A paper read by Dr. C.E. Cook before the Australian Academy of Science, Brisbane, 25th May, 1956.
In general, the health problems of the Northern Territory are those of the rest of northern Australia, but her they acquire special features owing to the unusual structure of the population.
The problems themselves derive from:
- The tropical environment which favours the endemicity of communicable diseases transmitted by arthropod vectors or requiring a warm and humid climate for the successful completion of an extra corporeal life’s cycle.
- The tendency to encourage settlement of this region by immigrants from countries of similar climate overseas where diseases of this type are endemic.
- The close proximity of countries of countries where a number of the so-called tropical diseases continue at high levels of endemicity.
- The frequency and rapidity of transport by air between these countries and Australia facilitating the undetected introduction of infection by sub-clinical carriers or persons incubating diseases.
- The tremendous practical difficulties confronting the sanitarian in an untamed country where the population is sparse, widely dispersed and composed of two main racial groups living at entirely different levels of social development.
The Territory lies between the 11th and 26th parallel of south latitude. The mean maximum temperature at Darwin is 90.9∞F. and at Alice Sprints 83.8∞F. The temperature range at Darwin is 67.4∞F – 93.8∞F. and at Alice Springs 38.5∞F. to 96.9∞F. The average annual rainfall is 60” along the northern coast diminishing progressively inland being only 5” along the southern border.
The climate is monsoonal – a hot, wet, northwest monsoon from November to March and a cool dry, a southeast monsoon from April to October. During the wet season water-courses become rushing torrents and extensive areas of level ground, particularly in the coastal plain, are inundated. There occurs a prolific growth of herbage which in the coast plains is rank and attains a height of up to 10 feet.
With the south-east change in April or May, drying is rapid. In the coastal plains the inundated areas contract to permanent red-bordered lagoons and water courses become saline for many miles from the sea. Grass fires rage through and completely destroy the rank wet-season growth, leaving the surface of the earth parched and devoid of herbage, except in damp localities where less exuberant new growth occurs. On the uplands water-courses run dry and early in the dry season consist only of sandy or rocky channels in which the water rapidly contracts to temporary or permanent pools at long intervals, the sparsely timbered and lightly grassed high ground between becoming parched and dusty.
Exclusive of full blood aboriginals, the population of the Northern Territory at the census of 30th June 1954, totalled 16,469, comprising 12,028 Europeans, 486 Asians, and 1.955 half-castes. The Department of Welfare the same year set the native population at 13,744.
Some 14,000 of the European and halfcaste population (85%) are concentrated on the axis Darwin (8,071) to Alice Springs (2,785) and along the Stuart Highway linking these centres. The balance of 2,000 or so is dispersed in small scattered rural groups throughout the rest of the Territory.
By contrast, of the native population, only 1,000 (8%) were, at the time of the census, living in the vicinity of densest white settlement. The remainder were domiciled partly in camps adjacent to pastoral homesteads but predominantly concentrated on remote missions and native settlements along the northern littoral and in tribal country inland.
Impact of White Settlement on Native Life
To understand the problem introduced into health administration by the native in the Northern Territory, it would be of advantage to trace briefly his evolution since the Territory was first settled by Europeans.
The native Australian lived as a migrant hunter building no permanent dwelling, establishing no village and undertaking no agriculture or animal husbandry. Small family groups carrying no impediments except their primitive weapons move over relatively extensive but definitely delineated and for the most part tribally exclusive areas living wholly upon the natural fauna and flora of the virgin bush. Contact between families of the same tribe was of course frequent and on occasions sustained, contact between adjacent tribes occasional and transitory, but contact between remote tribes did not normally occur even to the extent of successive occupancy of the same camp site.
The native had no conception of the nature of communicable disease and the basic principles of sanitation were quite unknown. No precaution in the disposal of wastes and excreta was consciously practised. Nevertheless it appears that he was relatively free from disease as we know it. Indeed, it may reasonably be surmised that his lonely migrant existence and effectual if undersigned inter-tribal quarantine, would eventually have permanently eliminated from his environment most of those infections which for generations have plagued the more static peoples of the human race settled in fixed communities in association with herds of domesticated animals and amidst the accumulated by-products of human and animal existence.
The social organisation of the tribes provided a strict system of polygamic marriage, the general effect of which was to allot to the older men a number of wives ranging in age from early youth to middle life. One result of this rigidly applied system was so to limit the birth rate that the population of the tribe was maintained at a relatively constant level.
The intrusion of the white man into this environment effected fundamental changes in the native economy and social order. The white man immediately set about recruiting to his service young able bodied natives of both sexes offering as inducements, food which the natives found more palatable, more assured, more readily obtained and more convenient to prepare than that to which he had been accustomed, tobacco and sometimes alcohol or opium.
The new holdings being unfenced and often sparsely watered, natives (even those unemployed) were encouraged by the same devices to remain permanently in the vicinity of the homestead in order that stock might not be harassed or dispersed from pastures and waters readily accessible to the stockman.
Very soon after the commencement of white settlement, too, denominational missions were established in various parts of the Territory. Their activities involved the attraction of as many natives as possible to a locality of restricted area to be retained there for purposes of religious instruction and moral supervision.
The cumulative effect of these influences was to concentrate natives upon limited areas where their natural foods were rapidly depleted by over-population and where the traditional mode of life having been abandoned, there commenced a type of existence entirely alien to their experience. The native brought to the new community life, the negligent habits of excreta and waste disposal which he had safely practised from remote times. Concentration in camps, on missions or in the vicinity of white settlements, led to the creation of deplorable conditions of insanitation and over-crowding. For the first time the native became permanently housed and his housing consisted of ill-ventilated and unlighted huts built from waste material and of a size hopelessly inadequate for the number of occupants. Camps were disposed without regards to water pollution and their vicinity became fouled with excreta and wastes.
The traditional native diet obtained by hunting and foraging had been high in protein, particularly in animal protein. The diet supplied on pastoral properties was different in content though probably was not greatly inferior in balance and caloric value to that obtainable by hunting. On missions and native settlements, however, where large numbers of natives were concentrated and fed principally with imported farinaceous foods and locally grown vegetables, nutrition was very gravely affected. Malnutrition, clinical avitaminosis and megaloblastic anaemias have been commonly reported. Simultaneously communicable disease – respiratory, gastro-intestinal, helminthic and protozoal – introduced by European and Asian immigrants to the fertile ground provided by overcrowding, defective housing insanitation and malnutrition have attained a very high incidence amongst natives formerly nomadic but now herded together without prior instruction in the dangers of communal living. The introduction and wide dispersion of gonorrhoea operated to upset the balance between birth and death rates, fertility being reduced to so low a level that the complete extinction of the race appeared susceptible of statistical forecast.
Three decades ago the white population numbered only 2,800 of whom half were dispersed in isolated rural groups dependent for communication upon horse and camel transport. Outside Darwin the European population was almost exclusively adult and principally male. In many districts there were no white women at all.
In close proximity to these rural homesteads of the European large numbers of more or less uncivilised and tribally intact natives camped for the greater part of the year. There was commonly the closest association between the races and amply opportunity for the transmission of communicable disease from one to the other – leprosy alone, amongst Europeans in the endemic areas about this time, reached an incidence of one in twenty.
In the townships and on the mine fields where the European and Asian population was more concentrated, almost every household employed a number of natives as domestic servants. Here the ravages of disease and addiction to alcohol and opium eventually so devastated and degraded the local tribes that they lost their identity, the survivors abandoning their migratory habit and become virtually part of the settled population.
The greater part of the native population however still remained aloof, maintaining its traditional mode of life in the isolation imposed by respect for tribal boundaries. This isolation provided an effective barrier to the dissemination of communicable diseases by natives infected in the settled areas.
The health problems at this time were largely one of controlling communicable disease in both races in the limited areas of white settlement. The incidence of disease in natives living in contact with Europeans threatened the very survival of both races. To meet this menace to the successful settlement of the Territory by a virile people, the Commonwealth in 1927 organised the Northern Territory Medical Service to provide at once an efficient medical service for the white and coloured population, to seek out, treat and if possible eradicate communicable disease from the native people and to organise in the vicinity of settlements, measures of sanitation and prophylaxis designed to minimise the opportunity for dissemination of disease and to avert the establishment of endemic foci.
A great deal of success has attended the efforts of this Service – how great a measure was paradoxically not evident until its activities were suspended during the war and postwar years. For example, during this period when routine measures for the control of leprosy were discontinued, the incidence of this disease rose from 3.7 per mille to 52 per mille. Before the war leprosy had been a disease of adults but it had now become one of childhood.
Notwithstanding the regression during the war and post-war years, some progress has been made in the rehabilitation of the native people and in the control of disease. Unremitting efforts to correct dietary deficiencies on missions and settlements and the provision of special medical and nursing staff assisted by radio communication and air transport 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 in defiance of tribal sanction has favoured the rearing of large families. The introduction of penicillin has led to the almost complete disappearance of gonorrhoea as a cause of infertility. Together these factors have contributed to a spectacular improvement in the birth and survival rates.
In 1954, the latest year in which native births were enumerated with reasonable completeness, these numbered 519. The native population in that year was 13,744. The birth rate in this group therefore is in excess of 37 per thousand, some 14 per thousand greater than the general Australian rate.
The present population distribution involving as it does a partial segregation of the races, contributes in some measure to the control of communicable disease. Only 8% of native are now domiciled in the immediate area of densest white settlement and only some 13% Europeans are dispersed amongst the heaviest native concentrations. Few natives are now employed as domestics in white households. These developments are attributable to the present policy of the Department of Welfare which concentrates natives on missions and settlements in tribal areas for the purpose of their education and elevation to the European standard of living.
The problem of 1927 – the control of disease in a population where both races were closely associated is not now so pressing. On the other hand, concentration itself has aggravated the problem of controlling disease in the native population. 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.
Important Communicable Diseases
The diseases which particularly cause concern are those which may be expected to attain a heavy endemicity in the tropical environment and which, once endemic, will threaten successful white settlement and the economic development of the Territory. Chief amongst these are the following:
Leprosy, introduced by indentured labour from Asia during last century, first involved natives in contact with Chinese on the mining camps along the Pine Creek Railway. The rapid extinction of the tribes in this area and the aloofness of adjacent tries at first prevented its dispersion but it attained a high local incidence and the domestic infection of Europeans by native employees was quite common. During the war cases under treatment in isolation at Darwin were permitted to return to missions where they infected large numbers of native children freely exposed to contact with them and leprosy attained an incidence of 52 per thousand.
Malaria. Both benign and subtertian malaria have from time to time been epidemic and have maintained a sporadic endemicity between epidemics. That malaria is not ineradicable has been shown by the disappearance of benign tertian during the twenties and early thirties of this century and the elimination of subtertian since 1933 after many years of regular recurrence.
Benign tertian malaria has persisted since the war in north-eastern Arnhem Land and along the Roper River. From these areas it has been carried by migrant natives to the vicinity of white settlement at Maranboy. Altogether, 127 cases were reported during 1955. Of these only 17 were in Europeans of whom 5 were infected overseas.
Vector control is not easily or economically undertaken. Thousands of square miles are flooded during the wet season and larvae control is beyond human capacity.
Nevertheless control is urgent lest this disease nullify mining and rice cultivation projects from which so much is hoped for the Territory’s economy.
It is especially necessary to avoid recourse to suppression as a means of control since this method of prophylaxis must be expected to add one more to the considerations which will influence white women against remaining and rearing families in the Territory.
Heavy reliance must be placed upon protection by identification and cure of every carrier, a form of prophylaxis which to be successful will require the utmost co-operation from the patient himself.
Hookworm is endemic along the northern and western littoral and its river systems. Introduced by indentured labour from Asia many years ago, it has attained its highest incidence in the vicinity of the longest established missions where up to 100% of the population are affected. In eastern Arnhem Land where tribal life has only comparatively recently been disturbed by mission and government intervention, the incidence is relatively low, from 0 to 50%. However as a direct result of the policy of concentrating native children in settlements the disease is gradually extending eastward and in areas already affected the incidence is rising. The species involved unfortunately is A. duodenale which difficult to eradicate with the anthelminthics at present known. The individual worm load in areas of highest endemicity is high and amongst the affected, haemoglobin levels as low as 40% are relatively common.
Trachoma presents a problem of the first importance in the arid centre where it involves 85% of the native population. The disease falls progressively in incidence towards the northern coast – having an incidence of 40% in the coastal hinterland and virtually disappearing along the northern littoral.
Salmonella Infections. Typhoid is not a current problem. A series of six cases were reported in Darwin in 1955 following the migration of a carrier. These cases were the first for almost half a century. Diarrhoea is a concern and recurring cause of invalidity and admission to hospital. Dr. S.D. Watsford, lately Deputy Director of Health, Darwin, in a personal communication reports that 364 per thousand children seek treatment for gastrointestinal infections in Darwin in any year. These figures suggest that the sanitary environment favours the dissemination of bowel infections and that the low incidence typhoid is fortuitous.
Amoebiasis threatens of recent years to become a serious problem, more particularly on coastal missions where natives are restricted to predominantly carbohydrate diet.
Measures to be supplied for the control of these disease demand enlightened co-operation from patient and the carrier. Contacts of leprosy must present themselves regularly for review. The sufferer from malaria must conscientiously conform to prophylactic restrictions on migration and meticulously comply with orders for therapy. He must infallibly report every pyrexial attack for investigation and treatment. The sufferer from hookworm or bowel infection must give his full co-operation in curative treatment and in hygienic sanitary practice. These prophylactic requirements go far beyond what can reasonable be expected of the native in his present condition. Yet assimilation will bring these people into the general community on social party with the European population.
Conclusion
The immediate problem is to control and eradicate these and similar diseases from a native population herded together under conditions which provide the optimum environment for dissemination. Successful control appears to be depend upon the training of the individual in his personal responsibilities.
Yet another problem clouds the future. At the Census 1933, 1,236 breadwinners, representing 41.5% of the population in the Northern Territory, were engaged in primary production and mining. At the Census, although the population had grown considerably, primary production and mining occupied only 2,140 (23.6% of breadwinners).
Stabilisation of the white population even at its present level appears to depend upon the maintenance of current Government works expenditure. Primary production does not, for the first time at least, appear likely to support it. It will clearly be necessary to find a stable means of subsistence in a productive field for the native half of the population which it is proposed to assimilate. If this is not done they must either displace Europeans from employment or live dependent upon the unpredictable bounty of the Commonwealth Treasury.
The health interest in this problem attaches to the risk that if it is not solved, the newly civilised native, no longer capable of surviving in the comparative security of his tribal hunting ground, will be compelled by economic forces to live in poverty, squalor and degradation, a prey to uncontrollable endemic disease, outcast from white society and without prospect of dignified economic and social survival.