Indigenous Health and Culture

The “Indigenous people of Australia” have been the most disadvantaged people for a long time. There are many health disparities experienced by them when compared with non- “Indigenous people of Australia”. The health status of “Indigenous people of Australia” has always been negative and it is still the same despite various interventions by the official authorities. The current status of Indigenous health focusing on the rheumatic heart disease will be described in this essay. This is an essay that will cover the cardiac aspect of Indigenous people's health as it will describe the current status of their health and health outcomes. It will also cover the possible historic and contemporary reasons that will best describe the current health status of the Indigenous population of Australia concerning the rheumatic heart disease. This essay also aims to identify Government interventions that is “Close the Gap” concerning the chosen health condition that is rheumatic heart disease. The non- Government health interventions will also be covered because the integrated efforts of Government and non- Government aims to Close the Gap concerning the health condition of rheumatic heart disease.

Rheumatic heart disease (RHD) is a long- term cardiac issue that contributes to a global burden of diseases in Australia (Roberts et al., 2014). In this condition, rheumatic fever is the cause of permanent damage to the heart valves as a result of which the normal person experiences a cardiac issue. This chronic condition is caused due to one or more episodes of acute rheumatic fever (ARF). In Australia, in 2017, 4255 people were suffering from RHD out which around 3687 people were Indigenous people (Australian Institute of Health and Welfare, 2020). This states that 87% of the total population suffering from RHD is accounted for by the Indigenous population and two-third of this 87% of Indigenous people who were diagnosed with RHD were females. The age group 15- 24 years is the most common age group at which RHD was diagnosed in Indigenous people of Australia. The overall rate of occurrence of RHD in the Indigenous population is 50 people per 100000 people of Australia (Australian Institute of Health and Welfare, 2020).Approximately 60% of the Indigenous people who were diagnosed with RHD were under the age of 25 years. In the year 2013- 2017 around 1043 new cases of RHD were diagnosed in Indigenous population and this states that this disease is more common in Indigenous population of Australia as compared with non- Indigenous population of Australia. In Australia, Northern Territory has the maximum cases of RHD diagnosis every year (Roberts et al., 2015).

This chronic cardiac damage health issue is a global cause of morbidity and mortality and it is known that this health condition is most common in the resource-poor settings.

The global burden of RHD has significantly declined from the past and this is contributed by the better living conditions (Russell et al., 2014). The Indigenous population have resource-poor settings, poor hygiene levels, poor living conditions and this makes RHD be most commonly experienced by Aboriginal people. The health condition of RHD is still common among the Aboriginal people of Australia and their communities. As per the data from 2005- 2010, 98% of RHD cases in Northern Territory were for Indigenous people thus it is stated that Indigenous people are 64 times more likely to develop the condition of RHD (RHD Australia, 2020). Indigenous people are about 8 times more likely to get admitted in the hospital for RHD as compared to non- Indigenous people of Australia. There is a huge difference in the mortality rates because of RHD between Indigenous people and non- Indigenous people of Australia (He et al., 2016). This disparity due to RHD is greater than the disparities caused by another chronic disease like diabetes, nephrosis and ischaemic heart disease. In the Northern Territory, Indigenous individual is at 54.8 times higher risk of dying due to RHD as compared to non- Indigenous individual (RHD Australia, 2020).

The Aboriginal and Torres Strait Islander people of Australia are known to experience poorer health and lower life expectancy rates that are mainly attributed to chronic conditions like RHD and other cardiovascular issues. The main reasons for high rates of RHD among Aboriginal people as compared to non- Aboriginal people are poor living conditions and non- affordable access to health care services and so on. The poor living conditions generate streptococcal infections that cause ARF that further becomes the cause of RHD. The Aboriginal communities make up to approximately 2.55 of the total Australian population and these are the communities that are predominantly living in the conditions of poor social, environmental and poorer economic conditions (Carapetis et al., 2016). These are highly disadvantaged people that are living in poor conditions that contribute to them suffering from RHD at higher rates. Both RHD and ARF are caused due to an infectious agent that is Streptococcus pyogenes that is a Gram-positive bacterial pathogen and the most significant sequale to S. pyogenes are ARF and RHD (Tandon et al., 2013).

One of the most common poverty-related risk factors for S. pyogenes infection is household crowding. The Aboriginal people are the disadvantaged people with social determinants of health like poor housing, low employment, low education opportunities and poor living conditions. These people have overcrowding housing schemes as compared to non- Indigenous people because they live in rural areas. These poor remote settings increase the risk of S. pyogenes infection among Aboriginal people of Australia (Carapetis et al., 2016). As per the study conducted, it was found out that the effects of overcrowding were such that when the beds were moved closer to each other, the risk of spread of infection due to S. pyogenes increased significantly (Clark et al., 2016). The Indigenous people with poor living conditions due to the historic reason for colonization and oppression are at more risk of developing this infection. This infection leads to the cause of episodes of ARF that further causes RHD with one or more of its episodes (Martin et al., 2015). Thus, there exists a strong association between overcrowded housing in Indigenous communities and the rates of streptococcal impetigo. This strong association is possible as crowding permits rapid S. pyogenes bacterial transmission (Mirabel et al., 2015). This is the main historic reason for the higher cause of RHD among Indigenous people as compared to non- Indigenous people of Australia.

The second most common reason for the transmission of this infection is poor nutrition in the children. Insufficient nutrition in the body of an individual increases the susceptibility of S. pyogenes as it alters the antibody responses. After the infection by S. pyogenes, the individuals with poor nutrition levels in the body are more likely to suffer from ARF thus RHD (Wyber, Zuhlke & Carapetis, 2014). The historic reason behind poor nutrition is poverty as this does not allow them to live in normal conditions. They have poor nutrition intake because of economic restrictions and this increases their risk of RHD. The risk factors that are the result of poverty are strongly associated with higher rates of ARF and RHD in Indigenous people of Australia. The historic events of colonization and oppression had such an impact on the lives of these people that they are socially, economically and health-wise the most disadvantaged people of Australia. The transmission of this infection is increased with poor living conditions that have a direct impact on the quality of life of Aboriginal people. The strong association of overcrowding of houses and poor nutrition value in Aboriginal people is the significant risk factor for the cause of RHD (Rothenbuhler et al., 2014).

The best way to control or to prevent the spread of this infection is the use of antibiotics as this is the standard treatment for RHD. The Indigenous people are disadvantaged in this aspect also as they do not have affordable and easy access to the health care services. The administration of antibiotics for S. pyogenes is the most common treatment for RHD but economic constraints do not allow the Aboriginal people to take this treatment. They have low awareness and are also not aware of the potential treatment options for this disease. The RHD control strategy that is cost-effective and clinically effective strategy is secondary prophylaxis along with the benzathine penicillin G (BPG). As per the data of 2017, among Indigenous population of Australia that was prescribed BPG, only 15% of the people received their 100% of the prescribed doses and only 21% of them received 80%- 90% of their prescribed doses (Australian Institute of Health and Welfare, 2020).

This represents the health disparities that exist between Indigenous population and non- Indigenous population of Australia. 28% of Indigenous people who were prescribed BPG received less than 50% of their prescribed doses. These low values represent low awareness among Aboriginal communities and the discrimination that they face while accessing health care services. This report from Australian Institute of Health and Welfare states that the prominent comparative values of the Indigenous population and non- Indigenous population of Australia that represents the health disparities not only in the cause but also in the treatment. The health care services provided to them are not easily accessible by them and are even not affordable for most of these people thus contributing to higher rates of RHD among Indigenous people of Australia.

The Australian Government has taken several steps to “Close the Gap” concerning RHD and its high prevalence among Aboriginal communities. The higher rates of RHD among Australia's Aboriginal communities are addressed by the Government as the Australian Government is funding the Rheumatic Fever Strategy (Australian Government, 2017). This strategy includes state-based register and control programs in maximum areas of Australia that works for the improvement of diagnosis, monitoring and management of this chronic health condition (Australian Government, 2017). This strategy also provides national education interventions and training resources that aim to educate the Aboriginal communities so that they access the health care services and also provides a data collection system. The Government of Australia has also supported RHD Australia that works alongside Indigenous people to lower the rates of RHD in Australia.

It develops evidence-based resources to provide culturally appropriate educational resources for the individuals and their family members with RHD (Cannon et al., 2017). The Closing the Gap Refresh retains a strong focus on the health outcomes that are related to RHD. It also aims to work on the social determinants of health to end health disparities among Aboriginal people and non- Aboriginal people. Some non- Governmental organizations are working in close association with the health care professionals to end RHD in Aboriginal people by conducting health promotion programs and by educating them to access the health care services. These organizations have RHD action plan to curb all the potential reasons that facilitate the spread of this infection thus RHD among Aboriginal communities (Colquhoun et al., 2015).

The conclusion drawn is that this chronic cardiovascular disease is more common in the Indigenous population of Australia as compared to non- Indigenous population of Australia. This health disparity is prominent with the current health status statistics that reveal the current health condition of Aboriginal people. The Indigenous people are disadvantaged and some of the reasons for higher rates of RHD in these people include overcrowding of the houses and poor nutrition. The social determinants of health like poor housing (overcrowded houses), low income, low employment rate, low educational opportunities and poor living conditions all contribute to the higher rates of RHD among them. There exists a disparity in the treatment received by them for the cardiovascular health condition as revealed by the statistics of the Australian Institute of Health and Welfare. This chronic condition is most common in the Indigenous population at the age of 14- 25 years who have low nutrition value. This is spread by S. pyogenes infection that can be best controlled with secondary prophylaxis interventions. The Government of Australia has taken several interventions like funding Rheumatic Fever Strategy and others like RHD Australia that are working alongside Aboriginal communities to support people and the family members who are suffering from this chronic health condition. The non- Governmental interventions also work towards this like the interventions by health care professionals and other agencies.

References for Indigenous Health and Culture

Australian Government. (2017). Rheumatic heart disease. Retrieved from

Australian Institute of Health and Welfare. (2020). Acute rheumatic fever and rheumatic heart disease in Australia. Retrieved from

Cannon, J., Roberts, K., Milne, C., & Carapetis, J. R. (2017). Rheumatic heart disease severity, progression and outcomes: A multi‐state model. Journal of the American Heart Association, 6(3), e003498.

Carapetis, J. R., Beaton, A., Cunningham, M. W., Guilherme, L., Karthikeyan, G., Mayosi, B. M., ... & Zühlke, L. (2016). Acute rheumatic fever and rheumatic heart disease. Nature Reviews Disease Primers, 2(1), 1-24.

Clark, B. C., Krishnan, A., McCarter, R., Scheel, J., Sable, C., & Beaton, A. (2016). Using a low-risk population to estimate the specificity of the World Heart Federation criteria for the diagnosis of rheumatic heart disease. Journal of the American Society of Echocardiography, 29(3), 253-258.

Colquhoun, S. M., Condon, J. R., Steer, A. C., Li, S. Q., Guthridge, S., & Carapetis, J. R. (2015). The disparity in mortality from rheumatic heart disease in indigenous Australians. Journal of the American Heart Association, 4(7), e001282.

He, V. Y., Condon, J. R., Ralph, A. P., Zhao, Y., Roberts, K., de Dassel, J. L., ... & Carapetis, J. R. (2016). Long-term outcomes from acute rheumatic fever and rheumatic heart disease: a data-linkage and survival analysis approach. Circulation, 134(3), 222-232.

Martin, W. J., Steer, A. C., Smeesters, P. R., Keeble, J., Inouye, M., Carapetis, J., & Wicks, I. P. (2015). Post-infectious group A streptococcal autoimmune syndromes and the heart. Autoimmunity Reviews, 14(8), 710-725.

RHD Australia. (2020). The burden of disease. Retrieved from

Roberts, K. V., Maguire, G. P., Brown, A., Atkinson, D. N., Remenyi, B., Wheaton, G., ... & Carapetis, J. (2015). Rheumatic heart disease in Indigenous children in northern Australia: differences in prevalence and the challenges of screening. Medical Journal of Australia, 203(5), 221-221.

Roberts, K., Maguire, G., Brown, A., Atkinson, D., Reményi, B., Wheaton, G., ... & Carapetis, J. R. (2014). Echocardiographic screening for rheumatic heart disease in high and low-risk Australian children. Circulation, 129(19), 1953-1961.

Rothenbühler, M., O'Sullivan, C. J., Stortecky, S., Stefanini, G. G., Spitzer, E., Estill, J., ... & Pilgrim, T. (2014). Active surveillance for rheumatic heart disease in endemic regions: A systematic review and meta-analysis of prevalence among children and adolescents. The Lancet Global Health, 2(12), e717-e726.

Russell, E. A., Tran, L., Baker, R. A., Bennetts, J. S., Brown, A., Reid, C. M., ... & Maguire, G. P. (2014). A review of valve surgery for rheumatic heart disease in Australia. BMC Cardiovascular Disorders, 14(1), 134.

Tandon, R., Sharma, M., Chandrashekhar, Y., Kotb, M., Yacoub, M. H., & Narula, J. (2013). Revisiting the pathogenesis of rheumatic fever and carditis. Nature Reviews Cardiology, 10(3), 171-177.

Wyber, R., Zühlke, L., & Carapetis, J. (2014). The case for global investment in rheumatic heart-disease control. Bulletin of the World Health Organization, 92, 768-770.

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