Director-General
19th June, 1951
INTRODUCTORY
The health problem created by the Northern Territory native can best be understood against the background of his mode of life prior to white settlement and his reaction to contact with European civilisation.
In his traditional mode of life, the native moved as one of a small family group over a relatively wide area of feeding himself by foraging and hunting, erecting no dwelling, accumulating no property, domesticating no plant or animal and never settling permanently anywhere. The range of his movement was limited only by respect for tribal boundaries. Contact between adjacent tribes was but transient and infrequent whilst contact between remote tribes did not occur at all.
The population was sparse and the small family groups lived a relatively isolated existence even though, in the course of a year they travelled considerable distances.
The small population was kept relatively static by the marriage customs of the tribes. These were so devised as to allocate a number of wives varying in age from childhood to late maturity, to each of the older men and the younger men of the tribe continued without consorts until late middle age.
There appears to be every reason to suppose that the native at this stage of his existence was free from those infections which have been the scourge of the more static populations of the world settled in fixed communities in close association with herds of domestic animals and in an environment infected by the accumulated by-products of human and animal existence. It would be a logical expectation, and indeed it is one confirmed by experience during quite recent times, that his lonely migrant existence, by facilitating their early elimination, would prevent many of the more important bacterial, protozoal and metazoal conditions becoming permanently and widely endemic should they be introduced from without.
The diet obtained by foraging and hunting was well balanced and high in protein, particularly in animal protein. No evidence has been found to suggest that dietary deficiencies, even in time of drought, exposed him to avitaminosis or malnutrition. On the contrary, it has been observed that when, during adverse seasons these conditions have appeared amongst natives living on missions, return to the arduous bush life has been followed by their disappearance.
In this relatively secure environment, the native developed no awareness of the dangers of insanitation. No conscious hygienic precaution in the disposal of wastes and excreta was practised, no knowledge of the nature of infection was acquired, habits and practices conducive to the wide dissemination of communicable disease was practised with impunity.
With the first white settlement during the second half of the 19th century, natives began to be concentrated near pastoral homesteads and around townships.
To assure himself a source of labour and to prevent migrant aboriginals worrying and dispersing stock on the unfenced leases, the grazier encouraged the tribe in his vicinity to remain static near the homestead during the dry season. He did this by issuing a regular and generous ration of meat, flour, sugar and tea supplemented by issues of tobacco and sometimes of alcohol and opium.
In the neighbourhood of towns and especially towns where there was a considerable Chinese population, the natives were attracted first by the opportunities to secure European food in return for labour and later by the impulse and opportunity to indulge new vices learned from the European and Oriental intruder.
In these new static concentrations of natives unfamiliar with the use of dwellings or the sanitary requirements of community life, gross conditions of insanitation rapidly developed. In remote pastoral areas communications were so poor that these were of little consequence epidemiologically since infection was rarely introduced, but they attracted attention on the grounds of public nuisance. In townships however to which the infective agents of bowel disease, tuberculosis, leprosy and similar conditions had been introduced by white and coloured immigrants, a high incident of communicable disease soon developed to decimate the native population. These diseases affected at first only those in immediate proximity to the settlement and later other members of the tribe to which they belonged. Adjacent tribes not in immediate contact continued aloof, respecting their tribal boundaries and for years remained free from infections which rapidly exterminated the tribes whose country had been settled.
The major health problem at this time was the protection of the organised European community from the heavy incidence of infection in the native population camped in their vicinity and employed as domestics in households. The incident of leprosy was such that approximately 1 in 20 of the white population at risk is estimated to have developed leprosy during this period. Malaria was endemic on the minefields and along the Roper and Victoria Rivers. Salmonella infections were a constant source of invalidity in Darwin and along the railway line to Pine Creek. Venereal disease attained such a high incident amongst native tribes in contact that the fertility of the women was reduced to a level which left the birth rate far behind the crude death rate and depopulation was rapid.
Towards the end of the 19th century and early in the 20th century, denominational missions were established in various parts of the Territory. At first these were sited in the immediate vicinity of white settlement, their purpose being the rehabilitation of the bedraggled remnants of the tribes there. It was soon found that missionary effort could make no progress in this field and the missions were transferred to more remote localities for the purpose of evangelising natives who had not been degraded by contact with white civilisation. It was hoped that conversion to Christianity and to European standards of morality might be successfully achieved here and that the convert would be the better able successfully to withstand contact with white civilisation when it later reached his country.
The basis of mission activity is the concentration of large numbers of natives in a limited area and their retention there for the greater part of the year. These concentrations of natives, untrained in community living and without any knowledge of sanitary practices were soon marred by conditions of insanitation similar to those found at other settlements. The introduction of respiratory infections, bowel disease and hookworm by mission agency has been followed by a rapid and marked deterioration in the general health and an increasing incidence of communicable disease. Meantime the failure of the mission to provide a properly balanced diet to replace that no longer available by hunting, has led to nutritional disturbances manifested by scurvy, beri beri, malnutrition and megaloblastic anaemias.
The remote missions were at first isolated from contact with tribes afflicted with leprosy, but shortly after the Commonwealth assumed control in the Territory, a church organisation established a mission at Oenpelli on the East Alligator River. The mission deliberately set itself to breaking down the tribal barriers confining natives to the east as far as the Liverpool and Goyder Rivers. Its efforts were attended with some success but for some time the visitors from the east were predominantly adult males. At the same time the mission encouraged the bedraggled remnants of tribes in the depopulated area to the west to seek refuge at Oenpelli in the hope that they might there be salvaged from the pernicious influences of the mining zone along the Pine Creek railway. The latter group included a few suffering from leprosy. Men of both groups where therefore exposed to close and uncontrolled association at the mission and leprosy contracted there by the eastern tribesman was soon carried deep into Arnhem Land to become endemic there in areas long protected from contact with it.
In 1927 the Commonwealth, in an effort to meet this situation, set up the Northern Territory Medical Service to provide an efficient medical and health service throughout the Territory, incorporating amongst the powers and duties of the Chief Medical Officer, all those of the Chief Protector.
A considerable amount of success attended the efforts of the Medical Service. By 1939 yaws had practically disappeared and cases of granuloma were few and derived mainly from remote areas. By the commencement of World War II it appeared that leprosy would shortly be brought under control. Admissions were limited to some to some 16 a year and the incidence 3.7 per thousand, notwithstanding sustained and energetic search throughout the tribal areas. It was still a disease of adults indicating that it had not yet been able to establish itself in families, infection depending in great measure upon contact incurred during employment or migration. These were, under the new organisation, reasonable easy to control. New infections of Europeans appeared to have ceased.
The methods applied in the attainment of this result were:-
- The detection of disease by-
- mass examinations regularly and periodically conducted in each year;
- individual examinations at the time of entering and leaving employment.
- The control of association between natives and between natives and Europeans by:-
- the regulation of employment including the conditions of housing;
- the control of migration whether in employment or otherwise.
- The treatment of disease of modern methods and the review of those treated for the detection of carriers.
- The supervision of diet:-
- in employment;
- on missions and settlements.
- The control of missions by medical inspection, subsidy being made subject to compliance with directions affecting the standard of sanitation, housing, diet, medical aid, nutrition and education.
The use of these measures was facilitated by the circumstance that the Chief Medical Officer was also Chief Protector of Aboriginals and in the latter capacity, vested with powers permitting their prompt and effectual application. The dual role also permitted the forming of both health and native policy in conformity with the requirements of a planned system of preventive medicine.
During the war and post war years, the activities of the Medical Service were suspended and the measures of control directed towards the eradication of communicable disease were discontinued. In the result, much of the improvement effected was lost. The deterioration in the general situation is perhaps best exemplified by the dissemination of leprosy. During the war cases in isolation at Channel Island were released to missions where they were permitted to live for some years in intimate and uncontrolled contact with the children resident there.
When surveys were resumed it was found that leprosy had become a disease of childhood with an incident of 52 per thousand.
New factors to be confronted today include:-
- The bulk of the native population is now concentrated on missions and settlements more or less remote from the white population. Indeed, the present population distribution involves some degree of segregation of the races. Only 8% of natives are now domiciled in the immediate area of densest white settlement and only some 13% of Europeans are dispersed amongst the heaviest native concentrations. Few natives are now employed as domestics in white households. On the other and, the concentration of the native population has itself aggravated the problem of controlling disease in the native. Large numbers of susceptibles are now more or less permanently herded together under conditions of insanitation and without that consciousness of the individual’s responsibility to the community which must play a fundamental part in the prevention of communicable disease.
- Native affairs are now administered by a separate Department. The Commonwealth Director of Health as the Executive Health Authority no longer possesses the power of control over the native so necessary for the ready, prompt and complete application of measures of control or facilitating efficient supervision.
- The new native authority possessing the powers which the Health Authority lacks is unequipped with the medical knowledge and the hygiene consciousness which would permit careful appraisal of disease risks attaching to casual administrative decisions or fundamental changes in policy.
- The Commonwealth Director of Health is an officer of the Commonwealth Department of Health and is directly responsible to Canberra. The Director of Welfare who is charged with native administration is an officer of the Northern Territory Administration and responsible to the Administrator of the Northern Territory. The Health Authority therefore is not so placed as to be automatically consulted in discussions of new policy or in plans to implement current policy. Where the application of native policy results in the correction of conditions contributing to the wider or more rapid spread of disease or present increased difficulties of control, he can do no more than accept these and endeavour to offset them.
- Notwithstanding the regression during the war and early post war years, some progress has been made in the rehabilitation of the native people and the control of disease. Unremitting efforts by the Medical Service to correct dietary deficiencies on missions and settlements and to encourage the provision of hygienic housing and sanitary facilities, the appointment of special medical and nursing staff assisted by radio communication and air transport to permit the prompt treatment of disease have significantly lowered the infant and general mortality. Meantime, wholesale conversion of the tribes to Christian monogamy and the early marriage of youths and girls without regard to tribal sanction has favoured the rearing of large families. The introduction of penicillin has lead to the almost complete disappearance of gonorrhoea as a cause of infertility. Together these factors have contributed to a spectacular improvement in health and survival rates.
- The old respect for tribal boundaries has disappeared and natives in all parts of the Territory have learned to extend their migrations far into areas which formerly would have been regarded as hostile country. It is now not uncommon for natives from the Centre to holiday on the northern coast and vice versa. The effectual quarantine imposed by the native’s respect for tribal boundaries has been lost and native migration whether in or out of employment has become an important factor in the dissemination of communicable disease from one area to another.
The intervention of government into life of the native people in attracting them away from tribal areas where they have been relatively secure and concentrating them in the unfamiliar environment of static settlement has created problems which is our responsibility to meet. Amongst these the most important are covered in the following pages.
Diet
The characteristic features of the native’s natural diet are its high content of animal protein and the variety and dispersion of natural sources of vitamin and mineral. The diet issued on native settlements and missions by contrast provides an excess of carbohydrate, is low in animal protein and deficient in vitamin and mineral. Where a deficiency of vitamin is suspected an effort may be made to supplement with artificial sources selected empirically and without accurate appreciation on either of the nature or of the degree of the deficiency.
A direct result of the nutritional inadequacies of the artificial diet has been the development of a relatively high incidence of megalocytic anaemia. Superimposed upon this on several settlements is the secondary anaemia associated with hookworm infestation, a condition which would better tolerated if the diet contained richer sources of iron and animal protein.
Many settlements are situated in localities where it is claimed pastures are unsuitable for grazing of stock. Even those situated in acknowledged pastoral areas fail to supply an adequate meat ration on the ground either that their herds cannot meet the demand or that beef is too expensive to buy from neighbouring properties. The usual course in both situations is to import flour, white or whole meal, and to rely upon supplementing this with such locally grown garden produce as cassava, pumpkin and leaf vegetables to which large numbers living on missions have no alternative.
The impairment of native health and welfare directly attributable to present methods of settlement and mission management warrants the confident assertion that no consideration of education, religious instruction or other social advancement can justify the attraction of natives to a settlement and their retention there unless and until they can there be fed a diet at least as satisfactory in form and value as that available to them in the bush.
As some means of immediate relief it is suggested that two courses are open –
- The effort should be made to convert the vegetable produce cultivated to animal protein for use in native dietary. Cultivation should be extended and the product used as fodder for goats, poultry and cattle.
- Available settlement labour should be used to create an enduring and improving asset justifying the purchase of adequate supplies of meat to provide a proper diet. Reafforestation offers an opportunity for this purpose and has the additional advantage that, undertaken on a liberal scale, it would involve such a dispersion of families that a considerable proportion would enjoy facilities for feeding themselves in native fashion.
Welfare – Medical Liaison
A large number of factors affecting the control of endemic disease in Northern Australia are intimately involved in native affairs administration. Plans for and methods of prophylaxis and management adopted by the health authority basically depend upon the co-operation of native administration and the stability of native affairs policy. Recent drastic changes in native affairs policy and practice involving compensating re-adjustment of health authority methods have materially increased the difficulties of health control and have created a situation fraught with the gravest danger for the future security of all races in the northern area. In order that both authorities concerned in native welfare – native administration and health, may be provided with ready means for constant liaison in the development of their mutual policies, it is suggested that a standing committee comprising State Director-Generals of Health and State Directors of Native Affairs, together with the Director of Welfare, Northern Territory, and representatives of the Commonwealth Department of Health, should be appointed to meet regularly to discuss and advise upon proposed policy changes and mutual problems.
Measures for the control and eradication of leprosy, tuberculosis, hookworm and trachoma require to be devised and thoroughly organised without delay and without regard to the artificial limitations of State and Territory boundaries.
Principle of Exemptions
In considering the principles of exemption due regard should be taken to (a) the acceptability of the individual to the general community and (b) his appreciation of his obligations and responsibilities as a citizen enjoying full citizenship rights.
Acceptability: In the past the standard of living in many northern white communities has itself been relatively low and an exempt native living under conditions and at a standard inconsistent with full acceptance by the generality of more advanced Europeans, has excited no remark.
In most of these areas today the general living standard is considerably improved and the failure of any individual to attain it renders him conspicuous. His claims to full acceptance are likely in consequence to be rejected by the general community.
Responsibility: In Northern Australia the heavy incidence of communicable disease in natives will for many years demand that the individual be kept under close surveillance whilst at large in the community. Only by such a measure can the future security of the population be adequately safeguarded. Whilst the native is a ward of the State this surveillance may be relatively easily applied. Once exempted it may well become impossible in a proportion of cases so large that effectual measures of preventive medicine are completely frustrated.
It is urged that the matter of exemption should be approached with the utmost caution. Whilst it is appreciated that in accordance with Government policy full exemption is a prescriptive right only to be withdrawn under certain specific circumstances, it cannot be over-emphasised that disease control and the security of all races in this area would be immeasurably facilitated were exemption a privilege to be won and retained by good citizenship. Intensive effort should therefore be made to train the rising generation of natives to live at the appropriate standard and to realise the responsibilities of citizenship and to release them from control only when this has been successfully attained.
As an alternative consideration might be given to conditional or limited exemption, entitling the individual to full citizenship rights and social equality with the limitation that the Health Authority retains certain powers affecting liberty, employment and migration to be exercised in the interest of the individual’s health.
Employment
It is a fundamental of preventive medicine in Northern Australia that natives in employment, particularly those employed in European households, should be regularly and frequently submitted to medical examination.
This examination should be performed at least –
(a) before commencing service to ensure that the native is physically fit for the type of work proposed to be undertaken and that he is not suffering from any communicable disease likely to be transmitted to his fellow employees and/or to the white household;
(b) on leaving employment to ensure that he has not, whilst in employment, developed any condition likely to impair his health after his return to a locality remote from medical aid or one likely to be transmitted to his fellow tribesmen living with him in primitive conditions.
It is also desirable in the interests of the native, that medical opinion be sought upon the conditions of employment, housing and maintenance offered by the employer before engagement is approve, to ensure that he will be exposed to no influence deleterious to his health.
Formerly opportunity for taking these precautions was readily available by reason of the fact that natives were employed under an agreement setting out the conditions of employment. Native employees could be medically examined at the time of executing and on terminating the agreement. Use of this agreement has now been discontinued and as a result the Native Affairs Branch is denied any opportunity of imposing special conditions in the interest of the native or even of ascertaining where and by whom any native is employed.
In country districts it was formerly the practice to require all employers proposing to engage native labour that they make adequate provision for the welfare of their employees. One requirement so enforced was the provision and maintenance of adequate landing strips to permit safe and ready access for medical officers and ambulances of the Aerial Medical Service. It appears that this precaution is no longer taken.
Extending from Newcastle Waters east to the Limmen Bight there is a zone of pastoral properties maintained by native labour to which access by aircraft of the Northern Territory Medical Service is impossible. This region is inhabited by natives with a high incidence of leprosy, hook worm and at times malarial infection and the security of the rest of the Territory largely depends upon adequate supervision being maintained here. This supervision is at present impossible.
It is recommended that conditions of employment be again imposed and written into employment agreements.
Social Service Payments
The Department of Health holds the opinion that a critical examination should be made of the purposes and use of these funds, in an atmosphere detached from philanthropic and sentimental influences.
- Child Endowment for Missions.
The actual amounts paid to particular missions are not certainly known and are not readily ascertainable but may be assessed on the basis of 10/- head of a number of native children accurately or otherwise submitted by the mission authority.
No supervision is exercised either in regard to the accuracy of the number serving as the basis of the claim or in regard to the use to which funds are devoted. It is assumed that it is the policy of the Department of Social Services to permit a mission to use these funds for its general purposes on the ground that any expense, whether administrative or other, is inextricably and fairly involved in the general welfare of the native child.
In practice there appears reason to believe that the funds may be disproportionately dissipated in the purchase of expensive equipment with but a brief period of utility, travelling expenses of questionable value, the increase of salaried staff and other projects more or less remote from the physical welfare of the individual native.
The Department of Health is concerned to find that one result of the more ready availability of funds and the prospect of even further accretion by increasing the mission population, has been to encourage missions in endeavours to extend their fields of influence before adequate and satisfactory provision has been made for the population already under care.
In particular, anxiety attaches to the unsatisfactory diet provided for the children and the insanitary conditions under which they are required to live. Both these factors have operated to effect serious and alarming deterioration in the health of the natives concerned by occasioning a serious degree of anaemia which lowers resistance to other disease and is incompatible with the safe use of certain important therapeutic agents.
Formerly, by common consent, natives of the north coast were acknowledged to be the finest physical specimens of the native race in the Northern Territory. Today it is noticeable that the children in this region are scaly, pot bellied, spindle legged caricatures of humanity, whose physical condition is in sharp contrast to the evident wellbeing of their properly fed brothers and sisters at the Channel Island leprosarium, notwithstanding that the latter are contending with a major chronic disease and exposed to the debilitating influence of sulphone therapy.
It is submitted that payment of all or of a proportion of Social Service funds to a mission should be conditional upon the mission-
- consistently providing an approved diet to children under care;
- maintaining records permitting the ready evaluation of the average diet;
- taking effectual action so to improve the sanitary condition of the station that children concentrated there are not thereby exposed to the ravages of communicable disease;
- attaining and maintaining an approve standard of living for the number of children claimed before any increase is granted.
- Natives Visiting Reserves
At present residence on a reserve disqualifies the native from Social Service benefits.
On compassionate grounds there is a temptation to argue that the native, particularly the native taxpayer, should be entitled to Social Service benefits whether he visits native reserves or not. This course is likely to find favour and advocacy with missions and settlement authorities eager to increase their incomes from Government sources.
The Health Authority is especially interested in the acceleration of the assimilation of the native into white society at living standard comparable to that of the generality of the population. It will support any proposal to extend to the native any benefit, financial or other, which will assist him to obtain or maintain this standard. On the contrary, it must offer uncompromising opposition to any benevolence which may delay or impede this objective.
The native population of the Northern Territory is estimated at 14,000. The great majority of these are content with a standard of living far below the minimum required to assure the health security of the general population and one which does not involve the expense associated with rent, clothing, education, medical care and diet incurred by the white population and dictating the necessity of financial assistance.
Recent census figures for the mixed blood population are not available but in the Northern Territory these may approximate or exceed 3,000. Many of these living at European standard but a proportion are not. The proportion of failures is probably greater in other States.
Failure is in large measure attributable to premature release from Welfare control. Incurring living costs not greatly exceeding those of the full blood native, while in receipt of Award rates of pay, survival does not demand of him continuous employment. Excess of earnings over expenditure leads to extravagances and indulgences prejudicial to health and moral and social welfare. The availability of sanctuary and succour on reserves in time of stress offers escape from the economic rigours attending improvidence and the payment of benefits can only provide an additional source of unearned income contributing even further to his social and economic degradation.
Half a century ago there were estimated to be 50 halfcaste children in the Northern Territory. Today one third of the children of school age are of mixed blood. The fertility rate of the part aboriginal far exceeds that of the white and considering the instability of the white population of the North it appears not improbable that they hybrid population will shortly dominate the scene there.
It must not be forgotten that many generations of settled community life have gone into the evolution of European character and social economic and moral standards. The influences determining the standard of living of the native, whether of full or part blood, have been the very reverse of those moulding our own. The essential difference lies in the attitude to the acquisition of property and appreciation of the value of capital in economic and social development.
It is irrational to expect the native to become adapted to our own standards unless he is subjected to the same formative influences as have evolved the European type. To protect him from these influences can only develop him as a dependent parasite. However disposed we may be out of sympathy and benevolence to tolerate this alternative rather than subject him to the rigours of rapid economic adaptation, we must concede that it is not in the interests of either race that a preponderant population of this type should develop in the vulnerable North.
Insofar as Social Service benefits delay the social and economic adaptation of the native they should be withheld. Payments should be made only to those consistently and with reasonable success maintaining themselves at a normal civilised standard. Persons who cannot qualify for benefits under this restriction should be made the subject of special Welfare care, provision and training.