Given by Dr. C.E. Cook, 12th September 1939
Before proceeding to detail the measures taken to provide adequate medical service for the Northern Territory, it is desirable to describe the conditions existing in the Territory in 1926, so that the factors contributing to the problem facing the Commonwealth may be made apparent and the somewhat unusual methods of meeting them understood. In 1926 there were two medical officers in Northern Territory. One was designated “Acting Chief Medical Officer” and was a private practitioner who acted as Health Officer, Government Medical Officer and Medical Superintendent of the Hospital. The other was a Quarantine Officer with the right of private practice. Both conducted private practices in the town of Darwin, retaining fees for private work and attending their private patients in the Hospital, so that friction was inevitable. There was no pharmacist in the Territory, either in Government employ or in business, and Medical Practitioners did their own dispensing, charging their patents for the preparations made.
There were two public hospitals – (a) Darwin, which was staffed by a matron and four sisters. There we no untrained nursing assistants and no probationer staff at the hospital. The daily average of occupied beds for 1926 was 6.6. There was no X-ray equipment, inadequate surgical supplies, a primitive theatre, and a wholly unsuitable building served as a maternity ward. Five shillings a day was collected by the Government for in-patients, but the administrator could waive all or part of this fee in special circumstances. Medical Officers, as far as I am aware, did not charge for attention upon their patients in hospital except in respect of surgical operations, midwifery and anaesthetics. For the most part, sick people remained at home and were there attended by medical advisers. Quite a large percentage of the population, however, had no home suitable for the sheltering of the sick. There were no nurses outside the hospital and no private hospitals. An unregistered midwife of Chinese antecedents served as a maternity nurse for most of the European confinements, (b) Pine Creek, where one sister was stationed on transfer from Darwin for a period of one month at time. This hospital was really only an ambulance pot in touch by telegraph with Darwin. There was a train once a week between Darwin and Pine Creek, and cases required more than first-aid were transferred to Darwin. The road was absolutely impassable to motor traffic most of the year. The trained staff for these two hospitals was recruited from southern States, at a salary of £200 per annum, rising y two annual increments each of £25 to £250 per annum. A girl on arriving receives a salary of £200, but each pay-day one 6th of her far is deduced from her pay, the total fare amounting to £25. At the end of twelve months’ service the Government reimburses her fare, the amount being paid to her in the first pay of her second year’s service. That was an effort to encourage a girl to remain for twelve months. Appointees were required to refund their fares to Darwin by deduction from salary over the first twelve months. On completion of twelve months’ service this was reimbursed to them. Sisters were entitled to once month’s recreation leave for each year of service, and one months’ traveling time with return first-class fare to a southern capital city on completion of three years’ service. Notwithstanding the apparently attractive terms of employment, it was difficult to retain the staff, the sisters usually resigned shortly after completion of twelve months’ service, when their inward fare had been reimbursed.
At the time of my arrival in 1927 all the sisters were on strike, the reasons for disaffection being given as objection to night duty, objection to staffing at Pine Creek, disagreements with the matron and medical officers, the filthiness of the hospital, deficiencies of essential hospital equipment, and interference by patients in the management of the hospital. These two hospitals were wholly maintained by the Government, a vote being made each year to cover cost of administration. The Chief Medical Officer was responsible for the management and control of the hospitals, and, under the Administrator, for the expenditure of funds voted by Parliament in respect of them. He received a salary of £700 a year and free quarters in respect of his services as Chief Medical Officer and Chief Health Officer. The Quarantine Officer received a salary of £750 per annum from the Commonwealth Department of Health and was primarily a quarantine officer only. At the urgent request of the local people the Department had consented to his being permitted the right of private practice. He was permitted to admit his patients to hospital but not to charge for attendance upon them there except as above detailed. In addition to those two Government hospitals the Australian Inland Mission maintained three hostels, one at Maranboy, 25 miles from Darwin, one at Victoria Downs, 450 miles from Darwin, and one at Alice Springs, 1,000 miles from Darwin. These, although staffed by trained nurses, were primarily only aid posts associated with the social welfare and other mission activities of the Australian Inland Mission.
Requirements:- It appeared to me in 1927, when I was appointed Chief Medical Officer, that the Commonwealth’s endeavour to establish a purely white population in a tropical area in juxtaposition to a primitive people, subject to tropical disease and particularly susceptible to newly introduced diseases, demanded, if success were to be assured – (1) The establishment of a health service which would – (a) Conduct a close investigation of diseases endemic in the native population, supplemented by rigorous methods directed towards the eradication of endemicity and the control of the conditions of association between the races. (b) Exercise rigorous control of the association between native peoples and any diseased amongst the white population from whom the former might contract infection, subsequently serving as a focus for dissemination in a more virulent form through the white community. (c) Exercise strict control of sanitation as far as the primitive condition of the country would permit. (2) The establishment of a medical service which would provide: (a) Prompt and effective medical aid to the local population whether oppidan (townspeople) or rural, to reduce the death and morbidity rates which were otherwise likely to prove effective barriers to progressive white settlement; (b) Assure security to women and children without whom it was seen that white male stock deteriorated and development stagnated, (c) Prosecute a study of all morbidity and of the population in health and disease at all ages from birth to death, so that the white reaction to this strange environment might be thoroughly understood, and the policy of White Australia saved from the likelihood of sacrifice through lack of knowledge or unfounded fear.
Plan Adopted – To meet these problems the following steps were taken:- (1) Subsequent to the decease of the private practitioner who was the Quarantine Officer, the practice of the remaining general practitioner was in 1928 purchased by the Government and his salary discontinued. Full-time medical officers were appointed, who duties were, under the direction of the Chief Medical Officer, to provide medical and surgical attention to the general public in and out of hospital and to furnish such records to the Chief Medical Officer as were from time to time required. These Medical Officers are paid £850 with annual increments of £50 rising to £1,000 per annum, according to length of service, and have the leave privileges of the Northern Territory Public Service, viz., one month’s leave for each year of service, on month’s travelling time and return first-class steamer fare to a southern capital on completion of three years’ service. In addition, they are granted an additional month’s study leave every three years. In respect of a married man or a man with a family, the fares of the wife and members of the family are paid for a period of three years. When I left the Territory there were seven medical officers in the Northern Territory Medical Service; three were stationed at Darwin, one at Katherine, one at Tennant Creek, one at Alice Springs and one on leave. Under this system of full time medical officers, appointees could look forward to careers in the service. Transfers were facilitated without the service losing the local experience and knowledge of the individual won by the former incumbent. (2) Hospitals were established at Katherine, Tennant Creek and Alice Springs, and the Hostels at Maranboy and Alice Springs were closed. These Hospitals were designed on modern lines and the object of each was to service as an efficient medico-surgical unit in its own area, with the understanding that Darwin and Alice Springs were to be quipped as based Hospitals for cases requiring specialised attention. The equipment of the Darwin hospital was brought up-to-date, a new maternity ward erected and an x-ray plant installed. Accommodation was provided for aboriginal patients in conjunction with all hospitals, except Tennant Creek, where the native population did not justify such a course. The hospitals were staffed as before, by trained double-certified Sisters, imported chiefly from the Brisbane General Hospital. The hours, salary and leave conditions remained much the same, but the system of duty was revised so that a Sister did six hours on and twelve off. On completion of twenty-four hours’ duty she took thirty-six hours off. In this way the objection to prolonged periods on night duty was overcome, and at the same time days off were increased in number. These changes have led to the trained staff continuing in the Service so that it became necessary to refuse re-appointment after six years except in special cases. A Nurses Registration Ordinance was brought into force in order to control the activities of unregistered midwives. No persons other nurses registered in other States of the Commonwealth were given registration in the Northern Territory. A system of training local girls as probationer nurses was initiated with the co-operation of the Queensland and Western Australian Nurses Registration Boards. In this way, it was hoped to provide in the Territory trained Territorians who, after marriage, might prove of assistance to the people in the neighbourhood of their homes. (3) Consulting rooms were established in the town of Darwin and at Katherine and Alice Springs. In Darwin the consulting rooms were staffed by a special Sister whose duties included the conduct of a pre-natal and infant welfare clinic, home nursing and district work in respect to tuberculosis supervision, (4) Centres for the issue of medical and first-aid stores with instructions for their use, were established at police stations and other strategic points where persons could be instructed in their use. (5) A pharmacist was appointed to undertake the dispensing of prescriptions, and subject to the Chief Medical Officer, the ordering and distribution of medical stores for all medical officers and hospitals and Bush Aid centres. (6) The duty of a routine medical inspection of aboriginals was imposed upon the medical officers. They were also required to furnish the returns necessary in respect of aboriginal natives. (7) A system of regular inspection and examination of school children was instituted to supplement the study commended in the Infant welfare Clinic. (8) A specially trained officer was appointed to travel by car throughout the Territory during the dry season. This officer was primarily intended as a malaria control officer, in which capacity he examined all aboriginals and Europeans for infection with malaria, treating the infected until parasite-free, but he was also available for the detection of other diseases. This officer conducted the Medical Service Laboratory routine until this work was undertaken by the Commonwealth Department of Health. (9 A motor ambulance was provided for transport of the sick. (10) The Medical Officer at Katherine was provided with an ambulance plane and steps were taken to have suitable landing grounds prepared in as many localities as possible.
It is not to be supposed that all these measures were put into effect simultaneously, with the aid of Government finance. On the contrary, it was necessary at the outset to undertake re-organisation and expansion with funds limited in amount to a figure commensurate with previous expenditure. In order to achieve development and expansion it was therefore necessary to increase the amount or revenue collected within the Territory by the Service itself, and it later became regarded as reasonable to ask from the Commonwealth funds approximating to £2 for every £1 locally raised. This was at that time the ratio of subsidies to rural hospitals by the Queensland Government. The principle of charitable support and voluntary donation was steadfastly opposed, being regarded on the one hand as extravagant and unreliable, and on the other as implying the right of subscribers to an influence in management out of all proportion to their financial contribution. The development of medical service in the Northern Territory was regarded as a matter of primate national importance, and no parochial influence likely to interfere with its development was permitted to develop.
At first the usual practitioner’s fees – 10s. 6d. per consultation and 12s. 6d. per visit – were payable to the Government, which endeavoured thereby to reimburse itself the outlay involved in guaranteeing adequate salaries to its medical officers. In order, however, to avoid the volume of accounting involved, and also to avoid the embarrassment of endeavouring to collect large accounts from impoverished people, the Northern Territory Medical Benefit Fund was established. The conditions of this fund were that contributors were entitled to free medical advice and treatment, drugs, dressings, ambulance transport and hospitalisation, but not to free anaesthetics, major surgical fees or obstetric fees. A single man contributed 1s. 6d. a week and a married man 2s. a week. Contribution at the married rate entitled a contributor and all dependants not in receipt of wages to all benefits under the fund. An obstetric fee chargeable by a medical officer was fixed at £4. 4s., of which £2 2s. was payable by the fund and £2 2s. by the contributor, payment of the fund’s share being conditional upon payment of the contributor’s. Privileges under this maternity section were also conditional upon an expectant mother attending regularly the pre-natal clinic and undertaking, after the birth of the infant to regularly attend the infant welfare clinic and cause dependants up to school-going age to report for examination every three months. In this way it was hoped to bridge the interval between infancy and school age in the supervision of the growing child. The Minister stipulated that there as to be no salary limit and that the fund must be voluntary.
Medical Officers were not permitted to retain fees in respect of services rendered except for major surgery anaesthetics and midwifery. These concessions were retained for them owing to the difficulty of otherwise providing remuneration for overtime worked, particularly in respect of midwifery and as an inducement towards improved proficiency in the art of surgery. How far this system is responsible it is difficult to judge, but there can be no disputing that surgical proficiency in Darwin is far higher than might reasonably be expected amongst practitioners in a very much larger town. It is no longer necessary for the emergency surgical case to travel south. The hospital charge for persons not contributing to the Medical Benefit Fund were fixed at 10s. a day, which was assessed on the basis of 5s. a day actual cost per bed and 5s. a day for services of the Medical Officer. There are no private wards, as the building does not permit of them. When patients are unable to pay fees these may be waived by the Administrator.
Management. – The Medical Service was under the management and direction of the Chief Medical Officer, who was responsible to the Administrator. The Chief Medical Officer submitted estimates for expenditure for the financial year in respect of staffing, hospital management and so forth, and he was responsible for the proper expenditure of these funds. Local government by a committee or board was always refused. It was felt, from Queensland experience, that hospital boards elected by apathetic subscribers are usually anxious to interfere and alter existing procedure in inverse ration to their knowledge and experience. As the Medical Service was to be progressive, and in Australia experience without precedent, such a committee could only have been a nuisance and a hindrance. Furthermore, Medical Service activities were regarded as of national importance, and as already stated, parochial interference could not be tolerated. As a measure to check the possibility of Medical Service Administration developing into an unsympathetic bureaucracy, a visiting committee was formed to report complaints and suggestions to the Chief Medical Officer. This, however, fell into desuetude owing to the apathy of its members.
The following aspects of the mobilisation of medical service finance resources by the establishment of a Medical Benefit Fund are worthy of note:- (a) It placed the contributor in the position of contracting with the Chief Medical Officer for certain services in return for his contribution, thereby enabling the latter to decline interference with hospital management, and establishing the contributor as an individual rather than integrating contributors into a collective body as might as first appear. (b) During the formative years of the Medical Service it reduced to a minimum the probability of an undesirable type of practitioner commencing practice in Darwin or elsewhere in the Territory, and thereby inducing the Government to retire from the field. (c) It mobilised financial contributions throughout the Territory, so that funds became available for expenditure in areas which could not otherwise have been served. For the information of the committee I append the following statements showing the revenue and expenditure of the Northern Territory Medical Service for the year 1938 and the work performed by Medical Officers and hospitals at various centres during that year.
REVENUE, MEDICAL SERVICE, 1937 – 38.
DARWIN MEDICAL DISTRICT: Out-Patients’ Clinic.
Consultations and visits during the year numbered 4,385 for 3,097 conditions. (2027 males and 1070 females.)
DARWIN HOSPITAL
Average daily number resident 44.4 days.
Operations under general anaesthesia, Darwin Hospital, totalled 127.
ALICE SPRINGS.
Consultation and visits during the year numbered 1,660 (901 males and 759 females.)
53 operations performed by the District Medical Officer.
KATHERINE.
Consultations and Visits totalled 269, for 235 conditions, 165 males and 70 females.
REVENUE, MEDICAL SERVICES, 1937- 38.
Disbursements in respect of Medical Services were-
DARWIN MEDICAL DISTRICT: Out-Patients’ Clinic.
Consultations and visits during the year numbered 4,385 for 3,097 conditions. (2,027 males and 1,070 females.)
DARWIN HOSPITAL
Average daily number resident 44.4 days.
Operations under general anaesthesia, Darwin Hospital, totalled 127.
ALICE SPRINGS.
Consultation and visits during the year numbered 1,660 (901 males and 759 females.)
53 operations performed by the District Medical Officer.
KATHERINE.
Consultations and Visits totalled 269, for 235 conditions, 165 males and 70 females.
KATHERINE HOSPITAL
Statistics relating to patients treated during the year are as under:-
TENNANT CREEK.
Consultations and visits during the year numbered 1,297 for 730 conditions. 538 males and 192 females.
TENNANT CREEK HOSPITAL
Statistics relating to patients treated during the year are as under:-
