Journalwatch: Indigenous people with lung cancer receive less treatment, die sooner

The Indigenous Health 19 May 2008 issue of the Medical Journal of Australia has just gone live, and the table of contents is available here. [Free registration is required to read the full-text articles.]

This research paper leapt out at me:

Survival of Indigenous and non-Indigenous Queenslanders after a diagnosis of lung cancer: a matched cohort study
(Michael D Coory, Adele C Green, Janelle Stirling and Patricia C Valery, MJA 2008; 188 (10): 562-566).

This cohort study looked at survival rates for people with lung cancer treated in Queensland public hospitals. Median survival time for non-indigenous people was more than twice as long as median survival for Indigenous people. In the past, it has been suggested that similar disparities may be related to diagnosis occurring at a different stage, or differences in the presence of co-morbidities such as chronic bronchitis or diabetes.

However, the authors in this study found that non-indigenous people with lung cancer were 53% more likely to have received active treatment for their cancer than Indigenous people – after adjustment for disease type, severity, and co-morbidities, leading to the following conclusion:

Survival after a diagnosis of lung cancer is worse for Indigenous patients than for non-Indigenous patients, and differences in treatment between the two groups are mainly responsible.

The authors draw to the readers’ attention similar results in the USA, where researchers found that white people with small cell lung cancer were more likely to receive surgical treatment than black people, and had a 31% increase in five-year survival as a result. (“Racial differences in the treatment of early-stage lung cancer“, PB Bach et al, N Engl J Med. 1999 Oct 14;341(16):1198-205).

Another pair of articles worth looking at:

1. “Racial disparities in infection-related mortality at Alice Springs Hospital, Central Australia, 2000–2005
(Lloyd J Einsiedel et al, MJA 2008; 188 (10): 568-571).

This audit found that Indigenous adults who died as inpatients in medical or renal units in Alice Springs were dramatically more likely to have died from an infection than non-indigenous adults. The raw mortality rate ratio (MRR) for infection death was 2.2 overall, and this rose to 11.3 after adjustment for age and year of death. The median age of patients who died with an infection was 49 years for Indigenous and 73 years for non-Indigenous patients. Infection deaths in Indigenous people were mostly related to bacterial sepsis, chronic hepatitis B infection, invasive fungal infections and strongyloidiasis. The authors postulate that the differences primarily reflect socioeconomic disadvantage, with disparaties in housing infrastructure, sanitation and education. It is hard to tell whether they considered the possibility of differences in in-hospital treatment.

2. “Effect of swimming pools on antibiotic use and clinic attendance for infections in two Aboriginal communities in Western Australia
(Desiree T Silva et al, MJA 2008; 188 (10): 594-598).

The British Medical Journal five years ago published research examining the effects of swimming pools on remote Aboriginal communities, in terms of decrease in skin and ear infections, provision of active leisure opportunities, and social engineering: “No school, no pool“.

This MJA study follows up the swimming pool intervention at Jigalong and Mugarinya communities in Western Australia. The authors found a decrease in clinic attendances for skin infections of 68-77% over the study period. In Jigalong, which had a greater infection problem, antibiotic prescriptions decreased by 45%, attendances for ear infections decrease by 61%, and attendances for respiratory tract infections decreased by 52%.

I’m finding it difficult to see a moral justification for withholding such an effective preventive intervention on the basis of school attendance records. Is it acceptable to use this sort of “carrot-stick” approach when the alternative is to condemn kids to dangerous infections that threaten them with deafness or even sepsis? Would it be ok to say “No school, no doctor”? “No school, no antibiotics”? Swimming pools aren’t just fun playspaces – they could be life-saving for some kids.

Lastly, check out the feature “Viewpoint” article: “Beyond Sorry — the first steps in laying claim to a future that embraces all Australians” (Lisa R Jackson Pulver and Sally A Fitzpatrick, MJA 2008; 188 (10): 556-558). This paper critically situates the Apology as a first step toward implementing the five principles of reparations discussed in the Bringing Them Home Stolen Generations report.

As health workers, we know that the failure to recognise this injustice will inevitably perpetuate anger, stress, poor health and other negative economic and social outcomes among survivors of the Stolen Generations and their families.


Inevitably, while the other four principles of reparations remain unresolved, they will obstruct our path towards real and sustainable solutions for the problems of today. However, redress for decades — nay, centuries — of negligent administration by governments is a human right, not atonement for the wrongs that created the Stolen Generations. The Prime Minister has had the courage to take on what the previous government failed to do. It is our view that he must continue walking down this road until he finishes the job Australia has overwhelmingly endorsed him to do.

Categories: indigenous, medicine, social justice


7 replies

  1. Today’s news discusses the higher rates of depression and suicide in indigenous communities as well, and links it to higher cannabis consumption.
    I know that chronic cannabis use can lead to psychoactive chemically mediated mental illness, but the media spin pushing all of the blame onto cannabis strikes me as more casting of the spectre of personal choices onto poor health outcomes.

  2. And it ignores some of the reasons that people will get into cannabis use in the first place ie. impoverishment of environment and attempts to self-medicate for anxiety and distress. There has been a fair bit of research in recent years into how lack of appropriate sources of stimulation (through education or recreation or work) in one’s environment can reinforce drug use. And in some communities there is simply nothing much to do.
    That lung cancer survival study is a pretty strong indication of systemic racism isn’t it? I noticed that the cohorts were matched for rurality so remoteness can’t really be a factor in treatment differences.

  3. There is often reluctance among Indigenous people to seek or return to hospitals for treatment because they are afraid of dying away from their country. There is also distrust because a lot of them fear that the doctors will stop them from going home, which the doctors do because they need treatment in hospital. Whether this had led to doctors throwing up their hands and not trying as hard for indigenous patients, I don’t know and having lived in Alice Springs I can confidently say that racism and established beliefs about Indigenous people affecting their treatment can’t be ruled out, but I would argue that it’s not all about racism. Lots of shades of grey in there.
    Certainly the conditions that many would go ‘home’ to, even in the town camps are abysmal and the threat of infection would be extremely high. Also getting adequate nutrition, medication, etc is probably going to be rather difficult.
    It would be interesting to know more about the swimming pool effect. Did they make the kids shower before using the pool, or was it the effect of the chlorinated water or the ‘bath’ effect of swimming that made the difference I wonder. It certainly suggests that the ‘no school, no pool’ should be thrown out. It’s easier to engage healthy kids in learning.

  4. Yeah I understand that distrust is a big problem and I guess I wonder about how flexible hospital services are in responding to that?
    The Early Childhood Intervention Programme that my children went to had assessed many indigenous children with developmental issues over the years but none of the families took up offers to attend the centre for classes. Instead the staff built relationships over time with the local Koori childcare centre and their staff. It was made really clear that the reason why no indigenous families would attend our centre was fear and distrust. There were also huge communication issues. Seemingly innocuous words like “meeting” and “appointment” were red flags for some indigenous people that their lives are going to be interfered with, that they could lose the power to make independent decisions and this is especially so in the case of their children.

  5. My thoughts were that the hospital responded by being really inflexible. Basically stay and be treated or bugger off and die at home. Of course not all doctors and nurses were like that, but that’s the general vibe I got. Of course, realistically it is difficult to be flexible enough to give everyone what they want.
    I think the whole ‘stolen generations’ thing is still having a huge impact on the Indigenous community and it will take a long time, and a huge shift in white attitudes before we really start to get anywhere.

  6. Distance is such a huge factor.
    Just a thought – could some elements of cancer treatment be made mobile? Maybe someone wouldn’t want to leave their country but would be happier to sit in an air conditioned RV or bus to get their chemo.
    And there’s also the dearth of education and resources. If someone’s illiterate and doesn’t have access to information and can’t evaluate that information, they won’t be able to advocate for themselves or their loved ones effectively.
    Some way of overcoming the tyranny of distance in remote communities to provide medical services, education and good nutrition is key I think. (I don’t pretend to know how!)


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