Cross Border Health: Renal Disease

It made the news nationwide when the Northern Territory banned those from adjoining border areas from going onto dialysis in Alice Springs no matter what family and tribal connections to the place they may have. Alice Springs has the largest dialysis unit in the southern Hemisphere.

The catalyst for the publicity and hopefully some action was the case of the famous artist Patrick Tjungurrayi from the Western Australia border community of Kiwirrkurra.

Kiwirrkurra is 200kms west of Kintore and is serviced from Alice Springs. There is no ability to get patients back from Kalgoorlie or Perth to Kiwirrkurra if they are evacuated west instead of east to Alice Springs without transiting through Alice Springs.

Renal patients in the border regions of South and Western Australia had to make the hard decision. Go to Adelaide or Perth far away from family and country or to stay on country and die. But is the wait any less in other capitals? My understanding is there is a wait list of over 40 for access to dialysis in Perth. Would you travel thousands of kilometres from home. To wait. And wait.

The stand by Patrick Tjungurrayi seems to have forced some action. The ABC reports that at the last Council of Australian Governments’ (COAG) meeting an agreement on cross-border dialysis was reached. I assume this means South Australia and Western Australia will pay for access. Despite the statement saying an agreement has been reached nothing has been signed. So there will be further delays until money starts flowing, extra facilities built, dialysis machines and staff ready to go.

A few days ago the Northern Territory Government released an extra $120 million to put into the health system.

  • $9.5 million for 95 nurses.
  • $7 million to run Darwin’s new cancer centre
  • $4 million for more staff at Gove Hospital.
  • $5 million Expanded dialysis facilities in Katherine and Tennant Creek
  • I don’t know where the rest is going but I think if they were expanding real services in Alice they would trumpet it as often and as loudly as they could.

    The artists of Papunya Tula many years ago painted their hearts and souls out and and raised $1million dollars auctioning their artworks to set up a dialysis machine in Kintore for people to visit home from Alice Springs. The Kiwirrkurra artists are part of this organisation and many donated paintings for the auction.

    As well as the chair and space in Kintore the “Purple House” in Alice Springs was purchased and the Western Desert Nganampa Walytja Palyantjaku Tjutaku (or the Western Desert Dialysis Mob) came into being. Kiwirrkurra people play a large role in this. But if the NT government’s decision stood it would mean they would have no access to it and no way to get home to country and family.

    Nganampa Walytja Palyantjaku Tjutaku have received an increase in funding from the Federal government as well as $500 000 from Medicines Australia. This will allow them to kit out a dialysis truck to move into various communities and bring people home in the tri-state border (NT/WA/SA) for visits. It sort of makes a mockery of state borders.

    I look forward to a signed agreement between South Australia, Western Australia and the Northern Territory so dialysis services can be increased in Alice Springs.

    To see the impact of end stage renal disease on remote Indigenous Australians take a look at the Australian Story program on Mandawuy Yunupingu

    Renal Disease in the Indigenous Population

    I have written quite a few times about the burden of disease, particularly chronic disease on Australia’s Indigenous population.

    On Monday night on ABC1 8:30pm Australian Story has a more personalised story on Mandawuy Yunupingu and his battle with end stage renal disease.

    For another personal view of Mandawuy head over to Bob Gosford’s “The Northern Myth” for a great post looking at Mandawuy’s life as Bob’s reminisces.

    And be watching Australian Story on Monday night.

    Here’s Mandawuy in his younger years fronting Yothu Yindi with their signature song “Treaty”

    I have also written previously about his younger brother Geoffrey Gurrumul Yunupingu

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    A Wander Through Chronic Disease and Indigenous Health

    In 2004-05 two surveys were undertaken by the Australian Bureau of Statistics to enable comparisons between the health of Indigenous Australians and non-Indigenous Australians.

    The survey showed that approximately 6% of indigenous Australians reported either having diabetes or High Sugar Levels (HSL). Indigenous people living in the towns and cities of Australia had close to half the incidence of diabetes or HSL than those indigenous Australians living in remote Australia (5% compared to 9%).

    But how does the incidence of diabetes in Aboriginal and Torres Strait Islanders compare to the rest of Australia?

    This is not a trick question.

    The answer of course is “pretty poorly”. Overall Australia’s Indigenous population was three times more likely to have diabetes than the non-Indigenous population. But it was much worse depending on where you live.

    Indigenous people living in remote areas of Australia were more than eight times more likely to report having diabetes or HSL than non-Indigenous people.

    In remote areas, Indigenous females were fourteen times as likely to have diabetes or HSL as non-Indigenous females. Indigenous males were nearly six times as likely to have diabetes or HSL as non-Indigenous males living in remote areas.

    Diabetes & HSL rates by Indigenous status 2004-05
    Diabetes & HSL rates by Indigenous status 2004-05

    There is a little, well, rather a big project underway in Australia analysing HbA1c data by postcode for five years.

    The “Mapping Glycaemic Control Across Australia Project” will collect, clean and analyse the HbA1c data annually for the next five years. Annual updated summary data will be made available for access through the Changing Diabetes Map providing a framework to track and monitor HbA1c levels.

    For the lay person reading this – the HbA1c is a measure of the amount of “sugar” in our red blood cells. As red blood cells last in our our body and are replaced in theory every three months or so it gives us a good picture of the last three months. The project states Australia’s average HbA1c is 7.6%. A well controlled diabetic would aim to have a HbA1c below 7%.


    The map searches by postcode. Except for remote areas that is. Then it uses huge geographic regions not allowing us to see HbA1c averages in remote Indigenous areas. It does show the increasing HbA1c levels generally seen in remote and rural areas compared to more urban areas.

    A recent news article stated Indigenous Australians have ten times (10x) the incidence of renal disease than other Australians (The same article quoted the figures that Native Americans have double the incidence of end-stage renal disease, and in Canadian Indians the incidence is two and a half times greater, compared with non-indigenous North Americans.)

    Now I don’t have a breakdown for renal disease for remote areas compared to non-remote areas as I do for diabetes. But with these much higher levels of disease you would expect healthcare and pharmaceutical costs to be through the roof compared to other Australians.

    Sit down for a little surprise.

    There is a lovely little report titled ‘Expenditures on health for Aboriginal and Torres Strait Islander peoples 2004-05‘. Note it covers the same period as the ABS diabetes statistics.

    Renal disease at ten times the incidence, diabetes (in remote areas) at eight times higher incidence yet the higher spend on healthcare for indigenous Australians was pitiful, especially when you look at the cost of providing healthcare in remote areas.

    In 2004-05, $1.17 per person was spent on Aboriginal and Torres Strait Islander health for every $1.00 spent on the health of non-Indigenous Australians. Average total health expenditure per Aboriginal and Torres Strait Islander was $4,718 compared with $4,019 per person estimated for non Indigenous Australians.

    The pharmaceutical spend was deplorable. The average expenditure on pharmaceuticals for Australia’s Indigenous population in 2004-05 was 40% of what Australia as a whole spent per individual (PBS subsidy). $140 spent per Indigenous Australian compared with $273 for each non-indigenous Australian.

    In remote areas medications are provided by what is called the S100 scheme. This gives us dollar values of what was shipped to remote clinics. Not necessarily what was used by patients. The government figures state that remote Indigenous Australians use $186 of Pharmaceutical Benefit Scheme medications per head. This figure is pathetic considering the incidence of these chronic diseases.

    But this Amount of $186 per remote Indigenous person overstates the amount of medications used to treat chronic diseases.

    This figure is the value of PBS medications shipped to clinics, not what is used on patients. Some clinics have massive waste due to not having ordering systems in place. And you do need to run with a slight excess and carry some emergency drugs that may go out of date (eg Reteplase at over $1000).

    Remote clinics also handle the acute presentations that in urban areas are looked after by hospitals. While these items are not expensive large numbers are used. Benzathine Penicillin, Normal Saline bags for IV use, Ceftriaxone and other parenteral antibiotics in numbers you would not see being dispensed by your normal pharmacy on the PBS. There is no where near $186 dollars per head being spent in providing medications to treat chronic disease in remote Australia.

    So what have we got. Massive incidences of chronic diseases in our Indigenous population compared to the rest of us. Despite chronic disease many higher in Indigenous Australians than other Australians there is overall only 17% increased health spending and well under half the usage of medications required to adequately treat these diseases.

    Looking at those figures it will come as no surprise that the same report states hospital separations for Indigenous Australians in remote and very remote areas are 820 and 606 per 1000 people respectively.

    Is it just me or is there something quite wrong in all this?

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