Been on a pocast…Dr Luke Crantock, Everyday Medicine
Few of us blame the Government for this virus pandemic but on a dreadful day when Australia has twice as many new cases as China (and a 60th of the population) we have to ponder whether we have done enough. Peter Wener in the Atlantic points to a major issues in the USA such as, “… the decision to test too few people, the delay in expanding testing to labs outside the Centers for Disease Control and Prevention, and problems in the supply chain. These mistakes have left us blind and badly behind the curve, and, for a few crucial weeks, they created a false sense of security. What we now know is that the coronavirus silently spread for several weeks, without us being aware of it and while we were doing nothing to stop it. Containment and mitigation efforts could have significantly slowed its spread at an early, critical point, but we frittered away that opportunity.” It sounds a lot like us. Five hundred people getting together at the moment is NOT safe. It is very hard to get tested, and we are being told it may be more difficult.
We have seen TV presenters, film stars and politicians come down with the virus. These people certainly mix with more people than we do day to day, but there are not many of them. So if we extrapolate back from their numbers and determine the rate of infection we will arrive at figures many orders of magnitude above that being reported. Let’s face it:
It is infectious, it is deadly and we need to stop it.
Economic predictions of impact are unlikely to be accurate and should not be listened to. Minimising the spread of the virus will have the most positive economic impact. Short, sharp, severe. Norman Swan has been getting air time to promote more health of the nation approaches. If we stop the growth, we can reopen schools and kindergartens. We can probably keep schools open now for children of emergency workers, health workers and other services that are understaffed.
Most of all we need to consider testing. At the moment we are testing a lot of worried people and groups of people who are in contact with an infected case. If we take a community view rather than an individual view and extreme social distancing is in place, we can check one member of a potentially infected household with symptoms and declare it positive or negative. That household should then be supported at home. Children are likely to be infected very quickly and have no difficulty. The disruption of treating individuals in this situation is massive and quite likely to lead to asymptomatic people thinking they are clear. Household members over 70 in infected households can be removed if asymptomatic and offered alternative accommodation if they do not have the virus after brief quarantine and testing.
Small towns with limited movement in and out can test the first locals with fever, and no travel or contact, as sentinel cases. If the sentinel febrile person is negative then we can assume safely that other fevers in that community are almost certainly negative for a period – perhaps the next seven days. This will be especially important when we add the usual winter viruses to the mix. Obviously any new arrivals with symptoms must be tested.
Regions, such as Central Australia, Cape York and Northern Western Australia (and many others) lend themselves to a regional community approach with community-based testing. The experts on our nation’s 60,000 year old cultures are at grave risk and require extreme measures of preservation. This requires checking all arrivals into the region (which is often one or two roads and an airport or two) and testing any of these who are symptomatic or develop symptoms over the next 14 days. We can tell them when we check them at the regional boundaries. In two weeks they become part of the “viral control” community. We will need sentinel testing in communities, perhaps one or two tests per week. The extraordinary thing in Central Australia is that this will require less than 100 tests a week. If we can “bank” the saved tests, we will be able to carry out contact tracing in the way Singapore has done.
If we are short of tests, lets think about how to use them effectively. It is time for extreme social distancing. Whatever we are putting in place, we need to know where the virus has spread.
I met a woman with two young children and a sore arm this week. Her husband broke it in a violent outburst and she took the plaster off because it was too itchy. It was healing well. Her husband was in jail. Later, at Ingkintja, the men’s clinic, I saw a man in his mid 30s who had taken on work and rented a flat since coming out of prison for violence and alcohol. He was bright and sophisticated. He didn’t want to go back but he had quit his job because his boss was unreasonable (long story with good insight). Centrelink could help him after 8 weeks. He was distressed, anxious and hyperventilating. What to do?
I see myself as a feminist, largely due to living with Merridy and letting her advice and thoughts through my defences from time to time. I am serious about it. Despite this, as a young man I slapped her once. On the face, hard. It was nauseating. I did it to my mother once too, as an adolescent. I never saw anyone else be violent to women; it was in me. I am ashamed to admit it, but when I do, occasionally others speak up. Once a dear and gentle friend told me how he lifted his young bride by the neck up against the wall. Just once. They both laughed as they told me the story. Merridy slapped me too, once. She’s quite strong. She immediately apologised; probably quicker than I did when I hit her.
Family violence has been gradually gaining attention over the past 40 years. My father could beat my mother with impunity; he didn’t, but he could have. Even watching in the emergency department as a young medical student in the 1970s doctors would not get involved with family stuff. Nor would the police. We would feel pity and patch it up. The first laws regarding family violence in Australia were national in 1975. At that time abused children were said by paediatricians to have Silverman’s Syndrome which was “discovered” in 1962 based on multiple healing fractures on Xray! We now call it child abuse. Reporting of child abuse became mandatory in the 1980s. In the NT family violence has been a mandatory report by any suspecting adult since 2009.
Now I am living in Alice Springs and there is apparently more violence about although I have not witnessed any. Rod Moss, the painter, has written a wonderful account of his relationships with local Aboriginal people called “The Hard Light of Day“. It is largely uncensored and observational, without much judgement. It is hard to read at times and tells stories of the shortened life of men who often spend time in jail, and their suffering women. This has a lot to do with family violence and a lot to do with alcohol.
Peter Sutton in his controversial work “The Politics of Suffering” has a more scientific angle and has investigated historical violence in the Wik people at Aurukun. He makes estimates of murder rates of women before contact, during the mission days and following that. Interestingly quite high rates dropped to virtually zero during the mission influence and have been higher still since. There is general concern about the level of death from violence in the NT. It appears to be warranted from anecdotal evidence and also from national statistics. Some years, such as 2010, all murders were of and by Indigenous people. One surprise, it affected both genders equally; the victims and perpetrators half male and half female. This is surprising to me. I looked on “GooGoo” and discovered there is a national effort to increase knowledge about male victims of family violence. Is this correct?
Australia as a nation has a very low homicide rate at 1.3 per 100,000, inherited from the UK which has been at this level since the 16th Century. The NT murder rate, as high as it is, is still far less than Brazil or many other countries and even when applied to the Indigenous population alone (15/100,000) is far below many cities in the USA such as St Louis, Baltimore or New Orleans which run at over 40/100,000. Alcohol is universally involved here. What are we doing about it? There appears to be one approach from the outside; we are incarcerating Indigenous men. Anecdotally, their assaulted partners visit them in jail and defy Restraining Orders to be with them once out.
There is more to this. My close Aboriginal friend, Ada, surprised me when we were working together in medical education in the 1990s. She had been the victim of domestic violence interstate and had separated from her partner. She attended a seminar on “Domestic Violence” with GP Registrars and came away quite perplexed. “I don’t call that violence”, she said to me. She had obviously been affected by the issues raised. We discussed the fact that it has only recently been seen as violence in the broader Australian society, and that I probably didn’t either until I was educated about it.
What happens when we apply our own legislation, based on an understanding arising from recently changed culture which aims to reduce already low levels of violence, to a population that has limited education in these matters and a relatively high pre-existing rate of violence? The answer would appear to be incarceration. Of men. To an unholy extent. To the shame of our country.
Is there an alternative approach? I was very impressed with Judge Roger Dive running the drug court in the recent “Ice Wars” program on the ABC. He has been working since 2004 keeping drug users out of prison and has developed an almost parental relationship with those in trouble. Could senior Aboriginal people work with someone like that to get an alternative approach to the use of alcohol and violence? The reason to do this is to try and get some community authority into the mix and communication and education as well. Just like those using drugs in Sydney, locals are using alcohol and drugs with similar consequences; and if it goes on long enough then it escalates. Does incarceration help? It does not appear to.
Apparently, I learned very recently on Friday night at Monty’s, this has been tried before in 2011. The SMART Court (Substance Misuse, Assessment and Referral for Treatment) was established in 2011 but then removed by the CLP in 2013, labelled “do-gooder”. Megan, a nurse working now for Congress but who was one of the SMART Court clinicians, was mortified when it closed; couldn’t believe it. I told her that people must forget very quickly as no one had mentioned it to me!
If a judge and Aboriginal elders were to reconstitute a suitable alcohol, drugs and violence court in the model developed by Judge Dive and the SMART Court , it would have to be a long-term bipartisan or Federal commitment. The decision makers would have to learn how to influence young people setting off on a path of violence. Other agencies would need to understand their role. The range of sanctions might be broader and more culturally sensitive and possibly include:
- Having intermediate educational and supportive environments which could take people who were doing well
- Having secure social environments where fathers, mothers and children could mix safely and with zero tolerance of alcohol or drugs – this might include after school centres or other facilities with security precautions
- Enabling community feedback to people with a history of alcohol or drug induced violence on a path to recovery in a safe way.
I have discussed this with some leading men at Congress. Steve, a visiting GP with a lot of experience in the NT, advised me to steer clear. He might be right, but I can only see opportunity. A lawyer from a women’s legal service came to see me and I raised this. Not sure what she thought. JL, the lead of the Ingkintja Clinic at Congress is talking to me about it, very aware that it can look like I don’t care about the women and children. That is what makes it so hard.
As a rural kid you learn that not everything comes past your door. I went away to school in the city and I could feel the difference. I didn’t like all of it but I liked the opportunities that seemed to present themselves. My parents had to move to a small house to keep it all going so I felt obliged to do my best. I road with Merridy to London and thrived; we spent 12 years there and had 4 children. It takes some bottle to head back to smaller places. The smaller the place, the more bottle.
Mutijulu is the furthest out of our (Congress’s) five remote clinics. I have learned all their names and some alternatives. (The Santa Teresa local names are still beyond me, but I have got Utju and Ntaria now). To get there Teena, Samarra (the team), Ann (from policy) and I take the 30 minute tourist flight west from Alice. I let some Germans have my window seat. The rain nourished African and Asian buffel grass works its tortured agar shapes as we come in to land, crowding out the bluer resident spinifex in many areas. Then there is the rock. Wow….. We get a car and drive through the park gate with a nod from Teena and the ranger. Everyone knows Teena.
Mutijulu is just to the east of Uluru where non-Aboriginal visitors gathered in the old days. Like Yulara for tourists today, Mutijulu is a centre for Aboriginal people from all around. No Sails or restaurants here for visitors though, just mats or cars as bedrooms. The population is running at about 3 times normal due to ceremony. We arrive at the clinic which is a Heath Robinson affair; disconnected, different parts in different styles, lean-tos and dongas tied together with electricity cables, all donning a modern shattered solar panel which has a pram on it! All this wrapped up in high fencing including a car park and a cage for the ambulance bay which leak with neat round human-sized holes at regular intervals. It looks like something from the war in the Iraq.
We meet the staff. A nod and a wry smile from Maria, the new clinic manager. She takes an angle on life which is not familiar. She has worked as a remote nurse for many years, diluting her angled Italian features with flavours from far flung places. A pair of sidelocks hang on each side of her friendly face like Hasidic payots. She is new here and an unknown to Sinead, a tall Irish nurse and midwife who has been working in remote and deprived parts of the world forever. They have two colleagues who are relieving for a while. Dr Julie is here too. She is an experienced remote doctor who survived taking care of the victims of the boat disaster on Christmas Island in 2010. She lives in Yalara with her husband who is the Park Ranger. Robby and his sister are working here; two locals who really know what is going on. Robby is busy with ceremony and his sister chats about how things are going. So many people wandering around town, awake all night, playing cards and having fun. Some break ins and damage by some of the young people. The shop too.
Robby has started training as an Aboriginal Health Practitioner and will be in Alice in a few weeks. I help with some stuff I promise not to talk about. It changes my view of myself as Australian, like my brain grew a little, pressing on my skull.
The toilet is blocked so patients have to use the one entered through the doctor’s room. You can hear and smell the consequences – sometimes there is a rush into the room and an accident. Dr Julie is not sure how long she can take it. The blocked toilet is part of the Heath Robinson construction with drains added to drains. It’s not going away. Bob the (local) builder charges $400 to clear it but it blocks again. It makes everything I take for granted seem so fragile and temporary.
We drive to dinner in Yulara and pass the Mutijulu swimming pool which is exploding with golden spray and gleaming children as we squint against the massive setting desert sun. The rock provides mood lighting above its recent rain nourished green beard.
The staff, like the locals from Mutijulu, are not allowed to drink at Yulara as Mutijulu is a prescribed community under the rules of the Intervention. This is not law but regulation to prevent upsetting tourists with intoxicated locals. Take-away alcohol is illegal. Sitting in the excellent restaurant we have many young Aboriginal people serving fine food and we hear about Sinead’s life. From Ireland to Africa to Canada and all over then to Australia and Mutijulu. She has been a fierce advocate for home birth, particularly in Canada where she did her midwifery training and her remote practice. We share a lot of heroes including Yehudi Gordon and Janet Balaskus who took care of Merridy and I when our children were born. The day I spent with Michel Odent is interesting to her. We share birthing stories – her’s are far more exotic than my London and Darwin homebirth stories. Respect.
I work as the Malpa that night, supporting Sinead on a call out. Two staff have to go to every call-out now due to a recent murder of a nurse in the PTY lands to the south west. Sinead works her web of magic with the family, slowly carefully, showing mother, aunty and grandmother care and attention. The febrile child settles and heads home in arms, cooler for the outing.
I vow to do what I can to get everyone I know to contribute to getting a beautiful clinic at Mutijulu, a place that reflects the values of our Board and managers. It is, after all, our most visible remote community and should reflect in part the offerings we make to our overseas visitors, many of whom have made less effort to get here than their Aboriginal shadows behind the grand ol’ rock. Now that’s a job.
Time to put some cards on the table so people can feel my aspirations, knock the edges off and gather shape. I came with some ideas about what I might achieve, and I presented them to the clinic staff. I feel a little at risk sharing my ideas early on but I want to take people with me if the innovations might be helpful.
My themes are simple but derived from my reading and experience both within and outside medicine. First, I want us (Congress) to be the best in the world at some things, and if we are already, for that to get known. We need to do things well to have an impact in health. I have chosen dealing with people with multiple health problems or co-morbidities as a genuine opportunity for Congress to stand out. A search on the internet (“GooGoo”) finds a number of papers and an Australian literature review confirming that no one really knows how to deal with patients like this, that is, many of our mob. If we just treat each separate condition according to the guidelines our patients will have no life other than health care. We amplify the patients’ burden of disease as they either soak up all sorts of outpatient visits and investigations or just turn away and get on with their already multi-dimensional and complex lives. How to compromise on patient effort and give some real benefit? How to feel it all from the other perspective?
Second, I want to change the idea of team to a dynamic concept; the team that suits the person we are with at that moment. It will vary a great deal depending on the personality, experience, the conditions, the person’s family and other supports. We need also need to vary our role; offer different knowledge and skills to different people at different times. It is maximising the relevance of the resources we have to hand at each encounter. I learned it at Palmerston Super Clinic from Chris Harnden and Sue Chambers. It requires preparation and focus. Patients then vote with their feet.
Third, I want to see if we can consult more effectively with multiple people at the same time and with the same sort of conditions (known as shared medical appointments). Will people like that? Will it impinge on their privacy? I think it will allow them to discuss what is going on and why. How did she get a better reading than me? What does it mean if your kidneys are not working as well as they might? What can we do that makes a difference? It is definitely a foreign concept in Australian medical practice but many of us have seen it work in special circumstances.
Finally, health care for chronic disease means very little to many people in the community; there is no experience of benefit from all of our interventions, except perhaps in late stages. It has to be accepted on trust and requires considerable health literacy. Congress carries a lot of trust; it belongs to and works for our patients and community. We can gain further trust in two key ways: an ongoing satisfying relationship with individual patients and effective management of acute illness. Both are palpable and offer clear value.
I think I did OK. It was a big audience for a GP and a lot more Aboriginal people than I usually speak to in such a setting. Some Aboriginal health practitioners, general practitioners, nurses, interpreters, receptionists, Aboriginal liaison officers, podiatrists, dieticians and drivers. A number of people drop past my room after this. I made a few friends. I hear some concerns and some ideas from a variety of people. Glen, the interpreter tells me about his after hours efforts to get a new opportunity out of town for kids who are niggling the police or courts. I promise to go out with Tony the bus driver. I confess I haven’t done that yet but I know my reputation will depend on it. But first I’ve got to meet the people working and living in our remote townships.
I started work. Well, I have been in a wash of information and glimpses of what is to come. Fortunately Samarra started on the same day and will be a key part of the team I am ostensibly leading. And Teena, another key team member, was there too. Both have been in Alice for a very long time and seemed to know everyone. Teena has done most jobs in Congress and is the local Wikipedia; she takes (great) care of the remote teams. We are to oversee the 3 town clinics and 5 bush clinics . Mutijulu is the furthest out at Uluru (“the rock”). We also have doctors at Alukra (women), Ingkintja (men), Headspace and in a variety of teams for the frail aged, disabled and people with kidney disease.
My introduction to the workplace and town is spread over five days, organised by Victoria. She is youthful, helpful and sharp; if in doubt, “Look it up on GooGoo!” Despite training from 12 grandchildren I have yet another vocabulary to learn here. A sort of international creole. Everyone is friendly, smiling, laughing. Its still raining so we can talk about the grass which is growing tall like spear grass in the very wet north. Not just snakes that I have to prepare for but moths, mosquitoes, locusts and, to the horror of many, mice.
I am clearly working for a mature and Aboriginal organisation. My boss Tracey is Aboriginal, as is her boss, the CEO. I am introduced to people passing by, or some just come into the room. My impression is that there is joy in the place, lots of energy. Commitment is obvious with concern for the Mutijulu community which has been flooded and now has an influx of people involved in ceremony that outnumbers the local inhabitants. Maria, the new clinic manager is having to swim against a lot of currents to keep things operational. She is the long distance type.
I have a phone and a car and a desk and a computer. I have brought my tools of the trade and have rescued them from boxes of guitar and microphone leads. I put them into empty draws in my desk. Stake my claim on reality. I have to learn to use Communicare, the health record system. I used it in the late 90s at Bagot in Darwin for a while but it has developed a great deal. No one seems to know exactly how to use it for everything, and some of the remote clinics had their own installation before joining Congress and the alignment is taking time. I know I can help with this.
This organisation is definitely a 21st century operation in a place of wonder and ancient ways. Aboriginal culture, mixed with Central Australian religious influences and business best practice; as a result a young Aboriginal man named Jonah fixes all my IT concerns. I get an email asking for feedback. What can I say?
There are some other cultural influences. Eric from South Africa runs the business department and is a very active and influential character. He knows how much Medicare each clinic claimed last week. I sense he has changed many things. Chipo from Zimbabwe manages risk. She is a force, managing accreditation, incident reporting and work health and safety. And Bipin, who runs CQI (continuous quality improvement) gets the data people need. In the clinics there are doctors from Australia, New Zealand, Belgium, Sri Lanka, China, Britain, Myanmar and Zaire. Many working here for more than 10 years and one over 20. I am the oldest though.
I am meeting an old place that has always been threaded with colour. I’ve got to choose my depth of field and focus. Best find a few people to help me with that.
I am a 61 year old general practitioner (GP) and I am on the move. With my family’s consent, I have accepted a job that will take me a way from most of the things I love and, I anticipate, challenge me more than any so far. I am heading to Alice Springs and the centre of Australia. I am a saltwater person so leaving the sea is painful, but I have my music with me.
I will be working in a number of clinics spread along the McDonald Ranges. The region goes as Central Australia, almost a state or territory of its own. Like most Australians I live 1500 or so kms away; in my case to the north, directly north, in Darwin where I have spent the last 25 years as a GP and educator. Darwin is the capital of the Northern Territory which includes Alice Springs but only part of Central Australia – of which Alice Springs is the unofficial capital. I have visited Alice Springs many times for a few days at a time, teaching or passing through when driving up and down the track to Adelaide and beyond. I have even seen the famous Todd River flow three times. That used to mean that you were never leaving Alice. It flowed again just before I got here so everywhere is green. That means first flowers and then snakes. I better be ready.
I took this picture in the Todd last night and wondered at the inhabitants. A group of Aboriginal people chatting with children playing, a group of Asian men playing volleyball and thousands of tadpoles trying to mature in the rapidly shrinking puddles. I have asked a few people where the Todd River goes. People just shrug their shoulders. Surely it joins the Finke after flowing through the famous Gap – the gateway to Alice from the south through the beautiful McDonald Ranges. More shrugs. I guess there are other names for this Gap that I will hear and ponder. How many?
So I know something about the Northern Territory and I know something about medicine. That is a good start for my new job. I will be working in a health service set up by local Aboriginal people to provide a service to their community. It is called Central Australian Aboriginal Congress and it was the second such clinic established in the country immediately after Redfern in the early seventies. On the front page of the website is a quote which has me in mind.
Our clients are the most important visitors on our premises.
They are not dependant on us.
We are dependent on them.
They are not an interruption on work.
They are the purpose of it.
They are not an outsider to our business.
They are part of it.
We are not doing them a favour by serving them.
They are doing us a favour by giving us the opportunity to do it.
This motivational statement is attributed to Ghandi but this is contentious as you can read on the Quote Investigator website. Historical attribution is always difficult and usually shifts to the person with media access. The struggle for attribution is a constant part of Northern Territory life. For instance, I know of two people involved with the establishment of Congress; Dr Trevor Cutter and Dr Fred Hollows, both European Australians. People have done some work to set that straight but I have a lot to learn about the struggle for health and dignity in this part of my world. I start work in the morning. I hope I sleep OK.