The health problem created by the native population in the Northern Territory today differs in some respects from that confronted when the Northern Territory Medical Service was first established. These differences are due principally shifts in emphasis upon particular aspects of the problem, shifts which derive in part from the successes of the Service in the past, in part from fundamental alterations in the native’s mode of life and in part from changes in government policy.
The principal features of change have been:
- The native population is increasing in number. Unremitting efforts by the Medical Service to correct dietary deficiencies on missions and settlements, to encourage the provision of hygienic housing and sanitary facilities and to afford prompt treatment by 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 without regard to tribal sanction has favoured the rearing of large families. The introduction of penicillin has lead 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 of the native population which a few years ago seemed doomed to early extinction.
In 1954, the latest year in which native births were enumerated with reasonable completeness, these numbered 519, a birth rate in excess of 37 per thousand or 14 per thousand greater than the general Australian rate.
- The native population today tends to be segregated from the areas of densest white settlement. It is now concentrated on missions and settlements more or less remote from the white population. Only 8% of natives are now domiciled in the immediate area of densest white settlement and only some 13% of Europeans are dispersed amongst the heaviest native concentrations. Few natives are now employed as domestics in white households.
- In response to official intervention, the native family has largely abandoned its traditional mode of life and has moved to permanent fixed settlements. This concentration has aggravated the problem of controlling disease. Large numbers of susceptibles are now more or less permanently herded together under conditions of insanitation and without the consciousness of the individual’s responsibility to the community which must play a fundamental part in the prevention of communicable disease. With the abandonment of tribal life the rising generation is becoming progressively less competent to live comfortably in the security of the bush and more and more dependant upon permanent residence in a community. For the latter alternative he is not yet socially, economically or psychologically equipped.
- The old respect for tribal boundaries has disappeared and natives from all parts of the Territory move uninhibited far into areas which formerly would have been regarded as hostile country. It is now not uncommon for natives from the Centre to holiday on the northern coast and vice versa. The effectual quarantine imposed by the native’s respect for tribal boundaries has been lost and native migration whether in or out of employment has become an important factor in the dissemination of communicable disease from one area to another.
- Employment is no longer rigorously controlled and the native is free to barter his services and enter or leave employment without entering into a contract.
- Native affairs are now administered by a separate authority – the Department of Welfare, possessing powers over the native which the Health Authority lacks but unequipped with the medical knowledge and the hygiene consciousness which would permit careful appraisal of disease risks attaching to casual administrative decisions or fundamental changes in policy.
- The Commonwealth Director of Health is an officer of the Commonwealth Department of Health and is directly responsible to Canberra. The Director of Welfare who is charged with native administration is an officer of the Northern Territory Administration and responsible to the Administrator of the Northern Territory. The Health Authority, therefore although represented on the Legislative Council is not so placed as to be automatically consulted early in discussions of new policy or in plans to implement current policy. Where the application of native policy results in the creation of conditions likely to contribute to the wider or more rapid spread of disease or presenting increased difficulties of control, the Commonwealth Director of Health can do no more than accept these and endeavour to offset them.
Whatever environmental measures of control may be applicable locally or generally, successful prevention of disease in the Northern Territory will, in the ultimate, depend upon the intelligent co-operation of the individual.
The campaign against leprosy is based upon the prevention of contact between the susceptible and the active case and this implies prompt identification of the infective patient. Review of family and other contacts, of suspects suffering from conditions not at first confirmed as leprosy and of patients discharged as cured but subject to remission, can be attempted at arbitrary periods of convenient length. Even the most efficient system of review however cannot be guaranteed to avert multiple exposures unless the individual can be expected to submit himself for examination when required and to report immediately of his own violation, the development of any suspicious clinical sign during the interval between examinations.
Environmental measures for the control of hookworm must inevitably fail unless supplemented by the constant conscientious and universal co-operation of the infected in the elementary requirements of sanitation.
So difficult is the environmental control of malaria that for some considerable time at least, the Northern Territory Medical Service must rely chiefly upon the complete cure of the gametocyte carrier. The success of this method will be directly proportional to the degree of co-operation proffered by the population – every pyrexial attack in a convalescent or a contact and every condition resembling malaria affecting any person exposed in the endemic area must be infallibly reported.
All these requirements demand of the individual and of the population, an enlightened sense of obligation and responsibility which cannot, in his present stage of development, be expected of the native. There can be no prospect therefore of successful control of endemic disease in the Northern Territory until the native has been trained to a standard of hygiene consciousness impelling him voluntarily and invariably to discharge his personal responsibilities or until the social organisation of the tribe has been so developed that the unco-operative individual will still be readily accessible to the Health Authority.
The basis of all planning for native welfare and health administration in the Northern Territory must be recognition of the indissoluble linkage between them and acceptance of the principle that both agencies must function together in policy and in routine administration. Whilst there is no function of the Department of Welfare with which the Health Authority is not concerned and which the latter could not, if suitable expanded, undertake, there is by contrast a broad segment of medical and health administration which the Department of Welfare could not take over from the Medical Service without substantial conversion.
On either side of any artificial line of demarcation intended to define the limits of responsibility of each Authority, there must always be a broad and ill-defined band of dual interest within which the functions cannot be arbitrarily segregated without causing confusion and inefficiency. The interests and activities of both will bring them into contact and unless there is good liaison, into conflict in this border zone.
Instances of this duplication of interest and responsibility repeatedly come to notice. The recurrent differences of opinion regarding the responsibility for the professional staffs of native hospitals and clinics may be cited. Unless co-operation is unstinted some segregation of responsibility is likely to be attempted, staff may be duplicated or both authorities may be brought into competition in seeking Public Service Board approval for the appointment of staff to discharge similar duties. This competition has already been evident:
- The proposal of the Department of Welfare to appoint catering officers to native settlements and the compromise proposal by the Public Service Board that the services of the Northern Territory Medical Service dietitian should be used in this capacity.
- The appointment of “social workers” by the Department of Welfare to visit the homes of mixed blood and native families to assist in their domestic education, to supervise child welfare and to report upon social problems.
These appointments compete with the need of the Northern Territory Medical Service to appoint district nurses to perform a similar function in the field of preventive medicine and to conduct the medical review and home treatment of sufferers, suspected sufferers and contacts of leprosy and other endemic diseases.
Formerly, to assure its access to the native in employment, the Medical Service took advantage of the legal requirement that the employee and employer must enter into a contract. To control the dissemination of disease by migration it used the prohibited area clauses of the Aboriginals Ordinance. In the safeguarding of remote tribes it was assisted by their aloofness and respect for tribal boundaries and influences tending to break these down were discouraged so that contact with centres of infection could be postponed. For a variety of reasons the Service has been deprived of these adjuvants to prophylaxis in recent years. Employment is not controlled, the prohibited area clauses are virtually in suspension and the policy of the Department and of church organisations is to encourage concentration of remote tribes at central missions and settlements. This concentration is assisted by substantial financial grants from the Department of Social Services.
It is submitted that these fundamental changes in native policy could profitably have been discussed beforehand with the Department of Health so that adequate alternative safeguards acceptable to both interests might have been devised.
No measures for the prevention of disease in the Northern Territory can be expected to be successfully applied unless officers of both agencies concerned – Welfare and Health – share a common and full understanding of the viewpoint and requirements, each of the other, and unless the measures themselves are so designed that they can be applied effectively and smoothly to the advantage of both and without embarrassment to either.
The Commonwealth Government has adopted and set itself to implement the bold and laudable policy of assimilating the native into the general community. The development of any successful system of preventive medicine in the Northern Territory depends for its planning and for its execution upon the elevation of the native to accepted European standards of education and behaviour. The executive departments immediately concerned, Welfare and Health, are therefore partners in a common enterprise.
Only irretrievable failure can be the outcome for the Government’s policy unless endemic communicable disease is brought completely under control. The Medical Service therefore, will play the dominant though perhaps not the titular role in the realisation of Commonwealth policy. For the performance of this role it must not only have unrestricted powers of access to the native, but must be assured that unilateral decisions of policy and expediency taken by the other partner do not impair the efficiency of the prophylactic instrument or involve repeated changes of method to meet new artificial conditions.
The time has come for the Commonwealth Department of Health as the agency upon which the ultimate success or failure of the enterprise depends, to asset its right to an effectual voice in policies of native administration. More is at stake here than the future of the native race. The very survival of the white component of the population in the north will be in jeopardy unless the Northern Territory Medical Service can eradicate or at least reduce the incidence of endemic disease before expansions of settlement at present projected are undertaken.
For the immediate future, effectual health administration in the Northern Territory demands:
- The closest liaison and co-operation between the Welfare and the Health authorities at both Territory and Canberra level. In this way not only may control measures be readily applied methodically and systematically, but –
(i) Overall government policy may be guided by an enlightened understanding of the medical problems involved.
(ii) The Director-General of Health may have timely advice of changes in policy and procedure which are under consideration by the Department of Territories. This will enable the Director-General to accommodate his own measures to assist the implementation of the new policies and to assure that consequential health problems likely to be created by them are foreseen, met and prevented from impeding their successful implementation.
(iii) Any unforeseen but unavoidable change in staff in either the Department of Welfare or the Northern Territory Medical Service which reduces the level of local experience will be offset by continuity at higher level.
(iv) The tendency to overlook the interests of the Northern Territory Medical Service in aspects of native administration in which the health significance is not obvious will be removed. The present organisation is such that both in Darwin and in Canberra the Health Authority is in some sense remote and it is of importance this this apparent detachment should be eliminated.
Co-operation at the executive level in Darwin has been freely forthcoming of recent months and at a conference between representatives of this Department and the Director of Welfare in April last, general agreement was reached on the facilities to be afforded by the latter to assist in the detection of disease, the control of association, the regulation of diet and the supervision of missions.
To facilitate the liaison and co-operation at the Canberra level it is recommended that a small interdepartmental committee be set up here to discuss in advance proposed changes in Government policy affecting native welfare and to inform the Ministers of Health and Territories on the broad implications of change as it may affect each Department.
- Education of the native population and welfare officers and mission staff in the health problems involved in the concentration of a primitive and unenlightened people in permanent and semi permanent settlements must be actively undertaken.
(i) Regular schools of instruction in hygiene and sanitation should be conducted for welfare officers, education officers and mission staffs each year. These courses should train the officer, not only in the hygienic management of settlements but in methods of imparting to natives the knowledge of the etiology of disease and the individual’s responsibility in control.
(ii) Special courses should be provided as often as practicable and not less frequently than twice a year for the training of native instructors who may service as sanitary supervisors and vernacular teachers amongst their own people.
(iii) More advanced courses should be conducted for the training of natives in laboratory techniques designed to facilitate constant surveillance of the incidence of hookworm, malaria and other infections on missions and elsewhere.
These schools should be conducted in quarters permanently set aside for the purpose of development as a museum and school and equipped for training natives in elementary laboratory techniques.
To supplement this training, district nurses should be appointed to pay regular visits to dwellings occupied by families of mixed and native blood in order to encourage and advise them in raising the standard of living by the adoption of hygienic domestic habits and to assist in the review of carriers and contacts of infectious disease.
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Employment for the Armed Services is arranged by mutual agreement between the Adjutant or other authorised officer of the Service concerned and the Superintendent of the Bathurst Island Mission. The Mission arranges for batches of employees to be transferred from Bathurst Island to the employing Service, the batch being changed at intervals of a few months. The engagement of an individual employee in such a batch is theoretically recorded with the Native Affairs Department, but officers of that Department were unable to show me that these records were meticulously kept, or even that they had at any one time the remotest idea of the identity of the natives employed by any one Service, or of the duration of their employment.
Medical examination of the native entering employment, previously a matter of strict routine, readily imposed, is now impossible. Nor has the Health Authority any means of preventing the employment of a native by a person regarded as medically unfit to be an employer. Only in Service employment does pre-employment medical examination appear readily practicable; but even here it has not been carefully applied. Following a discovery that natives suffering from leprosy and tuberculosis in an infective form had been at times employed as domestics in Service households where there were young children, Commanding Officers of the Services agreed with the Deputy Director of Health that periodic medical examinations of these Natives should be made. It was arranged that these examination should take place “as soon as practicable after engagement”, and not as a pre-employment precaution. This in itself is as a condition largely defeating the purpose of the examination. At first, examinations were made by medical officers of the Northern Territory Medical Service; later as one or other Armed Service acquired a medical officer of its own the work was delegated to him. With the inevitable changes of personnel there soon developed a situation where a Service no longer having its own medical officer and having a new Adjutant omitted to have the medical examinations undertaken.
Meantime diversion of this duty from the Northern Territory Medical Service left new staff in the Health Authority without any knowledge that the examination was required to be made or that it might not be made. In the result, infective natives have again been employed in the Services, a fact revealed not by any organised medical review but quite fortuitously. Whilst I myself was in Darwin, a leper discharged from Channel Island was accidentally encountered near the Administration Headquarters by a medical officer alighting from a motor vehicle. Interested enquiries as to his health and movements revealed that he was employed by the Army, although he had been discharged from Channel Island to Bathurst Island under treatment and surveillance. The Superintendent of the Mission was responsible for his retention at the Mission for those purposes. It was also ascertained that he had been in the Darwin area at times when the medical officer had visited Bathurst Island to review cases of his type. Notwithstanding the organisation theoretically designed to ensure effectual review, the fact that he had not been presented for examination was overlooked, no enquiry was made as to his condition or whereabouts and the Mission was not called upon to account for him.
The Department of Native Affair reports that from 180 to 200 natives employed in Darwin live at Bagot. About 300 work in Darwin, and those not in Bagot live in camps at the ten mile, at East Point, Shell Bay or West Arm. They drift in and out of Darwin possibly entering employment for a week or two, and return to the bush. Natives in unsupervised camps, in uncontrolled employment or at large in the Town area constitute a distinct health risk. Leprosy malaria, tuberculosis, hookworm and venereal disease controls are completely frustrated. Formerly this form of migration was prevented by strict application of the “prohibited area” clause of the Aboriginal Ordinance. Natives in the Darwin area were required to live under supervision within the native reserve except in a few cases where permits to reside on the premises of the employer were issued. In such cases, special precautions and opportunities for supervision were demanded. Officers of the native administration and the Police were active in enforcing this control which was applied strictly and with reasonable success.
It now appears that a direction has been issued from the Department of Territories that Police are to exercise a greater discretion in enforcing the “prohibited area” clause of the Native Welfare Ordinance. Confronted with the situation that acting as they suppose on behalf of the Native Affairs Department in arresting migrant natives, they as a result find themselves challenged by that Department for exceeding their duty, it has become the policy of individual Police officers if not the acknowledged policy of the Police Branch, completely to ignore the presence of natives within the town area or within its vicinity, unless a police offence is committed. Removal of natives from unauthorised camps to Bagot reserve has therefore become the exclusive responsibility of the Native Affairs Department officers who admit that they cannot possibility cope with it.
In the result the Health Authority today is unable to:
(a) Submit natives other than those on missions to regular medical inspection for the detection of communicable and other diseases.
(b) Avert the employment of infective natives in households where there are susceptibles, including children.
(c) Protect the native from employment under conditions in which he is exposed to communicable or occupational diseases.
(d) Prevent the dissemination of tropical diseases, e.g. malaria and hookworm, by the entry of carriers into receptive environment.
To correct this situation in the interests of both the white and the native population, it will be necessary to secure a much closer degree of co-operation between the Welfare Branch, Department of Territories and the Northern Territory Medical Service, not only in routine administration but in the forming of policy.
The recommendation frequently made by this Department on previous occasions is reiterated, namely, that a small inter-departmental committee be set up in Canberra to discuss in advance, all proposed changes in government policy affecting native welfare and to inform the Ministers of Health and Territories on the broad implications of proposed changes as they affect each Department.