Chapter 134: The health of Aboriginal and Torres Strait Islander peoples

The major health challenge in Australia (and several other developed countries) is the health status of its Indigenous peoples, which continues to be significantly worse than that of other Australians.

The 2017 AIHW figures estimated the average life expectancy for Aboriginal and Torres Strait Islander males was 69.1 years (a gap of 10.6 years compared with other Australians) and 73.7 years for women (a gap of 9.5 years).¹

The commonest cause of death is cardiovascular disease, especially ischaemic heart disease which causes about 57% of these deaths.² The contrast with other Australians is most marked at 25–54 years. Diseases of the circulatory system, injury and poisoning, respiratory illness and neoplasms continue to be important causes of death. Deaths from infectious diseases and genitourinary disorders continue to occur at much higher rates than among other Australians.

One in nine adults have type 2 diabetes—a prevalence 3.3 times higher at any age than the general population.³

Records written by early settlers indicated that the Indigenous people appeared to be in good health, probably better than the majority of new arrivals transported from England. The total Aboriginal population has been estimated as 750 000 in 1788. It fell to about 70 000 in the 1930s after 150 years of exposure to white civilisation. Significant causes were deaths at the hands of the settlers (recorded as approximately 20 000) and infectious disease.

The main diseases that decimated the population were smallpox (two severe epidemics: 1789 and 1829–30), influenza, TB (very severe), pneumonia, measles, varicella, whooping cough, typhoid and diphtheria. The Aboriginal and Torres Strait Islander population is now estimated to be 700 000.

The level of infant and maternal mortality continues to be a concern. After great reductions in infant mortality rates in the 1970s, there has been a levelling off, with rates remaining 3–5 times higher than those of other Australians. Despite some improvement, we all need to work to close the gap, and general practice is an ideal setting to embrace this.^4,5

It is important to understand that Aboriginal and Torres Strait Islander people have a diverse range of different cultures, with each group needing a special understanding of its cultural issues. This understanding is best gleaned from local community members and groups.

Practitioners working in primary health care in rural and remote areas in Central and Northern Australia are advised to use the CARPA Standard Treatment Manual.⁶

The first national survey of the health of Aboriginal and Torres Strait Islander peoples took place in 1994, and the most recent survey (2012–13) found that around 40% consider their health to be good or excellent.³

The 2012–13 survey highlighted the following disorders:

• asthma

• ear and hearing problems

• diabetes

• hypertension

• kidney disorders

• heart disease

• skin disorders

• eye problems, including trachoma

• nutritional status (especially obesity)

• substance abuse (e.g. alcohol, marijuana, petrol sniffing)

• dental problems (a reversed trend of dental caries)⁷

• psychological distress and family stressors

According to BEACH data, the seven most common problems managed at encounters with Aboriginal and Torres Strait Islander patients were (in order) respiratory infections, diabetes, hypertension, depression/anxiety, asthma, immunisation, otitis media.⁸

The low health status of Aboriginal and Torres Strait Islander peoples has many underlying causes, and should be understood in terms of the social determinants of health; these are what Professor Sir Michael Marmot calls the ‘causes of the causes’.⁹ Many of these stem from historical dispossession, poverty and intergenerational trauma. Determinants include geographical isolation, high population mobility, unemployment, poor housing, low education attainment, temperature extremes in central Australia, increased exposure to infectious diseases, especially in subtropical areas, and a lack of appropriate service deliveries.

Poor living conditions including overcrowding contribute to poor health outcomes, such as substance abuse, domestic violence, other social dysfunction and child malnutrition. Other environmental health issues, such as lack of adequate shelter, lack of basic amenities such as clean running water and adequate sewage disposal facilities, and lack of refrigeration, all impact on health.

Associated comorbidities of children admitted to the infectious diseases ward of the Royal Darwin Hospital¹⁰ included dehydration (50%), malnutrition (60%), hypokalaemia (70%), iron deficiency (90%), anaemia (25%), pneumonia (24–32%), chronic suppurative otitis media (37%), urinary tract infection (10%) and scabies (25%).

Priority health problems have been identified by the National Aboriginal Health Strategy and are summarised in TABLE 134.1.

An understanding of Aboriginal and Torres Strait Islander cultural issues is fundamental to successful management outcomes. Doctors should realise that, while examining Indigenous patients, they are themselves being examined. Failure to bridge the cultural divide leads to frustration on both sides: the patient has little faith in the promise of health gains, and the clinician cannot understand why his or her supposedly clear instructions are not being carried out.¹¹

Arguably, the most important step after dealing with the presenting complaint is encouraging the patient to feel welcome enough to want to return. Managing chronic health issues is a marathon, not a sprint. A single visit to a brilliant specialist is less useful than ongoing interaction with a generalist local clinician who is culturally sensitive and applies basic, evidence-based treatment according to the patient’s needs and preferences.

Handy communication hints include:

• Allow extra consultation time.

• Don’t be afraid of pauses during conversation.

• Avoid jargon; recheck the patient’s understanding.

• For complex explanations, use images.

• Be aware of your body language, including eye contact.

• Be humble and listen; you don’t have all the answers!

Doctors who work in Aboriginal or Torres Strait Islander communities (see FIG. 134.1) must appreciate and respect the local culture and be aware of its significance to health and behaviour.

Many patients feel more relaxed during the consultation if accompanied by a relative or friend, who can provide support and help them interpret your medical advice later.

Women’s business

‘Women’s business’ can be defined as the range of experience and knowledge that is the exclusive preserve and domain of Indigenous women. It encompasses issues about menstruation, pregnancy, childbirth and contraception.¹² Such matters may traditionally not have been discussed directly but were conveyed indirectly through stories, ceremonies and songs. For more traditional women it is taboo to talk about women’s health issues to male doctors or male health workers, or to be physically examined by them. Doing so may cause shame and embarrassment.¹³

Men’s business

Similarly, the cultural issue of men’s business needs to be understood and respected. This applies to manhood initiation rites, circumcision, sexuality and sexually transmitted infections.

Sorry business

‘Sorry business’ is the process of grieving, and this needs to be clearly understood. There is a cultural obligation for mourners to grieve the death of a relative in a special way, sometimes for many days or weeks. Mourners may change their appearance and avoid any mention of the deceased person’s name or any portrayal of his or her likeness. The place where the person died may be deserted for a certain time (which can impact on medical clinics) and then ceremonially ‘smoked out’.

Aboriginal and Torres Strait Islander children suffer the same spectrum of health problems as children in developing countries and Indigenous communities throughout the world, and the infant mortality rate remains high. The major problems are malnutrition, diarrhoeal disease, skin infections and respiratory tract infection. Common problems are presented in TABLE 134.2.

Acute respiratory tract infections are a common reason for admission to hospital. Bacterial pneumonias occur more commonly than in non-Indigenous children and usually present late. Chronic upper respiratory tract disease is typical in younger children and mucopurulent nasal discharge is present in most preschool children.

Chronic suppurative otitis media, which is almost universal in preschool children, is often refractory to treatment and can lead to significant hearing impairment in many children. It can develop without apparent preceding acute otitis media and may be related to poor nutrition and anaemia. The basic treatment is ear toilet with povidone–iodine solution, followed by dry mopping with rolled toilet paper/tissue ‘spears’, or initial use of the ‘spears’ followed by acetic acid drops.

Skin infection and infestation are almost as prevalent as respiratory tract disease. Scabies is endemic and occasionally reaches epidemic proportions. It can be a very debilitating problem and can present in very young infants, in the first few weeks of life.¹⁴

Anaemia, usually iron deficiency, is found in at least 25% of children in remote regions. Apart from reduced intake, intestinal loss from hookworm and other parasitic infection is an important factor. Treatment includes deworming in addition to iron supplements.

Diarrhoeal disease is a very common reason for hospital admission. Causes of infective gastroenteritis include rotavirus, bacteria including Shigella, Salmonella and Campylobacter, and parasites such as Giardia lamblia, Strongyloides and Cryptosporidium.

Other important and serious problems encountered more frequently in Aboriginal and Torres Strait Islander children include bacterial meningitis (especially Haemophilus influenzae), septic arthritis and osteomyelitis, pyomyositis, Streptococcus pyogenes infections with associated glomerulonephritis and rheumatic fever, urinary tract calculi, urinary tract infection (especially at 6–18 months of age), hepatitis B and petrol sniffing (see CHAPTER 128).

Appropriate levels of immunisation in these communities will have enormous health benefits. Poliomyelitis, diphtheria, pertussis, tuberculosis and H. influenzae are now rare and it is hoped that hepatitis B, varicella and HPV infections will be drastically reduced.

The GP attending Aboriginal and Torres Strait Islander patients should develop special skills in the diagnosis and management of the following health concerns:

• diabetes mellitus, frequently with hypertension and kidney disease

• trauma

• substance abuse, including alcohol and smoking

• ear and eye infections

• respiratory disorders—URTIs and LRTIs, asthma

• skin disorders (e.g. fungal infections, impetigo, leg ulcers, cellulitis, boils)

• parasitic infestations (e.g. scabies, lice)

• gastrointestinal infections (e.g. Campylobacter enteritis, giardiasis, Shigella)

• sexually transmitted infections

• psychosocial dysfunction

• bites and stings

• severe infections (e.g. meningitis, rheumatic fever, septicaemia)

• hepatitis B

• tropical diseases (where applicable)

• worm infestation (e.g. strongyloides)

However, the general management of medical disorders follows the principles and treatment guidelines outlined in this book. Antibiotic and other treatment guidelines for rural and remote communities are most useful.⁶

Cardiovascular disease is a major cause of continuing high rates of mortality and morbidity, particularly ischaemic heart disease, but also rheumatic heart disease and stroke. Mortality from ischaemic heart disease is almost twice that of the non-Indigenous population overall and 6–8 times higher in those aged 25–64 years. Reasons for this include high smoking rates (2.6 times the rate for others)³, type 2 diabetes (3.3 times the rate), obesity and low rates of physical activity. Rheumatic heart disease is 64 times as common in the Northern Territory Aboriginal population compared to the Australian average.¹⁶

Targets for secondary prevention of cardiovascular disease and diabetes mellitus are as presented in CHAPTER 20.

Otitis externa and otitis media with its acute and chronic complications are major health problems in Aboriginal and Torres Strait Islander children, especially in rural and remote regions. Acute otitis media should be treated early and aggressively with antibiotics to (somewhat) reduce the risk of chronic suppurative otitis media, which is very difficult to cure once established. Check carefully for a perforation, which may affect management.

Treatment guidelines¹⁷

Treatment guidelines

• Peri-orbital cellulitis and penetrating eye trauma. Arrange evacuation to hospital; if critically ill or delay in transfer give empirical treatment with ceftriaxone IM or IV once daily. Add gentamicin IM or IV as single dose for a child <3 months or patients with other risk factors such as diabetes.

• Conjunctivitis. Consider two swabs if indicated (for microculture and Chlamydia PCR). If not viral, apply topical chloramphenicol eye drops or ointment.

• Neonatal gonococcal ophthalmia and Chlamydia infection. Refer to CHAPTER 51.

• Gonococcal conjunctivitis. (Particularly if lots of pus, or in neonates) give ceftriaxone 1 g IM (children; 50 mg/kg/dose).

• Trachoma. These patients have ‘scratchy’ eyes and watery discharge ± red eye (see FIG. 134.2):

  • – if over 6 kg and not pregnant: azithromycin (o) as single dose

  • – if under 6 kg or pregnant: erythromycin or roxithromycin (o) for 21 days

  • – check and treat household contacts

  • – check routinely for ‘follicles’ of trachoma

Skin infections are the commonest presenting problem in many clinics.^18,19 These include a high incidence of scabies and tinea corporis (ringworm), boils and carbuncles, infected wounds, impetigo and cellulitis. A notably serious complication of skin infections is post-streptococcal glomerulonephritis secondary to S. pyogenes infection. Scabies is the most common skin infestation and commonly starts as an itchy rash with pinhead papules in the web spaces of the fingers.

Recommended treatment (in summary)^6,19

Impetigo and other skin sores

• Soak and remove crusts with saline or soap and water or povidone–iodine or potassium permanganate (Condy’s crystals) solution

• Antibiotic treatment (if required)

  benzathine penicillin, IM, statim dose

  or

  flucloxacillin/dicloxacillin (o) or cephalexin (o) or co-trimoxazole (o) for 3–7 days

Cellulitis (mild–moderate) and erysipelas

As for impetigo, above

or

procaine penicillin IM daily for 5 days

or

benzathine penicillin IM on days 1 and 3 or daily for 3–5 days

If no improvement: flu/dicloxacillin (as below) plus probenecid

Boils, carbuncles, abscesses, bullous impetigo (Staphylococcus aureus infections)

Flu/dicloxacillin (o) 6 hourly for 5–10 days

Suppurative wound infections

• Use local measures such as aseptic dressings and topical antiseptics

• If necessary, add flu/dicloxacillin (as above); consider clindamycin

Tinea corporis (ringworm)

• Use benzoic acid ointment, Whitfield’s ointment or one of the imidazole preparations: apply 1–3 times daily for 4–6 weeks or for 1 week after rash resolves

• Systemic agents (e.g. griseofulvin (o) once daily) may be necessary

Scabies

• Apply permethrin 5% cream or benzyl benzoate 25% emulsion (see CHAPTERS 117 and 120). Treat household members.

• For children less than 2 months use: sulphur 5% cream for 2–3 days

  or

  crotamiton 10% cream daily for 3–5 days

• For infected scabies, use flu/dicloxacillin or erythromycin

Pityriasis versicolor (white spot)

Refer to CHAPTER 121.

GABHS INFECTIONS

Group A beta-haemolytic Streptococcus (GABHS) infections are a significant problem, causing diseases such as pharyngotonsillitis, impetigo, cellulitis, otitis media and scarlet fever. Two important immunological reactions to the streptococcus toxin are acute rheumatic fever and post-streptococcal glomerulonephritis (PSGN).²

Acute rheumatic fever

Rheumatic fever and its effects are a serious cause of cardiovascular morbidity and mortality in Aboriginal and Torres Strait Islander peoples, who have the highest rate of acute rheumatic fever of any ethnic group in the world, with an incidence of 250–300 per 100 000 children.²⁰ It is a classic hallmark of overcrowding, poverty and lack of hygiene, all of which facilitate streptococcal infection (see CHAPTER 35 for clinical features).

Treatment is with benzathine penicillin (IM).

Acute glomerulonephritis

There is an association between PSGN (see CHAPTER 76) and streptococcal skin and throat infections. Impetigo is the more frequent antecedent to PSGN. A study based on the fact that the Aboriginal and Torres Strait Islanders have an incidence of end-stage kidney failure 10 times greater than the general population found that people with a history of PSGN in childhood had a risk of overt albuminuria more than six times that of a control group.²¹ There is no simple treatment of PSGN and preventing streptococcal infection remains the most important control strategy. Penicillin is beneficial in preventing spread during epidemics.

COMMUNICABLE DISEASES

Communicable diseases remain a problem, with an up to 10-fold increase over the non-Indigenous population for diseases such as hepatitis A, hepatitis B, meningococcal disease, Salmonella, Chlamydia and tuberculosis.³

Tuberculosis

The rate of TB in Aboriginal and Torres Strait Islanders is 10–15 times higher than for other people in the Northern Territory.² This is related to poverty, overcrowding, malnutrition and homelessness. Early diagnosis and treatment is the key to its control. This includes detection of latent TB infection in those at risk and strategies to prevent transmission in acute cases. BCG immunisation in high-risk groups is a key preventive strategy and is recommended for newborns from high-risk communities (see CHAPTER 29).

Leprosy (Hansen disease)

Leprosy (see CHAPTER 15) has been endemic in Northern Australia for over 100 years, although the incidence is reducing. Control strategies include early diagnosis of new cases, treatment with multidrug therapy, monitoring of treatment to ensure its completion, and prevention of nerve function impairment (NFI). NFI is monitored by a brief voluntary muscle and sensory test. If detected early, it responds to anti-inflammatory medication such as prednisolone.

BCG vaccination, used to prevent TB, has probably had a protective efficacy against leprosy of approximately 50%.²

Intestinal helminths are common in tropical northern Australia. Symptoms may include diarrhoea and abdominal pain with or without distension. Anaemia is common with hookworm infestation. Refer to CHAPTER 15 for more information.

Treatment⁶

• Hookworm, roundworm, threadworm—pyrantel embonate or mebendazole or albendazole

• Whipworm—mebendazole or albendazole

• Strongyloidiasis—albendazole or thiabendazole

• Cutaneous larva migrans—albendazole or thiabendazole

Community worm program. In selected communities a worm eradication program is recommended for children between the ages of 6 months and 12 years with either pyrantel embonate or albendazole.

In the discussion and management of STIs, it is important to be aware of the significance of men’s and women’s ‘business’; that is, the cultural sensitivities regarding specific gender feelings and issues, which need to be observed. For some women, it is inappropriate for a male doctor to discuss such issues with them but appropriate for a female doctor, nurse or health worker to do so. The same taboo may apply for a female health worker discussing STIs with a male patient.

STI screening consists of counselling, taking blood for RPR, hepatitis B and HIV, and a firstvoid urine sample for Gonococcus, Chlamydia and Trichomonas PCR (NAAT). Anyone who presents with an STI symptom such as a discharge or skin lesion should additionally have urethral/cervical swabs for Gonococcus and Chlamydia, ulcer swabs, viral media swab if suspected herpes, ‘snip’ biopsy (where appropriate) for Donovanosis or malignancy, and urine for MCU. Women can take their own tampon swabs instead of a cervical swab if preferred. All sexually active females under 25 years should be screened opportunistically for Chlamydia (in particular) and gonorrhoea. Follow-up after therapy and contact tracing, screening, treatment and notification are all necessary.

Specific treatment⁶

Refer also to CHAPTER 117.

Urethritis and cervicitis

azithromycin 1 g (o) as single dose

plus

amoxycillin 3 g (o) + probenecid 1 g (o)—single dose (but use ceftriaxone 500 mg (IM) in penicillin-resistant areas)

Genital sores

Herpes simplex, syphilis and Donovanosis are much more common than chancroid and lymphogranuloma venereum. Serology for syphilis is essential. Advise to avoid sex and for males to use condoms until treatment is completed and lesions well healed.

Syphilis

benzathine penicillin 1.8 g IM as single dose, if infected less than 2 years ago. If >2 years or unsure, repeat same dose weekly for 2 further injections.

Donovanosis (granuloma inguinale)

azithromycin 0.5–1 g (o) once daily for 7 days

or

1 g (o) once weekly for 4 weeks

(if not pregnant or breastfeeding); if so, give erythromycin or roxithromycin

Herpes simplex

See CHAPTER 117.

Genital warts

See CHAPTER 117.

Pelvic inflammatory disease

If sexually acquired, it is usually due to Neisseria gonorrhoeae or Chlamydia trachomatis (less likely). For treatment, see CHAPTER 103.

Vaginal infections

Refer to CHAPTERS 106 and 117 for treatment. Trichomonas vaginalis is usually sexually transmitted, while Candida albicans and bacterial vaginosis are not.

• Don’t assume English is a first language, particularly in remote areas.

• Don’t assume a nod means understanding and/or agreement to treatment.

• Check hearing as chronic ear infections can impair it.

• Appreciate the different family network, particularly the tendency of grandmothers and aunts to care for children.

• Don’t assume a broken appointment means the patient will not return for treatment. Often family and cultural duties take precedence.

• Be aware of cultural sensitivity.

• Don’t touch a patient, particularly of the opposite sex, without seeking permission and explaining what you are doing.

• Be aware that patients may not be comfortable with direct questions about their family and health.

• Don’t be too stern or authoritative during a consultation.

• Ensure receptionists and other staff understand the cultural sensitivities involved.

• Be accepting, respectful and non-judgmental.