The Health of Aboriginal Victorians, 2009

Home , Aboriginal Victorians

The health of Aboriginal Victorians, 2009

Victorian Aboriginal Community Controlled Health Organisation

31st March 2009

1 Contents

1 Introduction 7

2 Reports on Aboriginal and Torres Strait Islander health 7

3 Demography 8

4 Human geography 10

5 Health status 13 5.1 Self-reported health ...... 13 5.1.1 Chronic diseases ...... 14 5.2 Avoidable mortality ...... 15 5.3 Burden of disease ...... 16 5.4 Diabetes mellitus ...... 18 5.5 Kidney disease ...... 19 5.6 Cancer ...... 20 5.7 Heart and circulatory system diseases ...... 24 5.8 Child health ...... 25 5.9 Oral health ...... 26 5.10 Ear disease and hearing loss ...... 27 5.11 Injury ...... 27 5.12 Suicide ...... 29 5.13 Communicable diseases ...... 29 5.14 Social and emotional wellbeing, and mental health ...... 30

6 Health care 31 6.1 Health-related actions ...... 31 6.2 Hospitalization ...... 31 6.2.1 Hospitalizations for ambulatory care sensitive conditions ...... 32 6.2.2 Discharge against medical advice ...... 33 6.3 Screening and preventive health care ...... 33

7 Upstream determinants of Indigenous health in Victoria 33 7.1 Education ...... 33 7.2 Employment ...... 36 7.3 Income ...... 36 7.4 Families ...... 36 7.5 Contact with the criminal justice system ...... 37

2 7.6 Community safety ...... 37 7.6.1 Victims of crime ...... 37 7.7 Contact with the juvenile justice system ...... 38 7.8 Contact with the child protection system ...... 38 7.9 Housing ...... 38 7.10 Access to telephones and private cars ...... 39 7.11 Culture ...... 39 7.11.1 Language ...... 39 7.11.2 Land ...... 39

8 ‘Lifestyle’ determinants of Indigenous health in Victoria 41 8.1 Risk factors and disease progression ...... 41 8.2 Risk factor distribution ...... 42 8.3 Smoking ...... 43 8.3.1 Smoking and pregnancy ...... 44 8.4 Alcohol ...... 44 8.5 Substance use ...... 45 8.6 Overweight ...... 46 8.7 Physical activity ...... 46 8.8 Fruit and vegetable consumption ...... 46 8.9 Assurance of food supply ...... 47 8.10 Burden of disease and lifestyle determinants ...... 47

9 Expenditure on Indigenous health 48

10 Conclusion 48

3 List of Figures

1 Population pyramid, Indigenous and total populations, Victoria 2006 [5] ...... 9 2 Indigenous people as a proportion of the total population, Victoria 2006 [12] ...... 11 3 Indigenous people as a proportion of the total population, Melbourne area, 2006[13] . . 12 4 Indigenous people living in Statistical Local Areas [15] ...... 13 5 Admissions for diabetes mellitus, including renal dialysis, Victoria, 2006–2007 [26] . . . 19 6 Admissions for renal dialysis, Victoria, 2006–2007 [26] ...... 20 7 Cancer reported incidence, Indigenous and Non-Indigenous, NT 1991–2001 [29] . . . . 22 8 Cancer survival, Indigenous and Non-Indigenous, NT 1991–1999 [29] ...... 23 9 Admissions for injury, Victoria, 2006–2007 [26] ...... 28 10 Hospitalizations for ambulatory care sensitive conditions by age group. NSW, Victoria, Queensland, WA, SA and NT, 2004–06 [21] ...... 33 11 School participation by age, Victoria 2006 [36] ...... 34 12 School retention, Indigenous and Non-Indigenous students, 2006 [36] ...... 35 13 Indigenous Land Corporation holdings, Victoria 2008 [58] ...... 40 14 Native Title applications and outcomes, Victoria 2008 [59] ...... 41 15 Prevalence of selected risk factors, Victoria, 2004–06. Note: data for unsafe sex not available [18, 21, 17, 62, 36] ...... 43 16 Smoking by age, Victoria, 2004–05 [18] ...... 44 17 High-risk/risky drinking by age, Victoria, 2004–05 [18] ...... 45 18 Overweight and obese by age, Victoria, 2004–05 [18] ...... 46 19 Prevalence of burden of disease by selected risk factors, Australia 2003 [20] ...... 47

4 List of Tables

1 Selected reports into Aboriginal Health, 1978–2008 [1] ...... 8 2 Population pyramid, Indigenous and total populations, Victoria 2006 [5] ...... 9 3 Age-specific fertility, Indigenous and total populations, Victoria 2007 [6] ...... 10 4 Prevalence of self-assessed health, Indigenous and ratio compared with the total population, Victoria 2004–2005 [18] ...... 13 5 Distribution of health status among Indigenous people by selected socioeconomic indicators, Australia and Victoria [3] ...... 14 6 Long-term conditions, Victoria 2004–05 [16] ...... 14 7 Multiple long-term conditions [16] ...... 15 8 Avoidable and unavoidable mortality, Qld, WA, SA, NT, 2002–06, age-standardized rates /100,000/4 yrs [21] ...... 15 9 Avoidable mortality by cause of death, Qld, WA, SA, NT, 2002–06, age-standardized rates /100,000/4 yrs [21] ...... 16 10 Prevalence of burden of disease by major disease group, Indigenous and Non-Indigenous, Australia 2003 (prevalence as DALY /100,000) [22] ...... 17 11 Prevalence of burden of disease for selected conditions, Indigenous and Non-Indigenous people, Australia 2003 (prevalence as DALY /100,000) [22] ...... 18 12 Diabetes prevalence, Australia 2006 [24] ...... 18 13 Cancer incidences in Indigenous and Non-Indigenous people, SA 1977–2001 [30] . . . 24 14 Hospitalization for circulatory disease, NSW, Vic, Qld, WA, SA, NT, 2004–06 [21] . . . . 25 15 Birth weights, Victoria, 2006 [27, 8] ...... 26 16 Adult dental health, non-remote Indigenous, Australia 2004–05 [16] ...... 26 17 Injury hospitalizations for Indigenous people, Qld, WA, NT SA, 2004–05, age standardized [24] ...... 27 18 Standardized mortality ratios for selected injuries, Australia [43] ...... 28 19 Suicide rates by age group, Australia [43] ...... 29 20 Notifications of selected communicable diseases, Victoria 2007 [46] ...... 30 21 Health-related actions in the previous 2 weeks, Indigenous people, Victoria 2004–2005 [16] ...... 31 22 Crude hospitalization rate /1,000/yr by major cause, Victoria 2006–07 [27] ...... 32 23 Highest level of education achieved, Victoria 2004–2005 [36] ...... 35 24 Educational achievement and retention, Victoria and Australia [24] ...... 36 25 Employment, Victoria 2006 [24, 52] ...... 36 26 Family income, Victoria 2004–2005 [53] ...... 36 27 Single-parent families and large families, Victoria, 2006 [53] ...... 37 28 Victims of selected crimes, crude rates/100,000/year, Victoria, 2005–06 [36] ...... 37 29 Substantiated notifications to the child protection system, Victoria 2006–07 [55] . . . . . 38 30 Risk factors and chronic diseases [60] ...... 42

5 31 Prevalence of selected risk factors, Victoria, 2004–06. [18, 21, 17, 62, 36] ...... 43 32 Prevalence of burden of disease per 1,000 population, prevalence ratio and excess burden by selected risk factors, Australia 2004. Note that the total excess burden is not the linear sum of individual components. [20] ...... 48

6 1 Introduction

This report is a compilation of available data on the state of health of Indigenous people in Victoria in 2009. It is derived from published data from a range of sources, mostly over the period 2002– 2006. However, data on many aspects of Indigenous health are not available, particularly in Victoria, where Indigenous people comprise only 0.6% of the total population. The small proportion has con- sequences on data collection, so that Indigenous people are often not identiﬁed as such in statistical collections. In some cases surrogate data need to be used, sometimes using Indigenous populations from other states, the national non-remote Indigenous population, or even the entire national Indigenous population.

2 Reports on Aboriginal and Torres Strait Islander health

Aboriginal and Torres Strait Islander people have poorer health than any other identiﬁable part of the Australian population. This health inequality is a double burden, due to both ‘old’ (communicable) diseases and ‘new’ (chronic non-communicable) conditions. Over the last thirty years, this state of affairs has been documented many times in a large number of reports (Table 1 describes some key examples) [1].

7 Year Author Report 1979 House of Representatives Aboriginal Health Standing Committee on Aboriginal Affairs 1989 National Aboriginal Health A National Aboriginal Health Strategy Strategy Working Party 1990 Aboriginal Health Development Report to Ministers Group 1991 Aboriginal and Torres Strait Aboriginal and Torres Strait Islander Health Goals Islander Commission and Targets 1994 Australian Bureau of Statistics National Aboriginal and Torres Strait Islander Health Survey 1997 National Health and Medical Promoting the Health of Indigenous Australians Research Council 1997 Royal Australian College of Eye Health in Aboriginal and Torres Strait Islander Ophthalmologists Communities 1997 Australian Bureau of Statistics & The Health and Welfare of Australia’s Aboriginal Australian Institute of Health and Torres Strait Islander Peoples and Welfare 1998 Australian Institute of Health Expenditures on Health Services for Aboriginal and and Welfare Torres Strait Islander Peoples 1998 Australian National Audit Ofﬁce Aboriginal and Torres Strait Islander Health Program 2000 House of Representatives Health is Life Standing Committee on Family and Community Affairs 2001 Australian Institute of Health Expenditures on Health Services for Aboriginal and and Welfare Torres Strait Islander Peoples 2003 Australian Bureau of Statistics & The Health and Welfare of Australia’s Aboriginal Australian Institute of Health and Torres Strait Islander Peoples and Welfare 2003 Productivity Commission Overcoming Indigenous disadvantage: key indicators 2005 Human Rights and Equal Social Justice Report 2005 Opportunity Commission 2007 Australian Health Ministers’ Aboriginal and Torres Strait Islander Health Advisory Council Performance Framework Report 2006 2007 Oxfam Close the Gap Report

Table 1: Selected reports into Aboriginal Health, 1978–2008 [1]

3 Demography

From the 2006 census, the Australian Bureau of Statistics estimated the population of Victoria as comprising 33,517 Indigenous and 5,093,023 Non-Indigenous people. People identifying as Indige- nous in Victoria comprise 0.6% of the total population, compared with 2.3% of the national population [2]. A preliminary estimate by the ABS was of 30,800 Indigenous people in Victoria, with 27,700 Abo- riginal people (89.9% of the Indigenous population), 2,200 Torres Strait Islander people (6.6% of the Indigenous population), and 900 of both Aboriginal and Torres Strait Islander descent (2.9% of the Indigenous population) [3]. In this report the term ‘Indigenous’ is used to refer to both Aboriginal and Torres Strait Islander peoples.

8 The Indigenous population is considerably younger than the total population (Table 2 and Figure 1). The median age of Indigenous Victorians is 21 years, and only 4% are aged over 65 years, compared with the Non-Indigenous median age of 37 and proportion over 65 of 14% [4]. The reasons for the differences in the age structures between the two populations are because Indigenous women have more children and because Indigenous people die younger [5].

Indigenous Total 0–4 years 3,585 12% 305,941 6% 5–9 years 3,798 13% 314,825 6% 10–14 years 3,740 12% 329,624 7% 15–19 years 3,183 11% 335,181 7% 20–24 years 2,482 8% 338,713 7% 25–29 years 2,016 7% 323,826 7% 30–34 years 2,006 7% 354,051 7% 35–39 years 2,029 7% 375,042 8% 40–44 years 1,792 6% 366,307 7% 45–49 years 1,480 5% 356,503 7% 50–54 years 1,236 4% 323,016 7% 55–59 years 953 3% 300,866 6% 60–64 years 631 2% 233,599 5% 65 + years 1,210 4% 674,908 14%

Table 2: Population pyramid, Indigenous and total populations, Victoria 2006 [5]

Figure 1: Population pyramid, Indigenous and total populations, Victoria 2006 [5]

In Victoria in 2007, 70,313 births were registered; of these, 1,025 babies were registered as Indige- nous, including 638 babies born to Indigenous mothers[6]. For infants registered as Indigenous, 20.3% had both Indigenous mother and father, 42.0% had an Indigenous mother only and 37.8% had

9 an Indigenous father only. The median age of Indigenous mothers was 26.0, compared with a median age of all mothers of 31.6. The total fertility of Indigenous women was 2.416, compared with a total fertility of all women of 1.871 (Table 3) [6].

Indigenous Total 15–19 years 45.4 10.1 20–24 years 135.1 42.6 25–29 years 129.6 97.9 30–34 years 112.4 133.4 35–39 years 46.0 75.6 40–44 years 8.1 14.3 45–49 years – 0.8

Table 3: Age-speciﬁc fertility, Indigenous and total populations, Victoria 2007 [6]

Of the 33,930 deaths registered in Victoria in 2007, 95 were registered as of Indigenous people [7]. However, it is estimated that only 32% of the true number of deaths among Indigenous people in Victoria in the period 2000–2004 were classiﬁed correctly. Adjusting for the age structure of the population and for undercounting the standardized mortality ratio1 for Indigenous people in Victoria in 2000–2004 was 4.0 [8]. The lack of quality data on Indigenous deaths has frustrated attempts to provide estimates of Indigenous mortality [9, 10, for example], particularly in Victoria. The median age at death for Indigenous people in Victoria has not been estimated, due to the small numbers of recorded Indigenous deaths. In this report it is assumed that the pattern of mortality in NSW is not too dissimilar to that in Victoria. In NSW, the median age at death for Indigenous men in 2007 was 58.1 years, and 63.0 years for Indigenous women. The corresponding ﬁgures for the Non-Indigenous NSW population were 78.1 and 83.7 years respectively [11]. Estimates of the life expectancy of Indigenous people are also beset with problems due to lack of data. The Australian Bureau of Statistics has proposed a direct method of calculating life expectancy which gives a result of is considerably less than that of the total population, but shows the ‘life expectancy gap’ to be less than previously estimated. Estimates for Victoria are not available, but in NSW this method shows life expectancy at birth 2005–2007 for Indigenous males was 69.6 years, and for Indigenous females was 74.8 years [10]. Using this method the life expectancy gap is 9.1 years for men and 7.8 years for women [10].

4 Human geography

In Victoria, wherever they live, Indigenous people are a minority (Figures 2 and 3) [12].

1The standardized mortality ratio (SMR) compares the numbers of Indigenous deaths with the numbers of deaths expected if the age-speciﬁc rates of mortality of the total Victorian population were to apply to Indigenous Victorians. It gives an approx- imation of the overall ratio of death rates between the two populations.

10 Figure 2: Indigenous people as a proportion of the total population, Victoria 2006 [12]

In the 2006 Census, the estimated resident Indigenous population living in Melbourne was 15,925 persons, comprising 0.4% of the 3,743,015 total population [2].

11 12

Figure 3: Indigenous people as a proportion of the total population, Melbourne area, 2006[13] The majority of Indigenous people (49.6%, 16,629 people) live in major urban areas, and 34.9% (11,694 people) live in other urban areas, the remainder (15.5%, 5,194) in rural and remote areas (Figure 4)[14].

Figure 4: Indigenous people living in Statistical Local Areas [15]

5 Health status

5.1 Self-reported health

Self-assessed health is a good indicator of overall health status and questions on self-reported health make up the bulk of the National Health Survey. The National Aboriginal and Torres Strait Islander Health Survey 2004–2005 [16, 17, 3] is the most recent source of comprehensive self-reported health information for Indigenous people. In Victoria, Indigenous people are signiﬁcantly more likely to assess their health as ‘fair’ or ‘poor’ and less likely to assess it as ‘excellent’ or ‘very good’ when compared with the total population (Table 4) [3].

Indigenous Prevalence ratio Excellent or very good 47.7% 0.7 Good 30.5% 1.1 Fair or poor 21.8% 2.1

Table 4: Prevalence of self-assessed health, Indigenous and ratio compared with the total population, Victoria 2004–2005 [18]

Health status varies with socioeconomic status, and this holds within the Indigenous population, as well as between the Indigenous and Non-Indigenous populations. For example, a higher proportion of Indigenous people in the top 2 quintiles of (Indigenous) equivalized household income reported being of very good or excellent health than those in the lower 3 quintiles (Table 5). Similar gradients are observed with educational attainment and labour force participation [3].

13 Proportion with very good or excellent health Equivalized income (Australia) Lowest quintile 33.0% Top 2 quintiles 49.2% Educational attainment (Australia) Year 9 or below 28.4% Years 10–11 42.4% Year 12 or above 51.9% Labour force participation (Victoria) Employed 52.5% Unemployed 53.1% Not in the labour force 40.0%

Table 5: Distribution of health status among Indigenous people by selected socioeconomic indicators, Australia and Victoria [3]

There is a gradient of health status between Indigenous and Non-Indigenous people, which is still present after adjustment for age and socioeconomic characteristics. Indigenous people with any of the characteristics of Table 5 are 60% to 80% as likely to report very good or excellent health [3].

5.1.1 Chronic diseases

‘Chronic’ diseases, often termed lifestyle, degenerative or non-communicable diseases make up 70% of the burden of disease for both Indigenous and Non-Indigenous people [19, 20, 3]. When surveyed, about 68% of Indigenous Australians living in non-remote areas state that they suffer from at least one long-term health condition, and Indigenous people in Victoria are more likely to suffer from multiple long term conditions [16]. Common conditions reported include arthritis, cardiovascular, respiratory, renal, endocrine and neoplastic conditions. In Victoria, signiﬁcantly more Indigenous people suffer from these conditions than Non-Indigenous people. The outstanding example is renal disease where nearly 20 times as many Indigenous people suffer from this group of conditions (Table 6). Signiﬁcantly fewer Indigenous people are free from long-term conditions compared with Non-Indigenous people.

Condition Indigenous Victorians Risk ratio Arthritis 11.0% 1.6 Asthma 20.1% 2.0 Back pain or problems, disc disorders 14.9% 1.3 NS Diabetes, high blood sugar 4.3% 3.2 Ear or hearing problems 12.3% Eye or sight problems 32.5% 0.9 NS Heart and circulatory problems or diseases 15.2% 1.5 Kidney disease 2.2% 19.8 Neoplasms and cancer 0.7% 0.8 NS Osteoporosis 0.7% 0.6 NS No long term condition 25.2% 0.7

Table 6: Long-term conditions, Victoria 2004–05 [16]

In addition to being more likely to suffer from long-term health conditions, Indigenous people in Victoria are more likely to suffer from multiple conditions (Table 7) [16].

14 Australia Victoria, age-standardized Indigenous, non-remote Indigenous Non-Indigenous Risk ratio One 21% 18.6% 20.7% 0.9 Two 15% 16.3% 16.3% 1.0 Three 32% 48.8% 39.7% 1.2 One or more 65% 83.6% 76.9% 1.1

Table 7: Multiple long-term conditions [16]

5.2 Avoidable mortality

Avoidable mortality refers to deaths in persons aged 0–74 years from causes that can be prevented by health system interventions. It can be further categorized as primary avoidable mortality (mortality due to conditions preventable by public health programmes), secondary avoidable mortality (mortality due to conditions preventable by primary health care services) and tertiary avoidable mortality (mortality due to conditions preventable by hospital care). Victorian data are not available (due to the poor identiﬁcation of Indigenous status in mortality data), but data are available from Queensland, WA, SA and NT. In the 4 years 2002–06 avoidable mortality for Indigenous people was 656.3 /100,000/4 yrs resulting in a rate ratio (compared with Non-Indigenous avoidable mortality of 164.5 /100,000/4 yrs) of 4.0 (Table 8). The top 4 conditions were ischaemic heart disease, cancer, diabetes mellitus and (Table 9) [21].

Indigenous Non-Indigenous Rate ratio Avoidable mortality 656.3 164.5 4.0 Primary 334.6 89.0 3.8 Secondary 177.7 37.4 4.8 Tertiary 143.3 37.7 3.8 Unavoidable mortality 219.8 79.1 2.8 Total mortality 876.1 243.5 3.6

Table 8: Avoidable and unavoidable mortality, Qld, WA, SA, NT, 2002–06, age-standardized rates /100,000/4 yrs [21]

15 Indigenous Non-Indigenous Rate ratio Ischaemic heart disease 149.7 32.7 4.6 Cancer 115.2 60.8 1.9 Lung cancer 47.0 21.3 2.2 Diabetes 94.5 5.3 17.7 Suicide 26.3 11.1 2.4 Road trafﬁc injuries 26.3 8.2 3.2 Alcohol-related disease 37.1 4.1 9.0 Selected infections 27.2 3.6 7.6 Cerebrovascular disease 36.5 9.8 3.7 Chronic obstructive lung disease 39.2 8.0 4.9 Nephritis and nephrosis 27.0 1.6 16.4 Violence 9.0 0.9 10.0 Birth defect 5.9 2.7 2.2 Perinatal complications 4.2 1.4 3.1 Rheumatic heart disease 10.7 0.5 22.7 Other 47.6 13.6 3.5 Total 656.3 164.5 4.0

Table 9: Avoidable mortality by cause of death, Qld, WA, SA, NT, 2002–06, age-standardized rates /100,000/4 yrs [21]

5.3 Burden of disease2

The burden of disease is a summary measure of health which estimates contributions to ill health from both mortality and disability. It is expressed in disability-adjusted life years (DALYs). The DALY is a health gap measure that compares the current health status of a population against an ‘ideal’ in which everyone lives into old age free from disease. It comprises years of life lost (YLL) and years of life with a disability (YLD) due to disease or risk factors. YLD are calculated as the years of life with a disease or condition multiplied by a ‘disability weight’ due to the disease or condition. The burden of disease is calculated as DALY = Y LL + Y LD so that one DALY is deﬁned as one year of healthy life lost.

Y LL = m(LE), where m is the number of deaths and LE is the expectation of life, and

Y LD = iWdD, where i is the number of of new cases, Wd is the disability weight and D is the duration of the condition. There are no Victorian data for Indigenous people on burden of disease measures, but they have been calculated on an Australia-wide basis (Tables 10 and 11) [22].

2In this section all rates are age-standardized to the Indigenous population.

16 Indigenous Non-Indigenous Risk ratio Ischaemic heart disease 21.0 3.9 5.4 Stroke 5.7 2.1 2.8 Inﬂammatory heart disease 2.5 0.4 5.9 Rheumatic heart disease 2.1 0.1 25.1 Other cardiovascular disease 4.1 1.2 3.4 Total cardiovascular disease 35.3 7.6 4.6 Diabetes type 2 16.6 3.1 5.4 Diabetes type 1 1.3 0.4 3.0 Total diabetes 17.9 3.5 5.1 Suicide 7.2 2.2 3.2 Road trafﬁc accidents 6.4 2.3 2.8 Homicide and violence 4.1 0.5 8.1 Falls 1.4 0.8 1.7 Other injury 7.0 2.8 2.4 Total injury 26.1 8.6 3.0 Lung cancer 4.1 1.5 2.7 Breast cancer 1.5 1.4 1.1 Colorectal cancer 1.3 1.1 1.1 Mouth and pharynx cancer 1.1 0.3 3.8 Leukaemia 0.8 0.5 1.4 Other cancer 7.7 5.0 1.5 Total cancer 16.4 9.8 1.7 Chronic obstructive lung disease 7.6 1.7 4.5 Asthma 6.9 4.8 1.4 Other respiratory disease 3.5 0.6 5.8 Total respiratory disease 18.1 7.1 2.5 Anxiety and depression 15.7 10.5 1.5 Alcohol overuse 5.9 1.3 4.5 Schizophrenia 2.6 1.6 1.7 Heroin or polydrug dependence 2.6 1.0 2.7 Other mental 4.5 5.2 0.9 Total mental 31.3 19.6 1.6 Intellectual disability 11.1 4.1 2.7 Renal failure 10.4 1.4 7.6 Vision loss 1.8 1.3 1.3

Table 10: Prevalence of burden of disease by major disease group, Indigenous and Non-Indigenous, Australia 2003 (prevalence as DALY /100,000) [22]

This means that on average an Indigenous person with, for example, type 2 diabetes can expect to lose a total of 16.6 DALYs due to suffering from that condition. These DALYs are made up of years of life lost (42% of the DALYs lost in type 2 diabetes) and years of life with ‘disability’ (58% of the DALYs lost in type 2 diabetes). Disability in this context is calculated as years of life with disability multiplied by the disability weights of diabetes and its complications. The disability weights attempt to quantify the impact of diabetes and its complications on a person’s life [20].

17 Males, Australia Females, Australia Condition Indigenous Total Risk ratio Indigenous Total Risk ratio Ischaemic heart disease 25.0 4.9 5.0 17.0 2.6 6.6 Diabetes type 2 14.9 3.2 4.6 18.2 2.9 6.3 Anxiety and depression 12.1 7.3 1.7 19.1 13.9 1.4 Suicide 11.2 3.4 3.3 3.3 1.0 3.3 Road traffic accidents 8.3 3.3 2.5 4.5 1.2 3.7 Chronic obstructive lung disease 8.2 1.9 4.3 7.0 1.4 4.9 Alcohol dependence and harm 7.6 2.1 3.7 4.2 0.5 7.9 Asthma 5.9 4.8 1.2 8.0 4.8 1.7 Stroke 5.5 2.1 2.7 5.9 1.9 3.1 Homicide and violence 4.7 0.7 6.8 3.6 0.3 11.0 Low birth weight 4.2 1.7 2.5 3.4 1.5 2.3 Lung cancer 4.2 1.7 2.4 3.9 1.2 3.3 Pneumonia 3.7 0.6 6.1 3.3 0.2 6.8 Inflammatory heart disease 3.4 0.5 6.3 Heroin or polydrug dependence 3.3 1.4 2.3 1.9 0.5 3.7 Schizophrenia 2.9 1.8 1.6 2.3 1.3 1.7 Epilepsy 2.6 1.1 2.4 Hepatitis 2.5 0.6 4.0 Birth trauma and asphyxia 2.3 1.1 2.2 Otitis media 2.2 0.4 5.4 2.1 0.3 6.2 Breast cancer 3.0 2.9 1.0 Rheumatic heart disease 2.8 0.1 26.4 Deficiency anaemia 2.6 0.4 6.2 STIs (not HIV infection) 1.9 0.2 9.2 All causes 212.4 87.6 2.4 191.5 78.0 2.5

Table 11: Prevalence of burden of disease for selected conditions, Indigenous and Non-Indigenous people, Australia 2003 (prevalence as DALY /100,000) [22]

5.4 Diabetes mellitus

Type 2 diabetes mellitus is a major health problem for both Indigenous and non-Indigenous people. Victorian respondents to the 2004–05 National Aboriginal and Torres Strait Islander Health Survey reported diabetes with a crude prevalence of 4.3%. The age-standardized prevalence is 10.0%, resulting in a rate ratio of 3.2 [18]. The AusDiab study claims a prevalence of diabetes of 7.4% of the Australian population over 25 years of age, of whom half are unaware [23]. Australia-wide, Indigenous people are 3 times more likely to have diabetes than Non-Indigenous people (Table 12). Diabetes is the reason for 13% of all health care consultations made by Indigenous people and they are 6 times more likely to be hospitalized for it [24].

age Indigenous non-Indigenous 25–34 years 4% 1% 35–44 years 10% 2% 45–54years 21% 4% 55 + years 32% 12% age-adjusted total 12% 4%

Table 12: Diabetes prevalence, Australia 2006 [24]

18 Nationwide, Indigenous people carry a burden for diabetes of 17.9 DALY /100,000 people compared with the total population’s 3.5 DALY /100,000, resulting in a risk ratio of 5.1 [22]. In Darwin, in a survey of an urban community in 2004, 17.1% of adult participants had diabetes, and a further 12.9% had impaired glucose tolerance. Prevalence of diabetes was higher in persons of lower socioeconomic status for all socioeconomic variables examined [25]. In Victoria, diabetes is a major reason for hospitalization of Indigenous people. In 2004/05–2006/07, Aboriginal Health Liaison Ofﬁcers recorded 2,860 hospitalizations for Indigenous people with under- lying diabetes, comprising about 33% of Indigenous hospitalizations reported by Aboriginal Health Liaison Ofﬁcers3. Most of these hospitalizations (2,258) were for renal dialysis (Figure 5) [26, 27]. According to the Australian Institute of Health and Welfare, in the 2-year period July 2004–June 2006, there were 223 admissions to hospital in Victoria of Indigenous people for diabetes, resulting in an age-adjusted rate of 7.6 admissions /1,000 over this period. There were 38,267 admissions of Non- Indigenous people for a rate of 3.7 /1,000 over the same period, and a rate ratio of 2.1 [21].

Figure 5: Admissions for diabetes mellitus, including renal dialysis, Victoria, 2006–2007 [26]

5.5 Kidney disease

In Victoria, self-reported renal disease occurs in 2.2% of Indigenous people, on an age-standardized basis 19.8 times more than among Non-Indigenous people [16]. End-stage renal disease occurs in about 0.3% [24]. Nationwide, Indigenous people are 3 times more likely to have end-stage renal disease than Non-Indigenous people [24]. People with end-stage renal disease on haemodialysis consume very large quantities of health care resources. Nationally, only 13% of Indigenous patients with end-stage renal disease have received a transplant, compared with 46% of Non-Indigenous patients. Indigenous patients are 10 times more likely to be on dialysis [24], and frequently hospital dialysis. Australia-wide, hospital dialysis comprises 41% of all hospitalizations for Indigenous people, compared with 9% of hospitalizations for Non-Indigenous people [24]. Nationwide, Indigenous people

3There are Aboriginal Health Liaison Ofﬁcers in 27 Victorian hospitals and health services. Some major hospitals do not have AHLOs, and Indigenous patients in these hospitals are not recorded in datasets obtained by AHLOs.

19 carry a burden for renal failure of 10.4 DALY /100,000 people compared with the total population’s 1.4 DALY /100,000, resulting in a risk ratio of 7.6 [22]. According to the Victorian Admitted Episode Dataset for 2006–07 there were 3,797 hospitalizations for dialysis for Indigenous people, a crude rate of 126 admissions /100,000 for that year. This compares with 46 dialysis admissions /100,000 (225,348 admissions) for Non-Indigenous people. For Indigenous people these admissions comprise 32% of all admissions recorded by the VAED, and were distributed among a total of 64 patients. The major cause of renal failure in Indigenous people in Victoria is diabetes; according to data from AHLOs, diabetes-related renal dialysis accounted for 2,258 hospitalizations (Figure 6) [27].

Figure 6: Admissions for renal dialysis, Victoria, 2006–2007 [26]

5.6 Cancer

The age structure of the Victorian Indigenous population has a major impact on the incidence of cancer among Indigenous people. The median age of Indigenous Victorians is 21 years, and only 4% are aged over 65 years, compared with the Non-Indigenous median age of 37 and proportion over 65 of 14% [4]. Data on cancer among Indigenous peoples are not of good quality [28, 29, 30, 31], and are not available at all for Indigenous Victorians. Consequently data on the epidemiology of cancer among Indigenous people in Queensland, Northern Territory, Western Australia and South Australia are usually taken to represent the national picture. However, many of these data have not been assessed for quality, and it is estimated that the NT cancer registry undercounts cancers in Indigenous people by up to 15% [31]. In the Northern Territory in the period 1997–2001, Indigenous people had a similar or lower incidences of all cancers combined compared with Non-Indigenous people. However, there were differences by site. In the NT, lower incidences of skin melanoma, lymphoma, and cancers of the colon, rectum, prostate, bladder, kidney, and female breast were reported for Indigenous people, but a higher incidences of cancers of the lung, liver, cervix, and lip and oropharynx. Indigenous people had higher incidences of cancers amenable to preventable risk factors or screening (Figure 7) [31].

20 In Queensland and the NT, Indigenous people diagnosed in the 1990s to 2002 were 1.5–1.9 times more likely to die from their cancers than matched Non-Indigenous people with the same cancers. The risk ratios for dying were higher for most of the cancers studied and over four-fold higher for cancers of the lip and oropharynx, breast, and uterus, and lymphoma. Survival for 5 years for In- digenous people with cancers of the thyroid, female breast, and cervix was 69%, 56%, and 37%, respectively, compared with 95%, 85%, and 79% for all Australians combined (Figure 8). The lower Indigenous survival for some cancers results in part from Indigenous patients’ having more advanced disease when diagnosed and their being less likely to receive speciﬁc cancer treatments. Indige- nous patients were more likely (1.2 times) to have distant metastases or regional spread (1.1 times), when diagnosed than non-Indigenous patients. Indigenous patients were also 24% less likely than non-Indigenous patients to receive surgery, 20% less likely to receive chemotherapy, and 9% less likely to receive radiotherapy than non-Indigenous patients [31, 8]. There is a consistent picture for Indigenous cancer patients of more advanced disease at diagnosis, less aggressive treatment, worse prognosis and lower participation in prevention programmes. Participation in breast screening programmes by Indigenous women in the 50–69 years target age group is about 30–32%, compared with 57% participation for the total Australian female population [31]. Participation in Pap smear screening by Indigenous women over 18 years is about 40%, compared with 63% participation for the total Victorian female population [18, 32].

21 Figure 7: Cancer reported incidence, Indigenous and Non-Indigenous, NT 1991–2001 [29]

22 Figure 8: Cancer survival, Indigenous and Non-Indigenous, NT 1991–1999 [29]

In South Australia, an effort has been made over a decade to improve the collection of Indigenous status in the Cancer Registry, and it is believed that underestimation of Indigenous status is about 15% [30]. The overall difference between Indigenous and Non-Indigenous cancer is about the same magnitude in SA, and overall cancer risks may be broadly similar. The Indigenous population of South Australia is not directly comparable with Victoria’s, in that the proportion of Indigenous people is larger (1.7%) and a smaller proportion (about 80% in SA, 100% in Victoria) live in non-remote areas [33]. With these reservations, SA ﬁgures probably provide the best estimate of the incidence of cancers in the Victorian Indigenous population (Table 13).

23 Indigenous Non-Indigenous Rate ratio Oral, pharynx, oesophagus 29.7 8.5 3.5 Pancreas 11.4 5.8 2.0 Stomach 16.6 8.0 2.1 Lung 44.4 29.9 1.5 Liver 10.1 1.4 7.2 Gallbladder 10.1 2.3 4.4 Cervix 33.6 8.0 4.2 Unspeciﬁed 24.1 8.8 2.7 Melanoma 1.2 23.5 0.1 Lip 0 5.7 0 Prostate 13.1 63.5 0.2 Female breast 32.4 68.7 0.5 Bowel 17.8 39.3 0.5 Blood 15.5 26.6 0.6

Table 13: Cancer incidences in Indigenous and Non-Indigenous people, SA 1977–2001 [30]

In South Australia, the ﬁve-year survival from cancer among Indigenous people was substantially lower, at 37% in 1988–1994, as compared with about 56% for other South Australians. For Non- Indigenous people, even if they had the same age structure and suffered from the same types of cancer, ﬁve-year survival would be 49%, still above the 37% recorded for Indigenous people. Addi- tionally, cancers in Indigenous people tend to be found at a more advanced stage, but even when this is adjusted for, Indigenous people have poorer survival. Indigenous people have more co-morbidities and there is some evidence that Indigenous people receive less comprehensive treatment than Non- Indigenous people [30, 34]. Nationwide, Indigenous people carry a burden for cancer of 16.4 DALY /100,000 people compared with the total population’s 9.8 DALY /100,000, resulting in a risk ratio of 1.7 [22].

5.7 Heart and circulatory system diseases

In Victoria, 15% of Indigenous adults report a disease of the heart and circulatory system. After age-standardization, this is about 1.5 times higher than the prevalence in the Non-Indigenous population [16]. About 6% of non-remote Indigenous people report that they have high blood pressure [17]. Nationally, Indigenous people are 1.8 times more likely to have a cardiovascular condition. Crude hospitalization rates for circulatory diseases in 2006–07 were similar for the Indigenous (14 /1,000/year) and Non-Indigenous (17 /1,000/year) communities [27]. Nationally, however, Indigenous people are more likely to be hospitalized for cardiovascular disease [24]. National age-standardized rates of hospitalization for acute myocardial infarction are nearly 5 times higher, and rheumatic heart disease 9 times higher (Table 14) [24]. The prevalence of rheumatic heart disease in Victoria is not known. De- spite being hospitalized more often, Indigenous people are less likely to have modern investigations and treatment [35]. Age-standardized mortality from cardiovascular diseases for Indigenous people in Queensland, WA, SA, and the NT is 3.4 times higher than for Non-Indigenous people [36]. Na- tionwide, Indigenous people carry a burden for heart and circulatory diseases of 35.3 DALY /100,000 people compared with the total population’s 7.6 DALY /100,000, resulting in a risk ratio of 4.6 [22].

24 Indigenous age-standardized rate /1,000/2 yrs Rate ratio Ischaemic heart disease 15.1 2.0 Acute myocardial infarction 5.7 2.5 Other heart disease 11.6 1.9 Cerebrovascular disease 3.6 1.9 Stroke 7.5 2.0 Rheumatic heart disease 0.7 7.0 High blood pressure 1.3 3.8 All cardiovascular conditions 35.4 1.7

Table 14: Hospitalization for circulatory disease, NSW, Vic, Qld, WA, SA, NT, 2004–06 [21]

5.8 Child health

In 2007 the Australian Bureau of Statistics reported the births of 1,025 Indigenous babies in Victoria, resulting from 1,011 conﬁnements, 1.5% of a total of 70,313 births registered. Of these babies, 20.3% had both Indigenous mother and father, 42.0% had an Indigenous mother, and 37.8% had an Indigenous father. Total fertility for Indigenous mothers was 2.416, and 1.871 for Non-Indigenous mothers; the median age of Indigenous mothers was 26.02, and 31.6 for Non-Indigenous mothers [6, 37]. Perinatal mortality for children of Indigenous mothers in 2006 in Victoria was 15.81 per 1,000 births, compared with 10.1 per 1,000 for children of Non-Indigenous mothers [27]. Between 2002 and 2004, 1,234 births in Victoria were recorded as Indigenous, 19 of these resulted in fetal death [38]. In Victoria in 2005, 109 Indigenous women <20 years of age gave birth (48.4 /1,000 women <20), compared with 1,722 Non-Indigenous women (6.6 /1,000), for a risk ratio of 5.8 [21, Table 2.25.4]. Indigenous children have lower birth weights than Non-Indigenous children, and have a higher risk of low birth weight (Table 15). In 2005, the mean birth weight for Victorian Indigenous babies was 3,179g, and for Non-Indigenous babies was 3,369g. Children of Indigenous mothers are more likely to be pre-term; 12% of babies born of Indigenous mothers are born at <37 weeks gestation, compared with 8.3% of babies of Non-Indigenous mothers [27]. The Victorian Perinatal Data Collection Unit recorded the type of delivery for 569 Indigenous mothers in Victoria in 2006; of these women 74% had a spontaneous or assisted vaginal delivery, and 24% an emergency or elective caesarean delivery. Among Non-Indigenous mothers in the same year, 62% had a spontaneous or assisted vaginal delivery, and 32% an emergency or elective caesarean delivery [27]. Low birth weight and pre-term delivery are associated with a number of factors, including a higher risk among Indigenous mothers of:

• teen pregnancy, • illness during pregnancy, • smoking, • violence, • poor nutrition, • poorer educational attainment, and • poor socioeconomic circumstances.

The gap between Indigenous and Non-Indigenous people in Australia is greater than similar gaps in New Zealand, Canada and the USA [24].

25 Indigenous Non-Indigenous Proportion < 2,500g 13.4% 6.9% Mean birth weight 3,179g 3,369g Proportion preterm 12% 8.3%

Table 15: Birth weights, Victoria, 2006 [27, 8]

Indigenous mothers in Victoria are less likely to breastfeed their babies, 84% of Indigenous mothers and 93% of Non-Indigenous mothers reported breastfeeding (of any duration) in 2004–05[21, Table 2.24.1].

5.9 Oral health

Indigenous people have significantly poorer oral health (Table 16). In 2004–05 6% of Indigenous adults in non-remote areas had never visited a dentist or other health professional about their teeth and 53% had lost teeth[16]. In addition to their poorer dental outcomes, Indigenous people are less likely to use dental health services, often due to cost [39]. 4-year old Indigenous children enrolled in school dental services in metropolitan areas of NSW, SA and the NT in 2002–03 had an average of 2.89 decayed, missing or filled teeth (DMFT), and 86.8% of these were untreated. Among 10-year old metropolitan Indigenous children there was an average of 1.39 DMFT, of which 41.1% were untreated. The corresponding figures for 4-year old metropolitan Non-Indigenous children were 1.31 DMFT, of which 64.2% were untreated; and 1.00 DMFT, of which 35.1% were untreated among 10-year olds. Despite the higher prevalence of untreated disease, Indigenous children had higher rates of hospital admission for dental procedures [38]. A national survey of adults attending public dental clinics in showed 17.9% of Indigenous patients had periodontal pockets, indicating periodontal disease, compared with 10.1% of Non-Indigenous patients. In the same survey, Indigenous patients had a mean of 14.25 DMFT, including 4.37 decayed teeth and 2.79 filled teeth. Non-Indigenous patients had a mean of 15.35 DMFT (not significantly different), 2.62 decayed teeth (significantly different), and and 6.35 filled teeth (not significantly different) [40]. In a national survey of oral health in 2004–05 a crude proportion of 57% of Indigenous people and 25.1% of Non-Indigenous people had untreated decay of the teeth. The Indigenous participants in the survey had a mean of 2.7 decayed tooth surfaces, and Non-Indigenous participants had a mean of 0.4 decayed tooth surfaces [39].

Non-remote Indigenous Never seen a dentist 6% Lost teeth Non-remote Indigenous None 45% 1–4 31% 5–9 10% 10–14 3% ≥15 9% Dentures Non-remote Indigenous needed 12% not needed 6%

Table 16: Adult dental health, non-remote Indigenous, Australia 2004–05 [16]

26 5.10 Ear disease and hearing loss

In Victoria in 2002–03, 5.2% of admissions to hospital of Indigenous children were for otitis media, compared with 4.6 per cent of admissions of Non-Indigenous children [41]. In 2004–05, 8.6% of the non-remote Indigenous population of Australia reported deafness, and 12% reported a hearing problem [38]. Indigenous children suffer a greater degree of ear disease and hearing loss, with 10% of Indigenous children <15 having ear disease or hearing loss, compared with 3% of Non-Indigenous children [24]. In Victoria, all children are screened as school entry for hearing loss at 500 Hz at 30 dB and 1,000, 2,000 and 4,000 Hz at 20 dB [21]. In 2007, 33,996 Victorian children were screened for hearing in their ﬁrst year of school (55% of the ﬁrst year school population); 473 of these children were recorded as Indigenous. Hearing loss requiring referral was found in 7.82% of Indigenous children and 5.14% of Non-Indigenous children [26].

5.11 Injury

Nationally, injury was the second most-common reason for admission to hospital for Indigenous people, and assaults were the commonest external cause. Transport accidents are the commonest cause of injury hospitalization for Non-Indigenous people, but ﬁfth most-common for Indigenous people. However, the risk ratio for hospitalization for injury due to transport accident is the lowest among all external causes (RR=1.3). Transport accidents involving Indigenous persons in the Northern Terri- tory, Western Australia, South Australia and Queensland in the ﬁve-year period 1999–00 to 2003–04 have been investigated by the Australian Institute of Health and Welfare. Road vehicle accidents were responsible for 99% of injuries due to transport. Car occupants made up more than half of fa- talities among both Indigenous persons (52%) and non-Indigenous persons (55%). However, 35% of Indigenous persons were pedestrians compared with 13% of non-Indigenous persons and 3% of In- digenous persons were motorcyclists compared with 13% of non-Indigenous persons. The proportion of Indigenous persons among fatal injury rose with increasing remoteness; with 3% of deaths in major cities, 22% in remote areas and 62% in very remote areas [42]. For Non-Indigenous Australians, injury hospitalization is more common among the elderly than the young and males are at higher risk than females in younger age-groups. For Indigenous people males and females have equal risks in all age-groups, with a major peak in early and middle adult ages (Table 17) [24].

Males Females Persons External cause % Rate Ratio % Rate Ratio % Rate Ratio Assault 26.1 14.1 10.3 37.1 14.8 47.2 31.1 14.4 17.0 Accidental fall 15.9 8.7 1.5 14.4 8.3 1.3 15.2 8.6 1.4 Inanimate mechanical 14.5 6.3 1.4 8.5 2.9 2.2 11.7 4.6 1.6 Medical/surgical complication 8.4 6.8 1.7 12.0 7.8 2.1 10.1 7.3 1.9 Transport accident 10.8 5.0 1.3 6.1 2.3 1.4 8.7 3.6 1.3 Other accident 7.6 4.3 1.5 5.8 2.7 1.8 6.8 3.5 1.6 Intentional self-harm 4.7 2.3 2.4 6.8 2.7 1.9 5.6 2.5 2.1 Electrocution, ﬁre, animal, weather 4.2 1.9 2.1 3.4 1.3 2.9 3.8 1.6 2.4 Animate mechanical 4.5 2.1 2.3 2.3 0.9 2.2 3.5 1.5 2.2 Accidental poisoning 2.2 1.0 1.6 2.5 1.0 1.6 2.4 1.0 1.6 Other external 1.1 0.6 4.7 1.1 0.5 4.0 1.1 0.5 4.3 Total 100.0 53.0 2.1 100.0 45.2 2.6 100.0 49.1 2.2

Table 17: Injury hospitalizations for Indigenous people, Qld, WA, NT SA, 2004–05, age standardized [24]

Mortality from injury is also more common for all external causes. The mortality for Indigenous men for

27 assault is 6.3 times higher [24] and for transport-related injuries over twice as high [42]. Injuries leave more long term health damage among Indigenous people, Indigenous people were 1.4 times more likely (age-standardized) to report a long-term condition due to injury than Non-Indigenous people (Table 18). Nationwide, Indigenous people carry a burden for injury of 26.1 DALY /100,000 people compared with the total population’s 8.6 DALY /100,000, resulting in a risk ratio of 3.0 [22].

Male Female Land transport accident 2.7 4.4 Intentional self-harm 3.0 2.6 Assault 6.3 3.0 Other external 2.7 2.8 Total 3.1 3.7

Table 18: Standardized mortality ratios for selected injuries, Australia [43]

Indigenous people in Victoria were admitted to hospital for care of injuries and poisoning at a crude rate of 27 hospitalizations /1,000 population in 2006–07, compared with a crude rate of 21 /1,000 population among Non-Indigenous Victorians. Injury was the single most common cause of presentation of Indigenous people to emergency departments in hospitals, with 23.6% of all presentations [26]. During the period July 2004–June 2006 the age-standardized risk of admission to hospital for injury or poisoning was 28.8 /1,000 Indigenous population/2 yrs, compared with 22.7 /1,000 total population/2 yrs, for a risk ratio of 1.3 [21]. There is a difference between Indigenous and Non-Indigenous people in the age and sex distribution of admissions to hospital for injury. For Indigenous people, there is a steep increase in the rate of hospitalization for women as they get older, and Aboriginal women 45–64 years old have much higher rates of admission than older Indigenous men. This pattern is not observed with Non-Indigenous people, and men and women in this age group have very similar rates of hospital admission (Figure 9) [26].

Figure 9: Admissions for injury, Victoria, 2006–2007 [26]

28 5.12 Suicide

Suicide is more common among Indigenous people, particularly among girls and young men (Table 19) [24]. In Queensland, SA, WA and the NT the age-standardized rate of admissions of Indigenous people to hospital for self-harm is 2.9 /1,000 population; for Non-Indigenous people the rate is 1.6 /1,000 population [36]. In the period 2002–06, in Queensland, WA, SA and NT, age-standardized avoidable mortality (0–74 years) from suicide for Indigenous people was 26.3 /100,000/5 yrs, and 11.1 /100,000/5 yrs for Non-Indigenous people; for a rate ratio of 2.4 [21]. Nationwide, Indigenous people carry a burden for suicide of 7.2 DALY /100,000 people compared with the total population’s 2.2 DALY /100,000, resulting in a risk ratio of 3.2 [22].

Indigenous Non-Indigenous Rate ratio Age group Male Female Male Female Male Female <14 87.3 29.5 25.5 4.8 3.4 6.1 25 – 34 104.8 5.0 40.9 7.4 2.6 0.7 35 – 44 45.9 18.7 33.8 8.6 1.4 2.2 45 – 54 4.4 4.0 24.0 7.4 0.2 0.5 55 – 64 17.0 0 16.9 5.5 1.0 - 65 – 74 0 0 19.7 5.2 - - ≥75 41.4 10.3 22.8 5.3 1.8 2.0

Table 19: Suicide rates by age group, Australia [43]

Data on Indigenous suicides in Victoria are sparse. However, the Aboriginal Funeral Service noted 24 suicides (14 female and 10 male) in the period February 2006 to February 2008 [Aboriginal Funeral Service, unpublished data], a crude rate from this single source of about 40 /100,000/yr. In 2005, there were 505 deaths from suicide in Victoria among the whole population, for an age-standardized rate of 10.6 /100,000/yr [44].

5.13 Communicable diseases

Indigenous people suffer still from the ‘double burden’ of high rates of communicable as well as chronic diseases. In Victoria, an attempt is made at collecting data on Indigenous status for notifiable conditions. These data show that Indigenous people suffer from a disproportionate incidence of sexually transmissible infections, but (subject to the statistical uncertainties due to the low numbers) the gap is closing for many other conditions (Table 20). The risk of reported HIV infection among Indigenous people in Victoria in the 3-year period 2004– 2006 was 9.9 /100,000/3 years compared with 5.0 /100,000/3 years in Non-Indigenous people, for a risk ratio of 2.0. Indigenous males were notified at a rate of 8.9 /100,000/3 years, about twice the rate of the total population [21]. In Victoria, during the period 2001–2007, most of those Indigenous people who were newly infected with HIV acquired their infection from male-to-male sexual contact, for a crude annualized rate of 3.3 new notifications per 100,000, compared with 3.5 new notifications per 100,000 in the total population [Burnet Institute and Department of Human Services, unpublished data]. In the total Australian population, male-to-male sex was the risk for transmission for 71% of cases, compared with 44% of the notifications for Indigenous people. Both women and injecting drug users were more commonly represented among the cases in Indigenous people. Women made up 38% of all notified cases among Indigenous people, and 12% in the total population. Injecting drug users also made up 38% of the cases notified for Indigenous people, and 7% in the total population [43]. This means that for Indigenous people the total risk of HIV infection is higher, there is the same risk for male-to-male sex as in the total population, and a substantially higher risk for heterosexual transmission and transmission around injecting drug use.

29 In Victoria, most cases of reported tuberculosis are in people born overseas. In 2008 in Victoria, 353 cases of tuberculosis were reported, of whom 2 were Indigenous. For hepatitis C in 2008, 9 of the 154 reported cases of newly-acquired infections were in Indigenous people [45]. For Indigenous people, pneumonia is a common cause of hospitalization. During the period July 2004–June 2006 the age-standardized risk of admission to hospital for pneumonia in Victoria was 5.6 /1,000 Indigenous population/2 years, compared with 3.2 /1,000 total population/2 years, for a risk ratio of 1.7 [21]. Immunization with conjugate pneumococcal vaccine has reduced the incidence but increased the gap, with admissions to hospital for pneumococcal disease for Indigenous children under 4 in Queensland, WA, WA and NT falling from 0.6/1,000/yr in 1998–99 (rate ratio compared with all children of 5.9) to 0.2 /1,000/yr in 2005–06 (rate ratio compared with all children of 6.4) [21]. There were 7 cases of invasive pneumococcal disease notiﬁed in Victoria among Indigenous people in 2008 (2% of all cases) [45].

Victoria, crude rate Condition Indigenous Total Hepatitis C (newly acquired) 7.2 2.5 Invasive meningococcal disease, SGB 3.6 1.0 Tuberculosis 7.2 7.6 Chlamydia infection 183.2 103.1 Gonococcal infection 10.8 13.5 Infectious syphilis 14.4 7.9 Invasive pneumococcal disease 14.4 5.2 Shigella infection 3.6 1.9

Table 20: Notiﬁcations of selected communicable diseases, Victoria 2007 [46]

Nationwide, Indigenous people carry a burden for all infectious and parasitic diseases of 8.0 DALY/100,000 people [22].

5.14 Social and emotional wellbeing, and mental health

The concept of social and emotional wellbeing describes the state of positive mental health which per- mits individuals to cope with the normal stresses of daily life, contribute to their community, engage in positive relationships with others and achiever their potential. The term is often preferred by Indige- nous people as providing a broader view and reducing stigmatization that may occur with concepts of mental health and illness [47]. Social determinants provide a satisfying theoretical pathway for the causation of disturbances of social and emotional wellbeing and the occurrence of mental health and behavioural disorders. It is considered that these social determinants are translated to protective and risk factors which, in turn, decide the state of social and emotional wellbeing and mental health. Much of this is mediated through chronic mental stress and a perceived loss of control over one’s life. A study of Indigenous people’s perception of the causes of poor mental health showed that causes could be grouped around culture and spirituality; family and community kinships; historical, social and economic factors; fear and education; and loss [47]. Many of these causes have transgenerational impacts, with continuing loss of wellbeing over several generations. Much of this has related to the community’s experiences of colonization and is expressed through overrepresentation of Indigenous people in the justice system, family and intimate partner violence, welfare dependency, alcohol and other substance misuse, breakdown of traditional family structures, loss of cultural and spiritual identity, loss of individual self-esteem, security and happiness and physical ill-health [47]. In Victoria in 2002, 19% of Indigenous people reported experiences of discrimination or racism. When asked in surveys about removal from family, Indigenous people often responded that they did not wish to answer, or did not know [48]. In Victoria, 82.6% of Indigenous people reported

30 that they had been not been removed from their natural family, and 32.7% reported that their relatives had not been removed from their natural family [21, Table 1.14.6]. It is likely that the impacts of this family destruction will be felt for several decades. Data on social and emotional wellbeing and mental health are sparse and often of poor quality, and frequently measure only extreme outcomes, such as suicide or hospitalization. However, questions on social and emotional wellbeing were included in a large survey for the ﬁrst time in the 2004– 05 National Aboriginal and Torres Strait Islander Health Survey. In that survey, 29.4% of Victorian respondents stated that they had a ‘high’ or ‘very high’ level of psychological distress, about 2.1 times more than the Non-Indigenous population; and 69.9% reported low or moderate distress [49]. Indigenous people nationwide reported high or very high levels of mental stress following abuse or violent crime (42.2%), drug-related problems (40.5%), gambling problems (38.7%), racism (38.3%), among 15 life stressors [49]. In Victoria on an age-standardized basis, 10.3% of respondents stated that they felt ‘so sad that nothing could cheer [them] up all or most of the time’, compared with 2.5% of the Non-Indigenous population, and 8.4% stated that they felt ‘without hope all or most of the time’, compared with 3.1% of the Non-Indigenous population [49]. Hospitalization data are of poor quality and almost certainly underestimate the incidence and prevalence of mental ill-health. In Victoria Indigenous people up to the age of 74 years were admitted to hospital in 2002–2004 for depression at an age-standardized rate of 3.8 /1,000 population/year compared with a rate of 5.3 /1,000/year for the Non-Indigenous Victorian population, for a standardized admission rate ratio for this condition of 1.1 [50]. Similarly, Indigenous people were admitted to hospital for anxiety-related disorders at an age-standardized rate of 2.5 /1,000 population/yr compared with a rate of 2.3 /1,000/yr for the Non-Indigenous Victorian population, for a standardized admission rate ratio for this condition of 1.1 [50]. In the period 2005–07 Aboriginal Health Liaison Ofﬁcers reported that admissions for mental health problems made up 5.15% of all admissions of Indigenous people to hospitals with AHLOs [27]. The Victorian Admitted Episode Dataset recorded a crude rate of 20 admissions /1,000/yr for mental and behavioural disorders for Indigenous people compared with a crude rate of 8 /1,000/yr for Non-Indigenous people [27].

6 Health care

6.1 Health-related actions

Over a quarter of Indigenous people in Victoria consulted a doctor in the 2 weeks prior to the NAT- SIHS, 30% more than Non-Indigenous people (Table 21). Indigenous people were heavier users of all types of health care services except dental care [16].

Health-related action Rate ratio Admitted to hospital 14.1% 1.3 Visited casualty or outpatients 3.4% 1.5 Consulted GP or specialist 28.0% 1.3 Consulted dentist 3.4% 0.7 Consulted other health professional 14.7% 1.2 Days away from work or study 20.8% 1.8 Other days of reduced activity 13.8% 1.6

Table 21: Health-related actions in the previous 2 weeks, Indigenous people, Victoria 2004–2005 [16]

6.2 Hospitalization

In Victoria in 2004–06 there were 12,539 admissions of Indigenous people to hospital (an age- standardized risk of 337.4 /1,000/2 years), compared with an age-standardized risk 329.2 /1,000/2 years

31 for the total population, resulting in a risk ratio of 0.8 [21]. In 2006–07 the crude rate of hospitalization of Indigenous people was 394 /1,000/yr. Major causes for hospitalization were renal dialysis, pregnancy-related conditions, digestive and dental conditions, symptoms and signs, mental and behavioural disorders and respiratory disorders (Table 22) [27].

Major cause Indigenous Non-Indigenous Circulatory diseases 14 17 Congenital conditions 4 2 Digestive (including dental) conditions 25 22 Diseases of the ear 3 2 Diseases of the eye 2 4 Endocrine disorders 7 5 Factors influencing health status 158 83 Renal dialysis (factor influencing health status) 126 46 Genitourinary disorders 10 12 Haematological conditions 2 4 Infectious diseases 7 4 Injury and poisoning 27 21 Mental and behavioural disorders 20 8 Musculoskeletal conditions 9 9 Neoplasms (cancers) 7 15 Nervous disorders 7 7 Perinatal conditions 9 5 Pregnancy related 67 36 Respiratory disorders 20 13 Skin and subcutaneous tissue 6 4 Symptoms and signs 22 21 Undefined 0 0 Total 394 274

Table 22: Crude hospitalization rate /1,000/yr by major cause, Victoria 2006–07 [27]

Indigenous people admitted to hospital frequently have more than one diagnosis. Of a total of 467,822 admissions of Indigenous people to hospital in NSW, Victoria, Queensland, WA, SA and NT during the period July 2004–June 2006, 277,186 (59.3%) included additional diagnoses [21]. Similarly, Indigenous people in Victoria are high users of emergency departments in hospitals, with a crude rate of 489 attendances/1,000/year in 2006–07 compared with a crude Non-Indigenous atten- dance rate of 263 /1,000/yr [27].

6.2.1 Hospitalizations for ambulatory care sensitive conditions

Ambulatory care sensitive hospitalizations are admissions to hospital that are considered to be preventable, if appropriate preventive or primary health care interventions are used. They include vaccine-preventable diseases, acute conditions (including dehydration, gastroenteritis, kidney infection, perforated ulcer, cellulitis, pelvic inﬂammatory disease, ear, nose and throat infections, and dental conditions) and potentially preventable chronic conditions (including diabetes, asthma, angina, hypertension, congestive heart failure and chronic obstructive pulmonary disease). Hospitalizations for ambulatory care sensitive conditions provide an index of the functioning of other parts of the health system. In the 2 years July 2004–June 2006 there were 4,336 admissions of Indigenous people to hospital in Victoria for conditions considered to be sensitive to ambulatory care (a risk of 132.3 /1,000 Indigenous population) and 436,273 admissions of all people (a risk of 41.7 /1,000 Non- Indigenous population), for a risk ratio of 2.7 [21].

32 Pooled data from NSW, Victoria, Queensland, WA, SA and NT show a strong age-dependence of hospitalizations for ambulatory sensitive conditions, with increasing risk of admission with age (Figure 10). The top 10 conditions (diabetes complications, convulsions and epilepsy, chronic obstructive pulmonary disease, ear, nose and throat infections, asthma, dental problems, cellulitis, pyelonephri- tis, congestive cardiac failure and angina) account for 199.2 admissions /1,000 Indigenous population/2 years for and 38.7 admissions /1,000 total population/2 years (age-standardized), for a risk ratio of 5.1. A total of 339,870 bed-days was required for Indigenous people and 7,322,059 for all people [21].

Figure 10: Hospitalizations for ambulatory care sensitive conditions by age group. NSW, Victoria, Queensland, WA, SA and NT, 2004–06 [21]

6.2.2 Discharge against medical advice

In the period July 2004–June 2006, 267 separations of Indigenous people from hospital in Victoria were against medical advice (1.6% of admissions, an age-standardized risk of 5.4 /1,000 Indige- nous population/2 years). The risk ratio, compared with all admissions was 6.8 (0.2% of total admissions, an age-standardized risk of 0.8 /1,000 total population/2 years) [21].

6.3 Screening and preventive health care

Several forms of population screening have demonstrated effectiveness in preventing development and progression of chronic disease, particularly some cancers. Public health success of these programmes depends in part on participation. Generally, participation by Indigenous people in screening programmes is lower than by Non-Indigenous people. In Victoria in 2004–05, the age-standardized proportion of Indigenous women ≥50 years of age participating in BreastScreen mammography programmes was 38.1% compared with 58.0% of all women [21, Table 3.03.3]. The crude proportion of Victorian Indigenous women ≥18 participating in regular pap smear testing was 63.4% [21, Table 3.03.8].

7 Upstream determinants of Indigenous health in Victoria

7.1 Education

Education and educational attainment are highly correlated with health status. Indigenous children spend less time at school, and do not achieve as well as Non-Indigenous children (Table 24). In

33 Victoria, 25.7% of Indigenous children aged 3–5 years were enrolled in pre-school in 2005, compared with 43.4% of Non-Indigenous children of the same age. In 2006, 94.7% of Indigenous children aged 5–8 years were enrolled in school, compared with 92.8% of Non-Indigenous children [51]. Lower proportions of Indigenous children are retained at school compared with Non-Indigenous children for all ages from 12 years (Figure 11) and for all years from year 9 (Figure 12) [36].

Figure 11: School participation by age, Victoria 2006 [36]

34 Figure 12: School retention, Indigenous and Non-Indigenous students, 2006 [36]

Indigenous children do not attain the same educational outcomes as Non-Indigenous children, 55.1% of Victorian Indigenous students enrolled in year 11 in 2004 received a year 12 certiﬁcate in 2005, compared with 95.4% of Non-Indigenous students (Table 23) [36]. Lower proportions of Indigenous adults in Victoria have completed year 12 compared with Non-Indigenous adults, and lower proportions of Indigenous students achieve functional benchmarks such as literacy and numeracy (Table 24).

Year Indigenous Non-Indigenous 12 27.4% 48.4% 11 14.8% 15.2% NS 10 27.6% 15.9% 9 13.2% 7.4% 8 or below 17.1% 13.0%

Table 23: Highest level of education achieved, Victoria 2004–2005 [36]

35 Indigenous All Year 7 literacy benchmark 41.0% 91.0% Aus, 2004 Year 7 writing benchmark 78.8% 93.6% Aus, 2004 Year 7 numeracy benchmark 51.9% 82.1% Aus, 2004 Year 10 retention M 75.0% M97.9% Indigenous: Vic F 87.4% F 99.4% All: Aus, 2005 Year 12 retention M 30.5% M 71.1% Indigenous: Vic F 52.0% F 82.3% All: Aus, 2005 Year 12 completion M 56.8% M 83.2% Indigenous: Vic F 65.7% F 88.9% All: Aus, 2005 Adults with year 12 qualiﬁcation 23% 47% Aus, 2004–05 Adults with post-school qualiﬁcation 38% 60% Aus, 2004–05

Table 24: Educational achievement and retention, Victoria and Australia [24]

7.2 Employment

Employment is a fundamental determinant of health status, for individuals and for families. Indigenous people are less likely to participate in the workforce and are less likely to be employed if they do participate (Table 25). When they are in work, Indigenous people in work in Victoria are more likely to work for public sector employers, in the health and community services or manufacturing sector, and less likely to work in the retail, property and business services or education sectors than Non- Indigenous people. On an age-standardized basis, about 25% of Indigenous people in work are employed at skill level 1 and 11% are employed at skill level 5. For Non-Indigenous people the corresponding proportions are 30% and 17% respectively [52].

Indigenous Non-Indigenous In labour force 53.4% 63.3% Unemployed 15.7% 5.3% Proportion of population >15 employed 45.0% 59.9% Proportion of employed people in full-time work 58.1% 66.9%

Table 25: Employment, Victoria 2006 [24, 52]

7.3 Income

Income is strongly correlated with health status. Indigenous families have lower incomes than Non- Indigenous families (Table 26). In 2006, the median individual income per week in was $332 for Indigenous people over 15 years, and for Non-Indigenous Victorians was $457 [53].

Indigenous Non-Indigenous Median gross equivalized income $498 $726 Proportion in the lowest income quintile 41.2% 20.1% Proportion in the highest income quintile 7.6% 20.2%

Table 26: Family income, Victoria 2004–2005 [53]

7.4 Families

Single-parent and larger families are at higher risk of poverty and poorer health status. Indigenous families are more likely to be single-parent families, and more likely to include more children (Ta-

36 ble 27). Average household size for Indigenous households was 3.0, and 2.6 for Non-Indigenous households [53].

Indigenous Non-Indigenous Single parent families with dependent children 49% 20% Families with 4 or more children 11% 5%

Table 27: Single-parent families and large families, Victoria, 2006 [53]

A total of 82.6% of Indigenous people in Victoria in 2002 reported that they had been not been removed from their natural family, and 32.7% reported that their relatives had not been removed from their natural family4 [21, Table 1.14.6].

7.5 Contact with the criminal justice system

Indigenous people are more likely to be imprisoned than Non-Indigenous people. At the national prisoner census 30 June 2007 there were 238 Indigenous prisoners in Victoria, a crude prevalence of 1288.5 /100,000 adult population, compared with a Non-Indigenous crude prevalence of 99.1 /100,000 adult population[54]. The age-standardized prevalence for Indigenous people was 999.5 /100,000 adult population for Non-Indigenous people 100.8 /100,000 adult population, for a prevalence ratio for imprisonment of 9.9 [21].

7.6 Community safety

Indigenous people experience a lower level of community safety than Non-Indigenous people. In Victoria in 2002, 26% of Indigenous people reported being a victim of actual or threatened violence in the previous 12 months compared with 8% of Non-Indigenous people. In the same survey13% reported being a victim of abuse or violent crime (Non-Indigenous 3%); 13% reported witnessing violence (Non-Indigenous 2%); 16% reported a family member being sent to jail; and 19% reported experiences of racism [21].

7.6.1 Victims of crime

Indigenous people have a higher risk of being a victim of crime than Non-Indigenous people, with the exceptions of sexual assault of people under the age of 16, and for robbery (Table 28) [36].

Crime Indigenous Non-Indigenous Homicide 9.8 3.7 Non-domestic violence assault 1,229.7 443.6 Domestic violence assault 574.1 118.1 Sexual assault 159.8 70.2 Sexual assault, victim aged 0–15 214.6 194.3 Robbery 19.6 41.4

Table 28: Victims of selected crimes, crude rates/100,000/year, Victoria, 2005–06 [36]

4Indigenous people often do not wish to answer this question

37 7.7 Contact with the juvenile justice system

Indigenous youth have much higher rates of contact with the juvenile justice system. In Victoria in 2005 according to data then available to the Productivity Commission, Indigenous youth were subject to juvenile detention at a prevalence of 393.1 /100,000 Indigenous people aged 10–17 [36], compared with a Non-Indigenous prevalence of 8.1 /100,000 Non-Indigenous people aged 10–17, for a prevalence ratio of 37.5. Data from the Victorian Department of Human Services indicate that, in 2007, Indigenous males were subject to juvenile justice custodial orders at a prevalence of 4.9 /1,000 In- digenous persons 10–20 years of age and females at a prevalence of 0.3 /1,000 Indigenous persons 10–20 years. These results yield prevalence ratios of 11 for Indigenous males compared with Non-Indigenous males, and 17 for Indigenous females. Due to introduction of new procedures by the DHS comparisons cannot be made between results for 2007 and previous years [26].

7.8 Contact with the child protection system

In Victoria, Indigenous children ≤17 years of age are 10 times more likely to come into contact with the child protection system than Non-Indigenous children (Table 29). The type of abuse or neglect suffered by these children was physical abuse (31.3%), sexual abuse (4.9%), emotional abuse (44.8%) and neglect (19.4%). These proportions were broadly the same as for Non-Indigenous children, except for sexual abuse, which was higher for Non-Indigenous children (7.4%). Indigenous children are 10.1 times more likely to be on a care and protection order than Non-Indigenous children (prevalences of 47.6 /1,000 and 4.7 /1,000 respectively on 30 June 2007). Indigenous children are 12.7 times more likely to be in out-of-home care (prevalences of 47.8 Indigenous and 3.8 Non-Indigenous /1,000 children on 30 June 2007); of Indigenous children in out-of-home care, 38.1% were placed in Non-Indigenous settings [21].

Number Rate per 1,000 children ≤17 per year Indigenous Other Indigenous Other Total Rate ratio Victoria 697 5,891 56.6 5.3 5.9 10.6 Australia 6,554 25,869 31.8 5.8 7.0 5.4

Table 29: Substantiated notiﬁcations to the child protection system, Victoria 2006–07 [55]

7.9 Housing

Housing has a complex relationship with health status, having direct and indirect effects, through the quality of the environment and as a marker for broader social determinants [56]. People living in poorer housing tend to have a poorer health status than people living in high-quality housing, but the association between housing and health status is not as clear-cut as is often thought [56]. Tradition- ally, the focus has been on communicable diseases, many of which are intensely transmitted within households; and air quality, particularly the presence of cold, damp, moulds and pollutants, for example from unflued gas heating. Indigenous households are larger than Non-Indigenous households; the median size for Victorian Indigenous households in the 2006 Census was 3.0, compared with 2.6 for all households. Further, 17.1% of Victorian Indigenous households comprised 5 or more people, compared with 10.1% of all households [57]. In Indigenous households, an average of 1.2 persons shared a bedroom, compared with 1.1 persons in Non-Indigenous households [53]. Using the Canadian National Occupancy Standard for ‘crowding’ [21], in 2004–05 11.4% of the Vic- torian Indigenous population lived in households classified as overcrowded, requiring at least 1 additional bedroom, and 2.8% in households requiring at least 2 additional bedrooms. Of Victorian Indigenous households, 9.1% were classified as overcrowded, compared with 3.1% of all households

38 (risk ratio of 2.9). Victorian Indigenous people were 1.7 times more likely to require ≥1 additional bedroom, and 4.3 times more likely to require ≥2 additional bedrooms [21]. Indigenous people are more likely to move house than Non-indigenous people. Of Indigenous persons 15 years and older, 34.2% were living at a different address 1 year before the census, and 65.1% were at a different address 5 years before the census. Of the total population 17.0% were at a different address 1 year before the census, and 42.6% 5 years before [4].

7.10 Access to telephones and private cars

Access to the use of a telephone and a car is an indicator of mobility and economic success. In- digenous Victorians have lower access to both telephones and cars than Non-Indigenous people. In 2004–05, 87.6% of Victorian Indigenous people >15 years of age have a working telephone [21]. In 2006, the ratio of Indigenous Victorians to cars was 1.35 (1.18 for Non-Indigenous people). Among Victorian Indigenous households in 2006, 74.5% had access to a car, compared with 89.2% of Non- Indigenous households [21].

7.11 Culture

7.11.1 Language

A proportion of 1% of Indigenous people in the 2006 census in Victoria claimed to speak an Australian language at home [53].

7.11.2 Land

As at 30 June 2006, of the 227,416 km2 land area of Victoria, Indigenous people owned or controlled 100 km2 (0.04% of total land area) in 464 parcels (Figure 13), and Native Title has been found to exist in a further 398 km2. Native Title was not found in 10,520 km2 (0.2% of total land area) (Figure 14) [52]. In 2002, 63.3% of Victorian Indigenous people reported they recognized their traditional lands, 46.6% that they were able to visit them, 14.5% that they lived on them and 2.2% that they were not allowed to visit their traditional lands [21].

39 Figure 13: Indigenous Land Corporation holdings, Victoria 2008 [58]

40 Figure 14: Native Title applications and outcomes, Victoria 2008 [59]

8 ‘Lifestyle’ determinants of Indigenous health in Victoria

8.1 Risk factors and disease progression

Chronic diseases almost always have multiple contributing causes, leading to the idea of ‘risk factors’ for disease (Table 30). The presence or absence of these risk factors in an individual then deﬁnes whether that person is at risk or not, and many people have several risk factors. For example, smoking, high blood pressure and overweight are all risk factors for heart disease and their presence in an individual contributes to that person’s risk of overt disease. Risk factors can be demographic, behavioural, biomedical, genetic, environmental, social or other factors, which can act independently or in combination. Combinations of risk factors may increase the risk beyond additive effects. The prevalence of many ‘lifestyle’ risk factors is not very different in Indigenous people compared with Non-Indigenous people (Figure 15), yet the impact on health is disproportionately greater (Figure 19 and Table 32). Many chronic diseases are risk factors for other chronic diseases, leading to a cascade of disease and disability. Diabetes mellitus, for example is a chronic disease in its own right, but is also a risk factor for heart disease, kidney disease and many other disabilities. This cascade of ill health is a major feature of chronic disease, increasing disability for patients and complexity of treatment for health care services.

41 Behavioural Biomedical Diet Inacti- Smoking Excess Over- High High vity alcohol weight blood choles- pres- terol sure √ √ √ √ √ √ √ Cardiovascular disease √ √ √ √ √ √ √ Cerebrovascular disease √ Lung cancer √ √ √ √ Colorectal cancer √ √ Depression √ √ √ Diabetes √ √ Asthma √ COPD √ √ √ √ Chronic kidney disease √ √ √ Oral disease √ √ Osteoarthritis √ √ √ √ Osteoporosis

Table 30: Risk factors and chronic diseases [60]

After exposure to one or more risk factors there is usually a period of asymptomatic disease, where the person is unaware of the onset of pathological processes. This stage may persist for many years, and a person may never develop overt disease. For many diseases there are interventions which can reverse or stabilize the progression of pathology, and early treatment may be of value. For some diseases, early diagnosis by screening tests combined with conﬁrmatory testing and early treatment can reduce the progression of pathology. In the normal course of events, it is not until overt disease has occurred and been recognized by the patient that a diagnosis can be made. This may be many years after the commencement of risk. At this stage people may seek medical care. Depending on the condition, its progression and the treatment options available, health care may mitigate the course of the disease.

8.2 Risk factor distribution

Nationwide, on average, adult Indigenous people were exposed to 2.3 of the health risk factors investigated in the health survey of 2004–05. Approximately 95% reported at least one health risk factor and 16% reported at least four risk factors [61]. Adjusted for the age structure of the Indigenous population, exposure to numbers of risk factors among Indigenous people is not different from the Non-Indigenous population. With the exceptions of smoking, illicit drug use and violence, the distribution of key risk factors for chronic diseases among Indigenous people in Victoria is not very dissimilar to the exposure of Non- Indigenous people (Figure 15 and Table 31) [18, 21, 17, 62, 36].

42 Figure 15: Prevalence of selected risk factors, Victoria, 2004–06. Note: data for unsafe sex not available [18, 21, 17, 62, 36]

Risk factor Indigenous Non-Indigenous Smoking 47.0% 21.1% Overweight 54.6 57.5% Physical inactivity 74.0% 68.0% High cholesterol 7.2% 6.7% Risk or high risk alcohol 16.6% 12.2% High blood pressure 15.4% 10.3% Low fruit 45.0% 43.9% Low vegetable 86.0% 84.9% Illicit drug use 24.2% 13.0% Victim of violence 26.0% 8.0% Child sexual abuse 0.2% 0.2%

Table 31: Prevalence of selected risk factors, Victoria, 2004–06. [18, 21, 17, 62, 36]

8.3 Smoking

Smoking contributes more to the burden of disease than any other risk factor. More Indigenous people smoke than Non-Indigenous people, 52% of Indigenous people ≥18 reported smoking in 2004–05 [21]. Fifty percent of adult Indigenous Victorians smoke on a daily basis, 24% are ex- smokers and 24% have never smoked. In Victoria in 2004–04, 53% of Indigenous children <14 lived in a household with a regular smoker, compared with 35% of Non-Indigenous Victorian children; and 28% of Indigenous children lived in a household with a regular smoker who smoked indoors, compared with 10% of Non-Indigenous children [21]. Not only do more Indigenous people smoke, but they smoke more. Australia-wide, adult Indigenous cigarette smokers smoke on average 115 sticks /week, compared with Non-Indigenous smokers’ 97 sticks /week [62].

43 Figure 16: Smoking by age, Victoria, 2004–05 [18]

8.3.1 Smoking and pregnancy

Smoking is a risk factor for many adverse perinatal outcomes, including low birth weight, preterm birth, and complications of pregnancy. There are no data on smoking rates for pregnant Indigenous women in Victoria [63]. In NSW in 2004 57.6% of pregnant Indigenous women reported smoking, and in SA 58.9%. When analysed by remoteness, 51.3% of pregnant Indigenous women in urban areas, 55.9% in inner regional areas and 55.3% in outer regional areas reported smoking [63]. Similar to the trend associated with remoteness was a trend associated with socioeconomic status: 55.0% of the socioeconomically most disadvantaged quintile of pregnant Indigenous women reported smoking compared with 43.2% of the least disadvantaged quintile. There was little variation by age group, with 49.4% under 20 years of age reporting smoking, 51.9% in the 20–24 years age group and 50.5% of those over 35. In NSW, about half (54.3%) reported smoking more than 10 cigarettes per day, and only 2% of smokers reported not smoking at all in the second half of pregnancy [63].

8.4 Alcohol

The effect of alcohol consumption on health follows a U-shaped curve, moderate consumption is associated with better health outcomes than no consumption, but drinking at ‘risky’ or ‘high-risk’ levels is associated with markedly poorer outcomes [64]. Adverse health outcomes include

• Injury • Cancer • Liver disease

• Cognitive dysfunction and dementia • Alcohol dependence • Heart disease (at high levels of consumption) • Stroke

44 • Neuropathies • Social dysfunction.

The overall proportion of Indigenous people drinking at levels considered to be risky or high risk is much the same as among Non-Indigenous people (RR=1.4, NS) and 58% (Figure 17) [16]. Among Indigenous Victorians in the 2004–05 National Aboriginal and Torres Strait Islander Health Survey, 16% reported abstaining from alcohol, 58% reported drinking at short-term risky and high risk levels in the previous 12 months, 17% at these levels at least once a week; and 16% reported drinking at long-term risky and high-risk levels at least once a week [21, Table 2.20.3a]. On an age-standardized basis, 19% of Indigenous Victorians reported abstaining from alcohol, 50% reported drinking at short- term risky and high risk levels in the previous 12 months, 17% at these levels at least once a week; and 17% reported drinking at long-term risky and high-risk levels at least once a week. On and age- standardized basis among Non-Indigenous Victorians, 16% reported abstaining from alcohol, 38% reported drinking at short-term risky and high risk levels in the previous 12 months, 7% at these levels at least once a week; and 12% reported drinking at long-term risky and high-risk levels at least once a week [21, Table 2.20.3b]. Despite the broad similarity in alcohol use, alcohol-related harm is much greater for Indigenous people: with higher burden of disease (Figure ??) and a 4.2 times higher risk of hospitalization in pooled data from 2004–06 from NSW, Victoria, Queensland, WA, SA and NT [21].

Figure 17: High-risk/risky drinking by age, Victoria, 2004–05 [18]

8.5 Substance use

Of the Victorian Indigenous people who responded to the substance use questions in the National Aboriginal and Torres Strait Islander Health Survey in 2004–05, 32.8% reported using illicit drugs or substances in the previous 12 months. Of all responders, 10.9% reported illicit use of prescription drugs, 8.8% amphetamines or speed, 25.4% cannabis or derivatives and 41.4% reported never using illicit drugs or substances [18]. Among Non-Indigenous Australians aged 14 years and older surveyed in the National Drug Strategy Household Survey, 15.3% reported using illicit drugs or substances in the previous 12 months. Of those responding to the survey, 3.8% had used pharmaceuticals for non-medical purposes, 15.3% had used an illicit drug in the previous 12 months, 3.2% had used amphetamines or speed, 11.3% had used cannabis, and 61.9% had never used an illicit drug [65].

45 8.6 Overweight

Overweight and obesity are risk factors for many diseases, particularly hypertension, cardiovascular disease, type 2 diabetes mellitus and some forms of cancer [66]. Body mass index was calculated from self-reported height and weight in the National Aboriginal and Torres Strait Islander Health Survey. After adjusting for non-response, 48% of Indigenous Victorians were overweight or obese [18]. Nationwide, Indigenous people were 1.2 times more likely to be overweight or obese than non-Indigenous Australians, after adjusting for the age differences between the two populations and for non-responses (Figure 18) [16].

Figure 18: Overweight and obese by age, Victoria, 2004–05 [18]

8.7 Physical activity

Physical inactivity is associated with many adverse health outcomes, particularly through its role in the development of overweight status. Indigenous people in Victoria are more likely to be sedentary than Non-Indigenous people. In 2005–05 the crude proportion of Indigenous people who categorized their level of physical activity as sedentary was 38%, and 28% categorized their level of physical activity as moderate or high. On an age-standardized basis, 42% of Indigenous Victorians were sedentary, compared with 31% of Non-Indigenous Victorians (a statistically signiﬁcant difference); and 26% of the Indigenous population had moderate or high levels of physical activity compared with 31% of Non-Indigenous people (the difference was not statistically signiﬁcant) [21, Tables 2.22.2a and b].

8.8 Fruit and vegetable consumption

Fruit and vegetable consumption is associated with protection from a number of chronic diseases, including ischaemic heart disease, high blood pressure, some forms of cancer (including colon, lung and gastrointestinal cancers), obesity and type 2 diabetes. Conversely, inadequate consumption of fruit and vegetables is a risk factor for development of these diseases. Current Australian guidelines for adults recommend 5 serves of vegetables each day and 2 serves of fruit each day [67]. In 2004–05, about 11% of Indigenous Victorians >15 years of age reported no usual daily fruit intake and 3% reported no usual daily vegetable intake [18, 21]. Of Indigenous people in Victoria in

46 2004–05, 43% reported eating the recommended daily intake of fruit (≥2 serves per day) and 12% the recommended daily intake of vegetables (≥5 serves per day) [21, Table 2.23.5a]. On an age- standardized basis, 45% of Indigenous people reported eating ≥2 serves of fruit per day compared with and 12% of the Non-Indigenous population; and 14% of Indigenous people reported eating ≥5 serves of fruit per day compared with 15% of the Non-Indigenous population [21, Table 2.23.5b].

8.9 Assurance of food supply

A risk for inadequate diet is an intermittent food supply, often termed ‘food insecurity’. Indigenous people are at higher risk of running out of food than Non-Indigenous people. In Victoria in 2004–05, on an age-standardized basis, 21% of Indigenous people reported running out of food at some time in the 12 months before the National Aboriginal and Torres Strait Islander Health Survey. This compares with 5% of the Non-Indigenous population, for a risk ratio of 4.4 [21, Table 2.23.9]

8.10 Burden of disease and lifestyle determinants

There are no Victorian data on the burden of disease carried by Indigenous people associated with lifestyle determinants, but national data indicate that 14 risk factors are responsible for 29% of the health gap as measured by burden of disease (Figure 19 and Table 32). If the level of exposure to these risk factors were brought to the level experienced by Non-Indigenous people, then nearly one-third of the health gap could be closed [20].

Figure 19: Prevalence of burden of disease by selected risk factors, Australia 2003 [20]

47 Risk factor Indigenous Non-Indigenous Ratio Excess burden Smoking 24.5 3.9 6.3 10% Overweight 23.0 4.2 5.5 9% Physical inactivity 169. 3.1 5.4 7% High cholesterol 11.1 2.7 4.1 4% Risk or high risk alcohol 10.9 2.9 3.8 4% High blood pressure 9.3 2.6 3.6 3% Low fruit and vegetable consumption 7.0 1.0 7.0 3% Illicit drug use 6.9 2.4 2.9 2% Intimate partner violence 5.2 1.3 4.0 2% Child sexual abuse 2.9 1.1 2.7 1% Total 29%

Table 32: Prevalence of burden of disease per 1,000 population, prevalence ratio and excess burden by selected risk factors, Australia 2004. Note that the total excess burden is not the linear sum of individual components. [20]

9 Expenditure on Indigenous health

Expenditures on Indigenous health are difficult to estimate, as identification of both patients and expenditures is not of high standard. Australia-wide, for health overall, expenditure per person in 2004–05 was $4,718 for Indigenous people and $4,019 for Non-Indigenous people. Nationally, state governments spent $2,243 per Indigenous person and $823 per Non-Indigenous person. In Victoria in 2004–05 the state government spent $2,701 per Indigenous person and $1,327 per Non-Indigenous person on health services [68]. Expenditure on Indigenous people through the Medicare Benefits Schedule relied on a voluntary Indigenous identification scheme, which had low participation; but accepting these caveats, $478 per Victorian Indigenous person was spent through the MBS [68].

10 Conclusion

Indigenous Victorians clearly have lower health status than Non-Indigenous Victorians. This is exem- pliﬁed in nearly all indicators of health status or of health determinants. While the quality of the data could be improved the evidence is overwhelming that Indigenous people in Victoria suffer from a very substantial systematic disadvantage in health. While it has not been the purpose of this analysis to examine interventions to improve health, closing the health gap between Indigenous and Non-Indigenous people in Victoria will require, as a minimum:

• An approach to redress racism, socio-cultural and socio-economic disadvantage to remove upstream causes of poor health, • An approach to provide effective, evidence-based ‘lifestyle’ interventions to remove midstream causes of poor health, and • An improvement in health services to mitigate poor existing health.

Health services which meet Indigenous people’s needs are essential, and there has to be doubt about whether these needs are being met. There are obvious inequities in provision of services, through the entire spectrum from basic dental care to sophisticated intervention cardiology. Correction of these inequities should not be difﬁcult. However, most of the cause of poor Indigenous health lies

48 well outside health services, and it follows that most improvement in Indigenous health will come from an examination and renewal of the way the Non-Indigenous Victorian community interacts with Indigenous peoples.

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