Reform in Australian medical schools: a collaborative approach to realising Indigenous health potential

The Australian medical education system is at a critical juncture in relation to what and how it delivers for Aboriginal and Torres Strait Islander health. Since 2004, three key organisations concerned with medical education have worked to provide a toolkit for implementation of sustainable reform within medical schools. The aim is a medical workforce trained in Indigenous health, and more Aboriginal and Torres Strait Islander doctors, leading to better health for Australia's Indigenous peoples.     

Management of chronic hepatitis B virus infection in remote-dwelling Aboriginals and Torres Strait Islanders: an update for primary healthcare providers

Chronic HBV infection is common in remote Aboriginal and Torres Strait Islander communities, where resources are scarce and patients may have several concurrent illnesses. The management of chronic HBV infection has changed over recent years, with greater application of serological and radiological investigations and new, more acceptable treatments for chronic liver disease, cirrhosis and hepatocellular carcinoma. Optimal follow-up procedures for patients with chronic HBV infection are still being debated, but may not be applicable to Aboriginal and Torres Strait Islander communities where factors such as endemicity, remoteness, frequent comorbidities, shorter life expectancy and cultural differences in health priorities must be taken into consideration. We have defined an algorithm to assist primary care providers caring for patients with chronic HBV infection in Aboriginal and Torres Strait Islander communities. Patients are divided into one of three categories for follow-up and referral based on clinical features, and results of liver enzyme and serological tests.     

Overseas-trained doctors in Aboriginal and Torres Strait Islander health services: many unanswered questions

Aboriginal and Torres Strait Islander health services are heavily dependent on overseas-trained doctors (OTDs). These OTDs are increasingly from countries with variable English language and educational equivalency compared with locally trained doctors. Aboriginal and Torres Strait Islander health services create particular demands for all doctors, such as negotiating "cultural domains" and acknowledging the contribution of Aboriginal health workers. Little is known about the roles and experience of OTDs in health service provision in Indigenous communities. Barriers to effective research into the experience of OTDs include privacy legislation and a lack of standardised data. Researching the narratives of OTDs in Indigenous health services offers an opportunity to explore the diversity and complexity of the cultural interfaces in health service provision.     

The International Covenant on Economic, Social and Cultural Rights and the right to health: is Australia meeting its obligations to Aboriginal peoples?

There is evidence that Australia is not meeting its obligations to Aboriginal and Torres Strait Islander peoples for their right to the "highest attainable standard" of health, required under the International Covenant on Economic, Social and Cultural Rights (ICESCR). Poor access to primary health care for Aboriginal peoples and substantial shortfalls in government spending to address this are in violation of the ICESCR. Aboriginal and Torres Strait Islander peoples' share of the universal health coverage expenditure offered to all Australians is less per person than for other Australians. The failure to monitor the provision of mainstream health services to Aboriginal peoples and inequitable distribution of health facilities and services compound these violations. Equality in health between Indigenous and non-Indigenous Australians is achievable, but not until the shortfall in health services expenditure for Indigenous Australians is addressed.     

Health of Aboriginal and Torres Strait Islander children in remote Far North Queensland: findings of the Paediatric Outreach Service

AIM: To describe the pattern of disease and other health problems in children living in remote Far North Queensland (FNQ). DESIGN, SETTING AND PARTICIPANTS: Retrospective review of the FNQ Paediatric Outreach Service's Medical Director database for the period June 2001 to February 2006. Three subpopulations were compared: children from predominantly Aboriginal communities, predominantly Torres Strait Islander communities, and other communities. All children referred to the service during the study period were reviewed. MAIN OUTCOME MEASURES: Number of children seen and common diagnoses. RESULTS: 3562 children were referred during the study period, and a total of 3932 diagnoses were made; 56% of the paediatric population of the Aboriginal communities and 23% of the paediatric population of Torres Strait Islander communities were seen. Of 40 separate diseases/health problems reviewed, the three most common reasons for presentation were chronic suppurative otitis media, suspected child abuse and neglect, and failure to thrive. In the paediatric population of Aboriginal communities, the prevalence of fetal alcohol spectrum disorder was at least 15/1000 (1.5%), and in Torres Strait Islander children, rheumatic heart disease prevalence was at least 6/1000 (0.6%). Rheumatic fever rates were among the highest in Australia. CONCLUSION: Rates of preventable complex and chronic health problems in Aboriginal and Torres Strait Islander children in remote FNQ are alarmingly high. Areas requiring urgent public health intervention include alcohol-related conditions and rheumatic fever.     

How can Australia do better for Indigenous health?

Respect, tolerance and trust in Aboriginal and Torres Strait Islander people are needed from government to improve the health and wellbeing of Indigenous Australians.     

The National Health and Medical Research Council Road Map: a strategic framework for improving Aboriginal and Torres Strait Islander health through research

What impact has the NHMRC Road Map had on Aboriginal and Torres Strait Islander health? A review process now underway aims to find out.     

Remote Indigenous Australians with cataracts: they are blind and still can't see

Aboriginal and Torres Strait Islander people are three times more likely than non-Indigenous Australians to report vision loss due to cataracts, but are four times less likely to have cataract surgery. To increase access for Aboriginal and Torres Strait Islander people to cataract surgery, we need to identify the barriers to current services and trial strategies to overcome these barriers. Barriers to cataract surgery exist at the health service, community and individual level. Health service factors include infrastructure, cost, and provision of interpreters, escorts and transport. Community factors include social support, perceptions about the success of surgery, and beliefs about the causes of cataracts. Individual factors include ignorance that cataracts can be cured, fear of surgery or poor outcome, and comorbidity. Strategies proven to increase uptake of cataract surgery in other countries could be trialled in remote Australia.     

Indigenous participation in the Australian Health Survey: a response

The Australian Health Survey will deliver key health measures for all Australian children and adults, and collect information across Australia. The Australian Bureau of Statistics has consulted widely on the development of the Survey, and has shaped the survey according to strong and consistent advice in relation to Aboriginal and Torres Strait Islander peoples. It is hoped that this approach will maximise survey response rates and place us in good trust to embark on the next survey round.     

Our doctors making a difference

Aboriginal and Torres Strait Islander doctors walking in both worlds for the benefit of all Australians.     

Indigenous health: effective and sustainable health services through continuous quality improvement

The Australian government's Healthy for Life program is supporting capacity development in Indigenous primary care using continuous quality improvement (CQI) techniques. An important influence on the Healthy for Life program has been the ABCD research project. The key features contributing to the success of the project are described. The ABCD research project: uses a CQI approach, with an ongoing cycle of gathering data on how well organisational systems are functioning, and developing and then implementing improvements; is guided by widely accepted principles of community-based research, which emphasise participation; and adheres to the principles and values of Indigenous health research and service delivery. The potential for improving health outcomes in Aboriginal and Torres Strait Islander communities using a CQI approach should be strengthened by clear clinical and managerial leadership, supporting service organisations at the community level, and applying participatory-action principles.     

The upsurge of interest in Indigenous health in the 1950s and 1960s

During the 1950s and 1960s, there was a dramatic explosion in the number of letters to the editor about Indigenous health published in the MJA, reflecting increased reader interest. The letters from Barry Christophers were part of the Federal Council for Aboriginal Advancement's largely successful campaign for equal civil rights for Aboriginal and Torres Strait Islander people. His letters not only drew attention to discriminatory legislation and policies, but also emphasised the structural (especially economic) determinants of Indigenous ill-health, and the negative impact on Indigenous people of racist medical representations.     

Reducing the burden of cancer for Aboriginal and Torres Strait Islander Australians: time for a coordinated, collaborative, priority-driven, Indigenous-led research program

Australia's efforts to prevent, diagnose and treat cancer are not as successful for Aboriginal and Torres Strait Islander people as they are for other Australians. There is a need for a nationally coordinated, collaborative, priority-driven research effort to better understand what works, and we need to implement that knowledge. All aspects of the process must involve genuine Indigenous leadership and participation.     

Unidentified trematode eggs in faeces of Australian aboriginal children

In routine surveys for intestinal parasites among Aboriginal/Torres Strait Islander populations, eggs of unidentified trematode species have been found in the faeces of three children. In two of these, the eggs appeared to belong to a schistosome, or perhaps monogenean, species, and in the third, they were most likely from a monostome of dugongs. Although these probably represent cases of spurious parasitism, one or more may have been a true infection.     

Making a difference: the early impact of an Aboriginal health undergraduate medical curriculum

OBJECTIVE: To describe the implementation of an integrated Aboriginal health curriculum into the medical course at the University of Western Australia (UWA) and the early effect on students' perceptions of their knowledge and ability in the area of Aboriginal health. DESIGN, SETTING AND PARTICIPANTS: Final-year medical students at UWA in 2003 (first cohort) and 2004 (second cohort) were surveyed by questionnaire (with answers on a five-point Likert scale) to assess their attitudes to various aspects of Aboriginal health. A subset of students provided open-ended comments on key priorities in Aboriginal health, cultural security and suggestions for Aboriginal health policy. INTERVENTIONS: Integrated learning experiences were implemented within each year of the medical course, based on specific learning outcomes in Aboriginal health. MAIN OUTCOME MEASURES: Changes in students' self-perceptions of their preparedness for and future commitment to working for change in Aboriginal health. RESULTS: Response rates were 76% and 85% in the 2003 and 2004 cohorts, respectively. Compared with first-cohort students, second-cohort students were more likely to agree with items relating to their preparedness and ability to work with and care for Aboriginal and Torres Strait Islander people (P < 0.05); second-cohort students also reported greater preparedness to advocate and improve the health of Aboriginal people (P < 0.05); 65% of respondents in the second cohort (versus 34% in the first) agreed they had a social responsibility to work for change in Aboriginal health (P < 0.05). CONCLUSION: With a relatively small amount of targeted and structured teaching and learning in Aboriginal health, significant shifts in students' self-perceived levels of knowledge, skills and attitudes are possible.     

Indigenous health: chronically inadequate responses to damning statistics

In the 10 years 1990-2000, despite improvements in some conditions, there has been little or no overall progress in the health of the Aboriginal and Torres Strait Islander populations of Australia. This is in stark contrast to the gains made in Indigenous health in other countries. The issue is one of lack of commitment to and implementation of already existing policies. We need to (i) fully and adequately fund the Primary Health Care Access Program to provide the out-of-hospital services for prevention and early treatment required to break the cycle of ill-health; (ii) implement a National Training Plan to train the necessary health workforce; and (iii) introduce a National Infrastructure Plan to rectify the continuing deficiencies in water supply, sanitation, education and other basic services.     

Diabetes in Australian aboriginal and Torres Strait Islander peoples

Type 2 diabetes arises from a complex and multifactorial set of factors, including genetic susceptibility, behaviour (including diet and exercise), early nutrition, obesity and psychosocial stress, leading to insulin resistance and pancreatic failure. These factors in turn are influenced by social and physical environmental factors. Each of these may be important determinants of the high prevalence and incidence of type 2 diabetes in Australian Aboriginal and Torres Strait Islander people. Public health interventions for primary and secondary prevention need to recognize this complexity. Although a reduction in the prevalence of obesity or diabetes in the short-medium term is rarely if ever achieved, there are documented examples of community-based programs which have been effective in reducing the risk of developing type 2 diabetes and its cardiovascular complications. Such interventions need to be community-directed and appropriate to local circumstances in order to be effective.     

Diabetes care in remote northern Australian Indigenous communities

OBJECTIVE: To assess primary care processes and clinical characteristics of adults with diabetes in remote northern Australian Indigenous communities. DESIGN: Clinical audit from diabetes registers in 21 remote primary healthcare centres in the Torres Strait Health Service District (n = 921), three in Cape York, Queensland (n = 252), and three in the Northern Territory (n = 194), between September 2002 and February 2003. PARTICIPANTS AND SETTING: Aboriginal and Torres Strait Islander adults with diabetes who were receiving their routine diabetes care in these 27 centres. MAIN OUTCOME MEASURES: Provision of regular checks for weight, blood pressure, glycaemia (HbA(1c)), proteinuria, lipid levels, renal function, eyes and feet, influenza and pneumococcal vaccination. Weight, blood pressure and glycaemic control. RESULTS: Most routine diabetes checks were delivered according to recommended schedules, except for eye and foot checks in the NT. There were uniformly high rates of appropriate treatment for hypertension and albuminuria, but low rates of insulin treatment and self-monitoring despite a high mean HbA(1c) level (8.9%). Vaccination rates were low in the NT. Torres Strait Islanders with diabetes were significantly heavier than Aboriginals, but had lower mean diastolic blood pressure (77.3 mmHg compared with 79.5 mmHg) and lower prevalence of albuminuria and smoking. CONCLUSION: A high proportion of Aboriginals and Torres Strait Islanders requiring treatment for high blood pressure and proteinuria are receiving it. However, there is dissonance between the relatively high rates of routine checks and apparent lack of therapeutic action on glycaemia. More intensive management of glycaemia, including improved nutrition, exercise and (probably) insulin, is required to reduce microvascular complications.     

Beyond sorry--the first steps in laying claim to a future that embraces all Australians

The Prime Minister has issued a formal, unqualified apology to Australia's Indigenous peoples for past mistreatment, particularly for the sufferings of those who were affected by the forced removal of children from their families. The Apology needs to be seen as the first step in a reparations process that adheres to human rights principles, involves Australians at all levels, is sustainable and upholds self-determination. The Apology is the first of five steps recommended in Bringing them home: the report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from their Families. Further steps are: guarantees against repetition, measures of restitution, measures of rehabilitation, and monetary compensation, but the Prime Minister has steadfastly refused to discuss reparations or compensation. Monetary compensation has been recognised internationally as an essential component in the redress for similar experiences of the forced removal of children. As long as the final steps in reparation remain unresolved, they will obstruct our pathway to a future that embraces all Australians.