” While Closing the Gap has become an iconic representation of Indigenous advocacy, it remains essential to maintain focus on the individual components of disease processes, epidemiology, intervention delivery, and cultural mechanisms that influence the achievement of significant change.
The MJA will ensure it strengthens its role in delivering the relevant data to clinicians, policy developers, and the Australian community.
Indigenous health: One gap is closed See Part 1 Below
“DESPITE a slight narrowing over the past decade, the life expectancy gap between Aboriginal and Torres Strait Islander Australians and the general population remains significant.
On average, the lives of Aboriginal and Torres Strait Islander people are around a decade shorter than those of non-Aboriginal Australians – a shocking statistic for a high income country.
This gap has been attributed to many factors, most of which relate to high levels of socio-economic disadvantage.
Now, new research points to multimorbidity as a significant driver of higher mortality rates in Aboriginal and Torres Strait Islander populations.”
See Part 2 Below Multimorbidity as a significant driver of higher mortality rates
” Aboriginal people are under stress and we need to take some of that away by recognising their existence and their self-determination. The Uluru Statement is a good place to start.”
He says that he’s no hand wringer and he’s optimistic that the cultural change can happen.
The government won’t take constitutional recognition to a referendum yet because it doesn’t think the public has come around to it. But I think the public is ahead of the government here, just as it was for same-sex marriage. There’s an enormous willingness in the public to embrace First Nations people. I think there’s a huge capacity for change.”
The Uluru Statement is a good place to start SEE Part 3 Below
Part 1 Indigenous health: one gap is closed
The 2017 MJA Indigenous health issue explored the social determinants of health that are essential to closing the gap between health outcomes for Indigenous and non-Indigenous Australians, specifically targeting cultural awareness and communication.1
The issue also placed recent gains in the life expectancy of Indigenous Australians in perspective,2 and recognised achievements by an often silent yet dedicated clinical community.
The Journal has continued to develop these themes. In this year’s Indigenous health issue, four research papers and the accompanying editorials underline the progress we are making as a journal and as a medical community in bringing about meaningful change.
In this respect, the report by Hendry and colleagues,3 documenting the effective closure of the gap in vaccination rates, is particularly heartening. Vaccination is recognised by the World Health Organization as one of the most cost-effective interventions in public health.4 Hendry and her co-authors describe a program in which Aboriginal Immunisation Healthcare Workers identify and follow up Indigenous children due or overdue for vaccinations, a program that has achieved equality of full vaccination coverage for Indigenous and non-Indigenous children in New South Wales at 9, 15 and 51 months of age.
This remarkable outcome is especially significant given the high background susceptibility of Indigenous children to vaccine-preventable diseases. While it is not clear whether the improvement in vaccination rates is attributable to the dedicated program structure or to the deployment of culturally aware health workers, it is certain that partnerships between modern clinical methods and traditional cultural awareness will continue to be the model of choice for improving Indigenous health.
Also noteworthy is the authors’ combination of high quality research with statistically sound methodology in a culturally appropriate setting, a mix essential to the Journal, as detailed in the 2017 Indigenous health issue.1,5 Banks and colleagues6 applied similarly robust and culturally appropriate methodology to draw attention to the substantial undertreatment with lipid-lowering therapies of Aboriginal and Torres Strait Islander people at high risk of cardiovascular disease.
They found that 4.7% of Indigenous people aged 25–34 years are at high primary risk, but this age group is not assessed for cardiovascular disease risk under current national guidelines. The accompanying editorial7 summarises a suite of targeted interventions that build on these and other findings published in the Journal.8 While these approaches are no doubt important, adapting the successful approach of Hendry and colleagues’ to vaccination,3 to provide a similarly structured intervention for lipid-lowering therapy, could be a game-changing strategy for closing the gap in cardiovascular disease.
The MJA recognises the power of big data and data linkage studies. Randall and colleagues9 analysed linked hospital and mortality data to explore in depth multimorbidity in Indigenous patients in NSW.
The necessary policy and clinical responses are placed in perspective by Broe and Radford10 in their editorial. They note the especially higher level of comorbidities among Aboriginals in mid-life age groups than in non-Aboriginals of the same age, and that this difference is correlated with the age-group peak in the mortality gap between Indigenous and non-Indigenous Australians, highlighted in this Journal last year.2 While the wealth of information made available by big data-based research can sometimes be overwhelming, the MJA prioritises analyses that can change practice..
Finally, Gunasekera and colleagues11 report the high degree of agreement between diagnoses by audiologists and otolaryngologists of otitis media in Aboriginal children, suggesting that audiologists could triage cases in areas where specialist services are limited.
The false negative rate was low — in 3.0% of children, audiologists did not diagnose otitis media subsequently detected on image review by an experienced otolaryngologist — and the most serious form, tympanic membrane perforation, was never missed. These findings may open pathways for children in high risk settings — where otitis media is common (prevalence of 29% in this study) but otolaryngologists are few — to more efficiently receive specialist care.
The articles in this issue show that progress in medical and research methodology can be meaningfully combined with cultural sensitivity. The Journal welcomes submissions that further develop these approaches. More broadly, the MJA will continue to highlight emerging issues of significance to Indigenous health, and is leading a global collaboration with major overseas medical journals to publish a joint issue on the health of indigenous peoples around the world in 2019.
While Closing the Gap has become an iconic representation of Indigenous advocacy, it remains essential to maintain focus on the individual components of disease processes, epidemiology, intervention delivery, and cultural mechanisms that influence the achievement of significant change. The MJA will ensure it strengthens its role in delivering the relevant data to clinicians, policy developers, and the Australian community.
Published in the MJA, the study linked hospital and mortality data for around five and half million New South Wales residents, from 2003 to 2013.
The authors from the University of New South Wales, led by Dr Deborah Randall, found a much higher prevalence of multimorbidity (defined as two or more medical conditions) among people with an Aboriginal and Torres Strait Islander background than among the non-Indigenous population.
After adjusting for age, sex and socio-economic status, the rate of multimorbidity in Aboriginal and Torres Strait Islander people was more than 2.5 times that of the non-Aboriginal population.
The relatively higher rates were found across all age groups, and peaked at around the age of 40 years. In younger Aboriginal and Torres Strait Islander people, this was largely driven by mental health issues, while in those aged over 60 years, it was mostly due to physical conditions.
A secondary endpoint for the study was one-year all-cause mortality after 2013. The rate for this was also around 2.5 times greater for Aboriginal and Torres Strait Islander people, and was significantly associated with multimorbidity.
According to Professor Tony Broe, Conjoint Professor of Geriatric Medicine at the University of NSW and co-author of an editorial on the study, the research has two major implications, one for Aboriginal and Torres Strait Islander people and the other for chronic disease control in general.
“First, there’s the much higher rate of multimorbidity in Aboriginal people, which is no mystery, but what the study authors have done is to show the data and put a figure on the issue. That’s important.”
Professor Broe, whose recent research work has focused on Aboriginal health and ageing, says that the second lesson from the study is that Australia is not managing multimorbidity and chronic disease very well, whether it’s in Aboriginal and Torres Strait Islander people or across the general population.
“The current approach to chronic disease is that we treat by specific disease and specialty. So, the respiratory physician will deal with lung disease and the cardiologist will deal with heart disease et cetera. That’s the wrong approach. What those of us involved in Aboriginal health have done is to say, well, these diseases all have the same risk factors. So, we decided to look at hypertension, smoking, mental health disorders and other risk factors as a group of things to tackle.”
Professor Broe says that in order to reduce multimorbidity prevalence, there needs to be a switch of focus away from episodic medical care towards preventive medicine.
“You come in with pneumonia and they give you a treatment, but what we want to do is to prevent you coming in with pneumonia in the first place. We need more focus on preventive medicine and we should be getting the GPs to do it, not the specialists. The specialists can help out with chronic disease programs, but it should be GPs who are running them.”
But Professor Broe says that the preventive approach won’t be enough on its own to improve the health and mortality rates of Aboriginal and Torres Strait Islander people. A large part of the solution is non-medical, he says, and requires a major cultural change.
“A lot of the comorbidities of younger Aboriginal people relate to mental health issues, driven by stress and trauma. In fact, a study we’ve just published shows that even the high rates of late-life dementia in Aboriginal people are associated with childhood stress and adversity. Aboriginal people are under stress and we need to take some of that away by recognising their existence and their self-determination.
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Med J Aust 2018; 209 (1): 68 Free
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Part 3 THE Medical Journal of Australia and MJA InSight endorse the Uluru Statement from the Heart.
The Statement, a consensus from the First Nations National Constitutional Convention held in May 2017, calls for “establishment of a First Nations Voice enshrined in the Constitution” and seeks “a Makarrata Commission to supervise a process of agreement-making between governments and First Nations and truth-telling about our history”.
It affirms the connection of Aboriginal and Torres Strait Islander peoples with the land, and highlights the social difficulties and ongoing suffering faced by Aboriginal and Torres Strait Islander peoples. The MJA accepts the invitation of the Aboriginal and Torres Strait Islander peoples to join with them “in a movement of the Australian people for a better future”.
The MJA has been at the forefront of striving for health equity and equality for all Australians, including our First Nations peoples. We know the legacy of the MJA over 104 years is but a tiny fraction of the history of our nation, although our contribution in this short time has helped to spotlight our First Nations peoples’ health, including, all too often, the astounding and continuing inequities.
We recognise there is an ongoing health crisis that is clearly felt in the hearts of the First Nations peoples.
The 2018 Indigenous issue of the Journal, like those before it, continues to expand knowledge of Indigenous health determinants and issues and, even more crucially, begins presenting practical solutions to improve First Nations peoples’ health by harnessing modern medical understanding integrated with uncompromising cultural awareness. The task is far from complete. The Journal commits not only to support the Uluru Statement but to continue to prioritise publications that will integrate the statement into a health care and societal movement.
Health is integral to the spirit of all cultures; it is underpinned by social determinants obligating recognition, understanding and complete cultural awareness as identified in the Uluru Statement. If health equity and equality are to be achieved for all Australians, and if Australians all agree this is a fundamental human right and that it is un-Australian to think otherwise, then we must join hands and move forward to create a better future for us all.
Laureate Professor Nick Talley, AC, is editor-in-chief of the Medical Journal of Australia.