Indigenous health

TO THE EDITOR: Skin disease contributes to the health disadvantage of Indigenous Australians, and the recent publication of the healthy skin guidelines is welcome.1 Scabies is a significant health problem for some remote Indigenous communities, and the healthy skin guidelines describe a series of community‐based scabies control programs. These programs resulted in initial reductions in prevalence of scabies, but they were not sustained, as human scabies was eventually reintroduced.1 The guidelines used a systematic literature review to ensure that all relevant research was included. However, since the review of scabies was limited to studies of human scabies, implications of canine scabies may have been overlooked.2,3 Therefore, a statement such as “dog control programs are of no benefit to the community control of human scabies infestations” requires scrutiny. Canine scabies mites are distinguishable from human scabies mites by genotyping.4 Clinically, canine scabies can cause a transient human infestation, with no ongoing transmission cycle. The lesions of canine scabies occur primarily on body areas that have been in contact with dogs, and are intensely itchy after a shorter period compared with lesions of human scabies. The infestation is self‐limiting unless the person is reinfested.5 As with human scabies, the intense itch from infestation by canine scabies can lead to scratching and skin trauma, providing an entry point for bacterial infection. Complications such as post‐streptococcal glomerulonephritis and chronic renal disease can also arise from canine scabies. Moreover, outbreaks of scabies in humans can be caused by repeated transmission of canine scabies.5 Management of people affected by canine scabies includes treatment of affected dogs and their contacts.3 Comprehensive dog health programs provide broad‐based community benefits, including reduced injuries from dog attacks, improved community and workplace safety, reduced sleep disturbance from barking and fighting dogs, and enhanced dogs’ appearance, behaviour and wellbeing. Dogs are considered family members in some Aboriginal and Torres Strait Islander communities, sharing housing, bedding and food; hence, human and dog health and wellbeing are intimately linked. No trials have yet examined the impact of dog health programs on scabies transmission in humans or other health outcomes in the remote Indigenous communities where scabies is a public health problem.2 Without evidence from trials, the impact, or lack thereof, of dog health programs on human health is speculative.

Rosalie Schultz

To the Editor:Calabria and colleagues1 report that, overall, 9.8% of Aboriginal and Torres Strait Islander adults are at high absolute cardiovascular disease (CVD) risk, reflecting how poorly Australia supports the social and cultural determinants of health for the First Australians. However, this is a different nuance from their statement: “Absolute CVD risk is high among Aboriginal and Torres Strait Islander people”. Aboriginal and Torres Strait Islander people have median age of 23 years,2 and only 1.1% of those in the 18–24 age group are at high risk. The authors note undertreatment with lipid-lowering therapies of Aboriginal and Torres Strait Islander people at high CVD risk; many Aboriginal and Torres Strait Islander people who would benefit are not offered best practice care. However, 13% of people at low CVD risk are on lipid-lowering medication,1 which may be unnecessary treatment, with costs and side effects. As health professionals we need to beware of tendencies to emphasise pathology and risk among Aboriginal people.3 Many health professionals hold ideas of “the passivity, dependency, and non-compliant nature of [the Aboriginal] mob … The perception of Aboriginality as … a health risk, and predictor of unhealthy behaviours … reinforces stereotypical ideas of Aboriginality… and disconnects Aboriginal people from their own identities … [and] stories of strength and survival”.3 There is a tension between our desires to prescribe behaviour to reduce risk and enabling and empowering people to make decisions for themselves. Well intentioned efforts to manage Aboriginal and Torres Strait Islander people may have iatrogenic side effects. For example, health professionals may develop assumptions about people’s behaviour and worthiness to receive treatment,4 while Aboriginal and Torres Strait Islander people themselves may be disconnected from their sense of self-efficacy and community and cultural strengths and identity, contributing to disengagement from health care.3 Like other procedures in health care, absolute CVD risk assessment has costs as well as benefits. Educating community members about absolute CVD risk would promote health literacy and enable people to give informed consent to assessment of this statistic. Numbers hold both face and cultural values, so it is important that Aboriginal and Torres Strait Islander people have control of their statistics.5

Rosalie Schultz

In reply

Raymond W Lovett

To the Editor: The recent guideline review by Almeida and colleagues1 coincides with an international call for action to address the burden of low back pain.2 Low back pain is a major societal problem and the number one cause of disability internationally. Recent guidelines prioritise advice, reassurance and self-management as first line care. Implementing these simple, high value interventions is important in populations, such as Aboriginal Australians, where there has been limited previous recognition of low back pain as a problem. A recent systematic review of musculoskeletal pain among Aboriginal Australians3 summarised that the prevalence of low back pain is higher among Aboriginal Australians and has disproportional impacts. Qualitatively, low back pain has multidimensional effects, including functional, cultural and emotional. Access to both primary and specialist level care is lower for some musculoskeletal pain conditions such as osteoarthritis, and there may be parallels for low back pain. Worryingly, there is evidence that the health care that Aboriginal people receive for low back pain is worse than that received by non-Aboriginal Australians, including care with the potential to cause iatrogenic harm. These include higher rates of opioid prescribing and unhelpful low back pain information. Low back pain is associated with a higher number of comorbid health issues, psychological stress and income poverty, and may contribute to the complex milieu of health burden and disadvantage for some Aboriginal communities. The implementation of effective, high value, first line care described by Almeida and colleagues1 is critical for Aboriginal people with low back pain; however, it needs to be adapted so that it is acceptable, accessible and appropriate. For example, advice and education to reassure patients and encourage self-management may need to be supported by culturally appropriate low back pain information. This could include visual, story-based information that has been developed with input from Aboriginal people.4 Implementing successful self-management requires doctors to develop trusting relationships with patients in services that are culturally secure for Aboriginal people. Effective communication is critical.5 The provision of evidence-informed low back pain care to Aboriginal patients requires better recognition of low back pain as a health issue affecting Aboriginal Australians, and a greater understanding of how such care can be best implemented in Aboriginal communities.

Ivan Lin · Donna B Mak · Juli Coffin · Peter O'Sullivan

In reply

Matheus Almeida · Bruno Saragiotto · Chris G Maher

To the Editor:Your publication of a review on global approaches to antimicrobial resistance is timely.1 We especially note that antibiotic-resistant pathogens are not limited by borders, have greater impact on disadvantaged communities, and will require coordinated, high level government commitment to minimise their threat.1 In Australia, Indigenous communities bear a disproportionate burden of infectious diseases. This burden arises on a background of overcrowding, poorly built and maintained water and sanitation infrastructure, and colonisation of companion animals by human pathogens. The delivery of biomedically oriented health services leads to frequent use of broad spectrum antibiotics, promoting the development of multiresistant pathogens.2 The prominent multiresistant pathogen methicillin-resistant Staphylococcus aureus first emerged in hospitals, but, in Australia, it was soon identified in remote Indigenous communities.2 Health services have been unable to control its development and spread. As a consequence, community-acquired methicillin-resistant S. aureus is now the dominant strain of this bacterium in Central Australia, where Indigenous people are one-quarter of the population, but bear three-quarters of the S. aureus disease burden in Alice Springs Hospital.3 Primary health care is founded on full community participation and an intersectoral approach, incorporating education, housing and other sectors to complement health services.4 Housing for Indigenous communities remains inadequate, and government responses deficient, particularly in remote regions.5 As a result, even high quality health services have limited impact on Indigenous people’s health and wellbeing. Safe, secure, functioning housing that is appropriate for its occupants is a building block to manage other areas of Indigenous disadvantage.5 The deficit in appropriate housing contributes to bacterial colonisation, infection and development of antimicrobial resistance among Indigenous Australians.2 “Illness is a weapon” was intended as a metaphor for the resistance of Indigenous people to their ongoing colonisation.6 However, the threat of antibiotic resistance evolving through the neglected conditions in which some communities find themselves could make this metaphor more real than was likely intended. The spread of antibiotic-resistant pathogens in Indigenous communities and elsewhere is a global threat, which highlights the need to transform services for Indigenous people using approaches driven by communities and focused on their strengths.

Rosalie Schultz