Indigenous health: one gap is closed

Nevertheless: much remains to be done, and this will require high quality, culturally sensitive research

The 2017 MJA Indigenous health issue explored the social determinants of health that are essential to closing the gap between health outcomes for Indigenous and non-Indigenous Australians, specifically targeting cultural awareness and communication.1 The issue also placed recent gains in the life expectancy of Indigenous Australians in perspective,2 and recognised achievements by an often silent yet dedicated clinical community.

The Journal has continued to develop these themes. In this year’s Indigenous health issue, four research papers and the accompanying editorials underline the progress we are making as a journal and as a medical community in bringing about meaningful change. In this respect, the report by Hendry and colleagues,3 documenting the effective closure of the gap in vaccination rates, is particularly heartening. Vaccination is recognised by the World Health Organization as one of the most cost-effective interventions in public health.4 Hendry and her co-authors describe a program in which Aboriginal Immunisation Healthcare Workers identify and follow up Indigenous children due or overdue for vaccinations, a program that has achieved equality of full vaccination coverage for Indigenous and non-Indigenous children in New South Wales at 9, 15 and 51 months of age. This remarkable outcome is especially significant given the high background susceptibility of Indigenous children to vaccine-preventable diseases. While it is not clear whether the improvement in vaccination rates is attributable to the dedicated program structure or to the deployment of culturally aware health workers, it is certain that partnerships between modern clinical methods and traditional cultural awareness will continue to be the model of choice for improving Indigenous health.

Also noteworthy is the authors’ combination of high quality research with statistically sound methodology in a culturally appropriate setting, a mix essential to the Journal, as detailed in the 2017 Indigenous health issue.1,5 Banks and colleagues6 applied similarly robust and culturally appropriate methodology to draw attention to the substantial undertreatment with lipid-lowering therapies of Aboriginal and Torres Strait Islander people at high risk of cardiovascular disease. They found that 4.7% of Indigenous people aged 25–34 years are at high primary risk, but this age group is not assessed for cardiovascular disease risk under current national guidelines. The accompanying editorial7 summarises a suite of targeted interventions that build on these and other findings published in the Journal.8 While these approaches are no doubt important, adapting the successful approach of Hendry and colleagues’ to vaccination,3 to provide a similarly structured intervention for lipid-lowering therapy, could be a game-changing strategy for closing the gap in cardiovascular disease.

The MJA recognises the power of big data and data linkage studies. Randall and colleagues9 analysed linked hospital and mortality data to explore in depth multimorbidity in Indigenous patients in NSW. The necessary policy and clinical responses are placed in perspective by Broe and Radford10 in their editorial. They note the especially higher level of comorbidities among Aboriginals in mid-life age groups than in non-Aboriginals of the same age, and that this difference is correlated with the age-group peak in the mortality gap between Indigenous and non-Indigenous Australians, highlighted in this Journal last year.2 While the wealth of information made available by big data-based research can sometimes be overwhelming, the MJA prioritises analyses that can change practice.

Finally, Gunasekera and colleagues11 report the high degree of agreement between diagnoses by audiologists and otolaryngologists of otitis media in Aboriginal children, suggesting that audiologists could triage cases in areas where specialist services are limited. The false negative rate was low — in 3.0% of children, audiologists did not diagnose otitis media subsequently detected on image review by an experienced otolaryngologist — and the most serious form, tympanic membrane perforation, was never missed. These findings may open pathways for children in high risk settings — where otitis media is common (prevalence of 29% in this study) but otolaryngologists are few — to more efficiently receive specialist care.

The articles in this issue show that progress in medical and research methodology can be meaningfully combined with cultural sensitivity. The Journal welcomes submissions that further develop these approaches. More broadly, the MJA will continue to highlight emerging issues of significance to Indigenous health, and is leading a global collaboration with major overseas medical journals to publish a joint issue on the health of indigenous peoples around the world in 2019.

While Closing the Gap has become an iconic representation of Indigenous advocacy, it remains essential to maintain focus on the individual components of disease processes, epidemiology, intervention delivery, and cultural mechanisms that influence the achievement of significant change. The MJA will ensure it strengthens its role in delivering the relevant data to clinicians, policy developers, and the Australian community.