According to the Federal Department of Health website the Australian health system is “one of the best in the world, providing safe and affordable health care for all Australians.” What’s more, it’s a “key reason why we enjoy one of the longest life expectancies in the world”.
There is some truth behind this last statement. According to the Australian Bureau of Statistics from 2015 to 2017, Australian men could expect to live for 80.9 years and women, 85 years. These figures meant that in 2018 Australia ranked sixth in the World Health Organisation’s list of countries with the highest life expectancy.
But it isn’t entirely accurate, either. Over the same period, life expectancy for Indigenous people was estimated to be 71.6 years for men and 75.6 years for women. These figures would just place Australia in the top 100 of the WHO’s list.
These statistics reflect the myriad health inequalities felt by Indigenous people in Australia.
A recent increase in syphilis rates among Aboriginal people is one example that has health experts worried. From 1 July, 2020 to 30 June, 2021 rates of syphilis in Aboriginal people in WA increased by 48 per cent compared to the previous 12-month period — this compares to an 11 per cent increase in non-Aboriginal people. All regions bar the Wheatbelt and South West saw cases rise, with the rate per 100,000 people the highest in the Kimberley and Pilbara — 353.2 and 200, respectively.
These increases are part of a nationwide epidemic that entered WA in 2014. Dr Barbara Nattabi from the University of Western Australia School of Population and Global Health says health experts have been discussing the exponential trend for years. State and national response groups have been formed to respond to the outbreak, and there is an abundance of accessible data illustrating the imbalance. So why are rates continuing to rise? The answer is complex.
A national epidemic
According to the Western Australian Department of Health, the current syphilis outbreak in WA is part of a national epidemic that began in remote, northern Queensland in January 2011. The infection spread across the Northern Territory and arrived in the Kimberley region in mid-2014, and connected clusters were found in the Pilbara region in mid-2018 and, in the following year, the Goldfields region.
Professor James Ward is from the University of Queensland Poche Centre for Indigenous Health. He says context is critical when examining the outbreak’s escalation.
“In 2011 public health services were at a very minimum in Queensland. The Minister for Health had diminished public health services — including contact tracing potential — so the range of people working in sexual health services also decreased,” he says.
“The outbreak got out of control and moved into other jurisdictions from there. It took maybe two to three years to get a governance group up and running.
“We’ve always been chasing our tails.”
A Pitjantjatjara and Nukunu man, Ward has conducted a plethora of research into STIs, HIV, and viral hepatitis in Indigenous communities and has held various roles for more than 25 years in Aboriginal public health policy. When asked how the outbreak reached WA, Ward explains the fundamental tension between Aboriginal people’s culture of mobility and state divides.
“Our [Aboriginal] population is very mobile and it outlines the importance of sovereignty in this nation that borders are very porous. There are no borders when it comes to remote Aboriginal communities,” he says.
“People have always travelled between communities for family, ceremony, tradition, sporting events, carnivals and all sorts of different events.
“It’s always been that way — before colonisation.”
Social determinants of health — non-medical factors that influence health outcomes — play a key part in understanding why syphilis is disproportionately affecting remote Aboriginal communities.
Barbara Nattabi is a senior lecturer with 15 years combined experience working with rural populations in northern Uganda and regional Australia. Her research investigates these social determinants and how the quality of remote, Aboriginal primary healthcare services can be improved.
“Aboriginal people are not genetically more prone to contracting illnesses — it’s structural, social determinants of health that make them more prone.Dr Barbara Nattabi
“It comes down to investment in health services and proper, culturally sensitive care, as well as education, income, water, sanitation, good health, and nutrition. A lot of these things prevent disease in the very first place.”
But the inequity in the provision of these services among remote, Aboriginal communities is deeply entrenched. For example, food insecurity. The Northern Territory 2019 Market Basket Survey found the cost of a nutritious grocery basket that contained foods recommended in the Australian Guide to Healthy Eating was 56 per cent more expensive in remote areas than in major cities. And according to the Australian Institute of Health and Welfare the employment rate of Indigenous people living in remote areas is 35 per cent. In major cities, it’s 59 per cent.
Frederick Donohue-Roberts is a Bundjalung and Ngaku man whose relatives work in regional areas in WA where syphilis rates are high.
“The mob in some remote communities have access to a medical centre, but in other communities, they have to drive or fly,” he says.
“You have people with chronic health issues but in community shops, a lot of the stuff they sell is high in sugar and saturated fats.
“The system we live in was not made to benefit us.”Frederick Donohue-Roberts
A legacy of trauma and fear that continues to haunt Aboriginal people today, and has instilled an apprehension of authoritative sources — including health services.
Donohue-Roberts says: “My mother was raised at the back of sand dunes in a tin shack. The police kept coming around to take my mum and her siblings from their parents. Growing up with the fear of interacting with the police was just the way it was. And a lot of Aboriginal people are scared to go to the doctor. I get terrified of going to the doctor.”
Not so universal healthcare
Accessing health services in regional WA also comes with its own unique set of challenges. The state covers an area of 2.5 million sq km — roughly 40 per cent of Australia’s total landmass — and according to the Centre for Population, as of June 2020, 538,477 people lived in regional or remote areas.
The extreme seclusion echoes the scarcity of efficient and sustained healthcare across the isolated expanse. Ward says many remote Aboriginal communities in WA rely on local nursing and medical staff from Perth, interstate, and even New Zealand to work at health centres, often on a fly-in fly-out roster. But significant staff shortages and high turnover rates impede the provision of consistent healthcare, and the COVID-19 pandemic has further compounded such issues.
Senior research fellow at Curtin University School of Population Health Dr Roanna Lobo has researched how Aboriginal people living in remote areas engage with healthcare and health promotion campaigns. She says health professionals working in regional areas have reported that patients find it harder to form relationships with them due to the discontinuity of FIFO healthcare.
“Just as you’re building that relationship with a patient, as a FIFO nurse, you’re sent off to some other location. When patients are talking about sensitive health issues like sexually transmitted infections, they need to have trust with someone and this takes time to build,” she says.
Among Aboriginal people there is a fear of accessing healthcare services, in case they’ll be identified as a problem group again and there will be a terrible intervention or policy as a result.Dr Roanna Lobo
“But when services do re-engage with these communities, they do it well. Women can build a fantastic rapport with local midwives and nurses and come in for antenatal care.”
Trust is also established through culturally sensitive healthcare, which services such as Derbarl Yerrigan Health Services Aboriginal Corporation provide. As Australia’s second-oldest Aboriginal health service, DYHSAC supports thousands of patients across the Perth metropolitan area.
Although they don’t work with remote communities, medical director Dr Richelle Douglas says Aboriginal-led services like DYHSAC are an important part of responding to medical problems that disproportionately affect Aboriginal people.
“Our doctors have longer appointment times to ensure they can discuss all of their patient’s concerns,” she says.
“This is important in areas like syphilis and other STIs, where shame and stigma are massive.
“If DYHSAC can try to dispel these fears and normalise discussions of STIs, that will go a long way.”
The great imitator
Diagnosing syphilis in the first instance is tricky. According to the Australian Society for HIV Medicine about 50 per cent of patients with the STI are asymptomatic — this means people don’t think they have it and clinicians often don’t test for it.
The WA Syphilis Outbreak Response Group has strongly advocated for wider clinician education across the state. As well as being a general practitioner with an avid interest in sexual health, Dr Lewis Mackinnon is on the WASORG and helped to develop training materials for GPs across WA.
“It’s quite easy to overlook the initial stage of primary infection because clinicians are really looking for a genital ulceration,” he says.
In the absence of an ulcer — or chancre — at the site of infection, patients may also experience vague, flu-like symptoms that mimic a viral infection. As time passes, further chancres can develop, as can a scaly, rough rash on the palms of the hands and soles of the feet.
These symptoms will subside over time, after which people enter a symptom-free, latent phase that can last for years. But if syphilis is not caught and treated people may develop tertiary syphilis; at this point, the STI can present as almost any other disease, which is why it’s often referred to as the “great imitator”.
“Syphilis can infect any cell in your body or any organ. You can present with a rash, blindness, blood in your urine, infertility, chest pain — it can literally be anything,” Mackinnon says.
“It’s so hard to find and it’s not the most likely diagnosis, but GPs need to be thinking about it.”
A blood test is required to test for syphilis and in endemic areas such as the Kimberley, Pilbara, and Goldfields, rapid, point-of-care tests are used. POC tests provide significantly faster results than traditional blood tests — 15 minutes compared to up to two weeks, Nattabi says — which means treatment and contact tracing can commence almost immediately.
But testing isn’t being completed as frequently as it should in remote Aboriginal communities. Because syphilis can be asymptomatic, Nattabi stresses the importance of opportunistic testing among particularly high-risk groups, including young people between the ages of 15 to 29. However, GPs can find it difficult to ask the delicate question.
“A male doctor [in an outbreak area] once asked me, ‘how do we raise the question?’” she says.
“But doctors cannot wait for the patient to say, ‘Oh, I think I have a sexually transmitted infection’. If you offer a syphilis test, people are more likely to take it. The onus is on the GP who is aware of the risk factor to offer the testing.”
Gender also plays a role in the provision and uptake of testing. Nattabi mentions research has found female doctors are more likely to offer tests than their male counterparts, while Ward says patients feel more comfortable visiting GPs who are the same sex as them.
“We know the majority of healthcare providers in remote Australia are women, which means young men are not accessing healthcare and getting tested as often as women,” he says.
No magic bullet
Ward says the response to contain the outbreak thus far — the rollout of POC tests in remote areas — has been a single intervention approach and testing alone will not get it under control.
From speaking to experts it’s evident no solution will work in isolation, and a combination of accessible and culturally sensitive healthcare and health promotion, education, community engagement, testing, and contact tracing are key.
But before this can happen, the polarity between Aboriginal and non-Aboriginal healthcare also needs to be addressed.
Ward says it best: “The thing about this whole outbreak is it demonstrates the inequity that exists in the Australian healthcare system for remote Aboriginal people.”