Dr Noel Hayman, B.Med, MPH. Program Leader Indigenous Health, QEII Hospital Health Service District.

MEDICAL & CLINICAL ISSUES FOR INDIGENOUS MEN

I wish to thank the organising committee for inviting me to the 3rd National Men’s Health Conference to present a keynote address on an extremely important topic, medical and clinical issues facing Indigenous men.

But before I start my presentation I would like to honour the Traditional Owners of this Country we stand on and thank them for allowing me to talk here today.

I am a Murri doctor from Brisbane, Queensland. I have a varied background, probably just like most Aboriginal men who grew up in urban Australia where culture has been fragmented. Even though I may lack extensive knowledge of traditional lore, I will always defend my Aboriginality. I still got called "you black bastard" while going to school. But this only made me more determined to succeed in life. I had to work very hard to gain the respect of my white peers.

Growing up male and black is always difficult.

My grandparents were both from the stolen generation, taken away from their families and relocated to Purga Mission, which was approximately 50 kms south west of Brisbane. This mission was closed down in 1947 and the people were then sent either to Stradbroke Island, Cherbourg or Warrabinda. My grandfather was a Wakka Wakka man and his country is a 3 to 4 hour drive north west of Brisbane. I would like to dedicate my talk to him. He was a strong, devoted family man who stood up for his rights throughout his life. I had great respect for him. My grandmother was a Kalkadun, her country is up near Mt Isa.

Current estimates show that presently there are approximately 202,000 of us Indigenous males in Australia with about 120,000 aged 15 years and older.

A good analogy of the size of the Indigenous men’s population would be that of the recent NRL grand final between St George and Melbourne where approximately 110,000 people attended. Just imagine, you could fit the entire number of Indigenous men in Australia into Stadium Australia.

Depending on which area you come from an Indigenous male will become a man following initiation; this is usually around fourteen to fifteen years of age. Therefore a large proportion of Indigenous males is young boys and we must guide them on to a healthier lifestyle if we are to improve Indigenous Health. Because at present an Indigenous males’ life expectancy is only 56.9 years compared to 75.2 years for all Australian males, nearly some 20 years difference. Going by these statistics I have only 12 years of life left, but this is one statistic I aim to beat. I certainly want to be around to see my son and daughters grow up as well as my future grandchildren and I am sure all of you would wish the same.

Infant mortality of Indigenous males remains stubbornly fixed at 2 to 3 times that for non-Indigenous males. Infant mortality has improved dramatically since the 1970’s, but that gap between Indigenous and non-Indigenous still remains.

I do not want to bore you with too many statistics as you have probably heard them all before, particularly on the opening morning of this conference. But I do need to state some to demonstrate the areas where we need to concentrate our efforts for improvement.

One statistic that has not been mentioned as yet is that of age specific death rates. The death rates for Indigenous males are higher than those for non-Indigenous males for every age-group, especially between the 15 – 54 year age range where death rates are 3 to 7 times that of non-Indigenous males.

If we look at the causes of excess death in Indigenous males, the main four conditions include cardiovascular diseases, injury, respiratory diseases and endocrine, which is mainly diabetes. These four conditions together account for over two thirds of excess death.

With this in mind, the medical issues for Indigenous men that we need to target are heart disease, injury, respiratory conditions, diabetes, and hypertension. Coronary heart disease represents 55% of all deaths from cardiovascular disease amongst Indigenous males. Other cardiovascular diseases include rheumatic heart disease, stroke, heart failure, peripheral vascular disease and cardiomyopathy. It is worthwhile stating that the mortality rates from rheumatic heart disease in the Northern Territory are among the highest in the world. In Australia death from rheumatic heart disease is 12.5 times higher for Indigenous males compared to non-Indigenous males.

Respiratory disease is the second most frequent cause of hospitalisation for Indigenous males. Two important common infections causing death are pneumococcal pneumonia and influenza, thus stressing the importance of vaccination, namely pneumovax and fluvax.

Death from diabetes for Indigenous males is approximately 12 times that of non-Indigenous males. Between 1985 and 1994 the reported death from diabetes rose by 9.6 percent. The prevalence of diabetes varies from 10 to 20% in Aboriginal communities, but in some of the outer Island communities of the Torres Strait the prevalence of diabetes has been recorded up to 40% in the adult population. At home in one community that I visit the prevalence of diabetes is 15 percent. The prevalence of diabetes in the general population is between 3 and 5 percent, but also on the rise. The commonwealth will be launching a diabetes awareness campaign later this year; one of its themes will be to diagnose the undiagnosed.

Another condition that requires special mention is sexually transmitted infections, STI’s do not cause significant mortality but they do cause high morbidity and high prevalence, with the prevalence of syphilis and chlamydia, 7 and 77 times the all Australian male rates respectively. In Queensland some STI’s are one to two hundred times the rates of those in the general population.

A compounding factor for these high rates is that Indigenous males are reluctant to visit a clinic for treatment because of the lack of cultural sensitivity.

I will now cover the main behavioural risk factors that directly or indirectly affect the conditions I have just spoken about. These include smoking, alcohol consumption and diet, where obesity is prominent. To me smoking is the "silent killer" of our people. Many Aboriginal people think it takes one packet of cigarettes before smoking affects your health but more alarming is that 5% of Indigenous people believe smoking does not affect your health at all. At present the smoking prevalence in Indigenous Communities is anywhere from 50 to 80% depending where you go but this is more than twice the prevalence in the general Australian male population. Smoking is a risk factor in heart disease, lung infections, asthma and cancers, in particular lung cancer. If you are diabetic the one thing you should not do is smoke as it accelerates artery disease both macro and micro vascular disease.

Alcohol consumption varies from community to community, some communities elect to be dry. Most survey results show that the prevalence of alcohol use is less in Aboriginal people but those who do drink, drink at harmful levels. Alcohol contributes significantly to the mortality and morbidity from injury and as already stated injury is the second highest cause of excess death as well as been the second highest cause of mortality. Alcohol also increases the risk of cirrhosis of the liver and cancer for example oesophageal and stomach cancers. Alcohol also significantly contributes to death from suicide in Indigenous males.

Diet is also very important to good health, in Aboriginal health there seams to be undernutrition as children and overnutrition as adults leading to obesity. Obesity is a risk factor in heart disease. Indigenous people are nearly twice as likely to be obese then non-Idigenous people. Barriers to access good nutrition clearly need addressing. Remoteness should not be a barrier.

There have been recent reports linking low birth weight babies to heart disease in later life. Alcohol, smoking and nutrition are all important risk factors for low birth weight babies. In Queensland the rate of low birth weight babies to Indigenous mothers is twice that of non-Indigenous mothers. We need healthy strong babies to become healthy strong adults.

I would now like to move on to the clinical issues facing Aboriginal males.

One of the most important clinical issues for Indigenous males is the ability to access Primary Health Care Clinics. As an Aboriginal man as well as an Aboriginal doctor I known only too well how difficult it is for us to visit a doctor. It is usually when someone is seriously ill before they will access a doctor. I have been asked to see many patients at home because of concerned family members. These patients are usually young to middle age males who will not access clinics. Last year my program completed approximately 1000 home visits.

On several occasions I have diagnosed patients with a diabetic complication at first presentation and the alarming thing is the patient did not know that they had diabetes. One patient I can remember, he could not count fingers because of extensive diabetic retinopathy. To prevent diabetic complications we need to diagnose diabetes early and then stress to the patient the importance of good blood sugar control. The worse blood sugar control is, the more likely a patient will develop complications. Sadly most Indigenous people who have diabetes have poor diabetic control. But at my Inala Clinic I am seeing improved diabetic control in patients over time. Another important point is that diabetes is one of the leading causes of end stage renal failure in Aboriginal communities, with high rates here in the Northern Territory.

Another access barrier includes inappropriate thought by mainstream health services to cultural differences. For example, Indigenous men have been forced to see female doctors for men’s business. Male elders been cared for by young female nurses in clinics or hospital settings. In contrast older non-indigenous men would probably love to be bathed by a young pretty female nurse. A patient told me at clinic one day how he went to see a doctor about a lump on his penis. When he saw that the doctor was female he changed his presenting complaint to a sore throat. The funny thing about it he said, was that he was given a script for an antibiotic.

I was in Darwin recently and was impressed to see the local Aboriginal Medical Service has a specific men’s clinic. This clinic was not at the main centre but in a house a couple of blocks away. Indigenous men are more at ease with this concept of separate clinics and as a result are more likely to consult a male health worker or male doctor for a specific problem, and are also more likely to return for follow-up. This is an excellent concept and should be duplicated across Australia at appropriate settings. A paper was presented at our Indigenous Male’s Convention earlier this week on this very issue. In summary male attendance at a Medical Centre in the Top End increased by 600% over the first couple of years of intervention.

There is also an access problem for Indigenous males in the prison system, they are reluctant to present to the prison medical centre when sick. Because of this I have been doing Saturday clinics at two local prisons in Brisbane for the past 5 years. In Queensland 25% of inmates are Indigenous. Across Australia the imprisonment rate for Indigenous males would be 10 to 20 times the non-Indigenous imprisonment rate. Once at a prison clinic, I attended a young Murri in his late 20’s who was in acute renal failure from uncontrolled hypertension. This was because he refused to take his blood pressure tablets and now this person is on renal dialysis, he has no second chance.

This leads on to another important clinical issue confronting both Indigenous males and females and that is, poor compliance with medication. I know it can be very difficult to get our people to take medication but this is one area where we need to work harder. I have witnessed people dying needlessly from not taking their medication and in some cases I have had to sit back helpless and watch some of my patients die in their 40’s and 50’s from heart attack and renal failure because of medication non-compliance. What do we do? How can we improve medication compliance for those who refuse? Can we use both traditional and western medicine to improve compliance?

I have found some simple ways of improving compliance in patients. For patients who simply forget and who are usually older I have found dossett boxes very useful. These boxes are set out day by day and usually contain medication for a week. Another way which I have found useful in improving Indigenous compliance is to use once or twice daily dosing of medication instead of three or four times daily dosing. With some STI’s one off dosing is extremely helpful.

In summary, the health statistics indicate that Indigenous male health is poor. We are more likely to die from heart disease, have one or multiple risk factors for heart disease, that is, smoke too much, drink alcohol in excess, have diabetes, have hypertension, be overweight and do little exercise.

We need to address the area of mortality of young to middle aged male adults by looking at the risk factor profile, then Indigenous people develop and implement interventions.

Indigenous males are also less likely to attend clinical services, in particular Primary Health Care. Access needs to be improved significantly.

Perhaps we need more men’s groups around Australia to tackle this issue collectively. In Brisbane there has been various men’s groups but funding has always been the limiting factor. Funding for 6months or one year is not enough to make a difference. More men’s clinics for certain areas around Australia is certainly a positive step forward.

Prison health also needs to be on the agenda for change. I know some Aboriginal Medical Services go into prison’s like I do. But how many Indigenous men in jail miss out on appropriate clinical practice?

For Indigenous male health to improve it will be up to Aboriginal male health professionals like all of those at our Convention to participate in bringing about change. If we do not bring about change then the Aboriginal male population will stagnant and not prosper, health will continue to be poor. So to all my brothers out there, let’s get on with making change by planning for the future. I was very pleased to hear the Health Minster for the Northern Territory say that our three recommendations from our Convention would be easy to implement. I hope that Commonwealth Health will have a similar attitude towards these recommendations. If so then this will be the starting point to facilitate change and set up networks for Indigenous male health across Australia.

For the last part of my talk I would like to share with you the results of an intervention that I implemented at my clinic to improve Indigenous access. I have been traveling extensively lately and therefore have not had time to separate out male and female numbers attending clinic. But just think 40 percent, as approximately 40 percent of my patients are male.