The Austin Doyle Lecture, High Blood Pressure Research Council of Australia. Renal disease as a metaphor: towards a more integrated view of aboriginal health.

Abstract

1. The health of Aboriginal people in the Northern Territory of Australia is among the worst in the world, with mortality rates increased in every 'disease-specific' category and averaging overall approximately five-fold those of non-Aboriginal Australians. Health services, which in most regions are rudimentary, fragmented and under-resourced, have been slow to recognize and meet this challenge. However, the cost implications of an epidemic of renal failure have stimulated concern that broader mortality statistics could not. 2. In one high-risk Aboriginal community, we found that renal disease can be detected and its course chartered by a simple and reliable screening test. Renal disease arises out of a broad menu of risk factors that reflect poverty, disadvantage and accelerated lifestyle changes and its expression is progressively amplified with the simultaneous operation of more than one risk factor. It is intimately related to other 'diseases' through shared risk factors and pathophysiology. We also found that people with established renal disease participated enthusiastically in a pharmacological treatment programme, with excellent clinical responses that predict a marked reduction in renal failure and cardiovascular morbidity and mortality over the intermediate term. 3. It is likely that most other causes of excess mortality in Aboriginal people are, like renal disease, multideterminant, with a substantial base of shared risk factors. They are probably equally susceptible to modification. We must move away from 'single-cause' disease models, eliminate counterproductive specialty barriers and rectify the unbalanced focus and resource commitment to hospital-based, high technology treatments of people with advanced and irreversible disease. We must advocate for coherent, sustained, integrated public health and primary care programmes to improve the whole health profile and for screening and treatment programmes to modify the course of disease in people already afflicted.