A report to the NHMRC Committee on Tropical Physiology and Hygiene
by C.E. Cook, M.D., Commissioner of Public Health, W.A. (1948)
Health control in the North and North-west of Australia is beset with special difficulties and necessities which are not met to the same extent elsewhere.
(a) The major portion of the area is tropical in climate and as such is suitable for the endemicity and epidemicity of tropical diseases, notably malaria, leprosy, hookworm, dengue, amoebiasis and the dysenteries.
(b) The white population is sparse and lives under primitive conditions, at widely scattered points difficult of access for purposes of prompt diagnosis or early application of measures of control.
(c) There is comparatively large coloured population predominantly aboriginal, living under conditions of squalor and insanitation eminently suitable for dissemination of communicable disease. These people lack any knowledge of the fundamental principles of hygiene and have not even an elementary appreciation of human epidemiology. They are largely uncontrolled migratory, and for the most part beyond civic discipline.
(d) The quarantinable diseases smallpox, typhus, cholera, plague and yellow fever, may, owing to disruption of health services in adjacent countries of Asia, and to the increased rapidity of modern air transport, be introduced to this region by aircraft at any time, and it may be stated as a truism that the Commonwealth Quarantine Service can no longer hope with confidence to avert this contingency.
(e) Conditions obtaining in the area are such as to favour the uncontrollable dissemination of quarantinable diseases should they be introduced and their ultimate conveyance per medium of the local population to centres of white settlement elsewhere in Australia.
(i) Universal vaccination, the only effective prophylactic against smallpox, has never been attempted in Western Australia and has been neglected in the Northern Territory for several years. Owing to the dispersal and migratory habit of the uncontrolled native population, it cannot be effectively undertaken during the course of an epidemic.
(ii) Amongst natives indiscriminate soil pollution and exposure of faeces to flies is the rule rather than the exception, even in areas of closer settlement.
(iii) Water supplies are drawn principally from shallow wells and from surface water, most of which are continuously or periodically exposed to faecal pollution by natives. Water in a great part of the area is distributed and stored by primitive methods involving considerable risk of pollution, particular by natives. The control of cholera under these circumstances would appear impossible.
(iv) The distribution of the insect vector of plague is unknown, but the almost universal neglect of any effectual waste removal service, the utter disregard of natives for the careful disposal of organic wastes and the littering of the vicinity of camps and settlements with discarded rubbish provide food supply and harbourage for rodents.
(v) The insect vector of yellow fever breeds freely in the rainwater storage containers in the vicinity of dwellings and in the considerable and scattered areas of cans and broken bottles which litter the vicinity of settlements. Migratory natives are apt to transport such litter to new localities over a wide area, and would no doubt in epidemic times disseminate the virus during the incubation period to all parts of the region.
(a) Conditions in respect of endemic disease are equally bad.
(i) Leprosy imported into the coloured population has spread extensively amongst natives, until in the Kimberly region it has attained an incidence comparable to that in the areas of highest endemicity in the world. The migratory habit of the population has disseminated infection throughout the Kimberly division where incidence was negligible 20 years ago. Leprosy is now being communicated through families and the uncontrolled employment of lepers and potential lepers in European households constitutes a grave menace to the security of the white population of the area.
(ii) Malaria – The insect vector of malaria in this region has not certainly been identified, but anophelines suspected of being efficient carriers are numerous in the major River basins during the autumn months. At times following the introduction of infection by new migration virulent epidemics of high fatality have occurred, infection being rapidly disseminated from one point to another by natives. The reintroduction of the malaria parasite must be regarded as an ever present and imminent probability.
(iii) Hookworm – The unhygienic practice of promiscuous defaecation characteristic of the native fosters the free dissemination and intensive incidence of hookworm in suitable environments. Sporadic efforts at control have proved abortive hitherto, owing to their being conventionally designed and inadequate to meet the epidemiological situation created by native social practice. This disease has become, and will continue to be, a menace to the fitness of the white population.
(iv) Amoebiasis and other bowel infections are impossible to control in face of the pollution of water supplies, and exposure of infective material to flies and the unclean handling of food, which are inescapable epidemiological features of the situation created by the native population in its present condition.
(b) The accepted instruments of Health Administration in Western Australia – Local Health Authorities – are quite unable, owing to lack of staff, insufficient funds, and inadequate knowledge, effectively to control endemic or epidemic diseases within their areas.
In the Northern Territory, no local health authorities exist; their function being undertaken by Medical Officers of the Northern Territory Medical Service. This Service, originally designed and created to meet the peculiar sanitary problems of the region has become more and more preoccupied with therapeutic medicine and has largely lost its original character.
(c) Tuberculosis, introduced by European and Asiatic immigration has now involved the native population. The extent of this involvement has not been ascertained but it must be expected that tuberculosis will spread rapidly and extensively amongst natives who will in turn serve as a reservoir for its later dissemination to the population of the future.
Health control in the North, therefore, largely resolves itself into control of the native population, an objective the pursuit of which demands that the health authority shall be invested with all those powers over the group and over the individual which the law invests in the local and central health authorities in respect of the white population. These powers which include:-
- control of the disposal of human wastes;
- scavenging and cleansing;
- ordering the standard of dwellings;
- effecting the abatement of nuisances;
- safeguarding the quality of food;
- protecting water supplies;
- submitting persons to medical examination, immunisation, detention, and treatment;
- effecting the destruction of property presumed to be infective;
(This) can only be secured in respect of the native by vesting in the health authority the powers possessed by the Native Affairs Department. Health control in the North, therefore, can only effectively be undertaken either by a medical service charged with the responsibility and powers of native protection or by the Native Affairs Department itself.
The latter alternative will require the establishment in the Native Affairs Department of a highly organised medical and health service which, unless it is to be charged with the additional duty of undertaking the care of the white population, must be supplemented by a similar organisation to operate in areas of white settlement. Duplication in such a sparsely populated and economically poor area is not to be recommended, and whereas it is doubtful whether a medical service vested in the Native Affairs Department could satisfactorily serve the best interest of the white population, a medical service set up primarily for the care of the white can quite efficiently embrace the care of the coloured.
It is evident that the health authority will be powerless effectually to function in the North until it has the undisputed right to initiate, execute, and/or veto native administration policy, even in its routine minutiae.
In the interest of the National health and in the contention against this statement that a Department of Native Affairs is concerned with controlling employment, safeguarding wages, regulating housing, managing institutions and supervising religious missions, activities which appear to be exclusively phases of native administration and wholly beyond the ambit of the health authority.
It must, therefore, be emphasized that it is of the utmost importance that the Health Authority possess free rein in the exercise of these very functions.
(a) Employment: One of the great dangers to the maintenance of a satisfactory standard of health in the North, stems from the employment of natives by Europeans. Persons carrying certain infections should not be licensed to employ natives. Native suffering from, or likely to develop certain diseases, should not be employed by the white population or permitted access to white settlement. Conditions under which natives are employed should be such as to protect each race from infection by the other and should not predispose a native to impairment of health.
These precautions can only confidently be attempted by one Department, or by very close integration of two Departments, since it is not always possible for the Health Department to impart to the Native Affairs Department that necessary information or consciousness which are a necessary prerequisite to sustained and enlightened prophylaxis. It is, for example, impossible to notify the Native Affairs Department of clinical conditions from which prospective white employers of native labour may be suffering.
(b) Wages: In many areas money wages are largely nominal, and to the extent that they involve cash or book payments must be handled by an Accounts Branch in either Department. Wages in these areas, however, also include food, clothing, accommodation, medical care, etc., for the employee and for his dependants, and the adequacy or otherwise of such wages requires specialist knowledge available in a Department of Public Health but not necessarily so in a Department of Native Affairs.
(c) Housing: The conditions under which natives are housed in or out of employment, in institutions or elsewhere, are primarily and almost wholly the concern of the health authority just as is the housing of the white population. From control of native housing, however, the health authority is at present excluded, notwithstanding that the deplorable conditions or squalor in which natives live constitute an ever present menace to their health and to the security of the white population.
(d) Native Institutions: The greater part of a Department’s responsibility in administering a native institution will be that involved in safeguarding the health of a number of persons of nomadic habit lacking in hygienic conscience, who are concentrated in a settlement and detained there. Management of the institution demands in the administering Department a basic knowledge of hygiene and medicine which must cover all administrative decisions, planning and development.
(e) Religious Missions: Possibly nowhere in native administration is it more necessary that the Health Authority should have effective control than it is in respect of religious missions. Here are concentrated large numbers of nomadic natives who are held in a restricted area, housed under abnormal conditions, fed unfamiliar food, taught new wants, and deprived in time of their social organisation. The site where the mission is established, its sanitation, the quality of the water consumed, the standard of housing provided, the quantity and character of the food available, the conditions under which the diseased are permitted contact with their fellow, the promptitude with which infectious disease may be recognised, the handling and treatment of infected persons, the care of the newborn in the strange environment, the education of the nomad in communal life particularly as it affects hygiene and morality, the exclusion of tuberculosis and other disease from the mission, staff, and a host of other phases of mission activity, are of vital importance to the health authority.
These are not fantasies or abstractions, they are hard, cold facts clearly discerned by those experienced in health administration in this region and readily ascertainable by the study of the problem at first hand.
Incorrect feeding has in the past caused outbreaks of Scurvy and Beriberi with an appreciable loss of life, considerable suffering and no little expense.
Neglect of hygiene and elementary measures of disease control at times when these could, with little expense or effort, have easily eliminated the potential danger, have left us a legacy of epidemic Malaria and endemic leprosy, hookworm and bowel disease which will cost the white race millions of pounds and both races years of debility, suffering and mortality before the damage can be repaired.
Unless this sorry story is to become an interminable serial; unless new and even more tragic chapters are to be added to narrate the progress of smallpox, cholera and yellow fever through this unhappy region and from it to the more civilised community beyond, a hygienic conscience must be developed in native administration. This for a time at least can most effectually and expeditiously be achieved by integrating the protective function into the health authority.
In his natural state the Australian native was free from those endemic infections which constitute such a problem in the community life of other races. This circumstance together with his habit of migrating in tiny groups, his abstention from organised village life and the impermanence of his camping sites eliminated from his domestic economy those problems of sanitation which beset the more stable communities of the white race.
The inevitable result is that he is completely unadapted psychologically for rapid integration into community life. This incompatibility, though accorded its full nuisance value has never been squarely confronted by native administrations as demanding correction. Possibly retreat from this problem has be inevitable under the existing form of administration.
Lay executive officers though familiar with the objective manifestation of elementary sanitary routine in an organised community, have no deep appreciation of their significance and the importance and no knowledge of the basic principle underlying them. Without a hygienic conscience to guide every decision, and without the knowledge or ability to impart the necessary training to the mixed community during a period of transition, it is only to be expected that they would in despair accept the situation as it develops spontaneously.
Whatever the reason lay native administration has proved itself quite incapable of effecting the orderly integration of the migrant native into community life and it seems there can be no confident attempt to achieve this objective until native policy is subject to guidance by the health authority.
A somewhat similar situation confronted the Australian army during the recent war. For years a handful of men, experienced in tropical hygiene and holding subordinate rank, advised, argued and pleaded with the Defence Department in vain to establish an efficient hygiene organisation in its services.
Not until the medical disasters of Milne Bay, the Kokoda Trail and the Buna-Gona campaign jolted the Army out of it complacency, was an adequate opportunity given hygienists to conserve unit strength in the field from tropical infections. For the subsequent 2 ½ years the path of the Hygiene Officer was easier and unremitting efforts towards the necessary training of troops in camp and in the field enabled them to see the 9th Division successfully conduct a campaign in Borneo under the worse possible epidemiological conditions, yet with a standard of health conservation in troops unprecedented in history and unequalled by any other force similarly committed elsewhere in the world during the War.
Lessons so deeply learned in War should not be forgotten in peace. Whilst there is in the Commonwealth Department of Health no medical organisation to provide a hygienic conscience for native affairs administration, and whilst State and Territory Medical Services have no effective voice in the native policy, the National Health and Medical Research Council must remain the only body which can direct the Commonwealth Government’s attention to the dangers confronting tropical white settlement and the only authority which can advise the Federal Minister for Health of remedial measures considered necessary to be taken.
The most apparent and urgent of these at the moment is the close integration of the Department of Native Affairs into the respective Health Authorities administering North of the continent.