EDITORIAL Editorial Measuring the gap—It may well be worse than we thought Richmond W. Jeremy and Alex Brown University of Sydney, K25 Medical Foundation Building, Australia Baker IDI, W and E Rubuntja Research and Medical Education Building, Alice Springs Hospital, Gap Road, Alice Springs, Australia T he council of Australian governments has commit- ted $1.6 billion towards closing the gap in Indigenous health outcomes. Among the ever expanding list of con- tributors to this gap, chronic diseases, such as diabetes, chronic kidney disease and cardiovascular conditions, are the primary targets. In recognition, the Commonwealth government has set aside $805 million towards reducing the impact of chronic disease in indigenous populations. The aims of these investments include closing the gap in life expectancy within a generation and halving the gap in mortality rates for children under five years within a decade [1]. These aims will not be easy to achieve. In order to maximise the benefit of this single largest investment in Aboriginal health, we need to know just how big the gap really is, what the determinants of the gap are and what the potential intervention points are that will deliver most impact. Most people now recognise that Indigenous cardiovas- cular health is worse than for non-Indigenous people. However, do we really know just how bad the situation is and how good is the present data? In 2001, the life expectancy of Indigenous males was 59.4 years and of females was 64.8 years, compared to 77 years and 83 years for non-Indigenous males and females respectively [2]. The life expectancy gap is thus some 18 years and cardiovascular disease is the single most important contributor to the shortened life expectancy of Indigenous people. The report by Katzenellenbogen et al. in this issue of the journal seeks to provide us with better data about car- diovascular health, particularly myocardial infarction, in Indigenous people in Western Australia [3]. The authors’ starting premise was that previous data about incidence and case-fatality rates for myocardial infarction in Indige- nous people were potentially flawed, due to fragmentation of data sets. The authors therefore used a linkage approach to mortality and hospital admission data sets, in order to determine the rates of both in-hospital and out-of-hospital fatal myocardial infarction. The report on cardiovascular disease in Indigenous Aus- tralians, published by the Australian Institute of Health and Welfare in 2008, is based upon the cross-sectional National Aboriginal and Torres Strait Islander health survey (2004–2005) and the ABS National health survey (2004–2005). Using self-reported data, the standardised prevalence ratio for cardiovascular disease in Indigenous Australians was 1.2. An estimated one in eight indigenous Australians had a chronic cardiovascular condition with men 1.2 times and women 1.4 times more likely to have cardiovascular disease than their non-Indigenous coun- terparts. The report estimated that 1.2% of Indigenous Australians had coronary artery disease and 1.0% had heart failure, at rates twice that of the non-Indigenous population. Indigenous women fared much worse than non-Indigenous women [4]. These aggregate data obscure, to a significant degree, the true extent of the problem. The data presented by Katzenellenbogen et al. shows that myocardial infarction ravages young Indigenous Australians at a rate up to 30 times that of the non-Indigenous population. In many respects, this is the very face of the Indigenous chronic disease burden. Massive differentials exist in mortality at relatively young ages [5–7]. The rate of myocardial infarction in Indigenous males aged 35–39 years is equiv- alent to that of non-Indigenous males aged 60–64 years. The same pertains for Indigenous women. The seeds of cardiovascular disease are sown early with life-long con- sequences. Successful prevention must begin in childhood and adolescence, if we are to overcome this burden of early infarction. As might be expected, Katzenellenbogen et al. found that the case-fatality rates after myocardial infarction for Indigenous people were significantly worse than for non- Indigenous people. For the years 2000–2004, they reported 133 deaths in Indigenous males and 75 deaths in Indige- nous females in Western Australia. It is noteworthy that the 2008 AIHW report describes only 141 deaths for males and 83 deaths for females in the years 2002–2005 for Queensland, Western Australia, South Australia and the Northern Territory combined. It does indeed appear that the mortality rates from coronary disease have been underestimated in the Indigenous population. Whilst it has been recognised that Indigenous women have a relatively higher burden of coronary disease at a younger age than non-Indigenous women, the work of Katzenellenbogen et al. again indicates that the true 1443-9506/04/$36.00 doi:10.1016/S1443-9506(10)01530-1