PREFATORY
My purpose in tendering this submission is to draw the attention of the Board of Inquiry to what I believe to be certain fundamental requirements of the Medical and Hospital Service in the Northern Territory with which members may not be familiar, and the importance of which may not otherwise be brought to their notice.
I am not familiar with the considerations and the associated agitation which have led the Legislative Council to institute an expert enquiry into the Medical and Hospital Services of the Northern Territory. Of this, however, I am sure. In no other part of Australia has a population of similar size and constitution, even with Government assistance, been able to assemble funds adequate to develop and maintain for itself a service of the extent and quality currently provided in the Northern Territory by the Commonwealth Department of Health.
From my knowledge of the history of this area during my own life time, however, I can understand the reaction of its people to their inability to influence what they regard as a remote and unheeding bureaucracy. Criticism is always apt to be loud and bitter when the critic has no voice in the planning, no complete understanding of the purposes and no share of responsibility for the application of measures which in one way or another directly affect him and his peers. This disability is especially aggravating when the staff, the subject of the complaint, has no administrative nor disciplinary responsibility to the Administrator or other local authority accessible to the aggrieved.
The standard of the health and medical service required to cope successfully with the special environmental and racial problems of the Northern Territory will be beyond the capacity of the local population to finance or to staff. It would be most unfortunate if, to meet a reasonable demand for a voice in some aspects of its control, the quality of the service were prejudiced by vesting it wholly in a local body lacking the financial resources and expertise to sustain it.
I am not concerned to question or to defend the adequacy or the quality of the present hospital provision and administration in the Northern Territory. I have had no personal contact with nor first hand knowledge of these since my retirement from the Department. Rather do I wish to set out for the Board what I believe to be a basic standard of organisation and performance which may be used to evaluate not only that currently operating, but also any modification intended to improve it.
In doing so, I shall at times be critical of certain aspects of the present arrangement which I consider inconsistent with or prejudicial to good health administration.
HISTORICAL NOTE
In 1927, in recognition of the fact that native welfare and health administration were closely integrated problems which could not be successfully handled in isolation, the office of Chief Medical Officer and Chief Protector of Aboriginals were combined in the Territory of Northern Australia. Subsequently, and until 1939, the Northern Territory Medical Service and the Northern Aborigines Branch were administered together.
In 1939, a separate Native Affairs Branch was set up within the Northern Territory Administration, and the direction of the Northern Territory Medical Service was transferred from the Administration in Darwin to the Commonwealth Department of Health in Canberra.
The difficulties imposed on both disciplines by this dichotomy have been the subject of a number of discussions. Since 1950, the Commonwealth Department of Health has on a number of occasions sought clear administrative liaison with native administration. These attempts to achieve a close rapport with the native and his problems have had little tangible result.
SUBMISSION
In general, the problem of health administration in the Northern Territory are those of the rest of northern Australia and the chief components are:
- The tropical environment which favours the endemicity of diseases transmitted by arthropod vectors, or occasioned by parasites requiring a warm and humid climate for the successful completion of an extra-corporeal life cycle.
- The close proximity of countries where diseases of this sort continue at a high level of endemicity.
- The frequency and rapidity of transport by air between these countries and northern Australia, permitting the undetected introduction of infection by sub-clinical carriers or persons incubating disease.
In the Northern Territory, however, health administration is rendered especially difficult by the tremendous practical problems presented to the sanitarian by the unusual structure of the population which comprises two main racial groups living at entirely different levels of social development.
The greater member of those of European stock are settled in four main centres of population connected by the Stuart Highway – those of Aboriginal descent have been concentrated in missions and settlements remote from these. Apart from a few major mining centres, elsewhere settlement is sparse, widely dispersed and the standard of living ranges between squalor and modern civic refinement.
By far the greater part of the extra-urban population comprises a primitive people whose culture and social structure is disintegrating under alien conditions of existence. With the loss of their traditional culture they must also lose all sense of community obligation and of individual responsibility. Until this is replaced in a future generation adapted to the new order there will be no social attitude upon which the health authority could base a campaign for the control of preventable disease – infective, parasitic, nutritional or psychiatric.
The history of disease in the Northern Territory Aboriginal consistently demonstrates the peril of premature concentration of this hunting people into settlements without prior adaptation to the change. Over the years, tuberculosis, leprosy, enteric infection, helminth infestation, malnutrition, psychological maladjustment, have taken toll of life or well being.
The character of his pristine existence in isolation from outside contact and without permanent abode protected him from the communicable disease which have scourged more settled people, but did not equip him for community life – it permitted him to practice safely unsanitary habits which are fraught with danger for him now.
His diet, determined by the hunt and gathering from vegetable sources was well balanced and varied. On missions and settlements, fed from communal kitchens and bulk stores, he has had no opportunity of acquiring tastes which will assure his ability to choose from the shelf components for a nutritious, balanced diet. Nor can he be relied upon not to reject habitually important ingredients of a meal prepared and served for him as part of a well chosen settlement diet.
To illustrate the importance of individual cooperation by the patient in the control of disease, three examples may be cited.
Malaria
Whilst constant vigilance and methodical control may be successful in eliminating the dangerous vector A. punctulatus ferauti from the vicinity of settlements, wide spread flooding in the wet season preventing as it does even access to centres of potential transmission will effectually prevent control of even the less effective potential carriers A. amictus and A annulipes.
Malaria control in the Northern Territory for the present and for the foreseeable future, must depend upon the eradication of the parasite from the patient. This implies prompt notification or detection of attack and relapse, and effectual causal prophylactic therapy. Until the local population of whatever racial origin can be relied upon to seek appropriate treatment, and meticulously to comply with prophylactic requirements, it will be essential that the health authority have ready access to and effectual control over the human carrier of Plasmodia. This in turn implies a cooperation in hospital and in field practice only attainable, I believe, when medical staffing can be organised and directed as a cooperating team.
Suppression – a possible alternative – in a palliative device which perpetuates endemicity and risks the evolution of strains of parasites resistant to the drug used. It may be acknowledged that in continuing necessity to take regular suppressive drugs will discourage women from rearing families locally, and may unsettle the attitude of workers to employment in this environment.
Only with the utmost difficulty has malaria of recent years been controlled in the Northern Territory, and resurgence of endemicity and epidemicity are risks to be carefully weighed when administrative reforms are under consideration.
Leprosy
This disease currently poses one of the major problems in the Northern Territory. Its unusually high incidence in Aborigines, its involvement from time to time of European resident or of visitors to the Territory, its protracted course and incapacitating deformities when inadequately treated, are not generally realised in southern Australia. Only recently, the National Health and Medical Research Council as felt it necessary to issue a warning on this subject.
Control formerly attempted by segregation in special hospitals now relies upon initial treatment followed surveillance and maintenance therapy. Until all affected elements of the population can with confidence be relied upon to cooperate meticulously in this surveillance and maintenance therapy routine – and this is not yet – the health authority must rely upon the medical practitioner in the field and in the hospital to acquire the necessary expertise in diagnosis, and to be meticulous in policing this liberal method of control.
Hookworm
This debilitating helminth infestation is disseminated by contact of the skin with damp earth polluted by human excreta. Originally confirmed to a few limited areas to which it had been introduced by Asian pearling crews and indentured labourers, its area of endemicity has since been widely extended by involvement of missions and settlements lacking a satisfactory discipline. Worm loads may be so high as to defeat attempts to control the infestation by routine treatment.
Effectual treatment must be supplemented by strict measures of sanitary control. Admittedly, it is difficult to regulate the defaecation habits of Aboriginal toddlers, but the availability of damp, shaded ground for their use can be minimised.
Prevention of the introduction of the parasite to unaffected areas should present no difficulty to an enlightened and alert Native Administration.
Neglect of both these measures has facilitated, if not actually occasioned, the extent of today’s dissemination.
If the hazards to his future created by the disruption of his ecology are to be avoided, the conditions under which the Aboriginal lives must be kept under strict and informed scrutiny until he can undertake the task for himself.
Originally, the Medical and Native Administrations were combined, and there were better opportunities for this supervision and for the framing of policies to meet the conditions disclosed.
Since separation of these functions, the Medical Officer’s contact with the Aboriginal is episodal, and the usual sources of his information are brief clinical reports supplied by Welfare Department nurses or officers over a radio network, or communicated to nursing Sisters or pilots of the Aerial Medical Service. Opportunities for Medical Officers themselves to remain on native settlements for lengthy periods and to become familiar with this impact of social and environmental change upon the individual native are now relatively few.
Hazards to health which might in this way be detected and corrected before serious consequences many ensue, remain unobserved and unsuspected until an unacceptable level of morbidity or mortality prompts investigation. The necessary research into these occurrences I unusually entrusted to visiting teams with special expertise, flown up to the area for the purpose from southern capitals. In the result, medical and social research which should interest and assist the local Medical Officer is lost to him and is diverted to visitors who cannot remain in the locality to apply its results in prophylaxis. Apart from this, failure to detect the hazard in time means it is not appreciated nor studied until it has caused severe illness or loss of life.
SUMMARY
In summary, I commend to the favourable consideration of the Board of Inquiry the option that –
- Salaried medical and paramedical staff in hospitals should continue to be integrated into a Northern Territory Medical Service serving all sections of the population.
- Attention should be given to developing for this Service an acknowledged identity of its own.
- The Service should be afforded greater opportunity of participating in the planning and execution of welfare policies.
- Certain disadvantages of remote control by the Commonwealth Department of Health should be eliminated.
BASIC REQUIREMENTS
Essential to the successful planning and execution of health and medical administration under Northern Territory conditions are:
(a) Information – there must be prompt recognition of the pathological condition presenting in the hospital, in the clinic and in the field, and appreciation of its public health significance and the epidemiological hazards attending it under Northern Territory conditions. This in its turn implies thorough training of medical and paramedical staff in the recognition of these conditions, and in the action appropriate for each to be taken in respect of the patient and the community at risk.
(b) For the patient there should be no financial or other deterrent to the seeking of medical advice even for minor illness, for this may be of major epidemiological importance, and he can be no judge. For his part the medical practitioner must appreciate the importance of this close rapport and must welcome it and encourage it no matter how unnecessary or inconvenient he may at times feel it to be.
(c) Recognition of the special role of medical practice in the Northern Territory in observing and assisting the adjustment of the European to an unfamiliar and sometimes hazardous environment, and the protection of the indigenous race from new influences introduced by western civilisation – whether originating in communicable disease, environmental change, disruption of the social order or exposure to industrial hazard.
(d) Promptitude in the application of the appropriate corrective action. To provide this assurance, it would be necessary that the medical staff of hospitals should be fully integrated into the preventive medicine organisation of the Territory, and kept thoroughly familiar with the epidemiological, socio-economic and racial factors affecting the health of the population in the district the hospital serves.
Ideally, medical officers from the hospitals should be available to conduct medical surveys and special studies in centres of population within the district, the hospital administration including in its functions field research and the coordination and education of medical staff, the collation, retention and distribution of information – clinical, epidemiological and administrative.
(e) The closest cooperation between the Department of Health and the Director of Welfare in the planning and execution of policy – and this cooperation might well be included as an obligation in the official responsibility of both directorates.
Control of the Northern Territory Medical Service by the Commonwealth Department of Health, with its headquarters outside the Territory, is not without its disadvantages but these may not be insuperable.
Basic to all measures to improve health and medical services must be the creation of an effective liaison giving the Medical Service a voice in the planning of Aboriginal policy and an effective role at the point of execution.
Other matters which might profitably receive attention within the Department itself include:
- The integration of all branches of salaried medical and paramedical practice in the Territory into a medical service with its own identity.
- The Department, through its Public Relations office, might exploit the traditions of the Northern Territory Medical Service creating for it a public image more attractive to the aspiring young graduate than that of metropolitan medical practice.
Life and practice in the Northern Territory in an organised medical service can be more enjoyable, more rewarding and of greater professional interest than urban general or specialised practice, but there is no means by which the potential applicant for appointment could suspect this. On the contrary, advertisements for vacancies in Northern Territory hospitals are usually presented as appointments within the Commonwealth Department of Health – an organisation offering no particular attraction to an average young graduate interested in clinical medicine.
- Opportunities for promotion within the service should be developed. At present there is a tendency for officers to be promoted within the Department of Health, outside the Territory, where the valuable experience gained during their local service is lost to the Territory but can be of no value in the new posting.
- When experienced senior officers are transferred from the Territory, the opportunity to retain them in the Administration of the Northern Territory should not be lost. Senior officers, charged with the duty of directing the Territory medical services in Canberra, have usually come up through other disciplines and lack of specialised knowledge and local experience required to pass judgement on a recommendation from the Director.
- In Western Australia, the north West Medical Service allows medical officers three months study leave on full pay for each three years’ service, and a similar provision in the terms of appointment to the Northern Territory Medical Service should be considered.
- In times of staff shortage medical officers needed elsewhere are apt to be diverted to quarantine work which is accorded a higher priority. It is suggested that port surveillance still has its place, but that elimination of a receptive environment for quarantinable disease is today more important now that air transport provides so many opportunities for the undetected entry of disease by convalescent carriers or patients with incubating or sub-clinical infection.
These desiderata would seem to be best assured by the retention of a salaried service incorporating administrative field and hospital medical staff. The staff should be selected for medical competence and dedication to service – qualities only to be attracted perhaps to an organised service with a tradition and an enviable public image, to the quest of which I believe sustained and concerted effort should now be devoted.
The demands of preventive and therapeutic medicine in the Northern Territory will for a time at least demand from the medical profession practising there a degree of cooperation which on southern experience cannot be expected from the private practitioner.