Socioeconomic Barriers
The Australian Bureau of Statistics defines socioeconomic disadvantage in terms of an individual's access to material and social resources, as well as their ability to participate in society [1].
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Since we have described ARF and RHD as diseases of socioeconomic disadvantage, it is now necessary to explore how this form of disadvantage manifests itself among the Indigenous Australian community. The lower socioeconomic status of Indigenous people (both in Australia and across the world) has been mainly characterised by overcrowded living conditions and illiteracy as a result of a poor formal education. Unemployment and a low income also exacerbate each of these barriers and reinforce a cycle of poverty.
Overcrowded Housing
Poor quality housing in Indigenous communities and rapid urbanisation both create highly overcrowded living spaces where infectious diseases may readily transmit [3]. The strep bacteria is spread through mucous and bodily fluids when individuals breath or cough on one another [4]. This is more likely to occur when people live in close proximity. A study on two large NT Indigenous communities found that the median number of people living per house was 17 and 14, including an average of 7 people occupying each bedroom inside the dwelling [2]. Complicating this, Indigenous communities usually feature highly mobile populations, where individuals travel between dwellings on a regular basis [2]. The provision of social housing, or lower rental costs to reduce the "doubling up" of families in one house, could help remedy this barrier [5]. Economic development in countries like China, leading to improved living conditions, have seen a substantial decline in the prevalence of RHD [3].
Lack of Education
"Where there is overcrowding, the community burden of streptococci tends to be high" - McDonald et al. [2]
"Education provides the necessary skills to better access and utilise health and community services and information about welfare" - The Australian Institute of health and Welfare [6]
School retention rates for Indigenous students are much lower than those for non-Indigenous students, a complex issue which can be partly explained by poverty, institutionalised discrimination in the education system, language barriers, pressure to conform with traditional practices and limited access to schools [6]. A lack of health education prevents Indigenous people from seeking prompt medical assistance upon developing the symptoms of strep throat or ARF [7]. However where knowledge is absent, health-care providers play an important role in communicating the biomedical basis of ARF and RHD. Unfortunately practitioners often fail to communicate with Indigenous patients in a culturally-appropriate manner, leading to mistrust and a failure in adherence to treatment plans [8].
Politics and Bureaucracy
"We just need to... add some serious political commitment from territory, state and Commonwealth governments to make it (RHD eradication) happen" - The Australian Medical Association [9]
The socioeconomic barriers listed above are all underpinned by a lack of political and bureaucratic commitment to solving this inequality [10]. As ARF and RHD are diseases exclusively borne by the disadvantaged, the situation of these people is often forgotten about by governments and mainstream society. In Australia the rural and remote Indigenous communities where ARF and RHD occur the most are "out of sight" and "out of mind" to the majority of the population occupying the coastal, urban centres. Indeed, the low prioritisation of addressing this social injustice is perhaps the greatest global factor contributing to the neglected status of ARF and RHD across many populations on the planet.
Liddywoo's Story
Liddywoo Mardi is from the remote NT community of Belyuen.
At 18 years of age, he has already experienced the full brunt of socioeconomic barriers.
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Liddywoo developed strep throat infection as a young child from poor hygiene and playing in muddy water. Without treatment, it quickly progressed onto ARF and RHD.
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After travelling to Melbourne for heart surgery, Liddywoo returned home and was exposed to the same infection due to poor living conditions. He says that repeat infections made him feel "weak... so stressed trying to walk around... getting short of breath".
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Liddywoo's paediatric cardiologist Dr Bo Remenyi has found that "if a person returns to poor housing conditions that's packed with the strep germ, then they're starting back from ground zero... and they'll have another rheumatic fever episode."
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Even after three heart surgeries and the replacement of Liddywoo's aortic valve with a mechanical valve (that he calls his "grasshopper"), simple activites are still difficult - "walking around, playing with my brother, hunting, spearing, slow me down and I can't do it no more".
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Treating RHD with surgery is not a long-term solution (costing the taxpayer $100,000 to $200,000 per year) and instead the underlying socioeconomic determinants of the disease need to be addressed.
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Liddywoo's Story was originally published by the Australian Broadcasting Commission (ABC) [11].
Images: Liddywoo in Belyuen and at his weekly blood test appointments - Source: Australian Broadcasting Commission [11].
References
[1] Australian Bureau of Statistics. Perspectives on Education and Training: Social Inclusion, 2009 [Internet]. 2011 [cited 2017 Feb 19]; ABS cat. no. 4250.0.55.001. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4250.0.55.001Main+Features32009.
[2] McDonald MI, Towers RJ, Andrews RM, Benger N, Currie BJ, Carapetis JR. Low rates of streptococcal pharyngitis and high rates of pyoderma in Australian Aboriginal communities where acute rheumatic fever is hyperendemic. Clin Infect Dis. 2006;43(6):683-9.
[3] Okello E, Kakande B, Sebatta E, Kayima J, Kuteesa M, Mutatina B, et al. Socioeconomic and Environmental Risk Factors among Rheumatic Heart Disease Patients in Uganda. PLoS ONE. 2012;7(8):1-6.
[4] RHD Australia. What is Acute Rheumatic Fever? [Internet]. Casuarina, NT (Australia): RHD Australia; 2016 [cited 2017 Feb 19]. Available from: http://www.rhdaustralia.org.au/what-acute-rheumatic-fever.
[5] Richard J, Baker M, Venugopal K. Acute Rheumatic Fever Associated With Household Crowding in a Developed Country. Paediatr Infect Dis J. 2011;30(4):315-9.
[6] Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander people: an overview [Internet]. 2011 [cited 2017 Feb 19]; AIHW cat. no. IHW 42. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737418955.
[7] Parnaby MG, Carapetis, JR. Rheumatic fever in Indigenous Australian children. J Paediatr Child Health. 2010;46:527-33.
[8] Harrington Z, Thomas DP, Currie BJ, Bulkanhawuy J. Challenging perceptions of non-compliance with rheumatic fever prophylaxis in a remote Aboriginal community. Med J Aust. 2006;184(10):514-7.
[9] Gannon M. President’s message: Eradicating RHD – an achievable health goal. Australian Medicine. 2016;28(11):3.
[10] Brown A, McDonald MI, Calma T. Rheumatic fever and social justice. Med J Aust. 2007;186(11):557-8.
[11] Brown R. Rheumatic Heart Disease: Documentary calls for greater awareness of deadly but preventable illness [Internet]. Ultimo, NSW (Australia): Australian Broadcasting Commission; 2016 [cited 2017 Feb 19]. Available from: http://www.abc.net.au/news/2016-03-10/rheumatic-heart-disease-tackled-in-new-documentary/7237726.
Posted 19th February, 2017