Problems of Medical Service in Northern Australia

PRELIMINARY

During the past seven years my duties have brought the problems of Medical Service in Northern Australia under my immediate observation. Throughout that period I have been impressed with the urgent necessity of improving existing conditions both in respect of the service rendered and the cost of providing it.

As the field I have covered has embraced practically the whole of northern portion of the continent from its eastern to the western coast, I have been able to form a composite view of the medical problems of this region and to formulate a generally applicable plan of improvement.

I believe that the opportunities for the study of this subject which I have enjoyed have been shared by no other medical men. As in my own case these opportunities have been presented at the expense of the Governments of the various States and Territories concerned in the course of the discharge of my official duties in their behalf, I feel it to be my duty as a Public Servant to submit a report upon my observations notwithstanding that I have receive no instruction to do so. I have been fortified in this view by recent information that in certain parts of North-west Queensland the position is becoming acute and that the Australian Inland Mission is seeking to have the problem discussed at the forthcoming Premiers’ Conference. 

The region concerned is characterised by sparse white population a relatively high proportion of aboriginals, great distances with poor road and no rail communication, inadequate telegraphic and telephonic facilities and seasonal extremes of heat and cold, flood and drought. The centres of population are small villages of a few hundred or a few dozen souls, each the hub of an extensive and poorly settled district devoted principally to pastoral pursuits.

Settlement of the great area lying north of the 20^th parallel and west of the Flinders River, by a considerable and virile white population is of vital importance to the Commonwealth not only by reason of its immense economic value but also as a safeguard of White Australia. Unfortunately, however, population is receding here. Various factors have contributed to this result but not the least in importance is concerned with medical service. It is a well recognised fact that a high standard of white settlement is only reached where there is a permanent and substantial white female population. Where this condition is not fulfilled the male population tends to be unsettled or retrograde. Deprived of the society of women of their own colour male settlers drift towards intimate association with the aboriginal. Moral deterioration and the dissemination of disease are natural sequels. This association with the aboriginal has an economic aspect which must earn it condemnation of those who are indifferent to questions of morality. Where there is settlement by white females it is found that there is a constant spur of improvement of the environment. The cost of these improvements must be recovered from the property and it becomes necessary to develop ever increasing efficiency of method with a view to wrestling the maximum yield from the soil. The capital value of the property gradually increases, the need for increased return follows and constantly improving methods usher in a period of increasing prosperity and growth of population. Where on the other hand there is close association with the aboriginal properties are usually managed at a minimum cost. Improvements are neglected, labour costs are small, general costs of maintenance are limited to the wages and keep of a few stockmen who are permitted or required to exist at a standard not much superior to that of the unpaid aboriginal employees and the capital cost being relatively small returns are usually adequate notwithstanding that the full possibilities of the property are not exploited. Such conditions with the aid of cheap aboriginal labour yielding adequate returns there is no stimulus to the investment of further capital in improvement of the property or herd and new avenues of employment do not open. These very conditions lead to results which tend to aggravate and reproduce them .The youth of energy and ambition migrating to this environment either leaves in disappointment or remains to deteriorate. There is a natural selection of the apathetic in an environment tending to exaggerate apathy.

In these enlightened days when urban populations are so well provided with the necessities of civilisation, population, particularly female, is inevitably drawn from the unattractive outposts. Unless this drift is arrested it may be feared that great areas of pastoral country in North-western Queensland will become even less productive than they are at present.

Various measures must be taken to correct this drift but one of the most important for the purpose of arresting female migration is the provision of adequate medical service. It is therefore most disconcerting to find that in North-western Queensland, that very loss of population which is giving concern, has so completely disorganised the system upon which medical services were financed that in certain districts the former organisation has been abandoned in favour of a cheaper and less efficient once. At least three villages have been compelled to give up the attempt to retain a Medical Officer and are concentrating effort upon preserving their little hospitals. It is to be feared that the economy affected by dismissing the Medical Officer will be set off by further reduction in local support owing to the inferior service rendered. It may confidently be anticipated that unless some effective measure of correction is promptly taken the hospitals themselves will be compelled to close their doors. The urgency of arresting this drift cannot be exaggerated, for the inevitable result of its continuance will be further depopulation and retrogression of this region with serious economic loss to the Commonwealth. The old system, however, which arose spontaneously and without special planning to meet the needs and conditions of this area has definitely and irremediably failed. It must be replaced by a system based upon a plan indicated by past experience of the requirements and special problems of medical service in these districts.

REQUIREMENTS OF MEDICAL SERVICE IN THIS REGION

In the ideal Medical Service for these districts – 

1. the importance of hygiene, hitherto overlooked, as a factor in successful settlement will be recognised. The sanitary conditions of the region are ideal for the wide dissemination of such factors of depopulation as malaria, dysentery, typhoid and venereal disease. Attention must be directed towards the eradication of endemic and the limitation of epidemic disease, the study of the effect of environment climate and diet upon the white settler, observation of the reactions of the human organism from the antenatal period to death, and the identification and correction of all influences tending to impair the health of whites living and working in these districts. Proper provision must be made for the prenatal care of the mother, for skilled attention during childbirth and for instruction of mothers in the care of the new born. Children of pre-school and school age must be kept under regular and trained observation in order that factors of racial deterioration may be early detected and promptly corrected.

2. Medical Officers will be of a high professional standard specially trained in the prophylaxis and treatment of locally prevalent diseases. They will have been instructed in the requirements of hygiene administration in localities with a large or preponderating Aboriginal population and their activities will be co-ordinated by an authority kept in constant touch with all phases of medical service throughout the area.

3. Medical will be the best available and will be given at as reasonable cost as possible in order that

1. residents in these remote parts of Australia may receive proper medical care at terms within their means thereby sharing advantages enjoyed at present only by more fortunate urban population.
2. expense being no deterrent advice will be sought early even for minor maladies and full opportunity will offer for the further study of the diseases affecting the white settler in Tropical Australia;
3. the increased work resulting from (ii) will contribute to augmenting the work of the Medical Officer thereby reducing the periods of enforced idleness which at present play such an important part in causing discontent and inebriety. The very considerable increase of work associated with his duties as a hygienist will also serve this purpose.

4. Aboriginals, particularly those coming into contact with the white population will be regularly inspected with a view to the detection of disease. The issue of licences to employ aboriginals will be limited to persons to whom no objection is raised by the Medical Officer on the ground of ill-health, e.g. Tuberculosis. Employment of individual aboriginals will be preceded by Medical Examination and will be contingent upon good health. Proper arrangements will be made for the adequate care and treatment of diseased aboriginals.

THE EXISTING SYSTEMS

Even where the existing systems have not failed to survive the test of time they have not achieved or attempted to attain the objectives of medical service indicated.

In Queensland a local Committee in each village has maintained a cottage hospital on the basis of public subscription subsidised by the Government, until recently, on a £2 to £1 basis. The Committee has appointed a Medical Officer to the Hospital Superintendent at an annual salary calculated as sufficient to induce a practitioner to remain in the district and has permitted him to augment this salary by private practice. In addition a nominal sum may be paid annually by the Treasury for services in the treatment of Ophthalmia in schools and some £50 per annum by the Local Authority for the performance of certain duties as Medical Officer of Health for the Shire.

The system in Western Australia diverges less from the ideal indicated than does that of Queensland and herein probably lies the explanation of its greater stability. Medical Officers acting as Superintendents of Government Hospitals are paid their salaries by the Treasury. The salary is deemed to include payment for other duties performed for the Government e.g. magisterial. The work of Medical Officers is controlled and co-ordinated by the Principal Medical Officer at Perth and there is a close liaison between the Medical and Aboriginal Departments. Medical Officers are permitted to augment the salary by private practice. This system formerly obtained in North Australia but has been abandoned as unsatisfactory.

DEFECTS OF THE EXISTING SYSTEMS

Patently the most serious defect of the existing system in Queensland is its failure to survive economic variation in the remote North-west. There are, however, certain other very grave defects in both the State systems which indicate the desirability of reorganization. It may be remarked that these defects are more apparent in the Queensland system probably because Western Australian has not been concerned with such wealthy districts in the past and has been compelled to evolve an organisation upon a sound economic basis whilst Queensland’s system has developed  spontaneously during periods of comparative prosperity and has become universal in the State without regard to the ability of the individual district to maintain it. These defects are:

1. The basis of Hospital salary is inequitable and uneconomic. Under the Queensland system the salary paid by the Cottage Hospital Committee to its Superintendent amounts to a subsidy designed to retain a Medical Practitioner in the district. It follows that the smaller the population the few the subscribers, and the less the practice, the greater the relative proportion of the Medical Officer’s income to be found by salary. One resulting anomaly is that a small hospital like Camooweal pays its part-time Medical Officer considerably more than is paid by the much larger institution of Barcaldine and not much less than is received by the full-time Superintendent at Longreach. The salary is moreover out of all proportion to the value of the work done by the Medical Officer as the salary is moreover greatly in excess of the value of the work done by the Medical Officer as Superintendent. Furthermore the burden of maintaining the Hospital falls upon a devoted few who when themselves in need of medical advice or hospitalisation are required to pay full fees to the Medical Officer and Hospital. This defect is if anything exaggerated when the hospital has been proclaimed a District Hospital under the Queensland Hospital Act, for under these circumstances a rate is struck on land values. The individual holder of a large pastoral area becomes liable even in seasons of great loss – as in recurrent drought – for a considerable contribution yearly towards the maintenance of the Hospital and its Medical Officer. Quite commonly this sum may exceed £30 yet when this subscriber obtains advice or treatment for himself, his family or his employees he is liable for full fees. On the other hand the casual employee makes no contribution to the Hospital revenue and may claim inability to pay for attention received.

2. At present in these outposts of small and scattered settlement, under existing medical organisation, the activities of the Medical Practitioner are for the most part restricted to clinical practice – medical attention to the sick. Owing to the scanty population and the cost of service, work of this nature is necessarily limited with the result that –

1. the Medical Officer endures prolonged periods of enforced idleness during which, if he is keen and energetic he frets and become discontented. On the other hand if he is of idle habit owing to he lack of other opportunity for social relaxation and recreation and the trying climatic conditions he is likely to drift towards inebriety. The end result is that good men usually leave after a few months stay and appointments tend to fall and remain in the hands of drunken incompetents.
2. Lack of Medical Practice leads to professional deterioration for the combating of which no opportunities for post-graduate study are provided.
3. The urge to increase income to dimensions comparable to that of colleagues more fortunately situated drives the Medical Practitioner to the charging of disproportionate fees for work privately performed and for the long journeys sometimes undertaken. Patients are thus required to pay fees often far in excess of value received and fill-feeling is bred.

3. Difficulty is experienced in securing the proper examination and treatment of aboriginals. This work is distasteful to most practitioners and at best is perfunctorily performed. The utilisation of the services of part-time practitioners for this work has led to an inversion of the view of the relative positions of Government and Medical Officer. Instead of the Medical Officer being regarded as an Officer paid a salary to perform certain work, he is conceived as an independent person kind enough more or less efficiently to perform certain distasteful work for an inadequate remuneration.

4. The same difficulties attend the administration of hygiene. The separation, in Queensland, of allowances paid in respect of these duties from the general bulk of his salary gives the Medical Officer a totally erroneous view of the relative importance of his duties in this regard. Paid some £700 or so as Hospital Superintendent and some £25 to £50 per annum for hygiene administration, the Medical Officer neglects the latter as unimportant whereas its proper performance should bulk large in his routine. No effort is made to control endemic or epidemic diseases beyond the minimum required by the Health Acts and enforced upon him by the Commissioner. When special information is required by the Commissioner he must either visit the District himself or pay a special Medical Officer to conduct an investigation. No steps are taken to improve sanitation or educate the public, no antenatal maternal or infant welfare work is conducted, and with the exception of Ophthalmia work, the child of school age is neglected between the visits of the Education Department’s Medical Officer. Venereal Disease is only dealt with as a feature of general practice. Although the success or failure of white settlement in this region may ultimately depend upon the enlightened modification of white civilisation in consonance with the effect of the environment as determined by close study of the individual from the pre-natal period until death, no co-ordinated effort is made to study the acclimatisation of the individual or to record the clinical observations made amongst the population.

5. Co-ordination is impossible. Each District Medical Officer is an isolated unit with no access to the knowledge won by experience in adjoining districts or in his own district under his predecessors. Frequent change of officer deprives each district of the valuable experience won by the departing practitioner.

The sum of these defects and deficiencies is inefficient medical service. The lack of adequate medical service is one of the important factors determining the emigration of the female and her children and ultimately of the married man also. Depopulation follows and concurrently there is deterioration of the white stock remaining through miscegeny, venereal disease and similar factors.

These difficulties have been met in the Territories of North and Central Australia by a complete reorganisation of the system of Medical Service. This reorganisation has been directed towards eliminating the defects enumerated and conforming to the ideals of medical service already outlined.

1. Medical Officers are selected for suitability from applicants attracted by the offer of an adequate and guaranteed salary. The necessity for augmenting salary by private practice no longer exists and the right of Private Practice is withheld. By this means the Medical Officer is assured of an adequate income the scale of which is known to him in advance, whilst the pubic is protected from excessive fees.

2. Hospitals are fully maintained and managed by the Government. All fees for medical service whether private or Hospital are payable to the Government as reimbursement of the cost of providing the service. In order to avoid the keeping of accounts and in order to distribute the burden of upkeep, a voluntary Medical Benefit Fund has been organised. To this fund single persons contribute at the rate of 1/6d. per week and persons with dependants at the rate of 2/- per week. These contributions entitle the contributor and his dependants to free medical advice and treatment, free drugs and dressings, ambulance transport and hospitalisation, including maternity hospitalisation. The Medical Officer is permitted to charge the patient fees for surgical operations, anaesthetics and midwifery. In the case of the dependants of subscribers to the Medical Benefit Fund the midwifery fee is fixed by agreement at 4 guineas, of which two are payable by the Fund and two by the patient. This organisation serves a dual purpose of financing the service and ensuing treatment at reasonable cost for all maladies. It therefore serves to increase the work performed by the Medical Officer facilitating study and early treatment and reducing the time of idleness which young men find so irksome.

3. The salary is paid as a remuneration for which the Government requires a full performance of certain routine duties including besides the usual work of a medical practitioner, certain routine duties in Hygiene, Malaria and Endemic Disease control, Maternal, Infant and School Hygiene, Aboriginal Hygiene and Protection, Medical Surveys, add the compilation of records forming the basis of organized research into the influence of environment upon white settlers in Northern Australia. In this way, the Government is assured of a full return for its outlay, and the periods of idleness of the Medical Officer are considerably reduced.

4. An allowance of £100 per annum is paid towards the maintenance of a motor car by the Medical Officer and payment at the rate of 6d. per mile is made when journeys exceeding 20 miles from his station are undertaken. The actual cost of journeys to visit patients in distant localities is therefore reduced to a minimum and the patient is not at a financial disadvantage.

5. Co-ordination is effected by constituting all such Medical Officers members of a single service controlled by the Chief Medical Officer. Medical Officers thus guided and directed in their activities. The information and experience won in a district is available in future for that district and for other districts. The Medical Officers being subject to transfer are spared the monotony of prolonged sojourn in isolated and perhaps uncongenial villages and have prospects of promotion which compensate them for that sojourn. The knowledge that village residence is but temporary, the varied experience available from transfer to larger centres, the facilities for further study organised within the service all tend to remove the appalling prospects of deterioration which at present confront isolated Medical Officers in Western Queensland and North-west Australia. At the same time each transfer replaces an experienced man by other experienced man instead of as at present removing the Medical Officer with a sound knowledge of the district and replacing him by a recruit. 

The system is one which provides at once all those conditions required by the ideal service for this region and which removes all the remediable defects of the old. Experience in North Australia shows that it can be effected more economically than the old, the Government at once saving money and providing improved service. Our experience further shows that the increased revenue has been more than sufficient to defray the cost of additional Medical Officers who could not have been appointed under any other system. At the same time the conditions of Medical Officers individually have been vastly improved and appointments have been made to districts which could not possibly have attracted Medical Officers under the old system. One apparent drawback exists. The North Australia system is founded upon the mobilisation of the community into a Medical Benefit Fund on the lines of contract practice. The British Medical Association is opposed to any procedure which includes the wealthier classes in contact practice. In view of the fact, however, that the old method applicable elsewhere has definitely failed here, in view of the fact that the number of wealthy persons in the district is negligible and that the amended system is evolved as much in the interests of the Medical Officers as of the public, there can be no real objection to its extension by agreement with the British Medical Association to a specially defined area. If necessary an income limit of £400 may be imposed in respect of the right to medical privileges although from incomes over that sum the levy indicated should still be made in respect of hospital privileges. It is difficult to believe that a responsible and patriotic organisation such as the British Medical Association would oppose on principle alone a scheme for the better medical service of districts in which the existing system has failed, when that failure is full of possibilities of disaster not only for the local population but for the Commonwealth at large.

In view of the acute position which has arisen in North Western Queensland, and the very serious national consequences which failure to arrest this drift entails, it is recommended that the Commonwealth and the States of Queensland and Western Australia co-operate in the extension of the existing North Australia Medical Service to the districts of Burketown and Camooweal in Queensland and the Kimberley district of Western Australia. Explicit reasons for this extension and details of the necessary procedure in respect of Camooweal and Burketown have already been submitted by me and their prompt adoption is recommended. Further extensions may be considered as occasion and necessity arise.

In respect of Western Australia future medical appoints to Broome, Derby and Wyndham could be made through the North Australia Medical Service and the new conditions of organisation then adopted. Meantime co-operation could be commenced by the use of the Territory’s travelling Medical Officer. For administrative purposes in both States, local Medical Officers would continue to be directly responsible to the State Commissioners under the State Health Statutes, and would in addition be subject to co-ordination and direction in respect of local problems by the Chief Medical Officer, Darwin, who in turn would furnish regular reports to the Commissioners through the Department of Home Affairs concerning general matters affecting the States. The advantage to the States of adopting such a system would be the ready replacement of Medical Officers leaving or going on leave, by equally experienced men already trained in the Territory. On the other hand, in exchange for this advantage there would not require to be any sacrifice of the sovereign rights of the State in regard to health administration within its borders.

(Sgd.) Cecil Cook, M.D.

Chief Medical Officer, North Australia