“Let’s not talk about sex”; reconsidering the public health approach to sexually transmissible infections in remote Indigenous populations in Australia

To the Editor: Bowden and Fethers’ provocative recommendations for mass antibiotic treatment to reduce the prevalence of sexually transmissible infections (STIs) in remote Aboriginal communities is based on the failure of the current approach of screening and treatment of individuals to reduce STI prevalence.1 However, approaches that address a single health issue in isolation will not succeed in improving Aboriginal health.

The biomedical approach proposed could reduce the likelihood of a sexually active person becoming infected with an STI, but, in our experience, many Aboriginal people object to the “sheep-dip approach” of mass indiscriminate treatment. Moreover, it is ethically difficult to justify giving a cocktail of four antibiotics with potentially adverse side effects to all people in a population when only one or two out of 10 will benefit. The proposed staggering of doses would only increase the difficulty and reduce compliance. The people who don’t participate in current programs are the same people who would be least likely to comply with a new program.

The greatest merit of Bowden and Fethers’ proposal is in addressing the social determinants of poor health. The ancillary “life skills” programs they suggest could also be useful, and to this we could add interventions with the core groups2 and multifaceted interventions to reduce the use of alcohol and other drugs that fuel disinhibited and violent behaviour, including sexual abuse.

Most importantly, tackling STIs in isolation will fail to bring about improvements in the many areas of Aboriginal health requiring attention. Arguably, given the profound health inequalities experienced by Aboriginal Australians, the best approach would be to resource culturally secure, comprehensive primary health care services adequately,3 at a level greater than that available for urban middle class Australians. This has not yet been achieved in remote areas. Yet the complexity of Aboriginal social and health issues demands the most experienced and skilled health professionals rather than the current workforce, which is characterised by high turnover and consists too often of overseas-trained medical staff, nurses on short-term contracts and Aboriginal health workers, many of whom suffer from illness or family trauma.

Before contemplating mass community treatment, priority must be given to improving the social determinants of health, enabling Aboriginal people to have control over their own lives. This would effectively involve Aboriginal leadership at community level generating Aboriginal-led solutions. This would have a longer-term effect on health improvement and ensure good access to quality primary health care that could respond to the complex needs of Aboriginal people.4 It would require continuity of care from committed, appropriately trained health professionals who understand and work within the values and priorities of Aboriginal people. Aboriginal people want primary health care that delivers culturally secure, empowering and holistic care.5 Mass treatment fails in this. Enhancing multidisciplinary primary care with linkages to the community outside the clinic could help address the many other causes of chronic illness that contribute to the shameful gap in morbidity and life expectancy between Indigenous and non-Indigenous Australians.