increasing with age and remoteness and Indigenous Australians living in the north having worse health outcomes than the non‐Indigenous population.2 At 15 HOT NORTH forums held over the past 3 years, attended by over 1600 participants in locations from South Hedland to Thursday Island, we provided an opportunity for communities and local health staff to take control over the agenda, presentations and input to discussions. Participation increased, discussions became more interactive, and pride in the achievements of local health practitioners and researchers replaced the deficit data and focus of many previous presentations. The wider benefits of a consultative, locally designed and led health research and capacity‐building program are captured in the recent HOT NORTH impact report.3 While several initiatives have addressed regional and remote health care (eg, the Centre for Research Excellence in Rural and Remote Primary Healthcare, the Advanced Health Research and Translation Centre in Alice Springs, and Centres for Innovation in Regional Health in north Queensland and in regional New South Wales), we agree with Giuseppin that fundamental shifts in the rusted‐on core–periphery relationships are required to address the inequity of health coverage across Australia. However, in Australia (and its universities), this requires recognition of the pervasive dogma of “winner‐takes‐all” urbanism of “superstar cities”4 with their “creative class”,5 which arguably militates against an appetite and capacity for sustainably reshaping the service delivery and research landscape in response to the remoteness, cultures, power relations, social ties and other dynamics in rural and remote settings. Box – HOT NORTH capacity building, collaborations and regional engagement activities 2017–2019

Kevin Williams · Sean Rung · Bart J Currie

Liver disease and liver cancer incidence and mortality are unacceptably high among Indigenous Australians

Jessica Howell · James S Ward · Jane Davies · Paul J Clark · Joshua S Davis

Let us move our focus to building health care relationships and partnerships that optimise care for every Indigenous patient

Talila Milroy · Lilon G Bandler

Evidence to inform conversations on Aboriginal health issues — in response to COVID‐19 and beyond Nearly everyone has been affected in some way by the coronavirus disease 2019 (COVID‐19) pandemic, and it is a public health risk for Aboriginal peoples and communities.1 The impacts of the pandemic are pervasive, wide‐ranging and continue to affect people and communities differently. Concerns about the indirect impacts of COVID‐19, caused by missed, delayed and avoided health care — not as a direct consequence of COVID‐19 infections — are shared internationally.2,3,4 While the prevalence of COVID‐19 in New South Wales remains low,5 local data show significant changes in health utilisation across the state. During the 4‐month period from March to June 2020, compared with the same period in 2019, face‐to‐face primary care consultations decreased by 22.1%, breast screen activity by 51.5%, ambulance incidents by 7.2%, emergency department visits by 13.9%, public hospital inpatient episodes by 14.3%, and public hospital planned surgical activity by 32.6%.6 Such decreases are not unique to NSW.7 Before COVID‐19, Aboriginal people faced health disadvantages and inequitable access to health care. Any decrease in health care access for Aboriginal people through missed, delayed or avoided health care may lead to further adverse health outcomes and inequities.1,4,8 In recent months, we came together as a group of 12 Aboriginal community members from across NSW to share our experiences and perspectives regarding the indirect impacts of COVID‐19. We live and work on Eora, Wilyakali, Bundjalung, Yuin and Gumbaynggirr lands. The discussions occurred over three separate sessions, each held a week apart between 24 August and 1 September 2020. Six members of the group (DF, CP, PO, BO, DL and KB) captured the key messages identified from the talks and synthesised the findings into three main themes: community supporting the community; the social determinants of health; and access to health care. These conversations were hosted and supported by the Critical Intelligence Unit established as part of the NSW Health COVID‐19 response and the Agency for Clinical Innovation (TDB). Illustrative quotes shared by the co‐authors have been selected to demonstrate salient points. The term “mob” has been used throughout to identify who we are and where we are from — our connection to our shared identity as Aboriginal people. Community supporting the community is a real strength — in the pandemic, and always In responding to COVID‐19, we see that Aboriginal organisations are coming together, more than ever, to create a movement that will continue to inform positive change to address Aboriginal health issues. Mob are proud of how they are keeping each other safe. It is a point of pride that has strengthened community. Our mob are concerned about the safety of others and our elders. (CP) Aboriginal leaders and Aboriginal community controlled health services are active in responding to COVID‐19, drawing on experiences from the 2009 HINI influenza pandemic and implementing culturally appropriate resources.9 The pandemic has been disruptive, and community events and gatherings have been cancelled because of important and legitimate public health concerns. However, this does impact our community approach to health care, cultural practices and connection to country.1,10 Our mob aren’t able to connect for sorry business and funerals, marriages and births. The provision of our health care, along with the provision of our social and emotional wellbeing, has changed. And connectivity is the main ingredient for our mob to stay healthy. This is the biggest barrier. (CP) Social determinants of health for Aboriginal people Social determinants are the conditions in which people are born, grow, live and age, and how these factors influence our health and determine health inequalities.11 Cultural determinants of health such as connection to country (land and water), traditional practices and kinship systems promote resilience and support social and emotional wellbeing for Aboriginal peoples and communities.10,12 The COVID‐19 pandemic is likely to amplify the social determinants of health,13,14 and our concern is these determinants will continue to affect access to health care and increase health inequalities. Based on our own lived experiences and anecdotal community feedback, we are hearing that food security has increased for some Aboriginal people in response to COVID‐19. People are fearful of going into large shopping centres — fearful of catching COVID‐19. In some rural and remote areas, local shops are pushing up their prices, and people are left with no choice but to buy cheaper (and often less healthy) options to feed their families. Increase in government payments has resulted in the one and only shop in community providing food jamming their prices up. The price of food and water is beyond compare when you are paying $10 for a loaf of bread. Because of COVID‐19, people don’t want to come into town to do their shopping. (DL) We are concerned that restricted access to health care in response to border closures will impact the health and wellbeing of Aboriginal peoples. Some communities are being hit hard. To give a raw example, people are being refused medical treatment and are driving 600–800 km just to get any sort of medication or treatment around their health. (DL) We are also concerned that a lack of cultural safety displayed during COVID‐19 will lead to Aboriginal people being confronted with racism when trying to access health care.15 COVID‐19 has made accessing health care even more difficult Deciding to seek health care is difficult, and for some Aboriginal people, access to care has become more challenging during COVID‐19 with reduced availability of services. Many doctors and services have temporarily shut their doors to new patients, and this is likely to have a profound impact on people’s health. More generally, there have been efforts to overcome access challenges posed by COVID‐19 through the use of telehealth and virtual care. In our opinion, telehealth for diagnosis and e‐prescribing can be useful; however, there are challenges to using telehealth such as limited access to equipment and internet connection, and reluctance from some people to disclose personal information over a device. When we look at the provision of health care for our mob, one of the biggest barriers is having to sit in front of a computer. And talk to a computer, rather than a human connection. Our mob like to connect and have a yarn. (CP) Our view is that paying attention to the intersections of culture and diversity is essential to understanding the indirect impacts of COVID‐19. Within Aboriginal communities, there are minority groups who are significantly affected by COVID‐19. Minority groups include people with existing chronic conditions, people with disabilities, people experiencing homelessness, people living in rural and remote areas, and people who identify as lesbian, gay, bisexual, transgender, queer, asexual and questioning. Sistergirl and brotherboy are terms used for gender diverse people within some Aboriginal or Torres Strait Islander communities.16 If the mob aren’t receiving health related treatment, how this is feeding into direct or indirect impacts on disabilities. And how we can pick this up through the health system as disability is not in closing the gap. If we aren’t addressing it at a higher level, we are never going to address it at the ground level. (DL) We are also concerned about an increase in risk for our older people living with disability. These risks have been outlined by Aboriginal people with disability and their representative organisations, advocates and allies in international and national calls to action for governments to ensure Aboriginal disability‐inclusive public health, social and economic responses to the pandemic that put our mob at the forefront of any future planning in the health system.17 The recent drought, bushfires and now COVID‐19 are compounding risk factors for mental health issues and suicide. There is concern that some government measures to control the spread of COVID‐19 are triggering for mob — especially for those with trauma histories.18 We know mental health issues and suicide rates are high for our peoples,8,19 and we are concerned this level of disadvantage will worsen in response to COVID‐19. We support the recommendations made by the Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention at the University of Western Australia to manage COVID‐19 recovery and address adverse impacts.19 The recommendations focus on the right to self‐determination, the health and mental health workforce, social and cultural determinants of health, digital and telehealth inclusion, and evaluation that includes Indigenous data sovereignty. These recommendations directly align with our lived experiences and were running themes throughout our discussions and overall assessment of the indirect impacts of COVID‐19 in our communities across NSW. Where to next? We prepared this article to inform future conversations on Aboriginal health issues in response to the COVID‐19 pandemic and beyond. Our view is that drawing on the lived experience and realities of Aboriginal peoples, taking firm action on the social determinants of health and working collaboratively with Aboriginal peoples and communities is the most effective way to address the indirect impacts of COVID‐19.

David Follent · Cory Paulson · Phillip Orcher · Barbara O'Neill · Debbie Lee · Karl Briscoe · Tara L Dimopoulos‐Bick

Introduction: The 2001 Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Islander populations were revised in 2010. This 2020 update by the Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander Children used for the first time the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Main recommendations: We performed systematic reviews of evidence across prevention, diagnosis, prognosis and management. We report ten algorithms to guide diagnosis and clinical management of all forms of otitis media. The guidelines include 14 prevention and 37 treatment strategies addressing 191 questions. Changes in management as a result of the guidelines: A GRADE approach is used. Targeted recommendations for both high and low risk children. New tympanostomy tube otorrhoea section. New Priority 5 for health services: annual and catch‐up ear health checks for at‐risk children. Antibiotics are strongly recommended for persistent otitis media with effusion in high risk children. Azithromycin is strongly recommended for acute otitis media where adherence is difficult or there is no access to refrigeration. Concurrent audiology and surgical referrals are recommended where delays are likely. Surgical referral is recommended for chronic suppurative otitis media at the time of diagnosis. The use of autoinflation devices is recommended for some children with persistent otitis media with effusion. Definitions for mild (21–30 dB) and moderate (> 30 dB) hearing impairment have been updated. New “OMapp” enables free fast access to the guidelines, plus images, animations, and multiple Aboriginal and Torres Strait Islander language audio translations to aid communication with families.

Amanda J Leach · Peter S Morris · Harvey LC Coates · Sandra Nelson · Stephen J O'Leary · Peter C Richmond · Hasantha Gunasekera · Samantha Harkus · Kelvin Kong · Christopher G Brennan‐Jones · Sam Brophy‐Williams · Kathy Currie · Sumon K Das · David Isaacs · Katherine Jarosz · Deborah Lehmann · Jarod Pak · Hemi Patel · Chris Perry · Jennifer S Reath · Jessica Sommer · Paul J Torzillo

Introduction: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) cause significant morbidity and premature mortality among Australian Aboriginal and Torres Strait Islander peoples. RHDAustralia has produced a fully updated clinical guideline in response to new knowledge gained since the 2012 edition. The guideline aligns with major international ARF and RHD practice guidelines from the American Heart Association and World Heart Federation to ensure best practice. The GRADE system was used to assess the quality and strength of evidence where appropriate.Main recommendations: The 2020 Australian guideline details best practice care for people with or at risk of ARF and RHD. It provides up‐to‐date guidance on primordial, primary and secondary prevention, diagnosis and management, preconception and perinatal management of women with RHD, culturally safe practice, provision of a trained and supported Aboriginal and Torres Strait Islander workforce, disease burden, RHD screening, control programs and new technologies.Changes in management as a result of the guideline: Key changes include updating of ARF and RHD diagnostic criteria; change in secondary prophylaxis duration; improved pain management for intramuscular injections; and changes to antibiotic regimens for primary prevention. Other changes include an emphasis on provision of culturally appropriate care; updated burden of disease data using linked register and hospitalisations data; primordial prevention strategies to reduce streptococcal infection addressing household overcrowding and personal hygiene; recommendations for population‐based echocardiographic screening for RHD in select populations; expanded management guidance for women with RHD or ARF to cover contraception, antenatal, delivery and postnatal care, and to stratify pregnancy risks according to RHD severity; and a priority classification system for presence and severity of RHD to align with appropriate timing of follow‐up.

Anna P Ralph · Sara Noonan · Vicki Wade · Bart J Currie

To the Editor: Poor oral health profoundly affects a person's ability to eat, speak, socialise, work and learn.1 It has an impact on social and emotional wellbeing, productivity in the workplace, and quality of life. Pain from dental caries is a common experience. In children, dental caries may require treatment under a hospital‐based general anaesthetic — at considerable cost and itself not without risk.2 Poor oral health in childhood is the leading cause of poor adult oral health.1 A higher proportion of Australians who are socially disadvantaged have dental caries. In the 2012–2014 National Child Oral Health Survey, the mean number of deciduous teeth with dental caries in Indigenous children aged 5–10 years was 6.3 (95% CI, 5.2–7.4) compared with 2.9 (95% CI, 2.7–3.1) among non‐Indigenous children.3 In the 2004–2006 National Survey of Adult Oral Health, almost 60% of Indigenous adults had untreated dental caries compared with 25% of non‐Indigenous Australians.4 In the interests of equity, it is desirable for water fluoridation to provide a greater benefit to groups carrying the highest burden of disease. In Australia, this is the Indigenous population. Community water fluoridation is one of the most effective public health interventions of the 20th century. Its success has been attributed to wide population coverage with no concurrent behaviour change required. Evidence in Australia demonstrates that community water fluoridation has decreased both the prevalence (proportion of population) and severity (amount per person) of tooth decay by 44% in children and 27% in adults.5 However, nearly 3 million Australians (11% of the population) cannot access a fluoridated water supply.5 Access to fluoridated water in Australia varies. In Queensland before 2008, access was limited to 5% of the population.5 At that time, there were higher rates of untreated dental caries in non‐fluoridated than in fluoridated communities. In 2008, the Queensland Government mandated water fluoridation for all community water supplies that serviced communities of more than 1000 people; 134 water supplies were identified. Within 4 years, 90% of Queenslanders had access to fluoridated water and rates of dental caries declined.6 After the 2012 Queensland election, the new government overturned mandatory water fluoridation, with the decision to fluoridate community water reverting to water supply authorities. The subsequent deactivation of water fluoridation plants in 18 local government areas reduced the population coverage to around 76%. This had a disproportionate impact on Indigenous Australians, who are more likely to reside in areas where water fluoridation ceased after 2012 or in areas where it was never implemented. The consequence is that only 50% of the Indigenous population in Queensland have access to fluoridated water compared with 76% of non‐Indigenous Queenslanders.7 The denial of access to fluoridated drinking water for Indigenous Australians is of great concern. We urge the Commonwealth government, through current negotiations for funding agreements for public dental care, to mandate that all states and territories maintain a minimum standard of 90% population access to fluoridated water. Water fluoridation would then be an effective as well as socially equitable public health intervention to reduce the oral health inequalities between Indigenous and non‐Indigenous Australians.

Andrew McAuliffe · Chris Bourke · Lisa M Jamieson

To the Editor: We thank Davidson and colleagues1 for their comprehensive narrative review on skin infections in Australian Aboriginal children. A significant factor in both individual and mass drug administration therapy of scabies is the uncertainty regarding the safety of oral ivermectin in small children and during pregnancy. Australian guidelines state ivermectin should not be used in children aged under 5 years or who weigh less than 15 kg or in pregnant women.2 A retrospective cohort study of 170 children aged 1–64 months (median age, 15 months) or weighing under 15 kg treated with ivermectin (mean dose, 223 μg/kg) found only minor self‐limiting adverse effects in seven patients (4%).3 A review of previous literature found 60 children aged under 5 years or weighing less than 15 kg who had been treated with ivermectin at a dose range of 150–200 μg/kg for whom safety data were available.4 Only four of 60 children (7%) developed an adverse reaction, all of which were benign and transient, with no long term sequelae. A recent study of oral ivermectin (dose 400 μg/kg) in the treatment of head lice revealed no adverse effects in 54 children aged under 5 years.5 The Ivermectin Exposure in Small Children Study Group expected to commence the analysis in late 2019 of data collected from 2017 to 2019.6 Three studies totalling 363 women with inadvertent maternal exposure to ivermectin 150 μg/kg (76–85% in first trimester) for filariasis and onchocerciasis found no increased risk of congenital malformations, miscarriage or stillbirth.7 A study of 199 pregnancies with maternal treatment in the second trimester with ivermectin and albendazole, and 198 with ivermectin alone in the management of helminth infections, found no increased risk of adverse pregnancy outcomes.8 In France, the use of oral ivermectin is permitted during pregnancy and in children weighing less than 15 kg when topical therapy has failed.9 Further published data regarding the safety of ivermectin in these populations would be useful, particularly with respect to mass drug administration programs.

Sarah K Morton · Adam Morton