Indigenous health

Engaging First Nations peoples in public health emergencies is critical to reducing health inequities

Kristy Crooks · Dawn Casey · James S Ward

Understanding the multiple identity groups of Aboriginal and Torres Strait Islander LGBTQ+ young people can assist in meeting their health care needs Where does a young, LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and other non‐heteronormative or non‐binary sexual and gender identities, including asexual) Aboriginal and Torres Strait Islander person go for health care in Australia? Do they attend an Aboriginal community controlled health organisation in search of culturally sensitive care? Or do they visit an LGBTQ+‐friendly health service to access staff trained in sexual and gender diversity? Is there a space for them, and other LGBTQ+ Aboriginal and Torres Strait Islander young people, in the Australian health care landscape? These questions are being posed by Indigenous LGBTQ+ health advocates.1 Recent national policy documents outline the need for comprehensive health care for Aboriginal and Torres Strait Islander LGBTQ+ young people.2,3 Despite this identification in policy, limited information is available to health practitioners on working with Aboriginal and Torres Strait Islander LGBTQ+ young people (Box 1). Practitioners are limited by the absence of an integrated framework as well as a dearth of research into these young peoples’ health needs and service preferences. Intersectionality theory highlights that individuals can face multiple structural inequalities within each of the social groups that they occupy, which also affect their access to health, social and economic resources.4 We suggest intersectionality theory as a guiding principle for research and practice with Aboriginal and Torres Strait Islander LGBTQ+ young people. An intersectional approach means recognising that patients belong to multiple identity groups, such as sexual orientation and cultural groups, which are socially constructed and which affect their social positioning and subsequent treatment, such as discrimination, within health care systems.4 The health and wellbeing of Aboriginal and Torres Strait Islander LGBTQ+ young people Aboriginal and Torres Strait Islander LGBTQ+ young people occupy three intersecting identities, which, when considered separately, are each linked to risks for poor health. The risks for poor physical health and social emotional wellbeing among Aboriginal and Torres Strait Islander peoples are well documented.5 Within Australia, LGBTQ+ individuals experience heightened suicidality, serious assault, homelessness and psychological distress6,7 compared with their heterosexual, cisgender peers. These increased health risks do not indicate inherent vulnerability but rather are outcomes of discrimination, marginalisation, racism, transphobia and homophobia.15 Young people not only experience health risks associated with their development phase — for example, heightened risk of psychopathology, physical injury and emotional dysregulation9,10 — but are also often unaware of health services available to them or have fears around confidentiality.11 LGBTQ+ young people, in particular, report feeling isolated from health services.6 Health practitioners may therefore see Aboriginal and Torres Strait Islander LGBTQ+ young people in a variety of settings, including in suicidal crisis, seeking care after a serious assault or injury, or counselling for prolonged psychological distress. Although health care workers may be aware of the health risks associated with being Aboriginal and Torres Strait Islander, LGBTQ+ or young, the health outcomes for someone with these intersecting identities remain largely unknown. Emerging literature has begun to identify the health concerns of people who are both Aboriginal and Torres Strait Islander and LGBTQ+, although this work is thus far limited to adults.12,13,14 Consistent with research into these groups separately, findings suggest that suicidality, substance misuse and homelessness are primary health concerns for Aboriginal and Torres Strait Islander LGBTQ+ people. However, the evidence in adults also points to a set of health‐related concerns which are unique to being Aboriginal and Torres Islander and LGBTQ+. For example, some individuals move off Country in search of more accepting communities or to access gender‐affirming care.13,14 However, moving off Country can lead to feelings of dislocation due to loss of connection to Country, which can then precipitate illness. Arguably, Aboriginal and Torres Strait Islander LGBTQ+ young people find it harder to move off Country because of reduced financial and personal resources. Support and service in remote areas are also scarce.14 An inability to express gender or sexual identity is another health‐related concern for Aboriginal and Torres Strait Islander LGBTQ+ people. Some people report feeling pressure to suppress their sexual or gender identity when they are in Indigenous communities.12 Exclusion of gender diverse individuals from men's or women's business can negatively affect social and emotional wellbeing.13 Contemporary culture‐based wellbeing programs often continue this practice of providing support along binary gender lines. Some of the authors’ own experiences reiterate this unintentional bias; Indigenous health care providers use terms such as “sis”, “brother” or “sistergirl” when answering the phone, which can mean that people are misgendered. Although we acknowledge that these terms carry meaning to the Indigenous community, they can be problematical for trans and non‐gender‐conforming young people. There is therefore scope to develop a culturally sensitive way to bypass the use of these gendered terms until a young person's pronouns have been established. Intersectionality theory as a guiding framework International models8,15 provide a useful footing on which to consider intersectionality in the Australian health context. These models demonstrate how societal oppressions of racism and heterosexism within health care systems influence internal (eg, an individuals’ self‐concept) and external (eg, lack of LGBTQ+‐specific services, stigma toward multiple minority groups) risk factors. Importantly, the impact of these risk factors resulting from societal oppressions is not simply a multiplicative effect. Rather, individuals living within multiple minority groups face health disadvantage because of their unique social positioning. Common across these models is an emphasis on the social context of health outcomes because membership in multiple minority status groups can be associated with increased stresses and barriers impeding an individual's coping efforts. Further, when practitioners do not consider how a patient's gender, social class, ethnicity and sexual orientation influences their care needs, patients who experience multiple oppressions can become invisible by being left out of health research or ignored in policy and health promotion efforts, leading to delays in seeking care. Such invisibility in health care is a reported concern among Aboriginal and Torres Strait Islander LGBTQ+ people.12 Health care at the intersection: implications for health research and practice Adopting an intersectional approach to health care requires practitioners to consider the relationship between multiple structural inequalities faced by Aboriginal and Torres Strait Islander LGBTQ+ young people, and downstream consequences for this group's wellbeing. Doing so will likely require additional training and professional development. As Box 1 outlines, although not health providers per se, services and supports led by Aboriginal and Torres Strait Islander LGBTQ+ people have emerged in response to the multiple barriers presented by existing health services. These services provide a space for Aboriginal and Torres Strait Islander LGBTQ+ people to discuss intersecting identities. For example, the Gar'ban'djee'lum Network offers a space in which to celebrate sexual and cultural identity, and Black Rainbow partners with an online newspaper to publish content by Aboriginal and Torres Strait Islander LGBTQ+ authors, providing a platform for voices from people living at this intersection. Service providers can increase their awareness of the contemporary issues faced by Aboriginal and Torres Strait Islander LGBTQ+ young people by accessing online information from these organisations. Moreover, concrete steps which practitioners can follow can be guided by an awareness of intersecting categories, diversity of knowledges, power and multilevel analysis, reflexivity, time and space, and equity and social justice.8 Actions that practitioners can take which are consistent with these domains are outlined in Box 2. The increased focus on Aboriginal and Torres Strait Islander LGBTQ+ young people, led by and advocated for by Aboriginal and Torres Strait Islander LGBTQ+ community members and researchers, is a welcome step towards ensuring safe and effective health care for all Australians. However, there has been little guidance for practitioners on how best to work with this patient group. Health services wanting to support Aboriginal and Torres Strait Islander LGBTQ+ young people can: include an LGBTQ+ status question on intake forms; services can also use an open‐ended question format for young people to describe their gender, rather than tick‐boxes of “male”, “female” or “other”; provide visual displays of support in waiting rooms, such as displaying a rainbow pride flag and other pride flags alongside Aboriginal and Torres Strait Islander flags; and establish mechanisms for Aboriginal and Torres Strait Islander LGBTQ+ young people to provide service feedback (eg, asking patients from this group how the service can best meet their needs). Further, although there are increasing calls to apply an intersectional approach in health care — none more powerful than those of Aboriginal and Torres Strait Islander LGBTQ+ young people themselves — research has yet to systematically evaluate treatment outcomes for patients when such an approach is applied. Future research should measure treatment outcomes in services where staff apply an intersectional lens. The omission of young people from previous research into the health and wellbeing of Aboriginal Torres Strait Islander and LGBTIQ+ people also remains a pressing concern. Further research with young people is needed if practitioners and services working with young people are to effectively and appropriately work within an intersectional framework. Box 1 – Current services available for Aboriginal and Torres Strait Islander LGBTQ+ people* Organisation name Description Website Black Rainbow Advocacy for Aboriginal and Torres Strait Islander LGBTQ+ suicide prevention Support for homelessness, domestic violence, and people involved in the justice system http://www.blackrainbow.org.au/ Tekwabi Giz Provides support to the National LGBTI Health Alliance for Aboriginal and Torres Strait Islander LGBTQ+ people, specialised knowledge, advocacy https://lgbtihealth.org.au/tekwabigiz/ IndigiLez Women's Leadership and Support Group Special focus on Indigenous lesbians and same sex‐attracted women Advocacy for Aboriginal and Torres Strait Islander LGBTQ+ people, cultural retreats, safe sex workshops, family days, workshops, social activities, self‐defence workshops https://www.facebook.com/IndigiLez/ Sisters and Brothers NT Social change, advocacy, support, consultation, resource creation, and research, and awareness for sistergirls, brotherboys, and Aboriginal and Torres Strait Islander LGBTQ+ people https://www.facebook.com/SistersBrothersNTCelebratingDiversity/ First Nations Rainbow Acceptance, celebration, raising community awareness, improving wellbeing, and reducing stigma and discrimination https://www.firstnationsrainbow.org.au/ Yarns Heal Suicide prevention among Indigenous peoples, including sistergirls, brotherboys and LGBTQ+ individuals https://www.yarnsheal.com.au/ Gar'ban'djee'lum Network Support, advocacy, information on healthy lifestyles, social events, fundraising, and celebration of sexual and cultural identity https://www.afao.org.au/article/us-mob-garbandjeelum-network/ Blaq Aboriginal Corporation Celebration, representation and increased visibility of Aboriginal and Torres Strait Islander LGBTQ+ community members https://www.blaq.org.au/about-about * This list of organisations in not exhaustive but provides a starting point for practitioners wanting to learn more about Aboriginal and Torres Strait Islander LGBTQ+ health. Information in the table is taken from the organisations’ websites. None of the organisations listed are young people‐specific, although some make note of the importance of young people. Box 2 – Next steps in health care provision for Aboriginal and Torres Strait Islander LGBTQ+ young people Domain8 Next steps for research and practice Intersecting categories: health professionals should consider that patients likely occupy multiple social positions, not just the identity which appears most dominant Develop LGBTQ+ health information guides that are culturally sensitive to Aboriginal and Torres Strait Islander patients and easily accessible to young people Display the Aboriginal and Torres Strait Islander flags alongside the pride flags at health services Including LGBTQ+ status options on patient intake forms Because experiences of discrimination based on sexual and gender diversity among Aboriginal and Torres Strait Islander people can occur within the context of pre‐existing trauma,12 consider applying trauma‐informed care models when working with this patient group Specific health promotion efforts and programs targeted at Aboriginal and Torres Strait Islander LGBTQ+ young people Primary research into the social emotional wellbeing of Aboriginal and Torres Strait Islander LGBTQ+ young people Primary research into experiences and preferences of Aboriginal and Torres Strait Islander LGBTQ+ young people in the health system Diversity of knowledges: consider Indigenous and queer ways of knowing and being Seek Aboriginal and Torres Strait Islander LGBTQ+ young peoples’ perspectives on their health issues Assess whether Aboriginal and Torres Strait Islander LGBTQ+ young people have a culturally specific understanding of their health and wellbeing, which may differ from dominant, medicalised explanations Primary research into how Aboriginal and Torres Strait Islander LGBTQ+ young people conceptualise health and wellbeing Power and multilevel analysis: health professionals hold greater power than Aboriginal and Torres Strait Islander LGBTQ+ young people due to their positions in society; health issues for this patient group occur across multiple levels of society Reducing power differentials in the healing relationship by using less medicalised language with patients and asking them how to best cater to their specific needs Ensuring young people understand limits of confidentiality so that they can trust practitioners with disclosing their LGBTQ+ status Practitioners attend professional development opportunities that promote appropriate ways of working with Aboriginal and Torres Strait Islander LGBTQ+ young people (such training is currently provided by some organisations listed in Box 1). Primary research into the impact of various societal oppressions on Aboriginal and Torres Strait Islander LGBTQ+ young peoples’ wellbeing Primary research into enablers of effective service delivery in this patient group Reflexivity: consistent reflection on practice decisions and how they relate to patients’ social positioning Practitioners regularly reflect on assumptions they may hold about Aboriginal and Torres Strait Islander LGBTQ+ young people and the root cause of their health problems Discussions with LGBTQ+, Indigenous and mainstream health care providers around attitudes toward Aboriginal and Torres Strait Islander LGBTQ+ young people Time and space: patient needs and preferences are not static, and vary with social positioning Practitioners remain up to date on social trends which may affect this patient group (eg, recent legalisation of same sex marriage, release of the Uluru Statement from the Heart) Practitioners ask individual patients about their experience of living at this intersection, and not assume a universal experience Primary research into health care needs and preferences across the life course in this patient group Equity and social justice: advocating for increased inclusion of Aboriginal and Torres Strait Islander LGBTQ+ young people Health professionals can use their positions of social power to advocate for the needs of Aboriginal and Torres Strait Islander LGBTQ+ young people within their collegiate relations, workplaces and the broader health sector

Bep Uink · Shakara Liddelow‐Hunt · Kate Daglas · Dharma Ducasse

“Now we say Black Lives Matter but … the fact of the matter is, we just Black matter to them”1

If Black lives matter we need to be prepared to examine and address racial violence within the Australian health system My name is Kevin Yow Yeh and today I march for every Black death in custody but I especially march for my grandfather Kevin Yow Yeh Sr. At the age of 34 this man apparently had a heart attack at a Mackay watch house … This last month we've seen plenty of stats, 430 plus Black deaths in custody … and that's only since the Royal Commission, but what about all those deaths that led to that. My grandfather was one of them. Let's humanise these stories. When this man had a heart attack, he left his wife and he left five young children. My grandmother was still having his children when she had to put this man in the ground. That's why we march! Of course we stand in solidarity with our brothers in America. And, of course we stand in solidarity with our sisters in West Papua … but today we stand for our lives here, on stolen land.2 The statistical story of Indigenous health and death, despite how stark, fails to do justice to the violence of racialised health inequities that Aboriginal and Torres Strait Islander peoples continue to experience. This story has been reported on unremarkably in federal parliament for over a decade, as an annual account‐keeping exercise of policy failure and statistical targets not met.3 This story of failure and failing health has been told countless times in health and medical journal publications, and despite growing more frequent in number, these contributions to new knowledge never seem to translate to improved health outcomes. This story of failure does not do justice to the trauma and loss that Aboriginal and Torres Strait Islander communities experience. This story of failure does not do justice to the pain of never meeting the grandfather that you are named after. Tragically, despite the parlous state of Indigenous health, we have not been met here with the kind of urgency that the global Black Lives Matter movement has spurred elsewhere. What we have been presented with, aside from the Health Minister admonishing Black Lives Matter protestors for putting the health of the public at risk,4 has been the triumphal announcement of “research projects”,5 the release of a “landmark report”,6 and a drafting of “refreshed” and “historic targets”.7 All of these supposedly fresh responses were on track before the Black Lives Matter movement hit our shore. Rather than the “new normal” which the threat of coronavirus disease 2019 (COVID‐19) inspired, the Australian health system's Black Lives Matter moment is best characterised as indifferent; a “business as usual” approach that we know from experience betokens failure. When the threat of COVID‐19 loomed, action was swift and the Aboriginal and Torres Strait Islander leadership within and outside of the health system was even swifter in establishing taskforces, lobbying for additional resources for the community controlled sector, instituting special border control measures for remote Indigenous communities, and the development of emergency response plans to protect their communities.8,9 The effective response to the COVID‐19 pandemic sits in sharp contrast to the ongoing pandemic of racism that Indigenous peoples have been fighting since 1788 and which has taken far more Black lives in Australia. Sweet points out: “To date, there is very little sign that senior health policy makers, from the Chief Medical Officer to Health Minister Greg Hunt, will use their authority to name and address the system racism that contributes to poorer healthcare, as it does to overincarceration”.10 While broad attention is often focused on Black deaths in custody, the premature deaths of Indigenous peoples from supposed natural causes inside and outside of custody tell a consistent story of failure and violence that marks the Australian health system and society more broadly. Against the quietude of the Australian health system on racism are the powerful voices of Aboriginal and Torres Strait Islander peoples, on television screens, on public streets and in our spreadsheets, speaking the truth about how little Black lives seem to matter. Both Indigenous clients and clinicians have stories to tell of the violence of racism in the health system, of being cast in the category of less capable, less compliant, less deserving of care and less worthy of the category of human. This then brings us to the coronial inquiry, the endgame of not caring; of neglect. Here, never let us forget the mothers, the children, the cousins and the spouses weeping outside coroner's courts, bearing photos of their loved ones in their hands and on their clothing, simultaneously appealing for care and for justice.11 Moreover, let us not for a second dismiss the anguish of having to fight for the release of recorded footage of your loved one's final moments, to be replayed over and over, in which they too plead vainly, “I can't breathe”.12 So many grieving Indigenous families continue to appeal to the state for care and for justice via coronial inquiries in the hope that their tragedy will not befall another. But the awful truth is that the recommendations of coronial inquiries are not enforceable because the inquest is meant to discover what happened rather than determine responsibility. So again, regardless of the findings, the resulting outcome is business as usual. The coronial inquiry represents a theatre of power where, in the presence of an avoidable Indigenous death, the state declares its benevolence; duly recording the steps taken and policies and procedures adhered to or those requiring review, and the best efforts of police, medical officers or first responders, to deem the death another “unavoidable” tragedy. Gomeroi scholar Whittaker11 notes how the discourse of “natural causes” in coronial inquiries works to render Indigenous peoples as “fated to die” and beyond care because they were “already dead”. The coronial inquiry represents a moment of confluence of the health and legal systems and the state that seek to erase Indigenous existence and affirm the settler trope of a dying race. It represents the theatre of Indigenous health policy writ large. The story of Indigenous health failure, of persisting and alarming health statistics that are routinely attributed to a complex web of social, cultural and economic factors, sustains the notion of the inevitability of Indigenous ill health, of a race destined to die out, despite the best of efforts and intentions. How do we explain an unwavering commitment to a failed Indigenous health policy framework amid a global movement centred around the importance of Black lives, and a National Aboriginal and Torres Strait Islander Health Plan vision of a health system “free of racism” with no strategy for addressing systemic racism?13 How do we further explain the focus on the individual health behaviours or “choices” of Aboriginal and Torres Strait Islander peoples when we know “incessant racial health inequities across nearly every major health index reveal less about what patients have failed to feel and more about what systems have failed to do”.14 As Boyd and colleagues point out, “The solution to racial health inequities is to address racism and its attendant harms and erect a new health care infrastructure that no longer profits from the persistence of inequitable disease”.14 Earlier this year, the National Registration and Accreditation Scheme demonstrated the type of Black Lives Matter moment that the Closing the Gap refresh missed, by launching the Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020‐2025.15 The strategy sets clear directions for the Australian Health Practitioner Regulation Agency, the national boards and accreditation authorities, which regulate Australia's 740 000 registered health practitioners to ensure that patient safety for Aboriginal and Torres Strait Islander peoples is the norm. The landmark strategy embodies ambition and partnership to address racism and culturally safe care; shifting the blame of failure for good health from Black bodies and instead demanding structural and individual health reform of health practitioners and the systems that regulate them. It is this shift of focus that has been central to the calls from Aboriginal and Torres Strait Islander peoples. Black wounds have been laid bare, to reveal the violence of health and legal systems upon Aboriginal and Torres Strait Islander peoples in a desperate appeal for those same systems to care. At 34 years of age my grandfather died, where's his justice? … what about all the other families, what about all the other fathers, brothers, sisters, nephews and nieces …? What about all the other mob? Where's their justice? My name's Kevin Yow Yeh, f*** the system, if you're not with us you're against us! What is needed is an Australian health system that has a steadfast commitment to Black lives: not as in need of saving, but as deserving of care; one that matches the staunchness of grieving Black families marching the streets of our capital cities in the midst of a pandemic. Such a commitment demands that we abandon the failed Indigenous health policy of Closing the Gap16 in favour of a health justice framework,17 which would include, but not be limited to: A foregrounding of Indigenous sovereignty rendering visible the strength, capability and humanity of Aboriginal and Torres Strait Islander peoples, services and communities in all processes of health policy formation and implementation, not as partners but as architects. State and federal government commitment to the recommendations of the coronial inquiries into the deaths of Aboriginal and Torres Strait Islander peoples who have died of preventable or avoidable conditions in the health system, and the establishment of an Indigenous taskforce to oversee implementation. An explicit financial commitment from the National Health and Medical Research Council and the South Australian Health and Medical Research Institute (via the Indigenous Medical Research Future Fund) and the Australian Research Council for research that attends to the nature and function of race in producing the conditions that allow racialised health inequalities to persist, from birth to death, including the embodied consequences of racism. The establishment of awareness‐raising campaigns that make clear the various ways in which Aboriginal and Torres Strait Islander peoples may seek justice when experiencing discrimination within the health system, and commeasurable resourcing of legal services to support Indigenous peoples to take action. Introduction of publication guidelines for health and medical journals requiring research relating to racialised health disparities to foreground institutional racism in its analysis, rather than socio‐economic disadvantage and other social and cultural factors. Development of an interdisciplinary Indigenous health workforce agenda that centres the care of Indigenous people beyond capacity building to include attending to racial violence within workplaces across the Australian health system. We offer these strategies not as a solution, but as some small steps towards a radical reimagining of the Black body within the Australian health system; one which demonstrates a more genuine commitment to the cries of “Black Lives Matter” from Blackfullas in this place right now.

Chelsea J Bond · Lisa J Whop · David Singh · Helena Kajlich

As 60% of Indigenous people in the Northern Territory primarily speak languages other than English,1,2 greater use of interpreters in health care could improve outcomes for patients.3,4 Barriers to using Aboriginal interpreters at Royal Darwin Hospital have been described.1 We undertook a quasi‐experimental pilot study to determine the effects of a package of measures on the use of interpreters and patient outcomes at Royal Darwin Hospital. The intervention comprised employment of an Aboriginal interpreter coordinator (to advocate the use of interpreters, coordinate their efficient use, and support interpreters in the hospital), training for health care providers in working with Aboriginal interpreters, and the promotion of interpreter use. The primary outcome was the number of interpreter bookings by clinicians; secondary outcomes were the number of completed bookings — 20–30% of bookings are not completed because no interpreter with the required language is available, or the patient declines an interpreter, is discharged, or dies1 — and self‐discharge rates by Aboriginal patients. Language documentation and interpreter booking processes at the hospital are described in the online Supporting Information. The Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research approved the study (references, 2017‐3007, 2018‐3245). Interpreter bookings data (provided by the Aboriginal Interpreter Service) and hospital separations data were obtained for all Aboriginal people admitted as public patients to Royal Darwin Hospital during 1 April 2016 – 31 March 2019. Torres Strait Islander patients, patients admitted for dialysis or same‐day procedures, and patients receiving care in psychiatry units (with an already high level of interpreter use) were excluded from our analysis. Outcomes were assessed by interrupted time series analysis:5 the baseline period was April 2016 – March 2018, and the intervention period was April 2018 – March 2019 (Supporting Information). The intervention was associated with an immediate increase in Aboriginal interpreter bookings and a decline in self‐discharge numbers. During the baseline period, 10 582 of 21 163 Aboriginal inpatients (50%) required an interpreter; interpreters were booked for 1333 (12.6% of those needing an interpreter; 755 completed bookings, 57%). During the intervention, 5460 of 10 919 Aboriginal inpatients (50%) required an interpreter; interpreters were booked for 958 (17.5%; 607 completed bookings, 63%). The difference in regression slopes for bookings before (–0.35) and during (+0.16) the intervention was 0.51 (95% confidence interval [CI], 0.13–0.90) (Box). The difference in regression slopes for completed bookings was 0.21 (–0.11 v +0.10; 95% CI, 0.03–0.39). Self‐discharge rates fell from 12.0% to 10.1% (slope difference, –0.19; 95% CI, –0.34 to –0.04) (Box). The Aboriginal Interpreter Coordinator role appeared to be the most important component of the intervention, based on the timing of its introduction and its scope (data not shown). Increased use of Aboriginal interpreters, critical for improving the quality of care and patient outcomes, can be achieved by targeted strategies. By the end of the study period, however, fewer than one in five Aboriginal patients needing interpreters had access to one. Considerable improvement is needed in the supply, demand and efficiency domains. Supply must be increased with recruitment and retention strategies, including interpreter mentoring. Drivers of demand include health care providers being equipped to deliver culturally safe care by knowing the names of Aboriginal languages, identifying which patients need interpreters, and knowing how to book and work effectively with interpreters. Efficiency requires new models for integrating interpreters in different contexts (ward rounds, outpatient care) and service coordination. These aspects are being examined in the further stages of this project. Box – Study outcomes during the baseline and intervention phases. A. Proportion of Aboriginal patients requiring interpreters for whom interpreters were booked. B. Proportion of hospital admissions of Aboriginal people ending in self‐discharge* * Data points: monthly mean values; solid line: line fitted by linear regression; shaded envelope: 95% confidence interval for fitted line; dotted line: commencement date of Aboriginal Interpreter Coordinator appointment.

The Communicate Study group*

The major impediments to control are lack of commitment, funding and coordination, not lack of knowledge It has been a long time coming, but Australia is starting to understand the tragedy and injustice of rheumatic heart disease (RHD) in Aboriginal and Torres Strait Islander people. No condition is more emblematic of “the gap”: in Australia, the burden of RHD is borne almost exclusively by Indigenous people, with rates among the highest in the world. It is a disease with social determinants, including poverty and overcrowded housing, it starts in childhood but stretches into adulthood, it kills people prematurely, and, most devastatingly, it is preventable. The major impediments to its being controlled or even eliminated are lack of commitment, funding and coordination, not lack of knowledge. Over the past five years, a network of researchers and service providers has come together in the National Health and Medical Research Council‐funded End Rheumatic Heart Disease Centre of Research Excellence. The Centre is about to publish The RHD Endgame Strategy: The blueprint to eliminate rheumatic heart disease in Australia by 2031. It has already modelled what will happen if we fail to alter course in RHD control: more than 10 000 Indigenous Australians will develop RHD over the next 11 years, of whom 563 will die and 1370 will require heart surgery as a direct consequence of RHD. More than $317 million would be needed for their medical care alone.1 Hearteningly, END RHD, a coalition of organisations led by the Aboriginal Community Controlled Health Organisation (ACCHO) sector, has formed to support communities at greatest risk of RHD, to advocate implementation of the Endgame Strategy, and to educate Australians about the role they can play in ending RHD. END RHD is co‐chaired by the chief executive officer of the National Aboriginal Community Controlled Health Organisation, Ms Pat Turner AM, and includes representatives from ACCHO peak bodies in each of the jurisdictions in which RHD is a major problem. END RHD embodies the essential elements of what is needed to rid Australia of this devastating disease: Indigenous leadership, community empowerment, and a primary focus on the social determinants of disease, in addition to strategies targeting streptococcal A skin and throat infections and care for people with established RHD. A study in this issue of the MJA2 highlights RHD care, other elements needed to implement the Endgame Strategy, and some of the challenges in doing so. Francis and colleagues report a cross‐sectional echocardiographic screening survey of children and young people in the remote Northern Territory community of Maningrida. They found an extraordinarily high prevalence of definite RHD (5.2% of screened people aged 5–20 years), of whom 62% had previously been undiagnosed and 25% had severe disease. This project had many admirable elements that could inform activities in other communities. The focus on education and health promotion in local languages, intense community engagement, and local leadership were exemplary, to which the very high participation rate is testament. However, a range of questions remain unanswered. Why, for instance, are the reported results so different from the findings of the gECHO study,3 conducted a decade earlier? In this study, in which almost 4000 Indigenous children aged 5–15 years in remote communities across northern and central Australia were screened, the prevalence of definite RHD was 0.86%; 53% of cases were previously undiagnosed, and only one in 18 new cases was severe. While the prevalence of definite RHD was highest in the Top End of the NT (1.5%), where Maningrida is located, the threefold difference in prevalence between the two studies is remarkable. A single community may not be representative of an entire region, but if the Maningrida findings are to stimulate consideration of more widespread screening, how one identifies communities in which it is warranted is critical. The difference in prevalence found by the two studies is difficult to explain. There is no evidence that socio‐economic determinants of group A streptococcal infections and RHD had dramatically worsened in this region over the past 10 years to a degree that would explain such discordance. However, four years prior to the study by Francis and colleagues, a large cluster of acute rheumatic fever (ARF) cases was identified in Maningrida: more than 1.5% of 5–14‐year‐old children developed ARF over a 6‐month period.4 As most people with RHD in the NT do not have known histories of ARF, and ARF can be very mild or even asymptomatic, it is likely that a substantially greater proportion of Maningrida residents had ARF at this time.5 Such a significant outbreak has rarely, if ever, been reported for an Indigenous community, and the study of Francis and colleagues may have included a number of RHD cases related the ARF outbreak four years earlier. Francis and his co‐authors also point out that auscultation is still used in child health checks in NT Indigenous communities. This approach, however, is less accurate than flipping a coin for diagnosing RHD, and should therefore be abandoned for this purpose.6 We commend the authors for the careful wording of their recommendations. They recognise that echocardiographic screening may have obvious benefits; besides detecting new cases of RHD and facilitating life‐saving treatment and secondary prevention, it is an excellent tool for motivating a community to focus on RHD, which, together with education about prevention and related activities, can enhance engagement. But it is also intensive and costly: hence the need to focus on more practical methods for implementation, as the authors point out, but also to ensure that communities are advised about a threshold for screening in accordance with established criteria. They must also be provided with adequate technical support and advice before embarking on such screening programs. Australia has a rare opportunity to eliminate RHD by implementing the Endgame Strategy. In so doing, we will make an important step towards closing the health gap between Indigenous and non‐Indigenous Australians, not only by reducing the burden of RHD but also the burdens of other diseases that share similar social determinants. But success depends on communities being supported to direct local strategies that comprehensively address streptococcal A infections, ARF and RHD at many levels. Maningrida is a perfect example.

Jonathan R Carapetis · Alex Brown

Objectives: Using echocardiographic screening, to estimate the prevalence of rheumatic heart disease (RHD) in a remote Northern Territory town. Design: Prospective, cross‐sectional echocardiographic screening study; results compared with data from the NT rheumatic heart disease register. Setting, participants: People aged 5–20 years living in Maningrida, West Arnhem Land (population, 2610, including 2366 Indigenous Australians), March 2018 and November 2018. Intervention: Echocardiographic screening for RHD by an expert cardiologist or cardiac sonographer. Main outcome measures: Definite or borderline RHD, based on World Heart Federation criteria; history of acute rheumatic fever (ARF), based on Australian guidelines for diagnosing ARF. Results: The screening participation rate was 72%. The median age of the 613 participants was 11 years (interquartile range, 8–14 years); 298 (49%) were girls or women, and 592 (97%) were Aboriginal Australians. Definite RHD was detected in 32 screened participants (5.2%), including 20 not previously diagnosed with RHD; in five new cases, RHD was classified as severe, and three of the participants involved required cardiac surgery. Borderline RHD was diagnosed in 17 participants (2.8%). According to NT RHD register data at the end of the study period, 88 of 849 people in Maningrida and the surrounding homelands aged 5–20 years (10%) were receiving secondary prophylaxis following diagnoses of definite RHD or definite or probable ARF. Conclusion: Passive case finding for ARF and RHD is inadequate in some remote Australian communities with a very high burden of RHD, placing children and young people with undetected RHD at great risk of poor health outcomes. Active case finding by regular echocardiographic screening is required in such areas.

Joshua R Francis · Helen Fairhurst · Hilary Hardefeldt · Shannon Brown · Chelsea Ryan · Kurt Brown · Greg Smith · Roz Baartz · Ari Horton · Gillian Whalley · James Marangou · Alex Kaethner · Anthony DK Draper · Christian L James · Alice G Mitchell · Jennifer Yan · Anna Ralph · Bo Remenyi

For most patients, life continues beyond the intensive care unit, and this is where action is needed

Paul J Secombe · Alex Brown · Michael J Bailey · David Pilcher

The incidence of paediatric type 2 diabetes has increased in Australasia parallel to paediatric obesity and international guidelines available do not address the specifics for high risk ethnic groups

Alexia S Peña · Jacqueline A Curran · Michelle Fuery · Catherine George · Craig A Jefferies · Kristine Lobley · Karissa Ludwig · Ann M Maguire · Emily Papadimos · Aimee Peters · Fiona Sellars · Jane Speight · Angela Titmuss · Dyanne Wilson · Jencia Wong · Caroline Worth · Rachana Dahiya

Objectives: To assess long term outcomes for Aboriginal and Torres Strait Islander (Indigenous) Australians admitted non‐electively to intensive care units (ICUs). Design: Data linkage cohort study; analysis of ICU patient data (Australian and New Zealand Intensive Care Society Adult Patient Database), prospectively collected during 2007–2016. Setting: All four university‐affiliated level 3 ICUs in South Australia. Main outcomes: Mortality (in‐hospital, and 12 months and 8 years after admission to ICU), by Indigenous status. Results: 2035 of 39 784 non‐elective index ICU admissions (5.1%) were of Indigenous Australians, including 1461 of 37 661 patients with South Australian residential postcodes. The median age of Indigenous patients (45 years; IQR, 34–57 years) was lower than for non‐Indigenous ICU patients (64 years; IQR, 47–76 years). For patients with South Australian postcodes, unadjusted mortality at discharge and 12 months and 8 years after admission was lower for Indigenous patients; after adjusting for age, sex, diabetes, severity of illness, and diagnostic group, mortality was similar for both groups at discharge (adjusted odds ratio [aOR], 0.95; 95% CI, 0.81–1.10), but greater for Indigenous patients at 12 months (aOR, 1.14; 95% CI, 1.03–1.26) and 8 years (adjusted hazard ratio, 1.23; 95% CI, 1.13–1.35). The number of potential years of life lost was greater for Indigenous patients (median, 24.0; IQR, 15.8–31.8 v 12.5; IQR, 0–22.3), but, referenced to respective population life expectancies, relative survival at 8 years was similar (proportions: Indigenous, 0.78; 95% CI, 0.75–0.80; non‐Indigenous, 0.77; 95% CI, 0.76–0.78). Conclusions: Adjusted long term mortality and median number of potential life years lost are higher for Indigenous than non‐Indigenous patients after intensive care in hospital. These differences reflect underlying population survival patterns rather than the effects of ICU admission.

William G Mitchell · Adam Deane · Alex Brown · Shailesh Bihari · Hao Wong · Rajaram Ramadoss · Mark Finnis

Reducing smoking during pregnancy among Aboriginal and Torres Strait Islander women is a national priority, but there has been little exploration of their experiences and desired support

Michelle Bovill

Inclusion of the right to health in Queensland's Human Rights Act is historic but not without challenge In February 2019, the Queensland Parliament passed the Human Rights Act 2019, which took effect on 1 January 2020. Its introduction makes Queensland the third Australian jurisdiction to implement human rights legislation, after the Australian Capital Territory and Victoria in 2004 and 2006, respectively. While the Queensland Act is based on a model of rights legislation broadly consistent with the Victorian and ACT models, it differs in its inclusion of the right to health services (section 37): Every person has the right to access health services without discrimination. A person must not be refused emergency medical treatment that is immediately necessary to save the person's life or to prevent serious impairment to the person.1 The inclusion of section 37 is historic. The right to health is made subject to law on Australian shores and a state/territory government is finally accountable, by law, to protect and promote the enjoyment of the highest attainable standard of physical and mental health. Rights language is part of Australia's public health vernacular, evidenced by the Australian Charter of Healthcare Rights.2 However, unless such rights are expressed in domestic law, then right to health principles and policies are important words on paper without overt legal consequence for effective monitoring and accountability.3,4 As Australia lacks a legal tradition regarding the right to health, the introduction of section 37 creates interpretive challenges for the new Queensland Human Rights Commission (QHRC). The right to health has received limited robust attention in both Australian schools of public health and law, as well as in Australian public health‐related literature.5 The QHRC, and Queensland's courts and tribunals, will likely look to United Nations (UN) commentary on the right to health, and to overseas jurisprudence and scholarship for guidance on section 37's emergent framing.3,6 With the right to health found in over 100 national constitutions and the UN Special Rapporteur on the right to health issuing annual reports, guidance is available.7,8 Health service obligations and remedies under the new Act Queensland government departments and public employees will have a responsibility to protect and promote the human rights of Queensland individuals, and in their health service delivery and decision making, act in a way consistent with their obligations under the Act.1 Health agencies that fit the Act's “public entity” criteria are also bound to comply with the Act. If an individual alleges a section 37 violation, they should make a complaint to the government agency or public entity, which must respond within 45 business days.1,6 If an inadequate or no response is received, the individual — or two or more people jointly — can lodge a complaint with the QHRC.1 Given that the Act's regulatory model favours discussion, rights awareness raising and education, the QHRC will aim to pragmatically resolve section 37 disputes. Monetary damages will not be available.6 In the case of judicial review, a person might have the original decision quashed or referred back to the original decision maker for redetermination.6 In certain circumstances, pending legal advice, a section 37 complainant might have grounds to pursue a distinctly separate medical negligence cause of action if a health professional or service provider breaches their common law duty of care and the complainant has sustained pain and suffering, loss or injury.9 Some grievances against health service providers (notably private providers) can continue to be dealt with by the Health Ombudsman under Queensland's Health Ombudsman Act 2013, and the QHRC may indeed refer complaints to the Health Ombudsman (with the complainant's consent).1,10 However, potential complainants under either Act should be aware the objectives of both Acts markedly differ. The Health Ombudsman Act emphasises that the health and safety of the public are paramount, thereby framing health through a health security lens at the population level, whereas the Human Rights Act takes an individual level approach: the enjoyment of the highest attainable standard of physical and mental health of each and every person in Queensland is paramount (Box 1). Additionally, the Health Ombudsman Act does not recognise the special importance that human rights — and by extension, health and human rights and accessible, non‐discriminatory health service provision — has for Queensland's Aboriginal peoples and Torres Strait Islander peoples.1 On this point, there is no reason why the definition of health services in section 37(1) could not be interpreted to integrate a culturally responsive meaning for Queensland's Indigenous peoples, consistent with the UN Declaration on the Rights of Indigenous Peoples (Box 2).11 Interpreting section 37 and health rights protections found elsewhere in the Act The Act takes a narrow approach to interpreting the right to health Section 37 is modelled on the right to health in article 12 of the International Covenant on Economic, Social and Cultural Rights.12 The UN Committee responsible for the Covenant stated in General Comment No. 14 that article 12 contains two elements: the right to access health services; and the right to access the underlying determinants of health, or the underlying factors that promote conditions in which people can lead a healthy life.3 Regarding the first element of what accessible, non‐discriminatory health services might look like for section 37 achievement, General Comment No. 14 provides the QHRC with instruction (Supporting Information).3 The Queensland Parliament has clarified it will only adopt the first element of article 12 of the International Covenant, which protects right to health service access; section 37 will not extend to include Queenslanders’ right to the broader health determinants. By limiting section 37 to questions of access to emergency medical treatment and non‐discriminatory health service provision, Parliament cautiously chose not to conflate the parameters of section 37. For some right to health academic specialists, this measured approach is prudent.13 Although section 37 claims are not to incorporate the determinants of health, complainants may nevertheless lodge separate or concurrent claims that capture certain health determinants, such as the right to culture (sections 27 and 28). Public health practitioners are well aware that culture is a significant health determinant.14 Housing is also a major determinant of health, and a housing rights claim (that causally impacts a claimant's health and wellbeing) might be realised under section 24 (property rights). Claims that seek to protect and promote the rights of individuals and communities to access the determinants of health relating to food and water could be sought under the right to life (section 16). This is because, per the explanatory notes to the Human Rights Bill 2018 (Qld), this right reflects the positive obligation on states “to take positive steps to protect the lives of individuals through, for example … positive measures to address other threats to life such as malnutrition and infant mortality” (emphasis added).6 With this in mind, section 16 allegations that identify a compelling food or water security nexus that threatens the right to life could be made. However, the QHRC can refuse to deal with a complaint it considers “frivolous, trivial, vexatious, misconceived or lacking in substance”.1 The protection of other health rights elsewhere in the new Act As highlighted above, the content of section 37 claims will likely raise other rights contraventions. It is foreseeable, for example, that a section 25 right to privacy breach by a health service provider could directly or indirectly create a section 37 access to health service violation (and vice versa). Further, a section 37 contravention, or its ramifications, may be so egregious that the complainant could rationally argue that they have experienced a breach of their section 17(b) right not to be treated in a cruel, inhuman or degrading way by the health service. Section 17(c) also protects and promotes an individual's health and human right to “not be … subjected to medical or scientific experimentation or treatment without the person's full, free and informed consent”.1 Certainly, in some cases, a fine line will arise between informed consent to medical treatment and health service access under section 37. The Act also covers reproductive health and rights. Section 106 clarifies that the Act “does not affect laws about termination of pregnancy”, thereby referring to and upholding the Termination of Pregnancy Act 2018 (Qld). According to Queensland Health, that Act “ensures termination of pregnancy is treated as a health issue rather than a criminal issue” and “supports a woman's right to health, including reproductive health and autonomy”.15 Final comments Queensland Health already has antidiscrimination policies and protocols for its staff and for its patients and clients. Therefore, compliance with section 37 and the Act's wider provisions should not be onerous for government and many other public health service agencies bound by the new Act. However, if international right to health experience can teach Queensland anything, it is that government response to allegations of section 37 violations should not be reactive and visible at QHRC conciliation meetings alone.4 Advancing the right to health for all Queenslanders will not occur in legal silos but in complement with planned educational and promotional activities that help build a culture in the Queensland public sector and broader community that respects and promotes health and human rights, as well as promotes a dialogue about the nature, meaning and scope of health rights for Queensland's most important asset, its human capital.1,6 This will require the engagement of both government and non‐government stakeholders, as well as community members, beyond the health sector. Box 1 – Objectives and principles of the Human Rights Act 2019 (Qld) and Health Ombudsman Act 2013 (Qld) Human Rights Act 2019 Health Ombudsman Act 2013 Main objects: section 3* Main objects: section 3 † to protect and promote human rights; and to help build a culture in the Queensland public sector that respects and promotes human rights; and to help promote a dialogue about the nature, meaning and scope of human rights. to protect the health and safety of the public; and to promote— professional, safe and competent practice by health practitioners; and high standards of service delivery by health service organisations; and to maintain public confidence in the management of complaints and other matters relating to the provision of health services. Preamble* Paramount guiding principle: section 4 † In enacting this Act, the Parliament of Queensland recognises— The inherent dignity and worth of all human beings. The equal and inalienable human rights of all human beings. Human rights are essential in a democratic and inclusive society that respects the rule of law. Human rights must be exercised in a way that respects the human rights and dignity of others. Human rights should be limited only after careful consideration, and should only be limited in a way that can be justified in a free and democratic society based on human dignity, equality, freedom and the rule of law. Although human rights belong to all individuals, human rights have a special importance for the Aboriginal peoples and Torres Strait Islander peoples of Queensland, as Australia's first people, with their distinctive and diverse spiritual, material and economic relationship with the lands, territories, waters, coastal seas and other resources with which they have a connection under Aboriginal tradition and Ailan Kastom. Of particular significance to Aboriginal peoples and Torres Strait Islander peoples of Queensland is the right to self‐determination. The main principle for administering this Act is that the health and safety of the public are paramount. Without limiting subsection (1), the health and safety of the public is the main consideration for— the health ombudsman, when deciding what relevant action to take to deal with a complaint or other matter; and the director of proceedings, when deciding whether to refer a matter to QCAT; and QCAT, when deciding a matter referred to it under this Act. QCAT = Queensland Civil and Administrative Tribunal. * Reproduced from https://www.legislation.qld.gov.au/view/html/asmade/act-2019-005;8 † Reproduced from https://www.legislation.qld.gov.au/view/html/inforce/current/act-2013-036.10 Box 2 – The right to health: article 24 of the United Nations Declaration on the Rights of Indigenous Peoples* Indigenous peoples have the right to their traditional medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals and minerals. Indigenous individuals also have the right to access, without any discrimination, to all social and health services. Indigenous individuals have an equal right to the enjoyment of the highest attainable standard of physical and mental health. States shall take the necessary steps with a view to achieving progressively the full realization of this right. * Reproduced from https://www.un.org/development/desa/indigenouspeoples/wp-content/uploads/sites/19/2018/11/UNDRIP_E_web.pdf.11 Declarations are not ratified. Adopted by the UN General Assembly on 17 September 2007. Supported by the Australian Government on 3 April 2009.

Claire E Brolan

If we are committed to closing the gap, we should be committed to transforming relationships of power between Indigenous and non-Indigenous people

Chelsea J Bond · David Singh

Genetic research with Indigenous Australians is achievable with community engagement and appropriate governance mechanisms in place

Steven YC Tong · Heather D'Antoine · Melita McKinnon · Kyle Turner · Maui Hudson · Ngiare Brown · Jonathan R Carapetis · Dawn C Bessarab

Without specific investments in the health of adolescents, Australia will not redress health inequalities experienced by Aboriginal and Torres Strait Island peoples

Peter Azzopardi · Ngaree Blow · Tara Purcell · Ngiare Brown · Tirritpa Ritchie · Alex Brown

Screening guidelines specific to the needs of Australia’s Indigenous population are needed

Nicole Lowres · Ben Freedman

The evidence from real world implementation is compelling

Mike Daube · Julia Stafford

Cardiovascular disease (CVD) is a leading cause of preventable morbidity and mortality in Aboriginal and Torres Strait Islander peoples. This statement from the Australian Chronic Disease Prevention Alliance, the Royal Australian College of General Practitioners, the National Aboriginal Community Controlled Health Organisation and the Editorial Committee for Remote Primary Health Care Manuals communicates the latest consensus advice of guideline developers, aligning recommendations on the age to commence Aboriginal and Torres Strait Islander CVD risk assessment across three guidelines. Main recommendations: In Aboriginal and Torres Strait Islander peoples without existing CVD: CVD risk factor screening should commence from the age of 18 years at the latest, including for blood glucose level or glycated haemoglobin, estimated glomerular filtration rate, serum lipids, urine albumin to creatinine ratio, and other risk factors such as blood pressure, history of familial hypercholesterolaemia, and smoking status. Individuals aged 18–29 years with the following clinical conditions are automatically conferred high CVD risk: ▶type 2 diabetes and microalbuminuria; ▶moderate to severe chronic kidney disease; ▶systolic blood pressure ≥ 180 mmHg or diastolic blood pressure ≥ 110 mmHg; ▶familial hypercholesterolaemia; or ▶serum total cholesterol > 7.5 mmol/L. Assessment using the National Vascular Disease Prevention Alliance absolute CVD risk algorithm should commence from the age of 30 years at the latest — consider upward adjustment of calculated CVD risk score, accounting for local guideline use, risk factor and CVD epidemiology, and clinical discretion. Assessment should occur as part of an annual health check or opportunistically. Subsequent review should be conducted according to level of risk. Changes in management as a result of this statement: From age 18 years (at the latest), Aboriginal and Torres Strait Islander adults should undergo CVD risk factor screening, and from age 30 years (at the latest), they should undergo absolute CVD risk assessment using the NVDPA risk algorithm.

Jason W Agostino · Deborah Wong · Ellie Paige · Vicki Wade · Cia Connell · Maureen E Davey · David P Peiris · Dana Fitzsimmons · C Paul Burgess · Ray Mahoney · Emma Lonsdale · Peter Fernando · Leone Malamoo · Sandra Eades · Alex Brown · Garry Jennings · Raymond W Lovett · Emily Banks

Objectives: To assess the risks of stroke and cardiovascular mortality for Aboriginal and non‐Aboriginal Australians with atrial fibrillation. Design: Retrospective data linkage cohort study. Setting, participants: All people aged 20–84 years hospitalised with atrial fibrillation in Western Australia during 2000–2012. Main outcome measures: Stroke incidence rates and mortality after hospitalisation for atrial fibrillation, and 10‐year risks of stroke and of cardiovascular and all‐cause mortality. Results: Among 55 482 index admissions with atrial fibrillation, 7.7% of 20–59‐year‐old patients and 1.3% of 60–84‐year‐old patients were Aboriginal Australians. A larger proportion of Aboriginal patients aged 20–59 years had CHA2DS2‐VASc scores of 2 or more (59.8% v 21.8%). In 20–59‐year‐old Aboriginal patients, the incidence during follow‐up (maximum, 10 years; median, 7.1 years) of stroke (incidence rate ratio [IRR], 3.2; 95% CI, 2.5–4.1) and fatal stroke (IRR, 5.7; 95% CI, 3.9–8.9) were markedly higher than for non‐Aboriginal patients. Stroke incidence was higher for 60–84‐year‐old patients, but the difference between Aboriginal and non‐Aboriginal patients was smaller (IRR, 1.6; 95% CI, 1.3–2.0). Cardiovascular mortality during follow‐up was also higher for 20–59‐year‐old Aboriginal patients (IRR, 4.4; 95% CI, 4.3–5.9). The hazards of stroke (adjusted HR [aHR], 1.67; 95% CI, 1.22–2.28) and cardiovascular mortality (aHR, 1.47; 95% CI, 1.18–1.83) in younger Aboriginal patients remained significantly higher after multivariable adjustment; age/sex, principal diagnosis of atrial fibrillation, and CHA2DS2‐VASc score were the most influential factors. Conclusion: Stroke risk and cardiovascular mortality are markedly higher for Aboriginal than non‐Aboriginal patients with atrial fibrillation, particularly for patients under 60. Strategies for providing evidence‐based therapies and cardiovascular prevention to Aboriginal people with atrial fibrillation must be improved.

Lee Nedkoff · Erin A Kelty · Joseph Hung · Sandra C Thompson · Judith M Katzenellenbogen

The automatic assumption that sexually transmissible infections in young people means sexual abuse further stigmatises them and discourages them from presenting to health services

James S Ward · Belinda Hengel · Donna Ah Chee · Olga Havnen · John D Boffa

Inaccurate recording of Indigenous status in administrative datasets can influence health service decision making

Mary O'Loughlin · Linton Harriss · Jane Mills · Fintan Thompson · Robyn McDermott

Greater investment is needed to support eye health coordinators, community-based liaison officers, and family members and carers

Aryati Yashadhana · Ling Lee · Jessica Massie · Anthea Burnett

To the Editor: Over the past decades, the incidence of type 2 diabetes, rarely diagnosed in children and adolescents before the 1990s,1 has been increasing in young people in several populations, including Australia.2,3,4 Early onset type 2 diabetes appears to have a more severe phenotype compared with adult onset type 2 diabetes, and has a high prevalence of complications already present at the time of diagnosis despite the patients’ young age and short duration of the disease.5 We aimed to describe the characteristics of Western Australian children aged less than 10 years diagnosed with type 2 diabetes between June 2000 and June 2017. Demographic and clinical data for children diagnosed with type 2 diabetes during the study period were extracted from the population‐based WA Children's Diabetes Database and via manual review of hospital clinical files. Of the 193 children aged less than 16 years diagnosed with type 2 diabetes in WA during the study period, 12 children were diagnosed at less than 10 years of age, with the youngest aged 6 years and 11 months. These 12 patients had one or both parents diagnosed with type 2 diabetes, 11 children were Aboriginal Australians, one was Māori, 11 were obese (mean body mass index z‐score, 2.38; standard deviation [SD], 0.64); nine were female, and seven had one or more comorbidities. Of the 11 children examined, ten had acanthosis nigricans present on their skin. Three children presented with polyuria and polydipsia, six were unwell with other illnesses and three were asymptomatic. Type 1 diabetes antibodies were negative in seven of eight of the children tested, and the mean glycated haemoglobin level at diagnosis was 75 mmol/mol (mean, 9.0%; SD, 2.4%). Nine patients had one or more diabetes complications present at the time of diagnosis; seven had dyslipidaemia, two had an elevated albumin creatinine ratio, and three had hypertension. Our study describes the common clinical features of early onset type 2 diabetes in young children in WA, such as history of parental type 2 diabetes, Aboriginal heritage, obesity, and female sex, and provides strong evidence for the need to screen children with these risk factors for type 2 diabetes, irrespective of their age. Moreover, the high prevalence of diabetes complications present strongly supports the need for complications screening at the time of diagnosis.

Jacqueline A Curran · Aveni Haynes · Elizabeth A Davis

Introducing the floor price was followed by a significant reduction in ICU admissions associated with acute alcohol misuse

Paul J Secombe · Penny Stewart · Alex Brown · Michael J Bailey · David Pilcher

The similarity in mortality among Indigenous and non-Indigenous critically ill patients hides a complex story

Paul J Secombe · Alex Brown · Michael J Bailey · David Pilcher