Notes prepared by Dr Cook as a briefing paper for a conference in August 1950 following his general survey of June-July, 1950
It being no longer possible for Australia confidently to rely upon the successful exclusion of dangerous infections and disease vectors from overseas solely by practicable measures of Quarantine, attention must be directed towards so improving the environment at points of danger that undetected importation will not involve subsequent establishment and endemicity. This involves not only meticulous attention to the improvement of hygiene and sanitation along the overseas Air Routes within Australia, but also throughout contiguous areas, particularly those served by feeder Airlines. Under international agreement the Commonwealth is responsible for the sanitation of international airports but for Australia’s protection the standard of satellite airstrips must be equally high.
Throughout the North sanitary conditions are at present primitive.
- Water Supplies:
If Cairns, Darwin and Wyndham be excepted, water supplies for settled areas are inadequate, unsafe, exposed to contamination and often impotable. Supplies are drawn from:
- surface water unprotected from human and animal pollution;
- shallow wells inadequately protected and exposed to human and animal pollution. This water is commonly brackish;
- domestic rainwater catchment and storage usually secure from human contamination, but providing a nidus for prolific aedes breeding.
All three sources often fail during the dry season.
Universal reticulation for domestic purposes is the exception rather than the rule whether supplies are drawn from surface water or from shallow wells. Distribution may be by water cart from the source of supply direct or from a conveniently placed standard. Not infrequently distribution is by hand carried bucket.
Water cart distribution is to the last degree insanitary, the water being carried in open tanks or 44 gallon drums and freely exposed at all stages to human contamination. Supplies, moreover, are inevitably inadequate, whilst the cost is prohibitive. In Normantown and Port Hedland the water costs 5/ per 100 gallons; in Burketown 8/- per 44 gallon drum.
Where water is not reticulated but is delivered to the house by water cart it is stored, of necessity, in low open tanks or drums so that supplies may be dipped as required, thereby increasing the risk of pollution, and facilitating prolific aedes breeding.
- Excreta Disposal.
Over the greater part of the area methods of nightsoil disposal in hamlets and rural centres are defective, both as to collection and disposal, and must be acknowledged as inadequate to prevent the dissemination of imported and endemic bowel disease.
The large native component of the population practises promiscuous defaecation with pollution of the soil and not infrequently the source of domestic water supply.
- Waste Disposal.
Efficient systems for disposal of organic wastes are lacking and prolific fly-breeding is facilitated in the numerous deposits of garbage around the areas of settlement.
Incombustible wastes, discarded cans and bottles, which by reason of the peculiar economy of the area are more numerous than for similar communities elsewhere, are discarded haphazard or in numerous accumulations scattered throughout the vicinity, and serve during the wet season as foci for prolific mosquito breeding.
- Housing
In most of the remote areas housing is substandard. The neighbourhood itself provides no conventional building material. The high cost of transport and its infrequency make it difficult or impossible to import new building material. The efflux of population and the absence of building projects has removed tradesmen from many localities. Buildings therefore are mostly the relics of those hastily run up in the early years of the settlement during the last century, or ramshackle improvised structures inexpertly re-erected from time to time from the remains of such structures destroyed by fire, cyclone or termite.
Principal defects are imperfect ventilation, bad lighting, overcrowding, defective flooring, absence of suitable culinary, ablution and laundry facilities, and permeability to weather.
5. Many of the hamlets and most of the settled areas are exposed to seasonal plagues of blood-sucking insects. A-aegypti is a constant breeder in domestic water storage tanks and rain-filled litter. A. Vigilax occurs in seasonal plagues as the monsoonal rains fill the brackish marshes in the vicinity of the coast. C.fatigans is of variable incidence in accord with the practice of the locality in the disposal of fluid effluents and the availability of water to run to waste. Sandflies plague the coastal hamlets. Anopheline vectors are prevalent throughout most of the region.
Responsibility for health supervision in this area is vested in Shire Councils in Queensland, in the Roads Boards in Western Australia and for the Northern Territory in the Administration. None of these Local Authorities employs trained staff to advise upon problems of hygiene, to maintain an adequate degree of supervision, or to administer health legislation. In Queensland and Western Australia an Inspector from the Department of Health visits the hamlets at long intervals. No trained medical officer of health is available in Queensland. In Western Australia medical officers of the North-West Service, instructed by the Commissioner of Public Health, perform this function for the Roads Boards. In the Norther Territory responsibility for health administration is undertaken by Northern Territory Medical Service (Commonwealth Department of Health).
Sanitation of satellite aerodromes in respect of nightsoil disposal, waste disposal and ablution is either entirely lacking or is inefficient. At none is mosquito control complete, and in most not attempted.
The conditions under which natives (including hybrids) live in the vicinity of towns constitute a danger alike to themselves and to the settlement generally. It is usual to exclude the full-blood from the town proper and to require him to live in improvised camps on the outskirts of the town. alternatively, in special cases an employee may be permitted to reside in his employer’s premises. In either case provision of habitable accommodation, sanitary convenience, ablution facilities and appropriate cooking and feeding facilities are the exception rather than the rule. The camps usually have no protected water-point, water being obtained from nearby surface sources, or taps on adjacent property. Where a source of surface water exists near a camp it is usually liberally contaminated by bathing, laundering and occasionally even defaecation. Where a water standard is provided it is not infrequently damaged so that its vicinity is extensively flooded, providing permanent opportunity for the breeding of anophelines or, following pollution, the dissemination of hookworm.
Housing accommodation varies from ill-designed, ill-ventilated and inadequately lit structures erected by a public authority sometimes from new, but usually from second-hand material, to improvised shelters of scrap material and brush erected haphazard by the occupants themselves.
It is exceptional to find an efficient sanitary service provided by the camp. The provision or otherwise of such a facility seems to rest with local protector, and it appears unusual for this officer to give the matter his attention.
In areas where the hybrid is accepted within the town boundaries the accommodation available to him for himself and his family is usually little better than that available to the full-blood. Indeed in many localities this may be said of the accommodation available for white families also.
The hybrid, freely accorded citizenship rights by the Native Affairs Department, brings to his role of full white citizenship the lack of hygiene consciousness characterising the full-blood, or the institution in whose care his childhood was spent. Untrained in elementary sanitary practice, unfamiliar with the genesis of communicable disease, usually accustomed to a standard of housing, domestic comfort and cleanliness approximating to that of the native camps, his mode of life is an incongruity in what purports to be civilised community.
Correction must be effected by improvement in education during childhood. Meantime the situation calls for improved housing and the provision of welfare workers and health visitors, who may by precept and example make good the deficiencies in earlier training.
NATIVE SETTLEMENTS AND MISSIONS
Standards of sanitation and hygiene education on missions and native settlements are important not only because the concentration of natives there, of itself, constitutes disease risk under unsatisfactory conditions, but also because the native himself having no community background and no knowledge of risks and obligations of community life must learn his hygiene at the settlement. Generally speaking, native settlements, whether Government or Mission may be described s places where for no readily demonstrable purpose, large numbers of susceptible natives, fed a deficient diet are concentrated under insanitary conditions in contact with communicable disease introduced from elsewhere.
It is important that the Health Authority exercise some measure of control upon such stations.
(a) Policy. The policy of a settlement is of interest to the Health Authority. Left to themselves in their tribal areas natives are largely secure from communicable disease introduced by white agency. Concentrated in settlements they suffer an abnormal exposure to these infections under conditions designed to favour dissemination. Unless the policy of the settlement can justify this incursion and include compensating activities, the Health Authority may well question its wisdom.
Settlements create in the native new wants which they cease to gratify once he leaves school, so in adult life he is impelled into the towns, to reach which he may traverse long distances, destroying the natural inter-tribal quarantine which normally would exist. At some Government settlements the attempt is made, at considerable expense, to avert this migration by feeding natives at the settlement. Apart from the fact that this may be challenged as a pauperising extravagance the diet is ill-balanced and inadequate.
(b) Site: New Settlements should not be established without prior approval of the site. It may well be necessary to consider abandoning some already in existence.
Too often selection of the site has been made on the experience of one or two settlers who have reported the water supply as inexhaustible, the soil arable, and the locality free from disease. Under the heavy load imposed by a static population totalling some hundreds the water supply fails and the soil inadequately watered and heavily cropped, proves unable to sustain its initial fertility.
Shortage of water means dispersion of stock, failure of horticulture, poverty of diet, absence of ablution and laundry facilities, and a perpetually low standard of insanitary existence; there being evident reluctance to admit the error and abandon the enterprise.
The site should be well drained and not such as to render the control of hookworm and malaria difficult.
(c) Access. Siting should also be considered in relation to accessibility to administrative and medical supervision, and for facility of transport to make good repairs or deficiencies of supply. Sometimes there is no means of access to a settlement except by air and the station may be some miles from aerodrome, and unprovided with adequate surface transport. Most settlements recently visited were cut off from surface communication with the outside world for many months. Some relied exclusively on road transport – roads had been destroyed or the vehicle was out of commission. Some relied exclusively on boats – the boat was wrecked or out of commission. Some were inaccessible even by air owing to the nature of the terrain in which the settlement was situated or to neglect of the airstrip.
(d) Staff. It is necessary to maintain the staff of missions and settlements under medical surveillance. Hookworm, tuberculosis, leprosy and malaria have been introduced to new tribal areas by mission staffs, European and native. Four European missionaries have contracted leprosy on missions in the Northern Territory and Western Australia in the last quarter century.
(e) Diet. Strict supervision of diet is long overdue upon settlements. There is a strong trend towards using a vegetarian diets, bulk masking its deficiencies and ill-balance. The method of feeding varies widely from service of a cooked meal three times a day to the issue of dry rations once weekly. It is impossible accurately to access the caloric value or balance of any ration from such information as can be supplied on the settlement. At some a hypothetical native diet is supplemented by an issue of heavy meal-bread or a pannikin of flour which, cooked as damper, will assuage hunger and probably not be supplemented. Outbreaks of scurvy have resulted.
Failure of soil or water and exhaustion of vegetable crops seriously impair the settlement economy. At such times natives may be given a limited canned ration or “sent bush.”
Generous social service payments have made no visible difference to the diet scale on some settlements. On others liberal issues of marmite, canned fruit and dried milk are made to certain sections of the population. Apart from the fact that this is an extravagant method of feeding in a settlement which should endeavour to be self-supporting, natives are in this way taught to rely upon a form of diet which will not be available to them in adult years. Paradoxically the social service payment may prove an evil influence by encouraging settlements to take the easy course of purchasing canned food instead of maintaining herds and plantations from which the native may learn animal husbandry and horticulture to produce a wide range of foodstuffs for himself now and in the future.
On most settlements improvement in the mode of service is required. If the food is such that it cannot be eaten from the hand, it is commonly served into an unclean pannikin or jam tin presented by the recipient and consumed on the ground with the assistance of dogs and flies. Barely is an effort made to teach clean feeding habits or to provide the necessary washing facilities. Lamentably, in the isolated cases where a high standard in this and other respects is achieved with school children, no future is assured for them. On leaving school they are returned to the filth and low standards of the native camp, which by training and background they have learned to abhor.
(f) Water Supplies: Water is commonly drawn from surface sources used also for ablution and exposed to faecal contamination and the drainage of the camp. Where drawn from shallow wells these are usually open, unprotected and exposed to human and animal contamination.
Distribution is usually by bucket or drum inevitably contaminated in transit. Where distribution if effected by a limited reticulation, leaking joints and defective taps cause ground pooling, and potential anopheline breeding.
(g) Nightsoil Disposal: Usually a primitive bucket or pit service is provided for the staff and immediate vicinity of the administrative building and an inadequate service or none whatever for the natives. Collection is usually in improvised buckets under pansteads which are not fly-proof. The soil in the vicinity of privvies is commonly polluted. Disposal of pan contents too often is by trenching in the garden. In no case recently observed was the method of trenching satisfactory.
(h) Housing: Education of the native into community life by settlements has not included a sustained effort to inculcate the value of light and ventilation in dwellings. Exception may be made here of certain Queensland settlements. For the rest there is a tendency to herd the natives into dark ill-ventilated, overcrowded shanties, improvised from waste materials and with no provision for cleansing the floor.
(i) Endemic and Epidemic Disease. Control of communicable disease is necessarily the responsibility and function of the Local Health Authority. The national importance however, of certain phases of this control may require supervision of and assistance for these bodies.
A tendency is developing for Commonwealth and State interest to be expressed in occasional medical and entomological surveys by departmental Officers. This course has the merit that specifically trained men with appropriate equipment can cover a wider area.
It is to be noted, however, that past experience has revealed certain undesirable features in this practice:-
- Surveys are intermittent and discontinuous. The local health administration is not directly concerned, plays no part, is often uninformed of the results and does not profit by the survey. On the contrary a tendency to leave this work to the Commonwealth or State develops and repeated survey serves only to report progress.
- The occasion of the survey is determined by the convenience of the body undertaking it, rather by local requirements.
Admitting that a preliminary survey may be required to be conducted by experts, these should devote the closest attention to education of the local health and medical staff in the procedures necessary for sustained action. Every health and medical officer in the area should as a routine maintain constant activity between surveys, and all new officers should gain thorough experience whilst serving in the area under the guidance and tutelage of their seniors.
SPECIAL DISEASES
Standard procedures for each of the three racial components of the population – white, hybrid and aboriginal – are desirable in respect of –
A. Leprosy:
(a) isolation,
(b) entitlement for discharge and conditions of discharge,
(c) extramural treatment
(d) review of –
- discharged patients
- suspects,
- contacts;
(e) access to hospital by visitors,
(f) leper hospital births – disposal of infants and age of removal;
(g) transport of lepers,
(h) compensation for patient and dependant;
(i) public education
B. Malaria and Dengue:
(a) Delineation of endemic and potentially endemic areas,
(b) Patient control, records, treatment, review, control of migration,
(c) Vector control, responsibility, method –
- closely settled areas,
- sparsely settled areas,
- lines of road communication,
- lines of air communication
C. Ankylostomasis and Bowel Infections:
(a) Delineation of endemic areas (The prevalence of geophagia suggest a much more extensive incident of Hookworm than is generally accepted; lay and medical opinion is largely guide by the prevalence of ‘pot belly’ and no more reliable clue).
(b) patient control, records, treatment, review, control of migration,
(c) public education and hygiene supervision.
D. Tuberculosis:
(a) extent and methods of survey,
(b) disposal of patient, provision for treatment;
(c) measure for prevention
E. Trachoma
(a) extent and methods of survey;
(b) disposal of patient, provision for treatment,
(c) measures for prevention.
AIRPORT SANITATION
A determination is necessary upon the responsibility for the sanitary maintenance of aerodrome and their vicinity.
The aerodromes themselves may be under the control of either the Department of Civil Aviation of the R.A.A. F. Neither of these authorities is normally provided with adequate professional and technical staff to undertake the routine control of the area, nor has either the right of access to the contiguous portions of the local authority area.
On the other hand, the local authority of the area in which the aerodrome is situated may have the technical staff and equipment adequate to undertake maintenance, but will not ordinarily have access to the aerodrome.
A local authority may be reluctant to undertake the maintenance of the aerodrome without financial assistance, on the ground that no rates are received from the area. It may also, if the aerodrome is remote from the centre of the populated served, object that it is unusable without financial assistance to undertake control of the environs.
In some circumstances the aerodrome itself may be partly in one local authority area and partly in another, or may be wholly within one which lacks both staff and equipment to undertake control. If it be argued that the local authority should accept full responsibility for the sanitary maintenance of the aerodrome and its vicinity in the interests of its own ratepayers, it may be emphasised in reply that as a local authority under these conditions it would prefer the aerodrome to be situated elsewhere.
It is submitted for discussion that the Commonwealth, the State and the Local Authority undertake control in collaboration by agreement. It will be necessary to set out details of the standard to be maintained at international and satellited airports.