Cardiovascular Health in Aboriginal Australians

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Cardiovascular Health in Aboriginal Australians

• SAR Talk
• Karen E. Joynt
• October 31, 2006

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Presentation Outline

• Where is Australia, and is it as small as it
  looks on the map?
• Who are the aboriginal people in Australia?
• Disadvantaged overall health in aboriginal people
• Cardiovascular health in aboriginal people
• Understanding the problem of cardiovascular
  health in aboriginal people
• The good news?

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Australia a primer
4
Australia its really big
5
Australia a primer
6
So what about the kangaroos?
7
So what about the kangaroos?
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Who are Australias aboriginal people?

• aboriginal adj.
• Having existed in a region from the beginning
  aboriginal forests.
• Indigenous Australians Aboriginal Australians
• They were there first!
• 30,000-40,000 BC
• Captain James Cook, 1770

Natives opposing the arrival of Captain James
Cook 19th century engraving
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Indigenous Australians

• Made up of many tribes with distinct cultures,
  languages, traditions, land
• 492,700 people
• 2.4 of the population of Australia
• 30 metropolitan, 43 regional, 26 remote

Source AIH InfoNet 2005 Map www.wikipedia.com
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Sacred ground Uluru
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Sacred ground Uluru
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Overall social welfare

• Education
• 32 higher education (57 non-indigenous)
• 1 of higher education population
• Employment
• 13 unemployment (4.6 non-indigenous)
• Mean weekly income 394 (657)
• Housing
• Metropolitan 34 homeowners, 32 renters, 24
  state housing
• Remote 14 homeowners, 50 renters, 36 state
  housing
• High proportion of temporary / improvised housing

Source AIH InfoNet 2005
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Poor health across the lifespan

• High burden of poor health
• Low birth weight
• 13 versus 6 (non-indigenous)
• Infant mortality
• Three times higher than non-indigenous infants
  (16 per 1000 compared with 5 per 1000)
• Childhood disease
• Chronic otitis media
• Rheumatic heart disease

Source AIH InfoNet 2005
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Life expectancy in Australia
Source Zhao and Dempsey 2006
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International Indigenous mortality rates
(all-cause)
Source Ring and Firman 1998
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Age-specific death rates ages 45-54 years
Source AIHW National Mortality Database 1999-2003
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Thomas and Condon dz trends
Source Thomas et al 2006
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Risk for any cardiovascular death, indigenous
versus nonindigenous
Source AIHW National Cardiovascular Disease
Database
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Risk for coronary heart disease death, indigenous
versus nonindigenous
Source AIHW National Cardiovascular Disease
Database
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Cardiovascular disease Mortality
Source Thomas et al 2006
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Explaining the disparity

• Rheumatic heart disease
• Traditional risk factors
• Diabetes
• Hypertension
• Smoking
• Obesity and overweight
• Physical inactivity
• Psychosocial stressors
• Lack of access to care

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Rheumatic heart disease

• Incidence 200 cases per 100,000 population
• Prevalence 1.33 in children aged 5-14 (national
  prevalence 0.034)
• Mortality indigenous men and women are 27 and 23
  times more likely, respectively, to die of RHD
  than nonindigenous persons
• Up to 3 of excess deaths in males and 7 in
  females

AIHW 2002, Cunningham 1996
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Traditional risk factors?
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Risk factor burden, persons aged 15 or older
Source Australian Indigenous Health InfoNet
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Diabetes PrevalencePercentage of adults
reporting diabetes, 2001
Ratio 5
Ratio 9
20 impaired glucose tolerance
Source Australian Indigenous Health InfoNet
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Diabetes burden

• Hospitalization rates 10-15x higher than
  non-indigenous
• High rates of retinopathy, nephropathy
• Mortality rates 11-18x higher than non-indigenous
  persons
• High burden on females?

Source AIHW, Wang and Hoy 2004
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Hypertension

• By self-report 12 of indigenous males and 16
  of indigenous females (compared with 9 and 10
  of nonindigenous, respectively)
• By direct measurement roughly 50 in one sample
  of 592 patients taken in 1993-1997
• At well-person checks 49 of adults over the age
  of 35 were hypertensive in a sample of 2900
  patients taken in 1998-2000
• Both studies found 17 of males aged 15-34 years
  were hypertensive (5 of females)

Source ABS 2002, Leonard 2002, Miller 2002
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Cigarette smoking
Source CEITC 2006
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Physical inactivity

• 43 of Indigenous people classified as sedentary
  versus 30 of non-Indigenous
• 30 of Indigenous people classified as low
  exercise level versus 39 of non-Indigenous
• Little to no formal physical activity in terms of
  organized sports, gyms, etc.

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Obesity and overweight

• Essentially zero obesity in the Indigenous
  population until the 1960s
• Question of the thrifty genotype
• Impact of rapid lifestyle transition

Source McDermott 2000
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Psychosocial stressors

• Known to increase risk of CVD and negatively
  impact prognosis in established CVD
• Depression
• Loss, displacement, grief, mourning
• Anger, frustration
• The Stolen Generation

Caminka Art 2004
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The Stolen Generation

• The Aboriginal Ordinance
• 1900-1969 (perhaps even longer)
• 1 in 3 to 1 in 10 indigenous children were taken
  from their homes and families by government and
  religious agencies
• Over 100,000 children
• Placed in white families or institutionalized

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Governmental Apology?

• Australians of this generation should not be
  required to accept guilt and blame for past
  actions and policies. John Howard

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Access to care

• Only 15 of indigenous Australians in remote
  areas and 38 in urban areas have a Medicare
  number
• Lack of acceptable identification
• Language barriers
• Cultural beliefs about durable images of people
• Medicare is underutilized due to lack of access
  to centers providing MBS / PBS care
• Aboriginal Medical Services provide
  community-based primary care
• Often understaffed, underfunded
• No specialist services

Source House of Representatives 2000
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Access to care, continued

• Distances traveled to access health care often
  long
• Transfers from Darwin to FMC
• Transfers from Alice Springs to Royal Adelaide
• No family, high death rate
• Leads to mistrust and apprehension, especially
  for transfer of children

Source House of Representatives 2000, Henry
2004, Alex Brown, personal communication
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Access to care travel distances
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Access to care, continued

• Waiting time to access health care often long
• One cardiology clinic per two week period
• Rotating cardiologists, so little continuity
• No way to easily contact the cardiologist
• Cardiac rehabilitation not available
• Monitoring, telephone access often impossible
• Lack of holistic, culturally appropriate care

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So whats the good news?

• Self-determination versus mainstreaming
• Tangentyere Council
• CAYLUS
• RANP
• Rheumatic heart disease program (UNICEF)
• Meal programs
• Banking assistance

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Making indigenous health a priority!

• Offices of Aboriginal Health
• State councils on aboriginal health
• Aboriginal Health Australia
• Australian Indigenous Health InfoNet
• Menzies School of Public Health
• Centre for Remote Health

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Beautiful Australia
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Thank you

• Paddy Phillips, Chair of Medicine at Flinders
  Medical Centre
• The Cardiovascular Outcomes Research group at
  Flinders Medical Centre Dr. Derek Chew, Carolyn
  Astley, Sue Mattschoss, Danni Molloy, Leann Cox,
  and Dr. Luan Huynh
• Tangentyere Council
• The Duke Global Health program and Dr. Ralph
  Corey
• Dr. Diana McNeill and Dr. Andrew Muir

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References

• Australian Bureau of Statistics (2002) National
  Health Survey Aboriginal and Torres Strait
  Islander results. Canberra Australian Bureau of
  Statistics
• Australian Indigenous Health InfoNet (2005)
  Summary of Australian Indigenous Health, February
  2005. www.healthinfonet.ecu.edu.au/html/html_keyfa
  cts_plain_lang_summary.pdf
• Australian Institute of Health and Welfare
  National Cardiovascular Disease Database,
  http//www.aihw.gov.au/dataonline.cfm
• Australian Institute of Health and Welfare
  National Mortality Database 1999-2003,
  http//www.aihw.gov.au/dataonline.cfm
• Center for Excellence in Indigenous Tobacco
  Control, 2006, http//www.healthinfonet.ecu.edu.au
  /html/html_community/tobacco_community/publication
  s.htm
• Cunningham J, Condon JR. Premature mortality in
  Aboriginal adults in the Northern Territory,
  1979-1991. Medical Journal of Australia
  1996165309-312
• Henry B, Houston S, Mooney G. Institutional
  racism in Australian healthcare a plea for
  decency. Medical Journal of Australia
  2004180517-520
• House of Representatives Standing Committee on
  Family and Community Affairs. Health is Life
  Report on the Inquiry into Indigenous Health.
  Canberra, 2000. Chapter 2 Improving the
  coordination, planning, and delivery of health
  services.

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References

• Leonard D, McDermott R, ODea K, et al. Obesity,
  diabetes, and associated cardiovascular risk
  factors among Torres Strait Islander people.
  Australian and New Zealand Journal of Public
  Health 200226(2)144-149
• McDermott R, Rowley KG, Lee AJ, Knight S, O'Dea
  K. Increase in prevalence of obesity and diabetes
  and decrease in plasma cholesterol in a central
  Australian aboriginal community. Med J Aust. 2000
  May 15172(10)480-4.
• Miller G, McDermott R, McCullough B, et al. The
  Well Persons Health Check a population
  screening program in Indigenous communities in
  North Queensland. Australian Health Review
  200225(6)136-147
• Ring I, Firman D. Reducing Indigenous Mortality
  in Australia Lessons from other countries.
  Medical Journal of Australia 1998169
• Thomas DP, Condon JR, Anderson IP, Li SQ, Halpin
  S, Cunningham J, Guthridge SL. Long-term trends
  in Indigenous deaths from chronic diseases in the
  Northern Territory a foot on the brake, a foot
  on the accelerator. Medical Journal of Australia
  2006185145-9
• Wang Z, Hoy WE. Association between diabetes and
  coronary heart disease in Aboriginal people are
  women disadvantaged? Med J Aust. 2004 May
  17180(10)508-11.
• Zhao Y, Guthridge S, Magnus A, Vos T. Burden of
  disease and injury in Aboriginal and
  non-Aboriginal populations in the Northern
  Territory. Medical Journal of Australia
  2004180498-502
• Zhao Y, Dempsey K. Causes of inequality in life
  expectancy between Indigenous and non-Indigenous
  people in the Northern Territory, 1981-2000 a
  decomposition analysis. Medical Journal of
  Australia 2006184490-4