Health benefits of swimming pools in remote Aboriginal communities

We welcome the study in this issue showing improved health outcomes for children after swimming pools were installed in two remote Aboriginal communities in Western Australia—but with guarded optimism.¹ Improvements in Aboriginal children's health, particularly in remote communities, have been remarkably difficult to achieve, so successful interventions that are potentially transferable warrant serious consideration.

Optimism, however, must be guarded. There is no quick fix for the many health problems that occur in remote communities, including both infectious and chronic illnesses. As the authors note, pyoderma and chronic ear disease have remained intractably high in children for decades. In some communities the prevalence of trachoma is as high as 40% in children under 10 years.² Mortality for indigenous infants is 2.5 times as high as for all Australia,³ and hospital admissions for children under 14 years are 1.5 times as high.⁴ As the authors point out, continued efforts in the areas of improved housing, sanitation, nutrition, education, and access to health care are all a high priority. We would like to add community hope, involvement, and control as essential ingredients for change through community development.⁵

Adding a swimming pool has costs and benefits that have to be weighed in the context of the community's interest and capacity, including ecological capacity. An assessment with each community interested in a pool is an essential prerequisite, and several factors need to be considered.⁶ The cost of establishing pools and their associated amenities in remote communities and the cost and feasibility of maintenance are not addressed in this paper. Also not considered are the considerable opportunity costs in communities working to maintain basic goods and services. Nor is it known whether community members have been trained to maintain the pools, thereby gaining useful skills. A pool can turn from a place of fun and health gain to a source of illness and even tragedy if maintenance and supervision are neglected for any reason. Such threats, however, need to be considered in the context of the poor quality of natural water supplies turned to as alternatives, and the difficulties for adequate supervision that these pose. Moreover, artesian water is a precious commodity and some parts of the desert have insufficient water supplies to maintain a pool in the long term.⁷ Water savings in other ways may be necessary to offset the ecological “surprise” of an evaporating pool of water in hot, arid conditions.

The authors allude to population mobility, which continues at high levels as people move between communities and travel for ceremonial and other reasons.⁷,⁸ This will result in use of the pool being intermittent, which could have an impact on the effectiveness of pools as a health intervention, although in this study the children who were seen fewer than three times did not have a greater prevalence of sores than those seen more often. Certainly, high mobility is a major issue both for the design of suitable health interventions that are appropriate for a mobile population and for robust evaluation of such interventions.

The authors say that there did not seem to be any other changes that might have accounted for the health improvements seen, although this could be quite difficult to assess, especially given the high rate of movement in and out of communities. And it is impossible to tease apart the extent to which immersion in the pool, heightened awareness of skin hygiene, or a range of other factors contributed to the results documented in this study. However, it is probably more important to monitor whether improved health outcomes are sustained than to deliberate on the intricacies of their underlying mechanisms. The proposed ongoing monitoring in this study is very valuable.

Considerable health benefits for children and adolescents might be expected from regular relief from heat and boredom, combined with pleasurable physical activity in a safe meeting place where disruptions—such as those related to alcohol and petrol sniffing, which are issues in some communities—are likely to be banned. The improved school attendance in this study is testimony to the potential wider benefits from a pool where a community has influence over the management. The results to date support the view that swimming pools can be an important health asset, and it is with anticipation and hope that we await the continued results from this and other intervention studies. However, before installing a pool in a community is seriously considered, the community will want to assess the social, ecological, and economic impact. In some communities, the best way forward may be by another route.