This week, we take a look at why rheumatic heart disease is still a problem in Northern and Central Australia – despite it being almost eradicated in the rest of the country. We also discuss the health differences between refugee and asylum seeker women, and look at the need for registration among health practitioners who use ultrasound.

https://soundcloud.com/thinkhealth/33-rheumatic-heart-disease-health-differences-between-refugees-and-asylum-seekers

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Speakers:
Professor Liz Sullivan – Assistant Deputy Vice Chancellor of Research UTS
Sara Shishehgar – PhD student, UTS Faculty of Health
Annie Gibbons – CEO Australasian Institute of Ultrasound

Presenter: Ellen Leabeater
Producers: Ninah Kopel, Jake Morcom

 

START OF TRANSCRIPT

Ellen Leabeater:

Hello, and welcome to Think Health. Ellen Leabeater with you. Today:

Sara Shishehgar:

…We’re not sure that they will be settled in Australia, for example, in my project, or whether they will be deported to their country of origin. As you can see, it’s a very big stress for them, that may influence their health condition.

Ellen Leabeater:

The health differences between refugees and asylum seekers.

Annie Gibbons:

…What we have now, though, is we have a variety of people who are already registered by boards, so the nurses are already registered. The physios, the radiographers, doctors, nurses – so do they need, then, dual registration?

Ellen Leabeater:

The need for registration among health practitioners who use ultrasound.

But first on the show, you would be forgiven for thinking rheumatic heart disease is just another illness modern medicine has eradicated, given we almost never hear about it. For most of the population rheumatic heart disease, or RHD, is extremely rare. However, Aboriginal and Torres Strait Islander people have one of the highest rates of RHD in the world.

Male voiceover:

What disease starts as a sore throat in children and ends with open heart surgery, heart failure, stroke, and premature death?

Female voiceover:

We’ve had a similar outbreak of measles or meningitis or even Ebola around the world that would make the headlines and the news whilst this is something that the general public is aware.

Ellen Leabeater:

This is an excerpt from the documentary Take Heart. You just heard that RHD has some pretty devastating outcomes, like heart disease and stroke. But, to better understand rheumatic heart disease, you need to understand rheumatic fever first.

People get rheumatic fever following an infection caused by group A streptococcal bacteria. You may have heard the term ‘strep throat’ before. Put simply, if you have a throat infection and it doesn’t get treated, it can lead to rheumatic fever. In trying to fight this strep bacterium, your body mounts an immune attack. This results in inflammation in other parts of the body, such as the joints, the brain, and the heart.

If you keep getting these throat infections and your body keeps mounting these immune responses, the repeated inflammation can damage the heart permanently. This is rheumatic heart disease, and it means your heart valves struggle to open and shut properly to pump blood around your body, leading to those devastating outcomes you heard earlier.

Children are most at risk of developing rheumatic fever and by extension, rheumatic heart disease. It’s found almost exclusively in Aboriginal and Torres Strait Islander populations in northern and central Australia and it is 100% preventable.

Elizabeth Sullivan:

Rheumatic heart disease had been eliminated from most of Australia in the 1990s, because it’s traditionally been a disease which was found amongst people coming from low socioeconomic incomes, those who are disadvantaged –

Ellen Leabeater:

This is Professor Liz Sullivan, Assistant Deputy Vice Chancellor of Research at the University of Technology Sydney.

Elizabeth Sullivan:

And a professor of public health.

Ellen Leabeater:

The main reason why this disease is so prevalent among Aboriginal populations is because of overcrowded housing.

What in particular is it about overcrowding that makes this disease more prevalent?

Elizabeth Sullivan:

It historically has been a disease of overcrowding of housing, and housing is a symptom of poverty, and you have a lot of people in a house, so I suppose then that it is much more difficult to maintain adequate cleanliness. There’s a lot more physical contact, there’s closer living so if someone’s infected with something, they’re much more likely to be infected with it when you have close housing living. It also reflects, too, maybe poor nutritional status in that household, because there’s not enough money for food. Also, issues around heating and good quality water, and sanitation. All those sorts of things, unfortunately, are related to infection spread.

Ellen Leabeater:

Add in to the mix, poor access to medical services and you begin to understand how a child can have a repeated untreated throat infection.

Beyond treating the symptoms of overcrowding and poverty, and treating the original throat infection, the only other option for people who have had rheumatic fever is preventative antibiotics like penicillin.

Elizabeth Sullivan:

For young people who’ve had rheumatic fever, there is a way to prevent progression to RHD, and it can be prevented through something we call secondary prophylaxis, and that’s where someone’s who’s been exposed and has a risk of delivering rheumatic heart disease goes on a regimen of three to four weekly injections of a drug called benzothyne penicillin g, which we call Biocillin. You’re looking at about ten years of monthly injections.

Ellen Leabeater:

In case you missed it, that’s an injection of biocillin every three to four weeks for ten years. Children barely want to eat vegetables. How do you get them to go to the doctor for a needle every month, let alone a needle every month for a decade?

But what Professor Sullivan has recently been looking at is the effect rheumatic heart disease has on pregnant women. During pregnancy, the heart has to increase its workload by between 30 and 50% and as you can probably guess, the risks for mum and bub are grave.

Elizabeth Sullivan:

Women with RHD tend to have inferior outcomes for their babies in terms of a lot more preterm birth, and for women that might be on anti-coagulation therapy, there are much higher rates of stillbirth and also neonatal death. That’s the worst types of outcomes, and it particularly can affect their hearts so they may also have, during pregnancy, heart failure and that may restrict their ability to do things and result in hospitalisations.

Ellen Leabeater:

The research into rheumatic heart disease and pregnancy is the first in Australia, and data analysis is ongoing. Professor Sullivan says preliminary findings suggest that women have issues accessing culturally appropriate antenatal care.

Elizabeth Sullivan:

We had a study where we followed women’s journeys during pregnancy with rheumatic heart disease and what that showed was for these women that were Aboriginal, that there was a lot of structural issues. They perceived racism in the way that they were treated. There was a lot of issues around just really basic things; appointment scheduling, being able to physically get to appointments, coming from rural remote settings and being able to get to the hospital, organising their medication. Lots of things which really relate to health literacy around how you navigate the system successfully to get the health outcomes you need.

Ellen Leabeater:

However, Professor Sullivan does point out that there is a silver lining. Despite all these complications, birth outcomes are generally good, because we do have a robust health system. As this research is ongoing, we’ll keep you updated on the results as they are published.

You’re listening to Think Health. Hello, if you’re listening live on 2SER 107.3, online at 2SER.com, or on your favourite podcast app.

The terms ‘refugee’ and ‘asylum seeker’ are often used interchangeably in conversation, but there is an important distinction between the two. A refugee is someone who has fled his or her own country and has been given refugee status by either the United Nations or a third party country like Australia. An asylum seeker is also someone who has fled their own country, but has yet to have their claim for protection assessed.

Why the lesson in definitions? Well, the difference between the two groups has enormous implications for their mental health. Sara Shishehgar is a PhD student at the University of Technology Sydney. Sara spoke to Ninah Kopel about the health concerns of refugee and asylum seeker women.

Sara Shishehgar:

Some refugees in this study mentioned that they experienced their being in the new society as a dropping from the moon to the earth for them, so you can see that it’s a big stress for them. I have an example for culture shock in this area that they were concerned about the extent of changes. For example, their children’s behaviour, that the children in the new society were willing to assimilate themselves with the new culture and disregard their traditional values and beliefs and their parents, in particular, the women were very very concerned about this and it could affect their mental health negatively. Another category that I mentioned in my recent publication was social factors. For example, having a secure job or lack of, for example, convenient and affordable housing was very important issues that refugee women struggling with.

Ninah Kopel:

Why are these things extra burdens for women?

Sara Shishehgar:

It’s my belief that maybe women are more social and they like to share their experiences and they like to talk, so it was more important for them when they are in a new environment they didn’t have anybody or any close friends to share their experiences, and also for most of them, their language was not that competent to share their experiences with other people from other languages.

Ninah Kopel:

How do we help women get through this? Have you identified any ways that we can work through these problems?

Sara Shishehgar:

Actually, in this study, I found some strategies that this population tried to employ to reduce their stresses or integrate to their new environment. One of them was to, for example, seek support from ethnic communities. Ethnic community can help this population to increase their empowerment, and to feel more confidence and to provide them with opportunity to share their experiences with other people from their country of origin. And I believe that ethnic communities can help a refugee woman to maintain their health condition.

Ninah Kopel:

Something you mentioned before was the idea of psychological health. How important is psychological health as opposed to just the physical health concerns for this population?

Sara Shishehgar:

Their role as women in the family is more obvious and apparent when they are in a new environment and they have to support their family members, so if they feel depressed or they feel down in terms of their mental condition, maybe they cannot support their family and also they may suffer from some physical problems as well.

Ninah Kopel:

What kind of research would you still want to do? What questions do you think we still need to ask?

Sara Shishehgar:

In my next project, I’m working on asylum seeker women and I’m doing a research on asylum seekers because I believe that asylum seekers living in a secure residency and maybe their problems are more than refugee women.

Ninah Kopel:

Why is that? What is the distinction?

Sara Shishehgar:

Refugee women … Actually refugee has a definition. Refugee refers to people who, their refuge or their asylum application, has been accepted and they are settled in their recipient country. For example, in Australia. Asylum seekers are the people who are waiting for a response to their asylum application. They are not sure that they will be settled in Australia, as for example, in my project, or they will be deported to their country of origin. As you can see, it’s very big stress for them, that may influence their health condition psychologically and physically.

Ninah Kopel:

Is there any research already in this area on what kind of psychological impact waiting for refugee status, and also for asylum seeker status?

Sara Shishehgar:

Yeah. For asylum seekers, actually, I’m working on Iranian asylum seeker women, sorry, and I had a review on literature and I know that there’s no published documented evidence about this population. Actually, about other population, maybe about African women, there are some publications and there are some studies on them, about refugee African women, but about asylum seekers I didn’t find much knowledge or much publications about this population.

Ninah Kopel:

Obviously you’ve been speaking to people in this situation. Do you have any stories that might help people understand what these women or these people are going through?

Sara Shishehgar:

One thing that I can say in this stage is that all participants in this situation, they all complain of their insecure residency, and they are very concerned about not having a resort and not having a stable condition. What I found from this population in this stage, that they are very concerned about their condition, their children’s condition, their education that all of them are affected by their insecure residency condition in Australia and they wish to have a visa to be settled in Australia.

Ninah Kopel:

In terms of helping them with their health, is there a solution we can offer now? You know, psychological support and health assistance, or is it simply the matter of getting them a visa that would be the thing that would help them relieve that burden on their minds?

Sara Shishehgar:

Yeah. Actually, there are some things in healthcare services, for example as you mentioned, psychological support and counselling sessions that they use, but I still believe that when we have ongoing issues, application of these supports cannot help them that much, because they said that they are using their services, for example, counselling services, psychological services, but they are still suffering from mental issues.

Ellen Leabeater:

Sara Shishehgar, PhD in the faculty of health at UTS, speaking with Ninah Kopel.

Jake Morcom:

You’re listening to Think Health on 2SER 107.3.

Ellen Leabeater:

Type ‘ultrasound’ into Google and you’re likely to get the blurry black and white pictures we have come to associate with pregnancy ultrasounds, but ultrasound is more than just for pregnancy. Increasingly, ultrasounds are being used by a variety of clinicians from physiotherapists to emergency department doctors.

The problem is that many clinicians who use ultrasound to supplement their professional opinion, may have the education to read the ultrasound picture, but not the registration. Annie Gibbons is the CEO of the Australasian Institute of Ultrasound. She spoke to Jake Morcom about the push for dual registration.

Annie Gibbons:

My only experience, I suppose, with ultrasound was going there as a mum, and obviously my patients in nursing would go off for ultrasounds but I didn’t have a thorough understanding the way I do now, so for example, I would have had the common belief that you just go to ultrasound to see the baby’s picture, whereas it’s actually a diagnostic medical tool. It’s there to actually assess the baby’s health in an extensive way, not just to give you a pretty picture to put on your fridge or to pop up on Facebook. I suppose the medical side of it is a lot different than what the current consumer would actually think, and also the range and diversity of uses that ultrasound is now used for. It’s not just obstetric, there’s vascular, muscular, skeletal, general, cardiac ultrasound. It’s used to scan pretty much every part of the body and it’s an amazing diagnostic tool that more and more doctors are taking up. For example, in my current role, we have doctors from all over Australasia using it from radiologists, obstetricians, to emergency doctors and phlebologists and surgeons, so the use of ultrasound is increasing by a diverse range.

Jake Morcom:

When you just hear ultrasound I think the first thing you go to is you have an ultrasound during the term of pregnancy, but it goes outside the realm of practice, does it?

Annie Gibbons:

Absolutely. For example, a patient might be having a leaky heart valve. They can have an ultrasound, they have an echo cardiograph and actually have a little look at all the chambers of the heart and what’s happening there. They might have some vascular problems so their veins will get scanned in all parts of their body. You can have musculoskeletal injuries, so tears in joints and tissues, and so physiotherapists and sports physicians they will be actually scanning knees and ankles and hips, all over the place. They can even scan an eye and underneath the lid and find what’s happening.

It is quite amazing that depending on the field that the practitioner is working in, there’s basically an ultrasound course available for them.

Jake Morcom:

To go now to the Australasian Institute of Ultrasound, what is it that you do?

Annie Gibbons:

We’re the biggest provider of ultrasound education across Australasia, and so we have a large training faculty and we have a large training facility in the Gold Coast, so we’re based in the Gold Coast. We provide training to over 850 students every year.

Jake Morcom:

What is involved in the training? What are you prepping them for?

Annie Gibbons:

It depends on what their need is. If they’re in an emergency department, for example, they don’t want to do comprehensive scan with a very large modern machine, high end machine, with comprehensive reports. They actually want to scan someone’s heart or someone’s lungs and actually see, are they bleeding, do they need surgery? I’m using it as a diagnostic tool at the point of care, whereas other doctors will actually be doing a comprehensive scan, or a sonographer for example, they do two years post-graduate qualification and they’ll do a comprehensive scan which then requires a full report, signed off by their radiologist or obstetrician.

It depends on what that medical practitioner is actually using it for, to what course they then enrol in.

Jake Morcom:

Was it kind of an instance of, there would be a hospital or a medical setting that would have this equipment but they didn’t really know why they had it, or what it could then be used for?

Annie Gibbons:

No, they knew what it could be used for, but it’s one of those things that it actually is really challenging to learn those skills, to know how to scan. You buy this equipment but you actually don’t know how to use it. It’s like getting a phone and not knowing what all the buttons are, you know. It’s probably offensive to the professionals to think, “Oh, well, I can just do a short little course and then wave the ultrasound transducer over and I can see everything.”

You actually can’t. You’re looking at images in a very different way, and so one, being able to image and then two, to be able to be confident enough to view that image and diagnose off it is a real skill. It was more that the machines were getting sold and we needed to make sure that people who were then going to use them did so in a professional manner.

That also then led, I was on the diagnostic imaging board for the department of health, and so we were championing to actually define that those certificates in point of care ultrasound were then the minimum standard of user qualification. That’s still getting pushed through now, but at the moment, doctors can just scan without qualification. So can physios, so can vets, so can anybody. However, as a diagnostic tool, we would like to see that there is a minimum standard recognised by the government and hopefully that’s still to come.

Jake Morcom:

When is this push? How far in the future are you seeing this being installed?

Annie Gibbons:

Depends how quickly the health department responds to that need. I’d say hopefully within the next year or two. We’ve been campaigning for that for a good three to four years now. There’s obviously resistance from that, and it’s a complex issue. What I mean by that is we have a registration body called AHPRA, so whether you’re a doctor or a nurse or a physiotherapist for example, they’re all nationally registered, whereas ultrasound, sonographers, are not registered. They’re not nationally registered. It’s a diagnostic imaging tool and skillset, but it actually doesn’t come under its own profession that it’s registered.

If you then define the scope that those that skillset or qualification needs to be recognised by a license or a board, what we have now though is a variety of people who are already registered by boards. The nurses are already registered, the physios, the radiographers, doctors, nurses, so do they need then dual registration? Which then becomes financial and it becomes complex to manage. There’s that whole issue as well, then there’s also the financial and billing aspect that if you bill for an ultrasound scan if you’re the doctor billing for that, should you be able to bill the same rate as someone who’s doing a comprehensive scan as opposed to just doing a more focused specific scan? There’s complex issues of finance, government, regulations, politics, licensing, and so hopefully … My side of it has been purely just from an educational perspective that obviously if someone’s using something which then has a diagnostic response to it, I would like to see that a minimum standard of quality and expectation would be there and that’s defining its scope and putting it into a qualification.

Ellen Leabeater:

That’s Jake Morcom, speaking to Annie Gibbons, CEO of the Australasian Institute of Ultrasound. It’s an excerpt taken from another 2SER show, The Chat. If you want to hear more from that interview, visit 2SER.com/TheChat.

If you would like to find out more about anything you heard today, visit 2SER.com/ThinkHealth. This show is produced with the support of the University of Technology Sydney, Faculty of Health. If today’s program has raised any concerns, go and see your GP. I’m Ellen Leabeater, thanks for your company.

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