These community generator power failures often necessitates removing these drugs in a safe and approved manner from these communities and replacing them quickly. This often means items transported from another community.

Some emergency missions to overseas disasters have used large portable fridges. However these have needed careful monitoring with certain drugs placed in certain areas and adjustments to the thermostat if numbers of items are removed. Whilst these are good for setting up a remote emergency clinic they do require some specialised knowledge to maintain the correct storage for various drugs.

I have been trialling a new portable refrigerator. It has a volume of 25 litres which allows us to transfer adequate quantities of drugs urgently to a clinic until bulk supplies arrive in a week or two by plane.

Twinbird Vaccine Fridge

We obtained the Twinbird from Rollex Group Australia. While considerably more expensive than say an Engel, it performs very well.

I have been using it for several months monitoring temperatures with a third party data logger. The temperature monitoring and alarm system seem quite accurate. The fridge does use a different sort of cooling system than the compressor style, allowing more accurate temperature control. There are two baskets inside the refrigerator so there is no direct contact by the vaccine or blood products with the sides where they may freeze.

The power cord could be more robust, and it requires an optional DC converter to run inside on AC power (Engel etc require just a separate cord to plug into the unit). It is light, but seems quite solid and has handled rough bush trips with ease.. I would have liked some way to be able to lock the fridge. It also now comes with a printer option for temperature recording and I will be including this option in future purchases as we expand our on-lands logistics capability.

But then I think we have it easy compared to some locations around the world! This is the Vaccine Fridge CFS49IS System with CFS standing for “Camel Fridge System”.

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Consider it showing my newer subscribers some earlier “quality” posts.

So my ten most popular posts are:

1. “A Drive in The Country: It took this truck driver and his truck 18 hours. Bogged three times in sand. That’s a lot of wheels to dig out. And some pretty big holes. I guess that is something to look forward to as I drive out next week”.

2. When Remote Australia and Mining Australia meet: This surprised me coming so high in the ranking. My view on how mining companies in Australia seem to disregard and damage the remote communities near their sites.

3. A Little Bit of Rain: With plenty of photos and video it showed what Central Australia can be like after rain.

4. Remote Weather Report was a report I sent out to people who may be travelling in our area which I later posted. Describes what can happen when heavy rain hits - particularly for a very mobile population

5. Can Bush Tucker Reduce the Burden of Heart Disease and Diabetes? Here I commented on an Article in the West Australian Newspaper and talked about food and prices out bush.

6. Kunmarnanya my Lord, Kunmarnanya. I’m known as Robbo almost everywhere I go. I started using my nickname for cultural reasons. This explains why.

7. A Snake in the Hand is Worth…. is a little story about a snake on my fence: I race to the gate and instead of placing my hand on the expected tubular frame it landed on something sinuous, scaly and muscular.

8. Oodnadatta Track is a Pleasant Sunday Afternoon story with a picture of a stop sign in the desert. Believe me. That is all that is there.

9. You Have Peak Hour Traffic and I Have…… was a video looking at the traffic obstacles I have on my way to work. Camels and lots of them.

10. CRANA Opens its Doors where I commented on Council of Remote Area Nurses of Australia opening membership to other professions with some comments on other bodies representing those out bush.

Well that’s it for another year!

These facts and other amazing little delights can be found on the EPA-USA FAQ page. The EPA-USA said they have been looking into this problem since 1999. You can read a doozy of a 41 page report quaintly titled errata.pdf.

Should you be worried about your health? Again we refer to the EPA-USA FAQ page: Studies have shown that pharmaceuticals are present in some of our nation’s water bodies. Further research suggests that there may be some ecological harm when certain drugs are present. To date, no evidence has been found of human health effects from PPCPs in the environment.

The American Pharmacists Association produced a press release in February of 2007 on how to correctly dispose of pharmaceuticals. Here’s a few highlights.

DO NOT FLUSH unused medications. Consumers were once advised to flush their expired or unused medications

When tossing unused medications…..Crush solid medications or dissolve in water and mix with kitty litter or a solid kitchen substance….. then place in a sealed plastic bag …before tossing in the trash.

Check for approved state and local collection programs or with area hazardous waste facilities. In certain states, you may be able to take your unused medications to your community pharmacy.

This year the EPA-US Great Lakes ran the Great Lakes 2008 Earth Day Challenge with one of the aims to collect “1 Million Unwanted Pills”. To reinforce the point here’s a quote from the same page:

Traces of medicines have been found in streams and the Great Lakes where we get our drinking water and have also been detected near wastewater treatment outflows. Some of these medicines can lead to reproductive and developmental problems in fish and other animals. We often treat leftover medicine as a common household waste. More than half of people surveyed throw their unused medicines in the trash while a third flush them down the drain. In both cases, the medicines have the potential to be released into our rivers and lakes

August 6th 2008: Another press release from the EPA titled “EPA Continues Work to Understand Potential Impacts of Pharmaceuticals in Water”

The agency’s work to increase industry stewardship and scientific understanding of pharmaceuticals in water continues,” said Benjamin H. Grumbles, EPA’s assistant administrator for water. “By reaching out to the National Academy of Sciences and requesting information from the health care industry, EPA is taking important steps to enhance its efforts.

There’s a lot more words in that press release but I think you will agree that there is an adhoc approach in the USA for dealing with pharmaceutical waste, with a lot of nice words thrown in.

What’s happening in Australia?

It really is as easy as 1,2,3. July 2008 marked the 10 year anniversary of the Return of Unwanted Medicine Program. Simply walk into any retail pharmacy in Australia with your out of date or unwanted medications and they are accepted and placed in a yellow 20 litre sealable container. They are returned to the pharmaceutical wholesalers and from there collected by the waste disposal experts for high temperature incineration which is the safest way to destroy this sort of waste. Drivers are accredited and random audits are carried out. There is the chance for diversion but in 10yrs there have only been a handful of instances.

The RUM Project is funded by the Commonwealth Department of Health & Ageing.

Over 400 Tonnes (440t US)of unwanted and out of date medicines are collected every year.

( As an aside, Australia has about 22 million people. The USA had 305 million or so when I checked at the population clock. Would 6100t (US) of pharmaceutical waste really be stopped from going into normal waste in the States?)

If I’m writing this there has to be a bush slant. There is.
Our clinics are in one state, our head office and a lot of logistics come from another state (still one of the closest towns to us). When a pharmaceutical item goes out of date and put in the bin it becomes waste. This is then legally not allowed to cross state borders! Several years ago pharmaceutical waste was sometimes placed in the correct containers but most often not as it was difficut to have empty buckets supplied by plane. It was then driven back in the back of a troopie by anyone going into town to one of our suppliers, repacked (i.e. now double-handling waste) into the appropriate containers then entering the RUM process.

To improve this process we now deal direct with RUM. Our environmental health bloke and myself move around the lands and we are the ones who remove waste and sharps sealed in approved containers to a central point. The pharmaceutical waste is then placed into metal crates supplied by RUM and locked and trucked to Perth using a driver accredited to handle waste (again done by RUM for us). I have a key and the contracted waste management company in Perth has a key.

Now all we need is for the roads to be capable of taking trucks again and I can get some trucked out.

The system we run is probably the best, and simplest in the country and I hope can be emulated by other remote health services.

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One in six Aboriginal people in Australia report having been admitted to hospital in the last 12 months.

Despite staying longer when admitted, Aboriginal people are less likely to have treatment in hospital than other patients, and it seems that this difference is at least in part due to the differences in the way that Aboriginal patients are dealt with by the system and individuals within it.

There is a myth, a belief held by many Australians, including those in the media and in politics, that vast amounts of money have been spent on Aboriginal health over decades but all to no avail. This myth needs to be challenged.

It’s a myth on two counts. First, any increases in resources for Aboriginal health have been modest and patchy, as evidenced by the plethora of pilot programs that are trialled but not universally implemented.

Secondly, despite the relatively small increase in investment, there have been some measure of improvement in Aboriginal health status in recent years. The recent commitment to close the gap in life expectancy between Aboriginal and non-Aboriginal Australians within a generation is welcome. However no one should be under any illusion that this can be done without significantly expanding resources. I would suggest three key areas for action.

First we know that a person’s social and economic position in society, their early life experiences, their exposure to stress, their educational and employment status, and their exclusion from participation in society all exert a powerful influence on their health throughout life. Of particular importance are poverty and education, including parental and particularly maternal education. Therefore we have to make a determined effort to address the social determinants of health if we expect long-term changes in the health of Aboriginal communities.

Second, there is abundant evidence from overseas, both from Indigenous and non-Indigenous contexts, that access to appropriate, comprehensive primary health care services is critical to good health. There is also accumulating evidence from within Australia that improved primary health care services, especially those under Aboriginal community control, are contributing at both the local and national levels to better health in our communities. So we need to make a determined effort to extend and improve primary health care services.

Third, we need better and more appropriate hospital care for Aboriginal people. In recent times the focus has been very much on primary health care as the key strategy for improving Aboriginal health. This is as it should be given the long-term gains it is bringing to the detection and management of disease. However, we should not lose sight of the fact that one in six Aboriginal people in Australia report having been admitted to hospital in the last 12 months.

Despite staying longer when admitted, Aboriginal people are less likely to have treatment in hospital than other patients, and it seems that this difference is at least in part due to the differences in the way that Aboriginal patients are dealt with by the system and individuals within it.

This is the start of a speech given by Pat Anderson, Chairperson, Cooperative Research Centre for
Indigenous Health to the National Rural Health Alliance Public Symposium in September 2008.
For more see the NRHA newsletter .

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That was part of a post (pdf) I wrote in April 2007 to Auspharm. The article quoted is “Long-term trends in Indigenous deaths from chronic diseases in the Northern Territory: a foot on the brake, a foot on the accelerator ” published by the Medical Journal of Australia (free registration required)

The MJA article goes on to state:

significant improvements in mortality due to communicable, maternal, perinatal and nutritional condition and injury”. The report then states: “Mortality from chronic diseases, however, does not appear to have played a role in life expectancy gains

To reinforce this message the conclusion goes on to say:

Dangers remain, however if increasing death rates from chronic disease are not reversed

If we look back even further to December 2005 we see a widely reported speech by the then Indigenous Affairs Minister Amanda Vanstone (full text here). As well as the now famous “cultural museum” quote she talks about the viability of the 1000 small settlements of less than 100 people (80% with less than 50). She raised three points.

• How viable are they really?
• While some are doing OK and helping with drug rehabilitation and maintenance of culture, others may be risky environments particularly for women and children
• What level of amenity can be expected to be provided to small settlements in some cases hundreds of kilometres from each other?

Do they have to be viable? What does that mean anyway?
Risky environments? My limited experience over 10yrs and most states and territories have given me the impression that the smaller the community the less risk the people feel. The desert people used to wander in small family groups. I suggest their laws and customs are built around this way of life and living in larger communities has not been beneficial.

Enough of my anecdotal evidence. Let’s head back to the Medical Journal of Australia, in particular an article titled “Lower than expected morbidity and mortality for an Australian Aboriginal population: 10-year follow-up in a decentralised community.”

A ten year follow up. here’s the conclusion:

Contributors to lower than expected morbidity and mortality are likely to include the nature of primary health care services, which provide regular outreach to outstation communities, as well as the decentralised mode of outstation living (with its attendant benefits for physical activity, diet and limited access to alcohol), and social factors, including connectedness to culture, family and land, and opportunities for self-determination.

For those wanting to see the strength of the results:

Mortality in the cohort was 964/100 000 person-years, significantly lower than that of the NT Indigenous population (standardised mortality ratio [SMR], 0.62; 95% CI, 0.42–0.89). CVD mortality was 358/100 000 person-years for people aged 25 years or older (SMR, 0.52; 95% CI, 0.23–1.02). Hospitalisation with CVD as a primary cause was 13/1000 person-years for the cohort, compared with 33/1000 person-years for the NT Indigenous population.

Violet Petayrre Utopia

We all know prevention is best for all chronic diseases. In overworked remote health services it is hard enough keeping up with the presentations that come in through the door, let alone doing some education. It seems (and further research is needed) that these smaller communities might be just the ticket to improving lifestyle and health. So it concerns me that there seems to be an attempt to close these smaller communities or outstations down.

At first glance there is good news. There has been an increase in funds allocated for housing as well as increased funding for chronic disease (The Australian 1 Dec 2008). However, Indigenous Affairs Minister Jenny Macklin has stated

priority for new houses would be given to big communities where the need was greatest and the economies of scale allowed for the construction of additional houses.

No assistance for outstations here. Will funds for the chronic disease programs also be directed to larger communities?

Also of concern is the recent Northern Territory review into outstations by Patrick Dodson. He completed two weeks of public hearings but, according to The Australian newspaper said it was a “clear fault in the process” that government representatives were not visiting any outstation communities and that no interpreting services in Aboriginal languages had been arranged. Sounds like a nong planned this it or it was designed to produce nothing substantial.

The article goes on to say:

There is widespread fear in Aboriginal communities that governments are intentionally starving outstations of resources to force people into larger towns.

Much of that fear can be traced back to the colourful language of Howard government indigenous affairs minister Amanda Vanstone, who called outstations “cultural museums” that should be shut down.

And so we come full circle.

Are we are so intent on “economies of scale” that we are going to close these smaller communities down? These same communities that may provide the biggest bang for the buck in keeping people healthy.

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I could not attend the last camp Ngaanyatjarra Health held, but attended and presented at the camp in 2005. A great few days, but the relationships with youth and family I developed then continue on to today. FWPA produce a Mooditj newsletter and there is also a video presentation that explains what it is all about.

we have gone a bit further this year. A while ago I posted a job ad for a male youth health educator. This is to work on a program called officially the “Improving the Sexual health of Aboriginal and Torres Strait Islander Youth Demonstration Project”, but we call it the “Kungkaku Yangupalaku Healthy Relationships Project”.

This is one of six prgrams being run across Australia. These will be evaluated by the Australian Institute of Health and Welfare (AIHW) at the conclusion of the programs. If found to be successful I hope funds continue to be made available, rather than just another piece of research.

The first newsletter from the project is available here (600kb file - I apologise for the white blocks around the text - these appeared while shrinking the file from 2MB).

I was a little disappointed that there was only a couple of comments, with no explanation, about the much higher incidences of cancer within our remote indigenous population. This is despite a number of studies being done. One has shown those living in the Kakadu around the Ranger Uranium Mine have a 90% higher incidence of cancer than the rest of the Northern Territory.

One paragraph in the report noted that:

Incidence rates for many types of cancer are considerably lower or higher for the Northern Territory than for other states and territories. These differences are mainly due to low or high incidence of these cancers in Aboriginal and Torres Strait Islander peoples, who comprise 29% of the Northern Territory population (d’Espaignet et al. 1996; Condon et al. 2001).

There was no discussion on why the incidence rates would be so much higher despite several studies looking at this issue.

There was some discussion about lower rates of melanoma of the skin and the indigenous population. This discussion was about a quirk in the state based statistics. The largest number of indigenous people in Australia reside in New South Wales. However they are a still a small percentage of the total population in this highly populated state. A high percentage of the people living in the Northern Territory are indigenous. You would expect those living in the warmer northern parts of Australia to have the highest incidence of melanoma.

The incidences of melanoma per state are:

Queensland (65.3 cases per 100,000 persons)
Western Australia (53.0)
New South Wales (47.8)
Tasmania (45.5)
Australian Capital Territory (45.2)
South Australia (40.0)
Victoria (37.4)
Northern Territory (32.5)

We could perhaps expect that the Northern Territory would have a similar rate of skin cancer to Queensland. From the AIHW report:

8.2 Melanoma of the skin
The age-standardised rates for all forms of skin cancer are correlated with exposure to ultraviolet radiation (Jelfs et al. 1994). Therefore one would expect to see higher rates in the more northern states and territories, and lower rates in the more southern ones. However, the rates will also be affected by sun-protection behaviour and the percentage of the Indigenous population (which has a lower rate of skin cancer than the non-Indigenous population).

What about all the other cancers that indigenous people have a much higher incidence of. An article, again by Condon in the Medical Journal of Australia in 2004 (free registration required go to PubMed for abstract) explains why.

The NT Indigenous cancer mortality rate was higher than the total Australian rate for cancers of the liver, lungs, uterus, cervix and thyroid…… Differences between Indigenous and total Australian cancer mortality rates were more pronounced among those aged under 64 years for most cancers. NT Indigenous cancer mortality rates increased over the 24-year period for cancers of the oropharynx, pancreas and lung, all of which are smoking-related cancers. CONCLUSIONS: Cancer is an important and increasing health problem for Indigenous Australians. Cancers that affect Indigenous Australians to a greater extent than other Australians are largely preventable (eg, through smoking cessation, Pap smear programs and hepatitis B vaccination).

As well as cancer affecting our indigenous population earlier, the cancers that affect Indigenous Australians to a greater extent than other Australians are largely preventable (eg, through smoking cessation, Pap smear programs and hepatitis B vaccination).

Our indigenous population has smoking rates of 55% compared to the Australian average of 21% (men) 18%(women). The good news is that some money has been put aside for programs to reduce smoking rates in our indigenous people.

The cost of vaccinations on each states vaccination schedule is covered by the federal government’s Immunise Australia Program. As well as Hepatitis B, the Human papillomavirus vaccine for teenage girls is now covered, hopefully reducing the incidences of cervical cancer.

Ngaanyatjarra health has won an award for its vaccination efforts in the past. However, when a new vaccine is introduced there are no funds provided to assist in a program to vaccinate all members of a remote community.

These higher cancer ratesin indigenous Australia I feel highlight our health authorities failure to make funding available to ensure this hard to reach population group, who are often moving about in very remote areas, can be followed up and vaccinated.