more_vertPhotographer Philomena Hughes, working with Nadine Caron and Indigenous communities in northern British Columbia, Canada, has taken this series of photographs of people involved in supporting the health and wellbeing of Indigenous communities in this region. All the pictures were taken around Prince George, BC.
Preference: Indigenous Health
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[Comment] Canada’s efforts to ensure the health and wellbeing of Indigenous peoples
In September, 2017, Prime Minister Justin Trudeau stood before the UN General Assembly and acknowledged that the “failure of successive Canadian governments to respect the rights of Indigenous peoples in Canada is our great shame.”1 For generations, First Nations, Inuit, and Métis peoples in Canada were denied the right to self-determination and subjected to laws, policies, and practices based on domination and assimilation. Indigenous peoples lost control over their own lives.
[Comment] Challenges in health equity for Indigenous peoples in Canada
Canada’s health-care system, like the country itself, is a complex entity. As the two papers in The Lancet’s Series on Canada1,2 make clear, the country’s health-care landscape is made up of multiple people, places, and policies with often overlapping—and sometimes conflicting—jurisdictions, priorities, paradigms, and practices. These complexities are rooted in Canada’s fairly young colonial history that resulted in a nation comprised of a majority of settler and recent immigrants and their descendants, alongside a steady resurgence of Indigenous populations of First Nations, Inuit, and Métis peoples that are growing in numbers, political acumen, and agency.
Old and new meet in remote community
Home to the Western Desert art movement and name-checked by Midnight Oil*, the remote Northern Territory community of Kintore is simultaneously among the oldest and newest Aboriginal communities in the land.
Kintore, 350km west of Alice Springs and 30km from the Western Australian border, was first discovered by westerners in 1963. Until then, the Pintupi people were living an undisturbed traditional life on country they knew as Walungurru.
They were forcibly resettled to Papunya for assimilation. It didn’t work.
“We had a lot of problems. Pintupi people went from here, and they all went to Papunya, and started falling into bad ways – alcohol, everything,” Monica Robinson, the chair of the Pintupi Homelands Health Service Aboriginal Corporation board, said.
“They walked into Papunya healthy and strong, with no problems at all. As soon as they went to Papunya, they started getting sickness, drinking, causing a lot of fights and all that, kids not learning, and that’s why people realised that it was not right.
“The older people said that we need to go back to our own country, take the young ones so that we can go back and live in our own country.”
The Pintupi did that in 1981, founding the community of Walungurru/Kintore. Today, it is home to approximately 450 residents, predominantly Pintupi speakers, with small populations of Luritja and Warlpiri people.
“We were called nomads, we used to move around a lot until the 1960s and 70s,” Ms Robinson said.
“But this is our settle-down country. When we came back to Kintore in the 1980s, there was just humpies and spinifex here, no houses, no anything.”
Today, Kintore has an airstrip, a health clinic, a dialysis unit, a school, a police station, a swimming pool, and an art gallery.
At first, the clinic operated out of a caravan, and relied on a two-way radio to contact Papunya for help or supplies. The telephone was installed in 1994.
The clinic has four doctors, nurses, and visiting endocrinologists, cardiologists, podiatrists, obstetrician/gynaecologists, dieticians and dentists.
“This clinic belongs to all the people around Kintore. They own it. This is an independent clinic,” Ms Robinson said.
“Kintore is a small place but it grows. We plant the seed, we water the seed, and it grows.”
In the 1990s, the people of Kintore and the nearby Western Desert communities of Kiwirrkurra and Mt Liebig became concerned about family members being forced to move away from community to receive treatment for end stage renal failure.
Realising the need for a local dialysis treatment centre, local artists created four collaborative paintings, which were sold at auction for more than $1 million in 2004 to set up the service.
Kintore, a town with only 52 houses, currently has more than 80 residents with various stages of kidney disease, and 14 residents on dialysis. The dialysis unit, run by Purple House, has three dialysis chairs.
About 110 people have diabetes. Eight children are in the process of being diagnosed with Fetal Alcohol Spectrum Disorder (FASD).
AMA President Dr Michael Gannon said the AMA is interested in what it can do to help doctors do the work needed in remote clinics and communities, and in preventing people becoming sick in the first place.
“It’s great that we’ve got dialysis chairs out here on country where you live, but what we’d love to see is less people getting kidney disease, so that means less diabetes, less high blood pressure, less rheumatic fever – having less of the things that make people’s kidneys get sick,” he told the board.
“We spend a lot of time as doctors thinking about, not just in places like Kintore, but in the big cities like Sydney and Melbourne and Darwin, ways to stop people getting sick in the first place.
“We like to think about good healthy food, good tucker, lots of water, healthy pregnancies and looking after kids when they’re young, making sure they’re healthy, and they’re the things that we spend a lot of time talking about.”
Dr Gannon visited Kintore on April 16, with the Member for Lingiari and Shadow Minister for Indigenous Health, the Hon Warren Snowdon MP.
*Midnight Oil song sang about Kintore in the 1987 song Beds Are Burning: “Four wheels scare the cockatoos/From Kintore east to Yuendumu”.
MARIA HAWTHORNE
Snippets
Get your flu shots … but not too early
The AMA has urged people to wait until at least mid-April before getting flu shots, following a push by some pharmacy chains to get the vaccinations too early.
Some big name pharmacies began advertising in March for people to get their shots to avoid a repeat of last year’s deadly influenza outbreak.
But AMA Vice President Dr Tony Bartone said getting vaccinated for the flu too early could be counterproductive.
He said the vaccine’s effectiveness begins to wear off after three or four months. With the flu’s peak season being from July to September, a March shot was too early.
“If we’re going to maximise our protection before that effectiveness starts to wane, we want to match the timing of the vaccination with the timing of the peak,” Dr Bartone said.
“And for that reason, mid-April onwards is a perfect time to start having your vaccination.”
Feed time at Federal Council
History was made when the AMA Federal Council met at Canberra in March.
For the first time ever (we think), a baby was breastfed during Council proceedings.
While it made no ripple at all, we here at Australian Medicine thought it was so cool that we wanted to let you all know about it.
Dr Jill Tomlinson introduced daughter Anna to the Council on March 16. “She is four weeks old today,” proud Mum told AusMed.
We are not a hundred per cent sure that Anna didn’t vote during the Bupa motions.
PICTURE: Dr Jill Tomlinson and daughter Anna
Culturally safe waiting rooms
The promotion of designated waiting rooms for Aboriginal people in NSW hospitals has been met with a mixed reaction.
The State’s health department undertook research into why Indigenous patients are more likely than non-Indigenous patients to leave waiting rooms without receiving treatment.
The research found that some Aboriginal patients did not feel safe in waiting rooms, sparking calls for “designated Aboriginal waiting rooms” or “culturally appropriate space” for Indigenous patients.
Hanging Aboriginal artwork on waiting room walls could also help, the study concluded.
The recommendations have been both applauded and criticised.
AMA President Dr Michael Gannon said it was good that the concept of cultural safety is entering the popular narrative.
“The truth is that health outcomes for Indigenous Australians are significantly worse than non-Indigenous Australians according to just about every possible metric,” he said.
“The AMA strongly supports Aboriginal control when it comes to primary care and when it comes to Aboriginal and Torres Strait Islanders being in larger health facilities like our hospitals, I think we need to do everything we can to make them the appropriate settings for them to seek care.”
Doctors have role to play in drug-free sport
To coincide with the XXI Commonwealth Games, played on the Gold Coast this month, the AMA released its revised Position Statement on Drugs in Sport, and called on both doctors and athletes to ensure the event was free from any banned performance-enhancing drugs.
AMA President Dr Michael Gannon said the Games provided an opportunity to uphold Australia’s reputation for drug-free competition at all levels.
“While some athletes deliberately use prohibited substances to improve their performance, others may inadvertently ingest a banned substance in a prescription or over-the-counter medication,” he said.
“Doctors have an important role to play in reducing the use of performance-enhancing drugs in sport, and in helping athletes to avoid unwittingly taking banned substances in otherwise legal medications.”
The AMA Position Statement on Drugs in Sport – 2018 can be read in full at:
position-statement/drugs-sport-2018
CHRIS JOHNSON
Tuberculosis continues to threaten regional health security
During a World Tuberculosis Day speech delivered in the Senate in March, International Development Minister Concetta Fierravanti-Wells sought to highlight the devastating outcomes tuberculosis is still having globally, including in Australia’s region.
TB is the world’s top infectious disease killer. In 2016, 1.7 million people died from TB – almost 4,700 each day.
Twelve of the world’s 30 highest TB burden countries are located in our region, accounting for nearly half of all cases of drug-resistant TB and TB deaths worldwide.
“Turning the page on TB – once and for all” is a Federal Government priority, Senator Fierravanti-Wells said.
In the 12 months to December last year, there were 10 million movements out of Australia. Two million Australians visited Pacific island countries and Oceania and another 3.1 million Australians visited South-East Asian countries.
“Thirty highest TB-burden countries are located in our region and account for nearly half of all cases of drug-resistant TB and TB deaths worldwide,” the Minister said.
“Papua New Guinea, which is four kilometres to our north, has a major TB problem and, in particular, a drug-resistant TB problem. That not only puts PNG at risk; it also puts Australians at risk.”
In 2014, Australia’s National Notifiable Diseases Surveillance System received 1,339 TB notifications, representing a rate of 5.7 per 100,000 population
However, the Department of Health notes Australia’s overseas-born population continued to represent the majority (86 per cent) of TB notifications and Australia’s Aboriginal and Torres Strait Islander population continue to record TB rates about six times higher than the Australian born non-Indigenous population.
The Department estimates the cost of treating a single patient with drug resistant TB can be up to $260,000 in Australia.
“TB not only affects individuals, but it also cripples communities; disrupts tourism, trade and investment and sets back regional economic growth and development,” Senator Fierravanti-Wells said.
The Minister said that in June last year, the Government announced a new partnership with the World Bank, targeting drug resistant TB in vulnerable communities in PNG.
Another way that Australia is contributing to the fight to end TB is through research.
With one in four people with TB not getting treatment through public health programs, WHO Regional Director for the Western Pacific, Dr Shin Young-soo, continues to urge Governments to do more.
“The TB rate is coming down in the region, but it’s not happening fast enough. We need to do much more to achieve our goal of ending the epidemic once and for all,” he said
MEREDITH HORNE
Communiqué from March Federal Council meeting
DR BEVERLEY ROWBOTHAM, CHAIR, FEDERAL COUNCIL
Federal Council met in Canberra on March 16 and 17. Debate was robust as always and productive, with numerous Position Statements approved for adoption. These will be released to members and the public over coming weeks.
The President reported, as is our usual practice, in a town hall format, with questions of the President from Councillors and some debate. The President reported that the AMA had maintained a very high media profile over the summer period, with many press releases on summer lifestyle issues. These included avoiding heat stress, drinking in moderation, and driving safely. There were also significant Position Statements released, including the AMA Position Statement on Mental Health, which attracted a lot of positive interest from the mental health community.
In the week prior to the Federal Council meeting, the President had released the Public Hospital Report Card, highlighting the need for continued investment by Federal and State Governments in our public hospitals.
The major focus of discussion at this meeting was the recent actions of Bupa in announcing changes to its cover, which will impact doctors and patients alike. Federal Council urged the President to maintain his advocacy on the issue.
The Secretary General’s report again highlighted the scope of activity underway within the Federal AMA secretariat and the success of AMA advocacy on behalf of members; workforce initiatives; the granting by the ACCC of a further authorisation to permit certain billing arrangements to benefit general practices; discussions with the Department of Health on its review of medical indemnity insurance schemes; the raft of reviews relevant to reforms to private health insurance; the ongoing MBS reviews, and much more.
Federal Council considered a proposal for the introduction of post nominal letters to denote membership of the AMA, a move that has been long in the gestation. Further work is required before the Board considers amendments to the By Laws to make provision for the introduction.
Another key discussion was the change to the format of National Conference this year with the introduction of a day of policy debate. This change is being made in response to feedback from delegates that the opportunity for debate on issues by delegates needed to be enhanced. Federal Council considered a number of draft policy resolutions put forward by the membership, which will be further refined before distribution to delegates attending National Conference. Participation in the debate on the resolutions will be open to all AMA members attending the Conference, whether as an appointed delegate or fee-paying member.
Public health working groups brought forward a Position Statement on Men’s Health, and on Drugs in Sport. Council debated the issue of funding of access to bariatric surgery in the public health system. It also agreed to establish two new working groups to look at the issues of child abuse and neglect, and health literacy.
The Ethics and Medico Legal Committee tabled a revision to the Guidelines for Doctors on Managing Conflicts of Interest in Medicine, which was approved by Council. It is part of a wider piece of work before the Committee, looking at relationships between medical practitioners and industry.
Federal Council approved a new Position Statement on Diagnostic Imaging; and another on Resourcing Aged Care. The latter is one of the many advocacy documents in development or under review as part of the AMA’s expanded work on aged care issues. Council noted the report on the recent AMA survey of doctors’ views about providing care in aged care settings, noting the anticipated decline in the number of practitioners providing care.
A recent meeting of the Health Financing and Economics Committee had considered the issue of value based care as a model with the potential to concurrently increase hospital efficiency and improve patient outcomes. Quality data is needed to inform this work within public hospitals.
The Task Force on Indigenous Health, which advises the President on issues relevant to Indigenous health, continues its close involvement with Close the Gap initiatives. Its 2017 report card on ear health continues to be well received.
The various Councils of Federal Council provided their reports. The Council of Private Specialist Practice is monitoring the various reviews of private health insurance, including out of pocket costs and options to manage low value care in mental health and rehabilitation.
The Council of Doctors in Training (DiTs) discussed proposed reforms to bonded medical workforce schemes. The AMA has been active in influencing changes to the schemes which the Council of DiTs has strongly endorsed. The Chair of the Council of DiTs reported on the very successful AMA Medical Workforce and Training Summit held on 3 March 2018. The Summit brought together more than 70 important stakeholders in medical workforce and training to discuss the concerns of the AMA and many others in the profession with the distribution of the medical workforce, the long-standing imbalance between generalist training and sub- specialisation, the workforce position of different specialties and the growing evidence of a specialty ‘training bottleneck’ and lack of subsequent consultant positions.
The Council of General Practice tabled two Position Statements for approval. The first dealt with General Practice Accreditation and the second provides a Framework for Evaluating Appropriate Outcome Measures.
Federal Council supported a motion put forward by the Council of General Practice to endorse funding of universal catch-up vaccines through the National Immunisation Program for anyone living in Australia wishing to become up to date with clinically appropriate NIP vaccinations, irrespective of age, race, country of origin and State or Territory of residence.
The Council of Rural Doctors reported on its recent meeting with the new Rural Health Commissioner, Professor Paul Worley and discussions on the national rural generalist pathway.
The final item of business, but by no means the least important, was the adoption by Federal Council of a position statement on the National Disability Insurance Scheme, which followed a detailed discussion on the Scheme at the November meeting of Council.
Federal Council now prepares for the National Conference and its last meeting with its current membership in May. Elections are underway for several positions on the Council, evidence of increased member interest in its work.
May I introduce you to Esther?
BY DR SANDRA HIROWATARI, CHAIR, AMA COUNCIL OF RURAL DOCTORS
Starting on this page and spilling onto others, you will read a confronting story of Esther. Elements of this story ring true. We rural doctors will recognise Esther immediately. The Canadian version of Esther’s story has been Australianised by author Dr Janelle Trees, an Aboriginal GP. She tells me the story is all too true, she agrees it is appropriate to share it with you. I beg you to soldier on past the first few paragraphs no matter how offensive it reads.
Esther first came into being in Sweden in the late 1990s. It is a story based on an elderly woman caught between bureaucracies, receiving fractured and non-patient focussed care. In the process of her acute admission to hospital, she repeated her story 36 times, received care that was focussed on systems, care that was “Not best for Esther”. The Swedish Healthcare took this sad story and made system-wide changes. The changes always focussed on the question: “What is best for Esther?”
They now have a non-hierarchical voluntary network of over 7000 members from health and social services. The outcomes are staggering. For example, in 2004, hospital admissions fell from 9300 to 7300, the number of unnecessary days in hospital decreased from 1113 to 62 in 2011. The Esther Project received a national Swedish award for quality improvement.
Then last year, the NorthWest Territories (NWT), Canada took the story and put a First Nations spin on it. This is the story I was shown by an executive from Stanton Hosptial, Yellowknife. I have been given permission to share it with you. There is no known author. The story is so engrained in NWT Health that everyone knows Esther.
I don’t know that there is a firm plan established to incorporate Esther in the culture of Stanton, but because her story is ‘preached’ from the highest levels, and the trickle-down method is in place.
In contrast, Kent in the UK, and Singapore are now planning to follow the Swedish model, focussing on patient-centred, coordinated care for the elderly.
The First Nations focus resonates with me. I love how Dr Trees has Australianised it. Sadly the Indigenous health issues, poverty, social situations, and the ‘stuck’ mindsets are the same despite 15,000 km and 75-80 degree difference in temperature.
So now, rural doctors, I challenge you. Take Esther to your next staff meeting; invite Esther into the lunch room; write about Esther. Find at least two or three Esthers. Did you know Esther is both a boy’s name and girl’s name?
Start small, always ask Esther for opinions, follow a patient’s story from beginning to end, talk about improvements.
And always ask: “What is best for Esther?”
* Look for Esther (in Australia) in the National News pages of this site.
Chlamydia infection increases ovarian cancer risk
Chlamydia, a common sexually transmitted disease, can double a woman’s risk of ovarian cancer.
This is according to new research undertaken by the American Association for Cancer Research (AACR).
Women who had chronic chlamydia infections had twice the risk of ovarian cancer compared to women with no evidence of ever having been infected, researchers found in a report to be fully released at the American Association for Cancer Research in April this year.
“Our data is lending support for there being a role of pelvic inflammatory disease in ovarian cancer and the prime cause of pelvic inflammatory disease, particularly in the U.S, is chlamydia infection,” the National Cancer Institute’s Dr Britton Trabert told a briefing ahead of the meeting.
“We are seeing a doubling in ovarian cancer risk with a prior history of pelvic inflammatory disease.”
The AACR research undertook a retrospective analysis of two different cohorts and control groups, one of them, conducted in Poland, included 279 women with ovarian cancer and 556 matched controls. The other, data from an American National Cancer Institute (NCI) case-control study, included 160 women diagnosed with ovarian cancer during follow-up and 159 matched controls.
The AACR said that there needs to be a greater understanding about what causes ovarian cancer to improve screening and treatment and, ultimately, improve survival.
Chlamydia is treated with a single course of antibiotics but if left unchecked can lead to pelvic inflammatory disease and even infertility in women and testicle infections in men.
Over time, chlamydia causes widespread inflammation that can cause infertility. Now, this new piece of research suggests it may also cause cancer.
While ovarian cancer is not common, every year in Australia approximately 1,600 women are diagnosed with it and more than 1,000 succumb to the disease. If found in its early stages, women have an 80 per cent chance of being alive and well after five years. Unfortunately, 75 per cent of women are diagnosed in advanced stages. There is no early detection test for ovarian cancer.
Chlamydia, however, is very common. The latest data from The Kirby Institute shows Chlamydia was the most frequently notified sexually transmissible infection (STI) in Australia, with a total of 71,751 notifications in 2016. Three-quarters of these notifications were among people aged 15–29 years.
The Kirby Institute’s research also found the annual rate of notification of chlamydia in the Aboriginal and Torres Strait Islander population in the Northern Territory, Queensland, South Australia and Western Australia was 2.8 times that in the non‑Indigenous population in 2016. And in female sex workers, chlamydia incidence increased by 35 per cent between 2012 and 2016.
The Kirby Institute says the data strongly suggests a need for testing to be routinely offered to sexually active adolescents and young adults as the vast majority of infections in young people (15–29 years) remain undiagnosed and untreated.
The AACR research can be found here: http://www.abstractsonline.com/pp8/#!/4562/presentation/4037AACR%202018%…
The Kirby Institute’s HIV, viral hepatitis and sexually transmissible infections in Australia: Annual Surveillance Report 2017 is available here: https://kirby.unsw.edu.au/sites/default/files/kirby/report/SERP_Annual-Surveillance-Report-2017_compressed.pdf
MEREDITH HORNE
[Perspectives] Sadness and silencing
With the #MeToo and #blacklivesmatter campaigns, it feels as if the world is finally cracking open for human beings to speak their truths. An increasing number of people are working for and demanding change, but wider society does not always want to hear these voices. One part of the world where justice for past and present injury is sorely needed is Australia. What is widely known as Australia Day passed in January—the day in 1788 when the British first stuck a colonial flag in the soil. To many Indigenous Australians, it is known as Invasion Day or Survival Day.