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Preference: Indigenous Health

1

Federal Budget delivers – Medicare rebate freeze to be lifted

The AMA welcomes much of the health measures in the Federal Budget and commends the Government for taking action on the Medicare rebate freeze.

AMA President Dr Michael Gannon said the Coalition had won back much of the goodwill it lost with its disastrous 2014 Health Budget by this time handing down a Budget with numerous positive health measures.

Dr Gannon said the staggered lifting of the freeze on Medicare patient rebates was well overdue.

“This is a monkey that has been on the back of the Coalition Government since the 2014 Budget that cut significant dollars out of health. This is the chance to correct those wrongs,” he said.

The freeze will be lifted from bulk billing incentives for GP consultations from 1 July 2017, from standard GP consultations and other specialist consultations from 1 July 2018, from procedures from 1 July 2019, and targeted diagnostic imaging services from 1 July 2020.

The lifting of the freeze on Medicare rebates will cost the Government about $1 billion.

“The AMA would have preferred to see the Medicare freeze lifted across the board from 1 July 2017, but we acknowledge that the three-stage process will provide GPs and other specialists with certainty and security about their practices, and patients can be confident that their health care will remain accessible and affordable,” Dr Gannon said.

“Lifting the Medicare rebate freeze is overdue, but we welcome it.”

Dr Gannon also described many of the health policy breakthroughs in the Budget as a direct result of AMA lobbying and the consultative approach of Health Minister Greg Hunt.

“Minister Hunt said from day one in the job that he would listen and learn from the people who work in the health system every day about what is best for patients, and he has delivered,” Dr Gannon said.

AMA advocacy has also seen, in this Budget, the reversing of proposed cuts to bulk billing incentives for diagnostic imaging and pathology services; the scrapping of proposed changes to the Medicare Safety Net that would have penalised vulnerable patients; the delaying of the introduction of the Health Care Homes trial until October to allow fine-tuning of the details; the moving to an opt-out approach for participation in the My Health Record; and recognising the importance of diagnostic imaging to clinical decision-making.

The AMA supports the Government’s measures to increase the prescribing of generic medicines, when it is safe and appropriate and discussed with the patient, and preserves doctors’ clinical and prescribing independence, with savings to be invested back into the Pharmaceutical Benefits Scheme.

“We also welcome the Government’s allocation of $350 million to help prevent suicide among war veterans; the expansion of the Supporting Leave for Living Organ Donors Program, which allows donors to claim back out-of-pocket expenses and receive up to nine weeks paid leave while recovering; measures to increase the vaccination rate; and the ban on gambling ads during live sporting broadcasts before 8.30pm,” Dr Gannon said.

Mr Hunt said the Budget delivered on the Government’s commitment to guarantee Medicare and ensure Australia’s health system continues to be one of the best in the world.

“It ensures the essential healthcare services Australians rely on,” the Minister said.

“The 2017-18 Budget includes a $10 billion package to invest in Australia’s health system and the health of Australians.

“The Government will establish a Medicare Guarantee Fund from 1 July 2017 to secure the ongoing funding of the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme, guaranteeing Australians’ access to these services and affordable medicines into the future.”

The Medicare levy will rise by 0.5 percentage points in two years’ time, to help close the funding gap for the National Disability Insurance Scheme.

“This measure will collect $8.2 billion over four years for the NDIS,” said Treasurer Scott Morrison when handing down his Budget.

Shadow Treasurer Chris Bowen said the Government had failed the Medicare test because it had delayed reversing cuts to Medicare for three years.

“Budgets are about choices and Prime Minister Malcolm Turnbull has made his choices tonight,” Mr Bowen said.

“He has chosen multinationals over Medicare. He has chosen big business over battlers.” 

Dr Gannon said the Health Budget effectively ends an era of poor co-payment and Medicare freeze policies, and creates an environment for informed and genuine debate about other unfinished business in the health portfolio.

“We now need to shift our attention to gaining positive outcomes for public hospitals, prevention, Indigenous health, mental health, aged care, rural health, private health insurance, palliative care, and the medical workforce,” he said.

“The thaw in the freeze is the beginning, not the end.”

Chris Johnson

 

 

 

 

 

 

 

The Lighthouse Project

BY AMA PRESIDENT DR MICHAEL GANNON

Last year, when the AMA released its 2016 Report Card on Indigenous Health, it set out a plan for governments to eradicate Rheumatic Heart Disease (RHD) from Australia by 2031. Since the release of this Report Card, the AMA has been a part of growing efforts to reinforce to our political leaders that RHD must be stamped out, and that other cardiovascular health outcomes for Aboriginal and Torres Strait Islander peoples must be improved.

As part of our efforts to improve the cardiovascular health of Aboriginal and Torres Strait Islander people, the AMA has become a founding member of an END RHD Coalition – an alliance of six organisations with a vision to see the end of RHD in Australia, we participated in the inaugural Close the Gap Parliamentary Friendship Group which focussed on the enormous impact of RHD, and we recently met with the Australian Healthcare and Hospitals Association (AHHA) to discuss the Lighthouse Project – a joint initiative of the AHHA and the Heart Foundation to improve outcomes for Aboriginal and Torres Strait Islander peoples experiencing coronary heart disease.

The aim of the Lighthouse Project is to help close the gap in cardiovascular disease between Indigenous and non-Indigenous Australians through the provision of evidence-based, culturally safe care for acute coronary syndrome. With cardiovascular disease being the  leading cause of death among Aboriginal and Torres Strait Islander people, and  a major contributor to the gap in life expectancy between Indigenous and other Australians, it is imperative that the AMA and other health and medical organisations are actively engaged in this area.

It is unacceptable that Aboriginal and Torres Strait Islander people, who represent three per cent of the entire Australian population, are 1.6 times more likely to die from coronary heart disease than their non-Indigenous peers.  It is also unacceptable that Aboriginal and Torres Strait Islander people are less likely to undergo vital coronary tests and procedures once admitted to hospital.

It is clear that the hospital system must better respond to the unique health needs of Aboriginal and Torres Strait Islander patients.  Hospitals have an important role to play in improving access to care and addressing disparities for Aboriginal and Torres Strait Islander peoples. This is where initiatives such as the Lighthouse Project are extremely valuable.

During Phase 1 of the Lighthouse Project, cultural competence, having a skilled workforce, appropriate governance and the use of clinical care pathways were identified as four key areas of best practice for improving care for Aboriginal and Torres Strait Islander peoples with Acute Coronary Syndrome. In Phase 2, a quality improvement toolkit was developed and implemented in eight public hospitals across Australia. 

Through Phase 1 and Phase 2 of the Lighthouse Project, these public hospitals have achieved culturally safe environments and enhanced staff capacity to respond to the unique needs of Aboriginal and Torres Strait Islander patients, and have reported improved relationships with Indigenous patients and communities.

The Lighthouse Project must be seen as a positive example of how gains in health outcomes can be achieved for Aboriginal and Torres Strait Islander people. I am pleased that the work of the Lighthouse Project will continue, with the Commonwealth Government recently announcing that $8 million has been provided to support Phase 3 of the Lighthouse Project, which aims to extend the project to 18 hospitals across the country and allowing it to reach nearly one in every two Indigenous patients admitted to hospital for a cardiac condition.

Eliminating inequities in health service provision to the Aboriginal and Torres Strait Islander population is vital, and it is encouraging to see that the great work of the Lighthouse Project is being recognised. By increasing cardiovascular health outcomes for Aboriginal and Torres Strait Islander peoples, we can reduce mortality rates, increase life expectancy, and help close the unacceptable health gap that exists between Indigenous and non-Indigenous Australians today.

 

Close the Gap Parliamentary Friendship Group – an observation

The AMA joined the inaugural meeting of the Close the Gap Parliamentary Friendship Group, held on March 30 at Parliament House.

Convened by Greens Senator Rachel Siewart, ALP Senator Malarndirri McCarthy, and Liberal MP Lucy Wicks, the meeting aimed to raise awareness among key decision makers about the scourge of Rheumatic Heart Disease (RHD) on Aboriginal and Torres Strait Islander peoples.

Worldwide, RHD affects more than 30 million people, with Australia’s Aboriginal and Torres Strait Islander people having among the highest rates of this debilitating disease.

The fact that RHD is occurring in Australia, and the fact that we need to reinforce to our political leaders that they need to do something about it, is symptomatic of consecutive government failures to listen and act. RHD is a disease of poverty and it should not be seen in Australia.

Yet Aboriginal and Torres Strait Islander people, particularly children, continue to suffer from RHD every day.  Penny, a young patient advocate from Oenpelli in Arnhem Land, is one of those children. Penny was diagnosed with RHD at around ten years of age, and many of her family members are living with RHD as well – her mother, uncle, aunty, and cousin. While it is unacceptable that RHD is even occurring in Australia, it is intolerable that it is affecting whole families.

RHD can be usually resolved if it is detected early, but people are being treated for the condition when it is too late. Dr Bo Remenyi, a paediatric cardiologist in the Northern Territory described how she sees a new case of RHD being diagnosed among Indigenous children every second day – this is about 150 new cases per year.

RHD is no longer a public health problem in Australia.  This issue was solved for the majority of Australians about 50 or 60 years ago with the introduction of penicillin and better living conditions. RHD is now a political problem.

In the words of Dr Remenyi: “We have a surgical solution for a political problem. Australia needs a paradigm shift – we need to move away from surgical solutions.” We need to invest in prevention, and double the number of doctors and health workers on the ground – Aboriginal and Torres Strait Islander communities have the smallest health workforce in Australia. This is highly disproportionate, particularly when the health needs of Aboriginal and Torres Strait Islander people are two to three times higher than their non-Indigenous peers.

Part of the solution to addressing RHD is educating members of the community about skin infections, and how they can lead to Acute Rheumatic Fever, and then to RHD if they are not quickly treated. But most of all, there needs to be a strong will to put RHD in the history books.

The community, health professionals, people working laboratories, public servants and most of all, governments, are all responsible for helping to make this a reality. Our political leaders need to show leadership and take action to work with health professionals and communities to rid Australia of RHD.

Alyce Merritt 
Indigenous Policy Adviser AMA

 

International spotlight on Indigenous public health equity

Prominent Maori health advocate Adrian Te Patu led a yarning circle at the 15th World Congress of Public Health, which unanimously supported the establishment of an Indigenous Working Group within the World Federation of Public Health Associations.

Mr Te Patu is the first Indigenous representative on the WFPHA Governing Council and is well-known throughout is homeland New Zealand and internationally for his campaigning on health issues.

He will now formalise the Indigenous Working Group, following its acceptance at the World Congress, which was held in Melbourne in April.

The Indigenous Working Group will provide an opportunity to bring to the global public health and civil society arena a visible and prominent Indigenous voice that privileges an Indigenous world view and narrative.

“We intend to create a platform for change with the aim to address the health inequities experience by Indigenous peoples worldwide,” Mr Te Patu said.

The group was formed on the 50th anniversary of the WFPHA, at the 15th World Congress conference, when 40 Indigenous and non-Indigenous conference delegates of the yarning circle unanimously supported in principle its establishment.

The Public Health Association of Australia hosted the yarning circle that was led by Mr Te Patu.

A yarning circle, also known as a dialogue circle, comes from the traditional Aboriginal process of discussing issues in an inclusive and collaborative manner.

All participants are invited to have their say in a non-judgemental environment.

The WFPHA’s function and mandate includes its link into the global health governance mechanisms such as the World Health Organisation.

Chris Johnson

Trends in the prevalence of hepatitis B infection among women giving birth in New South Wales

The known In NSW, HBV vaccination of infants born to women at high risk commenced in 1987, and catch-up vaccination programs for adolescents in 1999. 

The new Among women giving birth, targeted infant and school-based adolescent vaccination programs were associated with an 80% decline in HBV prevalence among Indigenous women by 2012. HBV prevalence in Indigenous women was higher in rural and remote NSW than in major cities, but among non-Indigenous and overseas-born women it was higher in cities. 

The implications HBV prevention programs for Indigenous Australians should focus on regional and remote NSW and those for migrant populations on major cities. Antenatal HBV screening can be used to monitor population HBV prevalence and the impact of vaccination programs. 

Chronic infection with the hepatitis B virus (HBV) can cause serious liver disease, and contributes worldwide to a significant burden of disease. Most chronic infections are acquired early in life, predominantly by maternal transmission.1 While its prevalence in Australia is generally considered to be low (under 2%), the prevalence of HBV infections in Aboriginal and Torres Strait Islander (hereafter: Indigenous)2 people and in some migrant populations3 has been substantial.

A three-dose vaccine that is 95% effective in preventing HBV infection4 has been available in Australia since the early 1980s.5 In New South Wales, a targeted HBV vaccination program commenced in 1987.6 The program offered vaccination for babies born to parents from population groups considered to be at higher risk of HBV infection (defined as HBV prevalence ≥ 5%), including Indigenous Australians.7 In 1997, the National Health and Medical Research Council recommended universal HBV catch-up vaccination of children aged 10–16 years;8 in NSW, this was provided from 1999 to adolescents born since 1983 by general practitioners.9 The National Immunisation Program Schedule included universal infant HBV vaccination from May 2000. During 2004–2013, this was complemented by a NSW-wide school-based HBV vaccination catch-up program for year 7 students (born since 1991; online Appendix 1).5,7 In NSW, coverage through the universal infant program was reported to have exceeded 95% since 2003,10 and about 60% of eligible children not vaccinated as infants had been vaccinated through the school-based catch-up program in 2011 and 2012.11

To assess the impact of the vaccination programs on HBV prevalence in NSW, we determined its prevalence in women giving birth, as in Australia they are routinely screened for HBV during pregnancy.12 Our methodology was similar to that used in earlier studies that linked records of women giving birth and HBV infection notifications.2,3

Methods

Data sources and linkage

Data from two statutory registers were linked. The NSW Perinatal Data Collection (PDC) records all births in NSW of babies of at least 400 grams birth weight or 20 weeks’ gestation. The PDC contains details about the mother, such as year and country of birth, parity, postcode of residence, and Indigenous status, and about the birth, including the date of delivery and outcome. The NSW Notifiable Conditions Information Management System (NCIMS) is a population-based surveillance system that records reports of conditions deemed notifiable under the NSW Public Health Acts 1991 and 2010.13,14 The Act requires notification to NCIMS by any laboratory detecting HBV surface antigen (HBsAg), a marker of HBV infection, in a specimen submitted for diagnostic testing. The NCIMS records personal details, including date of birth, sex, postcode, and classification of the report as newly acquired hepatitis B infection or infection of unspecified duration (based on standard definitions15), notification date, and either the estimated onset date or date of the diagnostic test.

PDC records of women giving birth between January 1994 and December 2012 and NCIMS HBV notifications for the same period were available. Records from the two registers were linked by probabilistic matching of personal identifying details; this was conducted by the NSW Centre for Health Record Linkage (CHeReL), independently of the study investigators, to whom de-identified, linked data were provided for analysis. The reported false positive and negative rates for CHeReL linkage are about 0.5%.16

Study population and definitions

After linkage, we restricted our study population to women resident in NSW — using their postcode on the PDC record — of reproductive age (10–55 years at time of giving birth) who gave birth to their first child (ie, parity null) between January 2000 (when routine antenatal screening for HBV began17) and December 2012.

A woman was defined as having a chronic HBV infection at the delivery of her first child if there was at least one linked HBV notification in the NCIMS database that was recorded as unspecified and with a notification date earlier than the delivery date. Women with no linked HBV notifications were assumed to be not infected with HBV. Women with an HBV infection notified as being acute were excluded from the analysis, as it was unknown whether they would have cleared their acute infection or progressed to a chronic infection.

Statistical analysis

Women were categorised into four groups by their year of birth, which determined the likelihood of their being included in an HBV vaccination program: pre-vaccination era (maternal year of birth, 1981 or earlier); catch-up vaccination, predominantly GP-administered (1982–1987); at-risk newborn vaccination (1988–1991); and universal school-based catch-up and at-risk newborn vaccination (1992–1999; online Appendix 1). No women in our analyses were born during the period of universal HBV vaccination of newborns (from May 2000).

We also classified the women as Indigenous Australian, non-Indigenous Australian-born, or overseas-born women, based on their PDC record. For Indigenous status, we enhanced reporting in the PDC by linkage to other PDC records.18 Records with missing country of birth data (2090 records, 0.4% of all records) were placed in the “born overseas” category.

We calculated crude HBV prevalence for the four maternal year-of-birth categories, and used logistic regression to examine the relationship between these categories and HBV infection. We adjusted analyses for year of giving birth (in 5-year intervals) to account for possible temporal trends in HBV prevalence,2 and for the mother’s area of residence (two categories, based on residential postcode in the PDC record: major cities and regional/remote, according to the Accessibility/Remoteness Index of Australia19), as HBV prevalence in Australia varies between regions.3 The two most recent maternal year-of-birth categories (1988–1991, 1992–1999) were combined (1988–1999) for the logistic regression analysis because the numbers of records in the individual groups were small.

Ethics approval

The study was approved by the NSW Population and Health Services Research Ethics Committee (reference, 2009/11/193) and the Aboriginal Health and Medical Research Council Human Research Ethics Committee (reference, 841/12).

Results

Between January 2000 and December 2012, 482 998 women residing in NSW gave birth to their first child (PDC data); 54 were linked to an acute HBV notification and excluded from further analysis. Of the remaining 482 944 records, 11 738 (2.4%) were Indigenous Australian women, 319 629 (66.2%) were non-Indigenous Australian-born women, and 151 577 (31.4%) were born overseas. A linked unspecified HBV notification before the date of birth of their first child was available for 3383 women (HBV prevalence, 0.70%; 95% confidence interval [CI], 0.68–0.72%). HBV prevalence was estimated as 0.79% (95% CI, 0.63–0.95%) for Indigenous Australian women, 0.11% (95% CI, 0.09–0.12%) for non-Indigenous Australian-born women, and 1.95% (95% CI, 1.88–2.02%) for overseas-born women.

For Indigenous Australian women, the prevalence of HBV infection was significantly lower for those who were eligible for universal school-based or at-risk newborn vaccination (born between 1992 and 1999) than for women born during the pre-vaccination period (≤ 1981): 0.15% (95% CI, 0.00–0.35%) v 1.31% (95% CI, 0.91–1.71%; for trend, P < 0.001). For non-Indigenous Australian-born women, the prevalence also declined, but the fall was not statistically significant: from 0.10% (95% CI, 0.09–0.11%) to 0.04% (95% CI, 0.00–0.09%; for trend, P = 0.5). There was no significant trend for overseas-born women between the two periods (P = 0.1) (Box 1, online Appendix 2).

In analyses adjusted for year of giving birth and region of residence (Box 2), the proportion of Indigenous Australian women notified as having an HBV infection was 80% lower for those eligible for vaccination as part of the at-risk infant or universal school-based vaccination programs (born 1988–1999) than for women born during the pre-vaccination period (1981 or earlier) (adjusted odds ratio [aOR], 0.20; 95% CI, 0.09–0.48). There was no significant change for non-Indigenous Australian-born women (aOR, 0.87; 95% CI, 0.54–1.44). For overseas-born women, the number of notifications was significantly higher for women born during 1988–1999 than for those born before 1981 (aOR, 1.38; 95% CI, 1.15–1.67).

Box 2 also shows that HBV notifications were more frequent for Indigenous women living in regional and remote areas than for those in major cities (aOR, 2.23; 95% CI, 1.40–3.57). The opposite applied to non-Indigenous Australian-born (aOR, 0.39, 95% CI, 0.28–0.55) and overseas-born women (aOR, 0.61; 95% CI, 0.49–0.77).

The study timeframe and inclusion criteria (first births during 2000–2012) meant that the mean age of mothers was lower in later than in earlier birth year groups. After adjusting for maternal birth year groups, a significant decline in HBV notifications among Indigenous women of about 30% was still detected (aOR for each 5-year period, 0.69; 95% CI, 0.49–0.97; P = 0.03). A decline for overseas-born women was also found, but it was much smaller (aOR, 0.89; 95% CI, 0.84–0.93; P < 0.001), and there was no change for non-Indigenous Australian-born women (aOR, 0.99; 95% CI, 0.84–1.16; P = 0.90; Box 2).

To further explore the changes in HBV prevalence in overseas-born women, HBV notifications were also analysed by maternal year of birth and region of birth (Box 3). The highest proportions of women with HBV notifications were for those born in North-East Asia, South-East Asia, and sub-Saharan Africa. The small sample sizes made comparisons of trends across maternal year of birth less robust, but a consistent increase in HBV notification rates was observed for women born in North-East Asia and sub-Saharan Africa (for each trend, P < 0.001).

Discussion

This is the largest study to examine differences in HBV notification rates for women born before and after the introduction of HBV vaccination programs in Australia, analysed by country of birth, Indigenous status, and region of residence. We found that HBV notification rates for Indigenous women born after the introduction of targeted infant HBV vaccination were 80% lower than for those born earlier. For non-Indigenous Australian-born and overseas-born women there were no consistent associations between HBV notification rates and HBV vaccination programs in NSW. Despite limited data about the level of HBV vaccination coverage achieved when the at-risk newborn vaccination program was introduced in NSW in 1987, our findings suggest that it was highly successful. The estimates of HBV notification rates in Indigenous women were substantially lower among those born after 1987 than among women born before the start of the program (Box 1). It is notable that the 80% decline we report matches the 79% reduction found by a study that compared Indigenous women in the Northern Territory born before and after the introduction of universal newborn vaccination,2 suggesting that the targeted program was highly effective in reaching those at risk. The estimated fall is also similar to the results of investigations in other countries of the impact of universal newborn vaccination programs.20,21

A lack of consistent trend in HBV notifications among non-Indigenous Australian-born women might be expected, as the notification rate in this population before the introduction of vaccination was considerably lower than for Indigenous women. Further, most non-Indigenous women born during 1988–1999 would have been eligible only for school-based catch-up vaccination, which is less effective in preventing chronic disease than infant vaccination. Interpreting the relationship between birth cohorts and HBV prevalence in overseas-born women was complicated by a number of factors, including the differing prevalence of HBV in the regions from which overseas-born women migrated, their age at migration, and the lack of information about receipt of vaccination in their country of origin. When analysed by region of origin, the observed changes in notification rates could reflect either varying local uptake of infant HBV vaccination or differences in the populations that have migrated to Australia from particular regions over the 13-year study period. The smaller numbers of women involved in each group, however, limit our ability to draw conclusions.

Regional differences in HBV prevalence were also observed. Indigenous Australian women in regional and remote NSW were more likely to be HBV-seropositive than those in urban areas, whereas the reverse was true for non-Indigenous Australian-born and overseas-born women. These differences in HBV prevalence have been described previously in Indigenous Australians,2 but the reasons underlying them are unclear. The colonisation process and the institutional racial discrimination that Indigenous Australians experience affect their health outcomes, mediated by a number of different pathways, including unequal access to health care, housing and employment.22,23 As access to primary health care services relative to need is lowest in remote areas, and proportionately more Indigenous than non-Indigenous Australians live in remote areas,24 these factors may contribute to higher HBV prevalence among Indigenous women in rural and remote areas. In addition, an uncommon, more virulent HBV subgenotype circulates among Indigenous Australians in the NT, perhaps reducing the efficacy of vaccination;25 the distribution of this subgenotype in NSW, however, is unknown.

The higher prevalence of HBV among urban than regional non-Indigenous women may be related to the higher proportions of women in cities who inject drugs or are in prison, both risk factors for acute HBV infection.26 For women born overseas, the difference might be related to the fact that a greater proportion of migrants from high HBV prevalence countries (such as Asia) reside in urban than in regional and remote areas (online Appendix 3).27

It was not possible in our ecological study to take into account interactions between the effects of age and calendar year on HBV notification. Women who were born more recently, and therefore more likely to have been vaccinated, would have been younger at the time of our linkage, but also potentially subject to different risks of exposure at a given age. Including the year a woman gave birth as a factor in the regression model for Indigenous Australian women led to a small reduction in the effect of maternal birth year on HBV prevalence, and HBV prevalence was lower for more recent year of giving birth, after adjusting for maternal year of birth (Box 2). This suggests that temporal trends other than the effect of maternal birth year may have contributed to the decline in HBV notifications for Indigenous Australian women, although residual confounding related to inadequate adjustment for maternal birth year effects cannot be excluded. A similar trend, but of smaller magnitude, was seen among overseas-born women.

Antenatal screening for HBV infection enabled us to systematically assess HBV prevalence in a large population of women. Study limitations include our focus on women giving birth; our conclusions may not be generalisable to other women or to men, but we expect that the overall trends would be similar. We were unable to assess the impact of universal newborn vaccination on HBV notifications, as no women born after 2000 had given birth during the study period. Further, the ecological nature of our analyses depended on assumptions about the exposure of individuals to different vaccination strategies according to year of birth, whereas individual level vaccination data would assist us more reliably quantify their effects. Interpreting changes in HBV prevalence by country or region of birth was further limited by a lack of information about when women migrated to Australia. Some HBV notifications classified as “unspecified” may actually have been acute infections, but their frequency should not have differed between maternal birth year groups, and would therefore not have affected our estimates of HBV prevalence. Finally, linkage errors are possible, but their rate is known to be low.

Conclusion

Analysing routine antenatal HBV screening data is a simple and cost-effective method for monitoring changes in HBV prevalence in both the general population and in some high risk populations. The newborn and childhood HBV vaccination programs in NSW have had a significant impact on HBV prevalence in Indigenous Australian women, but it is still substantially higher than among non-Indigenous women. HBV infection prevention programs for high risk groups should be targeted differently, with those for Indigenous Australians focused on regional and remote NSW, and those for migrant populations on major cities. Finally, our analysis could be repeated periodically to assess the ongoing impact of universal newborn HBV vaccination and future targeted programs on HBV prevalence in Australia.

Box 1 –
Hepatitis B notifications for primiparous women giving birth, by maternal birth year, New South Wales, 2000–2012

* HBV notification rates plotted against the median maternal year of birth for each maternal year of birth category (≤ 1981, 1982–1987, 1988–1991, 1992–1999).

Box 2 –
Association between HBV notifications* and maternal year of birth, year of giving birth, and region of residence

Median age (years)

Number of women

Univariate analysis

Multivariate analysis

Giving birth

Giving birth, with HBV record

Odds ratio (95% CI)

P†

Adjusted odds ratio (95% CI)‡

P†

Australian-born women, Indigenous

Maternal year of birth

≤ 1981

27.4

3057

40 (1.3%)

1

< 0.001

1

0.002

1982–1987

20.8

4509

45 (1.0%)

0.76 (0.50–1.17)

0.79 (0.51–1.23)

1988–1999

18.8

4172

8 (0.2%)

0.15 (0.07–0.31)

0.20 (0.09–0.48)

Region of residence

Major cities

4916

24 (0.5%)

1

0.002

1

< 0.001

Regional/remote

6752

69 (1.0%)

2.08 (1.31–3.32)

2.23 (1.40–3.57)

Year of giving birth (per 5 years)

0.45 (0.34–0.61)

0.69 (0.49–0.97)

0.03

Australian-born women, non-Indigenous

Maternal year of birth

≤ 1981

30.7

227 608

227 (0.1%)

1

0.50

1

0.10

1982–1987

23.6

67 762

91 (0.1%)

1.35 (1.06–1.72)

1.47 (1.14–1.91)

1988–1999

19.9

24 259

18 (0.1%)

0.74 (0.46–1.20)

0.87 (0.54–1.44)

Region of residence

Major cities

242 392

298 (0.1%)

1

< 0.001

1

< 0.001

Regional/remote

77 195

38 (0.0%)

0.40 (0.29–0.56)

0.39 (0.28–0.55)

Year of giving birth (per 5 years)

1.04 (0.90–1.20)

0.99 (0.84–1.16)

0.90

Overseas-born women

Maternal year of birth

≤ 1981

31.7

116 659

2245 (1.9%)

1

0.10

1

0.001

1982–1987

25.2

29 431

580 (2.0%)

1.03 (0.93–1.12)

1.11 (1.01–1.22)

1988–1999

20.9

5487

129 (2.4%)

1.23 (1.03–1.47)

1.38 (1.15–1.67)

Region of residence

Major cities

144 926

2872 (2.0%)

1

< 0.001

1

< 0.001

Regional/remote

6621

82 (1.2%)

0.62 (0.50–0.77)

0.61 (0.49–0.77)

Year of giving birth (per 5 years)

0.92 (0.88–0.96)

0.89 (0.84–0.93)

< 0.001

* For the purposes of our analysis: defined as a record in the NSW Notifiable Conditions Information Management System of the detection of hepatitis B surface antigen (HBsAg) between January 1994 and December 2012 with the infection classified as being of unspecified duration (or not newly acquired). † For trend across categories of maternal birth year, calculated using the median maternal year of birth in each category. ‡ Adjusted for maternal year of birth, region of residence, and year of giving birth (5-year intervals).

Box 3 –
HBV notifications for non-Australian-born women giving birth for the first time, by region of birth

Mother’s region of birth

Maternal year of birth

≤ 1981

1982–1987

1988–1999

Number of women

Proportion with HBV record (95% CI)

Number of women

Proportion with HBV record (95% CI)

Number of women

Proportion with HBV record (95% CI)

North-East Asia

21 159

4.4% (4.2–4.7%)

4455

5.4% (4.7–6.1%)

583

11.2% (8.8–14.0%)

South-East Asia

22 824

4.3% (4.2–4.7%)

4596

4.5% (4.0–5.2%)

680

4.1% (2.9–5.9%)

Oceania (excluding Australia)

12 124

1.1% (0.9–1.2%)

3335

1.0% (0.7–1.4%)

1260

0.7% (0.4–1.4%)

Sub-Saharan Africa

4409

0.9% (0.6–1.2%)

965

3.0% (2.1–4.3%)

244

4.9% (2.8–8.4%)

North Africa or Middle East

9064

0.6% (0.5–0.8%)

4592

0.5% (0.3–0.8%)

1368

0.9% (0.5–1.5%)

South or Central Asia

12 268

0.3% (0.3–0.5%)

7292

0.4% (0.3–0.6%)

831

0.2% (0.1–0.9%)

Europe

25 899

0.2% (0.1–0.2%)

2764

0.4% (0.3–0.8%)

303

0.3% (0.1–1.9%)

Americas

7262

0.04% (0.0–0.1%)

1084

0.3% (0.1–0.8%)

126

0.0% (0.0–3.0%)

Other

1650

0.6% (0.3–1.0%)

348

0.9% (0.3–2.5%)

92

0.0% (0.0–4.0%)

National Social Housing Survey: a summary of national results 2016

This report presents a national summary of the results of the 2016 National Social Housing Survey (NSHS), and reports findings from public housing, community housing and state owned and managed Indigenous housing tenants. The report shows that the majority of tenants are satisfied with the services provided by their housing organisation, with community housing tenants the most satisfied. Tenants report a range of benefits from living in social housing and the majority live in dwellings of an acceptable standard.

Engaging Aboriginal and Torres Strait Islander doctors to become members of AMA

DR SANDRA HIROWATARI, CHAIR, AMA COUNCIL OF RURAL DOCTORS

The Council of Rural Doctors has pushed strongly for greater Indigenous representation on councils and committees, and I was delighted to see the Australian Indigenous Doctors’ Association (AIDA) attend the last AMA Federal Council, with arrangements being put in place to give Indigenous doctors a permanent voting presence on the Council. Collaterally, the AMA has a strong wish for Aboriginal and Torres Strait Islander doctors to become AMA members. The culture of Indigenous doctors will make the profession stronger. It is therefore in the interests of the profession to have more of this group join.

But it is not as simple as a motion or a wish. There are differences between non-Indigenous and Indigenous doctors. But rather than focusing on the differences, a wise elder has advised me to focus on the similarities.

The similarities are profound and predate the migration of Western culture to the Australian shores:

1.   Respect for elders. In Aboriginal and Torres Strait cultures, respect for elders is fundamental to good order. If a young warrior were to disagree with an elder, one would not pursue this in open defiance, but rather seek to gently and seamlessly change the mind of the elder whilst being sure to protect the dignity of the elder, so that the elder would not subsequently face accusations of back-flipping. Exactly the same can be seen in our medical profession, with Registrars and Junior Consultants going to great lengths to gently encourage the Senior Consultants to consider a new approach, whilst ensuring the preservation of the dignity of their senior colleague.

2. Both Indigenous Australians and doctors will circle the wagons around a fellow member of the group who is under attack from outside forces. This is not to say that poor practices should be encouraged, but we are all very aware how easy it is to make a small error of judgment that quickly precipitates very serious consequences. From my non-Indigenous point of view, this circling of wagons around a colleague needs to be cultivated. If a colleague were to tell us they are doing poorly, are we willing to let them do the collegial equivalent of letting them sleep in our spare bedroom or, if someone is already there, on a mattress on the floor? Do we have a buddy system? Can we see ourselves dipping into our pocket and paying for another’s membership fees until they are strong again? If not, why not? They would do that for us later when they are strong. You see, because we come from the same pool of life. We need to prevent some of the tragic doctor suicides we have seen in the past year.

3. Both groups face an exaggerated level of psychological trauma and PTSD. In the case of Indigenous Australians, this is from the ongoing cycles of trans-generational trauma, and grief of constant funerals and untimely deaths. Among our colleagues, we see the sequelae of being immersed in other people’s grief and suffering, and untimely demise. We can learn from each other how to best handle these stressors to care for our own mental health, relationship stress, and professional distress.

4. We also share the touchstone of our profession – the Hippocratic Oath. This Oath is familiar in the heart of our Aboriginal medical colleagues long before the first Indigenous doctor graduated.

 To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the physician’s oath, but to nobody else.

This is a familiar description of the Uncle-Nephew Relationship and how Lore is passed from one generation to the next. Although much of the technology of modern medicine is very new and at the cutting edge of science, the Art of Medicine is an Ancient and Sacred Craft.

Surely it is in the greater interest of the profession that, should we wish to preserve this ancient craft, we would seek to recruit a people to whom such precepts are already familiar.

There are just over 250 Indigenous doctors in Australia. If their numbers roughly were in the same ratio as the rest of us, there ought to be 60-80 Indigenous AMA members. The onus is on us to bring into our family any Aboriginal or Torres Strait Islander member. We in the AMA are looking into these ratios and numbers. Can you look into your hearts and find a personal way to recruit our medical brothers and sisters?

Thank you to my mentor, Dr Louis G. Peachey.

 

 

UK doctor to perform at National Folk Festival

Easter is fast approaching, which means it’s that time of year to escape to one of the exceptional music festivals Australia puts on annually over the long weekend.

There is of course, Bluesfest near Byron Bay, NSW – offering five days of outstanding contemporary blues, rock and roots music by some of the world’s leading acts.

This year’s headline offerings include greats such as Santana, Billy Bragg, Buddy Guy, Bonnie Raitt, Tony Joe White, Neil Finn, Kasey Chambers, Mavis Staples, the Doobie Brothers and the incomparable Patti Smith.

In the nation’s capital, however, is an even longer established music festival that has to be one of Australia’s national treasures.

The National Folk Festival has been a musical institution in this country since 1967, spending its first quarter century of existence rotating through the States taking turns as host venues.

Since 1992 the National, as it is fondly known, has been permanently and fittingly staged each year in Canberra – it is the National Folk Festival after all.

With 27 international acts this year, plus a horde of home-grown artists, musical flavours from around the world will converge on the capital for five days and nights.

There is a genre to pretty much please every musical taste.

(One of the best kept secrets about folk festivals is you can always find great blues music being performed at them.)

So if you are into bluegrass, ragtime, jazz, gypsy jazz, Celtic, flamenco, tango, Afro, Middle Eastern, Western European, Indigenous Australian, old English folk, old Australian folk, bush ballads, country, blues or late night rock music – it’s all on offer at the National.

Like Louis Armstrong once said: “All music is folk music. I ain’t never heard no horse sing a song.”

A feature artist from the UK this festival is a singing, Uilleann pipe playing medico Jarlath Henderson.

By day he’s a doctor, but he hasn’t had to give up his day job to also pursue his musical dream.

Jarlath Henderson is the youngest ever winner of the BBC Young Folk Award, which he won in 2003 aged 19.

He has created a sound that is being described as “defying convention” by dazzlingly juxtaposing the traditional with the modern.

From high-end entertainment to the expression of folk-life, the award-winning National Folk Festival is a celebration of all things folk.

With a program designed to inspire, enliven and entertain, from traditional and contemporary grooves to the quirky and the endearing, the National features all the key elements that make people want to come from everywhere to be part of it.

The 2017 Festival runs for five days at Easter (Thursday to Monday) across 18 venues all located within Exhibition Park in Canberra.

Discounted tickets are available until April 9 at the festival website. Patrons can BYO tent, motor home, caravan or hire a tent on-site with the festival’s Rent-a-Tent Accommodation.

More info at www.folkfestival.org.au or follow National Folk Festival on Facebook, Twitter and Instagram.

Chris Johnson

 

 

Youth justice in Australia 2015–16

There were about 5,500 young people (aged 10 and older) under youth justice supervision in Australia on an average day in 2015–16, due to their involvement, or alleged involvement, in crime. This number has decreased by 21% over the 5 years to 2015–16. Around 4 in 5 (82%) young people under supervision on an average day were male. Most (84%) young people were supervised in the community and the remainder were in detention. Indigenous young people continued to be over-represented in the youth justice system: young Indigenous people were 17 times as likely as non-Indigenous young people to be under supervision on an average day.

AMA backs call for inquiry into institutionalised racism

The gap between health outcomes for Indigenous and non-Indigenous Australians will not be closed until systemic racism is rooted out of the health system, the Close the Gap Campaign says.

Releasing its 2017 Progress and Priorities Report on National Close the Gap Day on 16 March, the Campaign Steering Committee called for a national inquiry into institutionalised racism in hospitals and other healthcare settings.

“The reality for Aboriginal and Torres Strait Islander peoples is that we have a life expectancy at least 10 years shorter than non-Indigenous Australians. We need urgent action,” Close the Gap Campaign co-chair Jackie Huggins said.

The report found that four interacting factors within Australia’s health system continue to be ‘potentially lethal’ for many Indigenous people:

  • limited Indigenous-specific primary health care services;
  • Indigenous peoples’ under-utilisation of many mainstream health services and limited access to government health subsidies;
  • Increasing price signals in the public health system and low Indigenous private health insurance rates;  and
  • Failure to maintain real expenditure levels over time.

“The persistence of these factors reflects systemic racism; that is, racism that is ‘encoded in the policies and funding regimes, healthcare practices and prejudices that affect Aboriginal and Torres Strait Islander people’s access to good care differentially,” the report said.

“Failure to engage effectively with Aboriginal and Torres Strait Islander people through their elected peak organisations allows such racism to continue.

“The progress of the headline targets in the Closing the Gap strategy will continue to be disappointing until these issues are properly addressed.”

The AMA supported the call for the inquiry, and for knowledge of Indigenous culture to be built into medical school curricula.

AMA President Dr Michael Gannon, AMA Vice President Dr Tony Bartone, and all eight State and Territory AMA Presidents toured the Winnunga Nimmitjah Aboriginal Health Service in Canberra on Close the Gap Day.

Dr Gannon said that while Aboriginal community-controlled health centres like Winnunga Nimmitjah were vital for primary care, it was not realistic to have hospitals dedicated to treating Indigenous patients only.

“It’s so important that patients feel safe in the hospital setting, whether that’s the tertiary hospital setting or in secondary hospitals,” Dr Gannon told reporters.

“If patients don’t feel safe, if they don’t feel secure, if they’re exposed to racism, well that’s simply not good enough.

“So we support that call for the inquiry. It’s so important that primary health care services are very much driven and delivered by Indigenous communities, but we need to do better when, inevitably, like all other Australians, Aborigines and Torres Strait Islanders end up in hospital.”

Keeping medical curricula up to date with community needs was a constant challenge, but more needed to be done to teach medical students about Indigenous culture, he said.

“We talk a lot about the importance of positive experiences at medical student level, at junior doctor level, into specialist training level in rural areas, and the same should apply when it comes to Aboriginal and Torres Strait Islander health,” Dr Gannon said.

“If I reflect on my training as a medical student in Perth, seeing Aboriginal patients was in many ways sadly commonplace.

“But it’s so important that we give medical students across Australia, whether that’s in the rural clinical schools or in the middle of our big cities, exposure to Aboriginal and Torres Strait Islander patients and their wants and needs.”

Dr Gannon said that days like Close the Gap Day were a good opportunity to recognise the advances that have been made, but to realise that there is still so much work to do.

“It’s going to take time, when we look at the metrics, whether they’re in the area of health, whether they’re in the area of employment or education, it is going to take time,” he said.

“But I think that it’s important that at least once a year on National Close the Gap Day, that we reflect on how far we’ve come, and hopefully as every year goes by, we talk about the gap shrinking in whichever target we’re talking about.”

Maria Hawthorne