Northern Territory Medical Service – 1951

The Northern Territory Medical Service was established in 1928 to provide effectual machinery to control and eliminate endemic tropical disease from Northern Australia and to ensure that the area might be maintained as one suitable for permanent occupation by a healthy and prosperous white community. Fundamental to its organisation were two basic principles of policy,

(a) In the primitive social state of the aboriginal population the Health Authority, to function satisfactorily, must be vested with all the power over the native, individually and collectively, conferred by the Aborigines Ordinances of the Chief Protector.

The Chief Medical Officer was therefore appointed Chief Protector.

(b) Every practitioner of medicine in the area must be under control and direction by the Health Authority in order that the Chief Medical Officer could satisfy himself that the routine minutiae of prophylaxis were met meticulously and invariably applied and so that the untrained and inexperienced practitioner should be constant under enlightened supervision and guidance.

A change in Commonwealth policy in 1939 which created a separate Native Affairs Department went far towards defeating the efforts of the Health Authority to control disease by denying the Chief Medical Officer sufficient control of the native population. The sinister effects of this re-organisation, particularly in the increasing rate of dissemination of leprosy and tuberculosis which it permitted were masked during the subsequent years of war and military occupation. They became more apparent in the years subsequent to resumption of activity by this Department and the measures of co-operation and liaison developed only in recent years with the Department of Welfare only now show some promise of overtaking and repairing the position.

A further and more recent change in policy, which will foster return to private medical practice in the Northern Territory, introduces new difficulties in Health Administration which unless successfully met from the outset may prove even more unfortunate and coupled with the residuary difficulties of the original change may result in the partial or complete frustration of efforts at successful Health Administration.

Briefly it may be said that rational plans for the control of endemic disease must be based upon the following:-

1. Accurate and prompt diagnosis of conditions intended to be controlled. This implies not only awareness of epidemiological possibilities in the practitioner attending the case but his meticulous use of diagnostic procedures available to verify his provisional diagnosis.
2. Notification. The Health Authority must be promptly informed of the occurrence or suspected occurrence of every case of disease subject to measures of control so that the necessary investigation and consequential action affecting the environment and detection and disposal and treatment of associated carriers may be promptly and efficiently undertaken.
3. Examination and where necessary treatment and review of cases, suspect cases and contact.
4. In certain conditions, for example malaria and hookworm, special measures of treatment to ensure that clinical cure shall invariably be associated with complete eradication of the effective organism or parasite.

To date the Deputy Director of Health has been assured at all times of the opportunity of verifying diagnosis assuring proper notification, ordering prophylactic treatment and studying the environmental and contact associations of each case because all patients seeking medical advice have been attended as out-patients or as in-patients by medical officers of his own staff.

The introduction of private practice will deny him this assurance. Universal experience throughout Australia unfortunately shows that private practitioners:-

1. are commonly unaware of the nature of tropical disease or other communicable infections;
2. are negligent in discharging the obligation to notify;
3. are commonly unimpressed with the necessity of verifying diagnosis by laboratory methods;
4. as individuals are apt to become acutely resentful at any suggestion of dictation in the method of therapy to be applied.

It is supposed that the resumption of private practice in Darwin will appreciably reduce the number of persons attending for examination as out-patients. It will also, unless special safeguards are applied, limit the opportunities for the Deputy Director of Health to confirm the diagnosis and review the treatment of persons admitted to hospital as in-patients. For information regarding persons suffering from malaria, dysentery or notifiable tropical diseases treated, for any reason privately in their homes or at hotels perhaps under conditions of extreme danger to their neighbours and contacts, he will be completely dependent upon the ability and goodwill of the practitioner attending.

Even if it be optimistically assumed that all such cases will be promptly notified to him whilst still awaiting diagnosis it is problematical unless special measures of coercion can be devised whether on confirmation of the diagnosis, they will be ordered or will in fact take, courses of treatment satisfactory to him or whether in the post therapy period, they will be carefully and competently reviewed.

It is not desired at this late stage to challenge or question the wisdom of the Government’s policy in this matter. It is however, desired to emphasise the pressing necessity of redesigning the system of preventive medicine hitherto operative in the Territory for the purpose of accommodating the new form of medical practice in an effectual system of tropical prophylaxis.

Attached you will find reports dealing with some of the observations upon Health Administration in the Northern Territory made by me on the occasion of my visit there last year before the present Deputy Director took office. They disclose that even with the theoretical advantages provided by the organisation hitherto obtaining measures for the prevention of disease have not been meticulously and competently applied on all occasions. There are several reasons for this failure, the chief of which appear to be:-

• Inexperience and lack of training in tropical medicine in medical officers of the service
• Failure of consistent adherence to the prophylactic policy
• Failure to apply in detail the principles of that policy even when carefully designed
• Inability to co-ordinate in the general policy of preventive medicine the activities of other Departments – Public Works, Native Affairs, Municipal Administration etc. – without whose enlightened co-operation no system of prophylaxis could be efficiently and consistently applied

I suggest for your considerations that the new situation demands immediate action on the part of this Department, first to repair the defects in the system hitherto which have been revealed by the survey and second to provide adequate machinery for meeting the situation introduced by the resumption of private practice.

It is my conviction that the Deputy Director of Health is too preoccupied with a diversity of responsibilities to keep detail of the organised prophylactic system and review under constant personal surveillance and the changes in professional and clerical staff have led to failure in its execution owing to interruptions in its application at many points over a protracted time. Furthermore this Department should play an active part in studying the epidemiological situation in the Territory and in planning and supervising measures of preventive medicine. It should collaborate with associated Departments whose head offices are here in order that the embarrassment of unilateral policy decisions may be removed or at least mitigated. I recommend, therefore that the officer, at present myself, occupying the office formally but not officially designated Director of Tropical Hygiene should be definitely made responsible to you for the organisation and general direction of preventive medicine in the Territory and should act as liaison officer with the associated Departments for this Department.

In addition, I recommend that there should be appointed to the staff of the Deputy Director a full time Medical Officer of Health who should be responsible to the Deputy Director for the direction, supervision and effectual application of all planned measures of disease control including the medical inspection of natives, the disposal of patients, the review of cases, suspects and contacts and the application of all organised measures of personal and environmental prophylaxis except those attaching to Quarantine. In order that this Officer may enjoy the opportunity of collecting from the Territory information regarding the prevalence of disease and the measures applied for purposes of control – information at present denied it owing to recognition that the Deputy Director cannot afford the time to engage in voluminous correspondence involved – the Medical Officer of Health should be placed in communication with me, through the Deputy Director.

I thought you might care to discuss these recommendations with Dr. Humphry on the occasion of your visit to Darwin and subject to your general approval and direction more specific detail can be presented to you following consultations between Dr. Wienholt and myself.

TOWN SANITATION

Allocation of Duties

The Municipal Section of the Northern Territory Administration is responsible for the general cleanliness of town, the management of public conveniences, public baths, tourist camps, beaches and cemeteries. Upon this section devolves also the duty of calling tenders and the letting of contracts for garbage and sanitary services, the specification of the terms of contract and supervision of its execution by the contractor.

Mosquito prevention measures on both private and public property are undertaken by a mosquito control gang under the direction of the municipal section.

The control of nuisances, other than mosquito breeding, on private property is left to the Inspectors of the Department of Health.

In Darwin the Municipal Section has one inspector (unqualified) in charge, and his duties include the reading of meters. In other towns a clerical officer of the section undertake the necessary inspections as duties incidental to his administrative work. These officers have no special training in health inspection.

Tourist Camps

(a) Darwin – Mindil Beach

According to the Municipal Section there were stated at the time of my visit to be twenty or thirty shacks in this area erected by the occupiers. In fact I found forty-three occupied camps, some of a temporary nature but the majority obviously permanent. Enquiries elicited the information that occupants numbered eighty to ninety including some children. Most of the adults were employed in various avocations in the town. The occupiers had no right of occupancy. There was no light and no fireplaces. Water is laid on to a shed originally intended as a dressing shed of bathers. Sanitary conveniences comprised four incinerator latrines for each sex, and four trough urinals for males.

No charge or levy is made. Mindil Beach is stated to be the only camping area in Darwin except those occupied by migrant natives.

In my opinion these camps present a danger to the public health. Effluent from septic tanks on Myilly Point nearby find their way to a creek in which campers and children wade and play. Anopheline breeding occurs in surface water nearby and the type of camper using the area is one likely to have traversed malarious areas in the interior, and during transit to have become a carrier of parasites. Parasite carriers in this camp will serve as a focus of infection for the nearby suburb of Myilly Point, and for persons visiting Mindil Beach at night.

(b) Alice Springs

Two camping areas for tourists exist also at Alice Sprigs. These are conducted by private enterprise on a rental basis. The standard of accommodation, conveniences, and hygiene of these privately conducted camps is in marked contrast to that of the publicly controlled area at Mindil Beach, and compares favourably with that of privately and publicly conducted caravan parks in the southern States. At the time of my inspection, I found accommodation provided, the cooking and messing facilities, the water supply, the methods of wastes disposal, the sanitary services and the amenities quite satisfactory.

Mosquito Control

Formerly the residential areas of Darwin Peninsula were relatively free from mosquito infestation except for-

• brief but intense evening plagues of A.vigilex following the November tides;
• slight and transient A.bancrofti visitations with the change to south-east from north-west monsoon; and
• A.segypti breeding in domestic water storage tanks in the early dry season.

In 1939 Darwin was reticulated with a water supply from Manton Dam. Some 250 gallons of water per head per day are now brought into the Peninsula area; of this quantity 60 gallons per head per day is estimated to be used for domestic purposes. It was to be expected that this change in the system of water supply would alter the entomological environment. Previously the water table on the Darwin Peninsula rose during the wet season to above sea level, and at this time springs were likely to appear on the cliff face, and low lying gullies near the town were apt to become marshy. During the drier season the drain on the water table effected by the pumping of domestic water from wells and the discharge of waste into the harbour, progressively lowered it, so that after June practically no surface water remained in the town and the springs were dry. Mosquito control was in some measure naturally effected by the turbulence of the water during the closing phases of the wet season and later by the sudden onset of the cold south-easterlies, the burning of the grass, and the rapid disappearance of surface water.

By contrast since reticulation from the Manton Dam, pumping from the water table by domestic wells has ceased. 250 gallons per head per day for a much larger population is brought on to the Peninsula, and a great part of this is discharged into the sub-soil by the watering of lawns and gardens, and by sub-soil drainage. It is to be expected therefore that the water table previously subjected to rapid lowering after the onset of the dry season will be maintained at a higher level and springs and pooling in low lying ground will continue later into the dry season, with only evaporation to lower them.

Visual confirmation of this is not lacking. In particular considerable streams of fresh water may be seen at low-tide to run from the cliff foot to the harbour. Such streams were not in evidence during the dry season before reticulation from the Manton Dam, and indicate a sub-soil water level sufficient to maintain springs and pooling in areas which formerly were dry early in the year.

In the result notable entomological features now are:-

• Absence of A.aegypti attributable to the elimination of domestic water storage tanks;
• Constant plague level of C.fatigans formerly of no significance but now prevalent at pest level throughout the year owning to prolific breeding in polluted surface water.
• Anopheline breeding (including A.ferauti) in surface water in springs, and in pools in low lying localities formerly dried out early in the south-east monsoon.

To cope with the constant plague level of pest mosquitoes in Darwin the Municipal Section maintains a mosquito control gang consisting of a foreman, and seven men; equipped with two trucks and two TIFA foggers. The gang which consists of men of mixed blood under a white foreman is broken into two divisions:-

1. sprayers;
2. weed clearers.

The two divisions work the same area concurrently. No drain construction is undertaken. Drains, outfalls of septic tanks and similar surface waters are said to be sprayed in every area once a week.

Considering that the problem is artificial and man-made, the cost of efforts at control is considerable. Each man is paid £800 per annum and £2,000 is provided for gear and material. In 1953/54 Budget provided for £27,500 (two gangs, totalling fifteen men). This was reduced by Treasury to £11,000 and actual expenditure (one gang) was £11,500.

For 1954/55 the estimate was £10,000.

Oil consumption for the replenishing of drip cans, knapsack sprays (40 gallons per day) is 10,000 gallons per annum at 5/- per gallon. Tropic oil and sovacide and D.D.T. are used.

Each TIFA fogger uses 45 gallons of spray per night (£29). The average cost for two machines working three hours is £80 per night. The machines are used three times per week subject to a suitable weather forecast, and the total cost is £12,000 per annum.

The break-up of costs for mosquito control arising from the surface disposal of fluid wastes is therefore:-

Morning and evening fogging is limited to three hours on account of overtime costs and fatigue. After the cut in estimates in 1954/55 use of TIFA machines was discontinued on account of their cost. It is estimated that two runs of three hours each will cover the whole town from the wharf to Myilly Point, from the Esplanade to McMinn Street, and the Stuart Highway. Although the TIFA made a number of runs during my stay in Darwin I was credibly informed that this was not usual, and that the use of the machine is currently limited to fogging the Botanic Gardens on the occasion of out-door concerts.

The efficiency of the mosquito gangs is open to question. I personally inspected drainage in the Kahlin Gully shortly after the gang had attended to them. I found several drains overlooked, both by the sprayers and the weed clearers. Incidentally it was observed on this occasion that mosquito control contour drains dug by the Australian Military Forces as a measure of malaria control during the war, are now being used as effluent drains from septic tanks in the neighbourhood.

Challenged on the inefficiency of application of various routine health measures, local authorities professed inability to cope with task on account of shortage of staff, and inefficiency of labour. One is driven to the conclusion that there has been too ready acceptance of the proposition that the solution of all problems is to be found in increase of staff and inflation of cost, rather than in the sustained and energetic application of carefully planned and rational measures.

The striking feature of Darwin’s current mosquito problem is that costly efforts to meet it have proved ineffectual yet it exists only because it has been created by carelessness and negligence in the disposal of septic tank effluents. These apart altogether from their mosquito breeding importance, constitute a public health menace as foci for dissemination of bowel disease, infective hepatitis, poliomyelitis, and helminths.

Nightsoil Disposal

The policy in Darwin has been the elimination of the conservancy system and so far as possible of incinerator latrines. The town itself is now served predominantly by a water carriage system based on the provision of a number of septic tanks to which groups of premises are connected. There are a few incinerator latrines except for the service of temporary shelters and new areas of development.

There are a number of septic tanks exclusive to individual premises.

About 20 premises are provided with chemical disolvenators.

Septic tanks for individual premises conform to the Queensland design and the effluent is carried to an absorption trench or pit. The Chief Health Inspector reports that although all fluid wastes from kitchen and ablutions are carried through these tanks they function satisfactorily and the subsoil has been found capable of containing all effluent permanently underground.

Objectionable features including some prejudicial to the public health attach to the septic tanks serving groups of premises. Apart from major installations of Imhoff type provided for the armed services and the hospital these appear to have been installed as temporary expedients pending installation of a sewered system. Corrugated galvanised iron tanks of 2,000 gallons, unlined, have been used. Most of these appear to be discarded domestic rain water storage tanks removed from dwellings and government buildings as a mosquito control measure following completion of the reticulated water supply. It is intended to replace these ultimately by permanent installations. It is hoped that replacement by lined tanks will be completed in 12 to 18 months subject to the availability of funds.

The planned capacity of each system assumes 25% allowance for sludge and 24 hours retention of sewage. Inspection is undertaken by inspectors of the Department of Works and Housing. As it becomes too solid or too thick, blanket is said to be removed and buried “in a convenient place in the neighbourhood.”

It is proposed ultimately to eliminate some of these temporary tanks by conducting a sewer line from Doctors Gully across Mitchell, Cavenagh and McMinn Streets to the outfall of No. 1 line (Francis Bay). It is intended also to eliminate all subsidiary tanks and all outfalls below the Esplanade but No. 1 tank will have to be supplemented to carry the extra load.

Whatever may have been the adequacy of these tanks for the demand made upon them at the time of their installation and for their expected period of service they are hopelessly inadequate now. It appears that the erection of new dwellings in the vicinity of premises already served by temporary thanks has invited their connection to the system without regard to its capacity to accommodate the extra load. Since all waste water from the premises is carried through the tank the capacity per head served per day should be not less than 20 gallons. Figures supplied by the Department of Public Works for 5 of these tanks gave a total of 12,000 gallons for 800 persons but study on the spot suggests that even this is a gross understatement of the load. For instance the 5,000 gallon tank at Francis Bay is stated by the Works Department to serve 500 persons yet it takes the drainage of the whole of the Darwin business area which includes, in addition to a considerable number of flats and dwellings, three hotels, the Stuart Theatre, three schools, the R.S.L. Club and the Workers Club.

An inspection of the septic tanks installed and maintained by the Department of Works and Housing reveals that they are in addition to being inadequate actually defective. Of the temporary installations improvised from galvanised iron tanks none were working efficiently. Obvious defects included –

(a) Gross reduction in capacity by the accumulation of sludge and blanket. This reduction in capacity resulting over a period had so significantly limited storage and treatment time that sludge had accumulated at an increasing rate until digestion had practically stopped, the inflow traversing a channel through the blanket and escaping from the effluent vent practically unchanged. It was usual to find faecal masses and paper in the effluent channels and these were open surface drains traversing ground to which the public have free access.

(b) Weathering and corrosion of the galvanised iron of the walls and roofs of the tanks had produced holes facilitating ingress and egress of mosquitoes and flies. Entry of rain water through these holes had permitted fly breeding in sections of the blanket in a number of these tanks.

The effluent from these tanks is practically untreated sewage but it is permitted to discharge through open surface drains to beaches or to adjacent low lying ground which are swamps in the wet season. On the Esplanade short open surface drains discharge over the cliff polluting the ground, traversing the beach below and polluting the waters of the harbour adjacent to Lammeroo baths and Doctors Gully in which a number of persons bathe or wade. At Kahlin Beach, Stuart Park, Parap and the old Police Paddock area, at the aerodrome and Qantas Rest House long open drains carry effluents to terminal pools overgrown with weeds and providing extensive areas for fly and mosquito breeding. All these drains which must be regarded as carrying infected material are unprotected and liable to be used by children at play. The cost of stripping the weeds from the edges and spraying to prevent mosquito breeding is considerable and is but imperfectly and intermittently carried out.

A mistake appears to have been made in reducing the number of tanks and endeavouring to serve a number of premises by one tank. Apart from the excess load it imposes upon the tank, this has increased the difficulty of sub-soil disposal of the effluent. Evidence afforded by tanks on individual premises makes it abundantly evident that the effluent from one household can be completely and efficiently contained underground on the allotments. The draining of the effluent of a large number of premises to one tank so increases the volume of fluid to be absorbed that underground disposal becomes impossible. Effluent, therefore, is constantly to be found on the surface where it plays a major part in the prolific pest mosquito breeding which has converted Darwin from a comparatively mosquito free area to a pest ridden one. 

Mosquito breeding also takes place in the tanks themselves and difficulties have been encountered in obtaining Public Works Department co-operation in the proper screening of tanks. Mica flaps have been used for his purpose, their life is short and with their dissolution ingress and egress for mosquitoes is free.

The surface disposal of septic tank effluent is a feature of this form of nightsoil disposal throughout the Territory. At Batchelor where Territory Enterprises Pty. Ltd. has constructed a model township for its Rum Jungle employees in an area apparently well suited for the disposal of household effluent into the subsoil all effluent wastes have been collected, at a considerable cost, for discharge into swamps contribute materially to the breeding of culicine mosquitoes at pest levels.

At various points along the Stuart Highway, hotels and cafes have provided septic tanks and in some of these, sub-soil disposal of the effluent has either been ineffectual or not attempted. This matter has been the subject of a previous report.

An effort should be made event at this late date to substitute separate septic tanks at individual premises for the group tanks. The ultimate installation of a planned sewered system would still be practicable and would entail only the connection of existing house drain or the effluent drain to the public sewer.

Even if it be felt that change of existing connections is not immediately practicable, it should be made firm policy that all premises shall be provided with individual tanks. If the present system is to remain, immediate attention must be given to disposal of the effluent from the tanks underground will, in most cases, be impossible owing to its high content of undigested organic matter.

The additional expense would in part be offset by the reduction in the cost of pest mosquito control, and in any event would be justified by the incalculable value of the consequent improvement in environmental comfort and security.