Health horizons - Issue 3

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Commentary
Outgoing Director of the Sansom Institute Professor Kerin O'Dea has contributed to many Indigenous health initiatives since her seminal work examining the positive effects of the hunter-gatherer diet in the '70s and '80s. Here she reflects on current challenges and recent achievements in Indigenous health.

Three scholars, three stories
Health horizons chats to three PhD candidates working in Indigenous health about what drives them and their research.

Research spotlight
Exploring the therapeutic potential of native plants

Sansom pharmacologists are collaborating with an Indigenous corporation in far north Queensland in a project to develop therapeutic products that harness the healing properties of native plants. 

Research in action
S
moking cessation strategy

A collaboration between Sansom researchers and the SA Aboriginal Health Council is helping Aboriginal Health Workers to stop smoking.

Five minutes with .....
Professor Robyn McDermott

Talking shop with leader of the newly-established Centre for Research Excellence in Chronic Disease Prevention in Rural and Remote Communities.


We've come too far to turn back now

Professor Kerin O'Dea A leading figure in public health, nutrition and chronic disease prevention, Professor Kerin O'Dea AO, recently stepped down from her role as Director of the Sansom Institute for Health Research in order to devote more time to her role as chief investigator in the National Health and Medical Research Council Program Grant, Improving Chronic Disease Outcomes for Indigenous Australians: Causes, Interventions and System Change. Originally training in biochemistry and pharmacology, Kerin is well known for her seminal work highlighting the positive health effects of the hunter-gatherer diet with Aboriginal people in the Kimberley in the late '70s and early '80s. Since then she has been instrumental in establishing numerous applied research programs with Aboriginal and Torres Strait Islander communities around Australia. Here she shares some insight gained from 35 years in Indigenous health.

I recently showed a friend my diaries from the seven weeks that I spent with the group from Mowanjum in the West Kimberley during the dry season of 1982. He was struck by the focus on food. Then the focus was on surviving day to day as well as learning so much about the fascinating way of life. Thirty years on I'm still passionate about food and the transformative effects of diet. Frustratingly, with our increasingly industrialised food system, the potential of truly healthy diets are still largely untapped as a means to prevent and treat chronic disease.

Fresh from several years overseas as a biochemist researching the cellular mechanisms behind obesity and diabetes, my first 'lifestyle change' study in 1977 marked a major turning point for me. From the short time that I lived the traditional hunter-gatherer lifestyle with the people from the Mowanjum community - hunting, fishing and foraging for food, sometimes going hungry - the results were clear: the participants showed marked improvements across a range of metabolic health indicators.

Five years later I went back and repeated the exercise, only on this occasion with people who had diabetes and this time the effect was even more profound. Within seven weeks every metabolic abnormality improved: their fasting glucose and insulin levels fell, triglycerides and blood pressure fell, and bleeding time (a crude indicator of thrombosis tendency) increased - indeed every risk factor for heart disease improved.

Three decades on, and the body of research has grown exponentially - everyone has a much better understanding of the impact of diet and lifestyle upon health. Frustratingly, the gap between health outcomes for Indigenous and non-Indigenous Australia remains; it's clear that knowledge in itself won't solve the problem.

What will actually work to alleviate the problems and address the disparity? Improving the circumstances in which people live so they are actually in a position to change their lifestyle for the better would be a good start. Healthy foods (fresh fruit and vegetables, lean meat and fish) are particularly expensive in remote communities, despite the best intentions of many stores. And despite people in remote communities often spending 40-50 per cent of their income on food, because most are living on welfare payments, they often resort to poorer quality processed foods. I have become very interested in the economics of food choice: energy-dense, nutrient-poor processed foods provide many more calories/dollar than do most fresh healthy foods. This probably is a good part of the explanation of why overweight and obesity are more common among socially disadvantaged sectors of the population in western societies such as Australia.

Much of public health research describes health problems and the impact of social disadvantage in great detail, without actually moving to the next step and doing something about it. We need much more intervention and evaluation research. We also need research that tells us the cost of not intervening (in addition to the cost of intervening).

My overriding objective in my time as Director of the Sansom Institute for Health Research has been to encourage research that makes a difference: more effective therapies; early intervention (in life and in the disease course) to minimise adverse health outcomes; a clear focus on interventions to reduce the adverse impacts of social and economic disadvantage.

It's not enough to treat disease when it presents, we must do more to intervene early to prevent illness. Boosting funding is important but there's also much that we can do to improve existing health systems and services and make better use of resources. Creating new therapies is well and good but we need to create more effective therapies, not just ones that may make a fortune for shareholders at some point down the track.

I've been proud to see an inspiring range of practical, Indigenous-driven research come about in our NHMRC program grant, Improving Chronic Disease Outcomes for Indigenous Australians: Causes, Interventions and System Change. The grant is supporting scores of projects and evaluations around Australia, looking at everything from optimising pre-pregnancy health to improving food supply in outback stores.

These initiatives go much further than simply quantifying the problem. They are about working with what we've got to make a difference, equipping a new generation of health leaders to produce research to bring about positive health outcomes - not only for Aboriginal and Torres Strait Islanders, but for anyone whose circumstances put them at a disadvantage, whether they are migrants, people experiencing homelessness, the unemployed or the growing ranks of the working poor.

Yes, the challenges are great, but what choice do we have but to rise to them?


Three scholars, three stories

A cohort of PhD candidates is based at the Sansom Institute for Health Research as part of the NHMRC Project Grant, Improving Chronic Disease Outcomes for Indigenous Australians: Causes, Interventions and System Change. Health Horizons spoke to three of them about their research, inspiration, and hopes for the future.

Yvette RoeYvette Roe is a Njikena /Jawuru woman from the West Kimberley whose PhD research explores the disparity of care experienced by Aboriginal and Torres Strait Islanders admitted to hospital for Acute Coronary Syndromes in Australia.

"I'm the eighth child of eleven, the first from my immediate family to go to university and the first to do postgraduate study. When you see people in your family who are dying young, primarily between the ages of 30 and 45, when ill-health is so normalised that good health is often the exception, and you realise there are concrete things that we can do to improve health outcomes, well, the desire to be an agent of change, it's very motivating.

"Cardiovascular disease is the number one killer in Aboriginal people, and it's particularly bad for women. Often we look at disease and illness in silos and we treat them separately - cancer, or diabetes, for example - but really it's a whole of life issue and asking how do we manage that, how do we engage people with a health system that can be very hostile, very alien, very discriminatory; That's not just for Aboriginal people, it can be the same story for women, for older people, people with mental illness, for anyone that doesn't have the skills or time or resources to negotiate their way around a disjointed and complex health system, it's easy to fall through the cracks.

"How do we engage Aboriginal people in ongoing care following an acute coronary event? We know that 12 months after the event that mortality rates are high and patient-clinician engagement is low. You can't just look at the problem and say it's that the hospital or clinicians are racist or Aboriginal people don't care about their health. I mean I've never met a health clinician who doesn't want to provide the best care and I haven't met an Aboriginal person who wants to die at 40 either. I think there's more in common than not and there's a lot of potential to improve outcomes by connecting acute care better with post-hospital care and rehab.


"As an Aboriginal researcher I think it's important to acquire very technical skills and be almost bilingual in our roles as intermediaries between Indigenous people and the research world. We don't need research that makes us experts on Aboriginal people, we need Aboriginal people to be experts and leaders in high quality research. We need to be on the front foot about driving the research agenda with our non-Indigenous colleagues and designing programs that lead to improved health outcomes. Research that identifies and describes the problems is well and good but we have to be courageous and mature enough to use that knowledge to make a difference with practical programs."

Karla CanutoKarla Canuto is a Torres Strait Islander and PhD candidate at UniSA who is leading a trial examining the health effects of a structured exercise program for Aboriginal and Torres Strait Islander women.

"I studied sport and exercise science at James Cook University, Townsville before returning to far north Queensland. After a year back in my home town of Weipa working for Queensland health I took a job on Thursday Island, where my father grew up. It was a short-term research project with the University of Queensland targeting youth and physical activity. Then I ventured down south only to find myself back on Thursday Island three years later.

"It was through this opportunity working for Queensland Health as senior physical activity health promotion officer that I found my passion. I started yarning to my cousins and aunties about their barriers to exercise and healthy living. I also researched what other communities were doing and together with my work colleagues we came up with an eight-week team exercise program called the Thursday Island Women's Fitness Challenge. And it was a success! The women loved it and participants lost an average of 5cm each from around their waists.

"Securing funds for the program was extremely difficult. We were assisted by two small grants but could not support the program over the long term or in the other 20 communities of the Torres Strait and Northern Peninsula Area. It was at this time that I was offered the opportunity to come to UniSA to do a PhD. It gave me the chance to turn that small project into a randomised trial, thoroughly evaluate it and assess overall metabolic health, not just waist circumference.

"For me the most exciting part of this work is that I'm working with people, over a hundred amazing women, not just a dataset. It's also rewarding to hear women say that the program has changed their lives and that they're now making healthier choices for themselves and their families and they can appreciate that by doing this research they are contributing to a project that will potentially benefit thousands of other women and their families. From here I hope we have enough evidence to advocate for these types of community programs that can make a real difference to people's lives."

Andrew Black with his daughterDr Andrew Black's PhD research examines the nutritional impacts and health effects of subsidised fruit and vegetables upon families at the Bulgarr Ngaru Aboriginal Health Service in northern NSW.

"Working in rural and remote health is a lot of fun and it's taught me a lot, professionally and personally. I feel privileged to have lived in places like Arnhem Land, different parts of Asia and Papua New Guinea; I've learned so much, not just about other people and cultures, but also about myself.

"I'm a GP, but based in remote areas, I've run entire health services and been called upon to do everything from obstetrics to optometry. The clinic I'm now based at provides health services to a 5000-strong Aboriginal population spread around the Grafton area, including the Baryulgil community at the site of a former asbestos mine.

"I first heard about Bulgarr's subsidised fruit and vegetable program when I was working in Canberra at the Department of Health and Ageing and I met Ray Jones, a GP who first helped set up the program. I saw the opportunity for some research to provide a clearer picture of the program's health effects, so in 2008 I came to live in Grafton, working part time as a GP and part time as a researcher. I have been fortunate that others, particularly Kerin O'Dea, shared my enthusiasm.

"I've compared the health records of 60 families before and after 12 months of receiving a subsidised box of fruit and vegetables every week and the impacts are clear: fewer visits to GPs and hospital emergency department, fewer skin infections experienced, and less antibiotics prescribed. The health effects were accompanied by improvements in blood biomarkers showing increased fruit and vegetable intake. The results are encouraging but there are many questions still to be answered, like what are the economic benefits, and how do you provide these sorts of programs while still encouraging independence and self-sufficiency?

"What's my manifesto for Indigenous health? There have been so many ideas and reviews and reports but really I think it's about fostering people's ability to make their own choices, creating independence and letting Aboriginal people determine what's important to them."


Exploring the therapeutic potential of native plants

researchers are working to develop a healing product from the dodonaea polyandra plant

A unique collaboration between an Indigenous corporation and pharmaceutical scientists to develop new products that harness the healing properties of native plants is gaining accolades and opening up an exciting new area of research.

Five years after UniSA pharmacists first got together with members of the Chuulangun Aboriginal Corporation of the Wenlock and Pascoe Rivers region in Cape York Peninsula, Queensland, the partnership is hitting its stride, with a patent pending for plant compounds with anti-inflammatory properties that could provide an effective new treatment for conditions like psoriasis and dermatitis.

Research associate Dr Bradley Simpson, of the Sansom's Institute for Health Research's Quality Use of Medicines and Pharmacy  Research Csentre, who has been part of the collaboration from the start, says that the project is making real headway following recent success in the laboratory.
"At the moment we're focussing on one particular plant, Dodonaea polyandra (known as 'Uncha'), which our partners have traditionally used to treat toothache," he says. "After examining the whole plant and its active compound's properties, we tested the activity in an animal model of inflammation, with encouraging results."

The compound has been shown to be effective in treating both acute and chronic skin inflammation in vivo, giving the research team - which also includes Chuulangun's David Claudie and UniSA's Dr Susan Semple and Adjunct Professor Ross McKinnon - strong justification for continuing. "The research is gaining recognition at international conferences, and IP Australia is using it as a case study on its website," Brad says.

Supported by an NHMRC development grant, the project is driven by the traditional owners who have an agreement with UniSA to protect the intellectual property and share any commercial benefits. The next step will be to determine the mode of action of the compounds, refine formulations of both extracts and pure compounds and do further tests to identify any potential side effects, with a long-term goal to produce a product that will provide income and employment opportunities for the traditional owners.

"Developing new therapies from native plants is an exciting area to be working in because what we're doing is unique in Australia and it offers unlimited potential," says Brad. "It's incredible that we're in 2012 and there's just so much that we don't know about the medicinal properties of our native flora."


Research part of strategy to tackle Indigenous smoking rates

smoking

With close to half of Aboriginal and Torres Strait Islanders over the age of 15 being smokers and tobacco the leading contributor to the burden of disease in Indigenous Australia, reducing rates of smoking is a pressing priority in Indigenous health today.

A Sansom Institute-based project is working to tackle the problem by helping Aboriginal health workers to stop smoking - and in the process, it's proving that bottom-up, applied research works, informing policy and practice to achieve positive change.

A collaboration between the Aboriginal Health Council of South Australia (AHCSA) and the Sansom's Social Epidemiology and Evaluation research group, the Smoking Reduction Strategy Development and Intervention Among Aboriginal Health Workers initiative signals a departure from outdated one-size-fits-all anti-smoking campaigns in favour of a more nuanced, cooperative, and culturally-sensitive approach.

Funded by SA Health's Strategic Health Research Program, the project included surveying Aboriginal Health Workers to identify the factors contributing to their high smoking rates. (Aboriginal health workers were targeted because with smoking rates around 50 per cent they represent a microcosm of the wider Indigenous community; they're also role models who have the potential to influence clients' attitudes and behaviours.)

Project partner and AHCSA Tackling Tobacco Coordinator Harold Stewart says the research is the first to provide a detailed picture of the complex issues at play. "The World Health Organization seems to suggest that disadvantage is a big contributing factor to high smoking prevalence, and while we believe that disadvantage is a factor it's not the only factor," he says.

Harold and his colleague Alwin Chong say that as well as issues such as dispossession and racial discrimination affecting the wider Indigenous community, health workers reported that they were under stress at work, with a lack of professional recognition and advancement options on top of the strain of being the first point of contact for people in crisis.

The project has been informed by a 2011 productivity commission report, Overcoming Aboriginal Disadvantage that backs the notion that when people have a degree of mastery and control over their lives - as opposed to being overwhelmed by stressors associated with work, housing, money etc - that their health status improves and there is less of a need to smoke or abuse substances. As chief investigator Dr Margaret Cargo says: "It's all about identifying the determinants - that is, the circumstances that drive high smoking rates - and then focusing on creating a context to enable cessation."

One major driver for many Aboriginal people, points out Harold, is the ongoing pain and suffering caused by the forced removal of children from their mothers. "I believe there's a lot emotional healing that need to occur before many Aboriginal people will feel able to quit," he says. And an ingrained association of smoking with grief can make the task of stopping smoking permanently even more difficult. "I'm a former smoker and when I look back over my journey, what got me smoking again was grief and loss. You'll always see a cloud of smoke at an Aboriginal funeral - even people who don't smoke much will light up at a funeral."

After identifying the determinants and barriers, the research team (which as well as Harold, Alwin, and Margaret also included UniSA's Dr Anna Dawson and Professor Mark Daniel) consulted with Aboriginal Health Workers and other health service staff to produce a list of 74 practical strategies to help them to stop smoking - such as subsidised nicotine replacement therapy, addressing workplace stressors, tackling the normalisation of smoking at work, and developing culturally-relevant smoking cessation resources.

The next step will be to visit health services to help formulate stop-smoking action plans, prioritising strategies for each local setting. It's all part of an overriding participatory approach that sets the project apart, according to Anna Dawson. "We share all the decision-making and we adhere to Iga Warta principles, which are all about pro-active prevention, a sustainable approach, and respecting Aboriginal notions of time, space, family and community," she says. "We're also constantly feeding back results to the health workers themselves and to Quit SA and Drug and Alcohol Services SA so they can apply what we're learning straight away."

It's an approach that, in combination with ramped up social marketing campaigns and an expanded tobacco-specific workforce, is starting to have an impact, says Harold. "We've influenced government and policy makers, and there's been a general shift in attitude in the community. Where once it was normal to be a smoker it's now normal to be quitting. There's been a big change in behaviour so that now smoking in workplaces, cars and the home is no longer accepted."


Five minutes with .... Professor Robyn McDermott

Originally training as a doctor and later epidemiologist, you've worked to improve health services for Indigenous people in Australia and migrant and minority groups around Asia in a career that has spanned four decades. In your view what are the essential conditions necessary to successfully address health inequalities in disadvantaged groups?
As a health service provider I would say just decent basic primary health care, but there are also social determinants like getting the best start in life, good food, security, jobs, economic opportunities and education that are absolutely critical. None of this is rocket science, but we seem to be uniquely unable to deal with that in Australia when it comes to Indigenous people.

We hear a lot about the health problems faced by Aboriginal and Torres Strait Islander populations, but what are some of the positive developments in recent years that we should be building upon?
One of the positive developments I've seen in North Queensland is the extraordinary transformation that's taken place in the Torres Strait in the last 10 years. They realised that diabetes was a big problem and they came up with a plan that has really changed the way they deal with it - including putting a lot more local people into senior management and leadership roles in the organisations charged with tackling the problem.

More recently, we're doing a trial in 12 remote communities in North Queensland looking at training local community members who have basic health care qualifications to be able to take responsibility for chronic condition coordination within communities - the enthusiasm with which they've taken to this has been really encouraging, and I'm confident that our trials are going to show tangible results for people with chronic conditions.

I'm also impressed with the enthusiasm with which Indigenous health workers and managers have taken to using IT to improve their quality of care. Having access to health information systems in primary health care services has made a big difference to many workers, giving them the data they need to make informed decisions to benefit clients.

You supervise a number of research students working on projects relevant to Aboriginal and Torres Strait Islanders as part of an NHMRC-supported push to incubate a new generation of Indigenous leaders in health. Why do you think we've had so few Indigenous health leaders and what needs to change to achieve real improvements in the long term?
One of the reasons is that kids still aren't staying in school long enough to go into health professions in universities. So the first thing that needs to change is kids need to stay in school, and what really helps is if they have some good role models to show them what they can achieve. A lot of the Indigenous doctors I've worked with have told me they would never have considered a career in medicine to be possible unless someone had come out and talked to them about how they had done it.

For many Indigenous kids they have to leave home to go to university - or even high school for those in remote areas - so it's tough. Having said that I think we have got some incredible indigenous health leaders, particularly the younger generation who are graduating now.

You've been instrumental in the recent establishment of the Centre for Research Excellence in Chronic Disease Prevention in Rural and Remote Communities. What do you hope the Centre will achieve?
In the first place I hope that we can get a better handle on quality improvement in chronic disease management by linking care processes to health outcomes rather than just auditing the activity. Number two would be to open some career pathways for our Indigenous researchers. And number three would be to move towards understanding how the workforce needs to change to better deal with the real health needs of the population in chronic disease.


Areas of study and research

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