Downloaded from http://bmjopen.bmj.com/ on September 14, 2017 - Published by group.bmj.com Open Access Research Transformation of mortality in a remote Australian Aboriginal community: a retrospective observational study Wendy E Hoy,1 Susan Anne Mott,1 Beverly June McLeod1,2 To cite: Hoy WE, Mott SA, ABSTRACT Strengths and limitations of this study McLeod BJ. Transformation Objectives To describe trends in ages and causes of of mortality in a remote death in a remote-living Australian Aboriginal group over a ► The broad sweep and historical depth of this study, Australian Aboriginal recent 50-year period. community: a retrospective the unique data sources and the integration of Design A retrospective observational study, from 1960 to observational study. BMJ Open clinical and demographic information have allowed 2010, of deaths and people starting dialysis, using data 2017;7:e016094. doi:10.1136/ delineation of the profound and recent transformation from local clinic, parish, dialysis and birthweight registers. bmjopen-2017-016094 of mortality not previously appreciated in the Setting A remote island community in the Top End of Australian Aboriginal setting. ► Prepublication history and Australia’s Northern Territory, where a Catholic mission ► It is inevitable that we have failed to capture additional material for this was established in 1911. The estimated Aboriginal paper are available online. To some deaths in the past, which probably results in population was about 800 in 1960 and 2260 in 2011. view these files please visit the understatement of the magnitude of this transition. Participants All Aboriginal residents of this community journal online (http:// dx. doi. In some recorded natural deaths, the assignments whose deaths had been recorded. org/ 10. 1136/ bmjopen- 2017- were approximate and the contribution of multiple Outcome measures Annual frequencies and rates of 016094). causes was underestimated. terminal events (deaths and dialysis starts) by age group Received 24 January 2017 and cause of death. Revised 28 June 2017 Results Against a background of high rates of low birth Accepted 29 June 2017 weight, 223 deaths in infants and children and 934 deaths in a remote-living Aboriginal Australian in adults (age >15 years) were recorded; 88% were of group over the last 51 years. natural causes. Most deaths in the 1960s were in infants The Tiwi people live in three major and children. However, over time these fell dramatically, across the birthweight spectrum, while adult deaths communities (and several smaller ones) on progressively increased. The leading causes of adult Bathurst and Melville Islands off the coast of natural deaths were chronic lung disease, cardiovascular the Northern Territory (NT), about 90 km disease and, more recently, renal failure, and rates were by sea from Darwin (figure 1). They lived increased twofold in those of low birth weight. However, in relative isolation for perhaps 7000–15 000 rates of natural adult deaths have been falling briskly since years, and consider themselves distinct from 1986, most markedly among people of age ≥45 years. The mainland Aboriginal people, with their own population is increasing and its age structure is maturing. unique origins, language and customs.3 Conclusions The changes in death profiles, the In 1911, a Catholic mission was established expression of the Barker hypothesis and the ongoing by the Missionaries of the Sacred Heart, led increases in adult life expectancy reflect epidemiological by Father Francis Xavier Gsell.4 Changes and health transitions of astonishing rapidity. These probably flow from advances in public health policy and followed in lifestyle (from nomadic hunter– healthcare delivery, as well as improved inter-sectoral gathering to living in fixed dwellings), in diet services, which are all to be celebrated. Other remote (from food from the bush and sea to depot communities in Australia are experiencing the same supplies of less perishable, high caloric density phenomena, and similar events are well advanced in many food, of flour, fat, meat and sugar), in family developing countries. and community structures (from polygamy and networks of carers within extended fami- 1 lies to monogamy) and in the establishment Faculty of Medicine, Centre BACKGROUND of dormitories, schools and clinics. Transition for Chronic Disease, UQCCR, The University of Queensland, Recent literature describes a rapid shift in has been especially accelerated since World Brisbane, Australia patterns and causes of death in most coun- War II. Cigarettes were widely introduced 2Menzies School of Health tries and regions. Infant and childhood around this time (anecdotal evidence). Research, Darwin, Australia deaths have decreased, life expectancy has The 1967 referendum formally recognised 1 5 Correspondence to increased and more deaths in adults are Aboriginal people in Australia and they Prof. Wendy E Hoy; associated with non-communicable chronic were thenceforth included as residents in the w. hoy@ uq. edu. au diseases.2 Here we describe such a transition national census. Legal access to alcohol began Hoy WE, et al. BMJ Open 2017;7:e016094. doi:10.1136/bmjopen-2017-016094 1 Downloaded from http://bmjopen.bmj.com/ on September 14, 2017 - Published by group.bmj.com Open Access doctors for intermittent periods. Local hospital beds were closed in the early 1990s, and all persons needing hospital admission were thenceforth streamed to the Royal Darwin Hospital, transported by small plane. Responsibility for clinical services was transferred from the mission to the NT government in the early/mid-1990s. Anthropologist Charles Hart enumerated a Tiwi popu- lation of 1062 in 1928.3 John Hargrave estimated the Tiwi population at about 800–900 in 1957, compatible with a 1954 Commonwealth Government estimate of 920.9 10 Regular government census estimates have been published every 5 years since 1986. Figure 1 The Tiwi Islands, Northern Territory, Australia Note: Traditionally, Tiwi people have only occasionally Wurrumiyanga was formerly named Nguiu. Source: Adapted transmigrated, usually for purposes of intermarriage from Google Map data. The Tiwi Islands. Google; ©2017 [cited 2017 Jan 10]. Available from: https://www.google.com. according to tribal edicts. The destinations of people who au/maps/@-12.2087082,130.7314414,8.75z. travel, and the movements and locations of community members, are known by all. Deaths of people who die out of community (usually in Darwin or while visiting other around that time. The first social club, serving alcohol, communities) are documented in their medical records was opened in the largest Tiwi community in 1967. in their ‘home’ community clinic and added to the death Some early insights into remote-living Aboriginal register. people in the NT are provided by Ellen Kettle, the first Death rates in the Tiwi community, along with those in Rural Survey Sister in the NT, who pioneered mobile Aboriginal people in Arnhem Land, have been the highest health work in isolated areas and established indi- in Australia: in the 1990s, with age standardisation, they vidual health records, and by Dr John Hargrave, the were six times those of the Australian mainstream.11 This first Aboriginal Health Officer, who examined members generally reflects the much younger age of Tiwi people at of many communities in 1957/1958. Both advanced death. Cases of kidney failure began to attract attention understanding of Aboriginal health and development of in the 1980s12; for several decades, Tiwi people had the services and policy. They described endemic conditions highest rates of renal failure yet described, and the first (yaws, malaria, infestations, trachoma) and imported haemodialysis unit in a remote Aboriginal location was conditions like leprosy, syphilis (arguably), tuberculosis, established in Wurrumiyanga on Bathurst Island in the measles, small pox and influenza. They documented late 1990s. High renal failure rates have followed in other florid malnutrition and frank starvation, high infant and remote communities. The characteristics and speculative maternal mortality and conspicuously low birth weight. causes of the renal disease have been described exten- They then described, over time, dramatic reductions in sively.12–14 We have previously described the high rates of infant mortality, the appearance of alcohol-related disor- low birth weight in this community and the risk exacer- ders and occasional overweight and obesity, as well as the bations for natural deaths in infants, children and young emergence of non-communicable chronic diseases.6 7 adults associated with low birth weight.15 16 These phenomena occurred against a background of continuous improvements in remote Aboriginal health services, including management of infections and infes- AIMS AND OBJECTIVES tations, immunisations, better obstetric services, better To describe trends in mortality over more than 50 years maternal and child care and cancer surveillance. Chronic in a remote Aboriginal community in the NT of Australia. non-communicable diseases, predominantly type 2 diabetes, cardiovascular disease, chronic lung disease and chronic kidney disease, now dominate the adult health METHODS profile and are the focus of most of health service provi- Data sources were the written logs of deaths maintained sion for remote-living Australian Aboriginal adults.8 by the clinics, dialysis unit records of NT Renal Services, Clinical services were established by the mission, and in this staunchly Catholic