The Director-General of Health
Hygiene – Northern Territory
In the course of my recent itinerary through the Northern Territory, I made a cursory enquiry into the current standards in the control of communicable diseases.
The following observations are submitted to indicate desirable improvements in prophylactic routine.
I should like, at the outset, to emphasise that no remark of mine is intended as a criticism of or a reflection upon any officer of the Northern Territory Medical Service. All those with whom I came in contact were conscientious and zealous in the execution of their duties and frankly avowed their anxiety to learn more from experienced officers of the requirements of health administration in this unfamiliar area. I attribute the shortcomings in administrative health routine to officers’ unfamiliarity with the novel conditions existing in the Territory and the special demands created in the area by tropical diseases concerning which they have had no experience.
For the defects in sanitary administration I hold responsible the peculiar and difficult administrative structure which divorces the central health authority – vested in the Northern Territory Medical Service – from the local – represented by the Administration.
In respect of communicable disease I cite the following observations as indicative of imperfect organisation in the Medical Service itself.
- Leprosy
- At Roper River Mission I saw five cases of leprosy with frank active lesions. Two of these had recently been discharged from Channel Island.
A week prior to my visit these cases had been seen by a medical officer of the Service and smears had been taken by Mr. Martin, Technician at Darwin Health Laboratory. Smears had proved negative and no further action was taken.
No instructions for the disposal, treatment or observation of these cases were issued to the Sister-in-Charge at Roper River. It is to be remembered that any one of these patients might at any time convert to an “open” case and in the interests of the patients themselves and of inmates of the Missions, the Sister should have been advised upon –
- Therapeutic measures directed towards maintaining a non-infection condition;
- precautionary measures to minimise infection of the associates in the event of conversation; and
- signs to be observed to give timely warning that a risk of contagion had developed.
- At Bathurst Island Mission where there are some 600 natives in intermittent contact with the white and coloured population of Darwin and the mainland, I was informed there were 36 suspect and discharged lepers who had been inspected and reported by medical officers of the Service some months previously. No instructions for the disposal of treatment of these natives had been issued to the Sister-in-Charge and no subsequent action or review had been taken. The medical officers who made the inspection frankly admitted that they were unfamiliar with leprosy and listed the individuals for early review, but this recommendation had not been pursued. I was unable to assist in this direction on the occasion of my visit as the natives concerned had been dispersed on “walkabout”.
- At Port Keats Mission there are five lepers discharged from Channel Island some considerable time ago who were still under treatment. I was informed by the Sister-in-Charge that the routine treatment for these patients consists of a daily dose of three grams of sulphetrone for a period of three months, followed by an interval of 14 days during which they are sent bush. No instructions were received from Darwin regarding these cases and they had at no time been reviewed. In addition there are a few cases “slightly suspect” who are not certainly diagnosed. The Sister stated that she reported all cases “considered necessary” to Darwin but no medical examination had been made to verify the tentative diagnosis or prescribe or modify treatment.
- No organized system exists for the recoding of discharged lepers, suspect lepers and leper contacts and the old routine for the regular periodic re-examination of these persons appears to have fallen in desuetude.
2. Malaria.
(a) At Roper River Mission, on my arrival, I was asked to see the wife of the Superintendent who, on clinical appearances and therapeutic response, was evidently suffering from benign tertian malaria. I asked the Superintendent whether he had reported this case to Darwin and replied in the negative. He informed me, however, that he had some weeks before reported himself and two other white patients on the occasion of their manifesting similar symptoms which were confirmed as malaria by the Sister at Groote Island who claimed to have demonstrated parasites in blood films. This Sister had attended a course on Laboratory Procedures in the State Health Laboratory, Brisbane. The Superintendent informed me that following this report to Darwin, the Mission had been visited a week previously by a doctor and pathologist for the purpose of conducting a malaria survey. According to the Missionary, the Medical Officer, on arrival, asked if there were any sufferers from malaria at the time. On being informed in the negative, no further action was taken. No spleen survey of the native population was conducted and no parasite survey attempted. No instructions were left for the treatment of future cases, if any. At the time of my visit the only orders for the treatment of malaria were those issued by an Army medical officer in 1945 and the necessary drugs for compliance with this order were not available at the Mission.
Before leaving the Mission I made a hasty spleen survey of some 12 children, in the camp and amongst these two presented palpable spleens.
(b) Whilst in Darwin I discussed, at his request, the incidence of malaria in the Territory with Dr. Barbour. Following our conversation two natives in the Darwin Hospital who had been under treatment for other conditions were identified as suffering from malaria. Officers of the Medical Service in this situation were not familiar with measures of control necessary or desirable to be taken.
- Hookworm
There is evident that hookworm is progressively moving eastward with the active co-operation of the Department of Native Affairs and Mission Organizations. At Oenpelli which before the war was free from hookworm, the incidence was stated by the Arnhem Land Scientific Expedition to approximately 96%. At Yirrakala, which was also free before the war, the same authority estimated the incidence at about 30%. The two settlements on Groote Island were reported free but conditions there as at all missions are peculiarly adapted to wide dissemination and opportunities for the importation of the parasite are freely offered by the uncontrolled movement of infected natives between the mainland and the Island.
The importance of hookworm as an endemic disease amongst natives is not fully appreciated. At Bathurst Island where infestation has been endemic for a considerable time, it is not uncommon to find children with haemoglobin concentration below 40% of normal. Taken in conjunction with the iron deficient diet which is commonly supplied to settlement inmates and the freedom with which lay persons prescribe in respiratory and other conditions protracted and frequently repeated courses of sulphamerazine in substantial dosage, hookworm anaemia becomes a matter of first importance. For example, at Forrest River in Western Australia, the Superintendent was puzzled because children suffering from respiratory disease die under “adequate” sulphanilamide therapy. The suggestion that these deaths may have been associated with hookworm anaemia, he replied that hookworm did not exist on the Mission, an opinion which I contested. I have since received a telegram from him confirming hookworm prevalence there.
The existence and importance of hookworm infestation does not appear to have been appreciated by medical officers of the Northern Territory Medical Service. The occurrence of geophagia did not lead to suspicion of hookworm, but the interest of the Service was evinced by despatch of specimens evidence of a mineral deficiency in the diet. Generally speaking, hookworm is only suspected where native children are excessively pot-bellied. In my opinion this sign is of no significance whatever but serves rather as an indication of an excessively vegetable diet.
- Granuloma.
Granuloma, a venereal infection common in natives, appears to be mistakenly regarded by medical officers as yaws or syphilis. The Medical Officer at Katherine reported to me a number of cases of both sexes detected at Maranboy and detained in the native wards at Katherine Hospital for a protracted period, during which they underwent a prolonged and costly treatment for syphilis, without response.
The basis of the diagnosis of syphilis was a positive Wasserman reaction given by the patients at a time when the genital lesions were regarded as chancres. Apart from the improbability that a sufferer from primary syphilis would present a positive Wasserman or that an active syphilitic of some duration would present a chancre, a high probability that the Wasserman reaction was in fact a relic of a previous framboesia was overlooked.
Cases of granuloma at a stage sufficiently early to be regarded as primary syphilis respond rapidly to antimonials. At later stages when antimony may prove less effective, streptomycin effects a rapid cure. Apart from the expense, drug wastage and unnecessary diversion of ward space involved in the prolonged and ineffectual treatment by penicillin and other anti-syphilitic therapeutics, the psychological effect of protracted hospitalization upon the natives is an important consideration.
- Framboesia
The etiology, clinical features, incidence and treatment of yaws do not appear to be understood. Some indication of this is given by the incident related above in respect of granuloma. That this lack of knowledge is not limited to inexperienced immigrant graduates at country stations is indicated by the remark made by the A/g Chief Medical Officer himself in intra-departmental correspondence, in which, after consultation with his colleague, he expressed the view that framboesia was transmitted as a verneral infection.
SANITATION
The divorce of the Medical Service from the Northern Territory Administration and the failure of these two agencies to evolve an efficient basis of liaison and co-operation, are reflected in the development of a number of hygiene problems the resolution of which presents apparently insuperable difficulties. A number of these sanitary defects are listed hereunder. It may be said that both the Medical Service and the Administration are aware of their existence but in the absence of a stable allocation of responsibility, each feels unable to take effective remedial action but rather awaits intervention by the other.
Mosquito Control
(a) The vicinity of Darwin includes, adjacent to the beach, a number of low lying areas which become swamps during the wet season. Over the years since 1911, temporary and permanent drainage work has been undertaken by successive authorities to minimise mosquito breeding during the late wet and the dry season. These drainage systems have in certain situations been provided with flood-gates to prevent access of seawater.
Much of the drainage reticulation and some of the flood-gates have fallen to disrepair from neglect or have been rendered ineffectual by the interference of new works undertaken by the Department of Works and Housing. Such works include the blocking of the drains by spoil left by earth-moving machinery in the grading of roads and the discharge of drainage into the swamps.
Whilst it is the function of the Northern Territory Medical Service – and it may here be remarked that this function is actively performed – to inspect and report upon these drainage projects, the Administration is presumably the authority charged with the responsibility for their maintenance. The Administration has no organisation or equipment for such maintenance but is wholly dependent upon the services of the Department of Works and Housing for this purpose. The Administrator has no direct authority over the Department of Works and Housing and the difficulties confronted in maintaining the efficiency of these installations through the agency of the Department of Works and Housing can best be appreciated in the light of the fact that that Department is often responsible itself for the disruption that exists.
(b) Some of the swamps discussed in the previous sub-paragraph are separated from the sea only by shallow banks of sand which are under threat of submergence at high flood tide. The irruption of the sea into these areas would be calculated materially to change for the worse the mosquito breeding possibilities of the swamp. Particularly is this a risk at Darwin where the successful exclusion of A. Sundaicus, an important malaria vector likely at any time to be imported from Asia by air, demands that opportunities for salt and brackish water breeding shall be reduced to a minimum, particularly in the vicinity of the aerodrome.
Contractors to the Department of Works and Housing were at the time of my visit busily engaged in excavating sand from the beaches above high water mark. At certain points flood tides had already broken through these excavations into the low lying ground behind the combination of November tides and north-west gales threatens extensive incursion of sea water into the coastal swamps.
The Northern Territory Medical Service has repeatedly made representations in this matter. The Department of Works and Housing informed me that it has no jurisdiction, control in these matters being vested entirely in the Administration. In the course of an interview with me on the matter, the Government Secretary elicited from the Director of Lands in the Administration the admission that his Branch was responsible but lacked the necessary staff, an illuminating admission when it is possible for any visitor or casual observer to detect offenders red handed at any time of the day, any day of the week.
(c) The Department of Health has, at some considerable expense, recently conducted an entomological survey of the vicinity of the Darwin aerodrome and made recommendations for more effective control. Adjacent to the aerodrome lies Merara swamp, in itself a formidable problem.
Extensive drainage projects were undertaken in this area during the war but a considerable section has been rendered ineffectual by the construction of an improvised swimming pool in one of the main drainage canals, by the expedient of a galvanised iron and mud dam. This dam, it was alleged, was constructed by the R.A.A.F., an Armed Service which admits no responsibility to the Medical Service, the Administration or the Department of Works and Housing.
(d) Prior to 1939, water for domestic supply in Darwin was drawn by wells from the subsoil and from the close of the wet season, the subsoil water level was rapidly lowered by the heavy draft upon it. Since that time water has been pumped to Darwin from Manton dam. Not only is the subsoil water no longer drained by withdrawal from wells but a considerable volume of water is brought into the town from a distance and discharged into the subsoil. Surface seepages from the subsoil which formerly dried out in May and June now continue unabated throughout the year and provide foci for mosquito breeding in areas which formerly were completely free from danger. Defects in the reticulation system – broken joints, defective valves and the like – are numerous throughout the town area, and pools of water in the vicinity offer a permanent source for mosquito breeding Several of these were found in Berrima native compound and attention was directed to the danger in anopheline breeding here. Subsequently a case of malaria was isolated from the compound and a rapid mosquito survey revealed larvae of A. punctulatuf farauti breeding in the pools created by the leaking system.
(e) Pending completion of the sewerage system a number of premises have been equipped with septic tanks. No systematic effort appears to have been made to ensure that effluents shall be disposed below ground. The result has been the creation of a large number of foul sullage pools in which there is prolific breeding of Culex fatigans. This pest mosquito was never a problem in Darwin prior to the war but it is at the moment unquestionably the most important mosquito in the area.
(f) The effective control of A. aegypti is rendered impossible by –
- the breeding opportunities afforded during the wet seasons by the extensive accumulations of petrol drums at various sites throughout the town;
- the uncontrolled dumping of incombustible litter in gullies and watercourses inaccessible to spraying; and
- the breeding opportunities offered by wrecked buildings.
(g) In certain areas, for examples, Stuart Park and the Police paddock, people have entered into occupation of Army camps under a fortnightly tenancy. As Army camps the premises were provided with a more or less elaborate sullage water drainage system but these have been broken down or removed and are no longer functioning. Sullage discharges haphazard through the area of habitation and no tenant is prepared, having regard to the conditions of tenancy, to spend the labour or the money required to effect repair.
2. Garbage Disposal.
Garbage removal and disposal is undertaken by the Administration, combustible refuse being burnt in an incinerator in the Parap area. Ash and incombustible wastes are dumped in a valley nearby where they interfere with natural drainage and serve no useful purpose. This material was formerly used as filling for the reclamation of mosquito breeding swamps and reversion to its use for this purpose should receive consideration.
- Under pressure exerted by the housing shortage a tendency has developed to tolerate sub-standard shacks and dwellings erected from scrap material or evolved by the modification of Army camps on the outskirts of the town. The provisions of the Building Regulations apparently have not been extended to these localities. Past experience over many years has shown that such habitations run up as a matter of expediency in boom times, become in periods of recession a major health and social problem on account of the peculiar constitution of the local population. Every effort should be made to prevent the erection or occupation of any more of these structures and to reduce, as rapidly as possible, the number of those occupied.
NATIVE SETTLEMENTS
Adequate surveys of native settlements both Mission and Government do not appear to have been made for some considerable time. Some have not been visited at all by a medical officer. Where medical visits have been made it does not appear that any attention has been given to the medical inspection of the population, the sanitary condition of the settlement, the adequacy or quantity of the water supply, the nature of the diet, the quality of the housing or the methods of waste disposal. At none of the settlements visited were conditions satisfactory in respect of any of these matters, on the contrary, at many, including all Government stations, disgraceful conditions of insanitation obtain.
I wish to reiterate, if necessary with added emphasis, that these remarks are actuated by a desire to assist and are in no way intended as a criticism of any officer of the Medical Service, the Administration or collateral Commonwealth Departments.
The difficulty of achieving that co-ordination and co-operation which can avert the evolution of these defects, has long been a feature of Northern Territory Administration. Years ago it was realised that only the Medical Service could provide the knowledge, the inspiration and the spur to have them effectually corrected and it was for this reason that in 1927 it was recommended to the Government that medical practice as then obtaining be terminated and that all medical, health and native administration be vested in an integrated service. Considerable improvement and development followed the adoption of this recommendation although the meagre funds available prevented attaining all the objectives which were the ideals of the officers concerned.
By comparison, ample funds appear to be available today and it remains to devise a stable basis of co-ordination and co-operation which will ensure that these funds are not idly dissipated.
The fundamental inadequacies in the Northern Territory at the moment are –
(a) the inexperience of personnel, both professional and lay, not only in the Medical Service but in the Administration and in other Commonwealth Departments. Hardly one individual remains in any Branch of the Commonwealth Service, who has not to learn for himself by costly errors all those lessons which would be available to him from the experience of his predecessors;
(b) the unfortunate but possible inevitable severance of the Medical Service, first from the Administration and second from the Native Affairs Department. No satisfactory executive for the maintenance of an effectual routine has been devised and it appears unlikely that officers on short term appointments and lacking rich experience of Territory problems over the course of years, will ever be able to devise one.
I wish to reiterate my opinion already expressed to you that no improvement is likely to follow the appointment of yet another Chief Medical Officer or Deputy Director of Health lacking Territory experience and to emphasise my opinion that remedy lies in the promotion of a man already gaining Territory experience, who is attracted by the prospect of some years of service during which he can build up an integrated and comprehensive medical and health organisation with a wealth of experience and a proud tradition.
C.E. Cook,
15th July, 1954.