There is so much more to learn and talk about – General Practitioner, Dr Bruce Barker shares his and his wife Dr Jennifer Barker’s experience

I have been a GP for 35 years now, and for most of this time, we have been in minor centres,

firstly near Geelong, Victoria and then Launceston, Tasmania. An injury made it briefly (5 months) impossible for me to work and this enforced lay-off gave me the opportunity to rethink how I wanted to spend my medical twilight. I had met with a representative of the Remote Area Health Corps (RAHC) a few years ago, and this meeting was a dormant kernel until my injury occurred. My wife is also a GP and just like me, was thinking about alternatives to semi-urban practice. It was our mutual decision to approach RAHC about working in the NT. Medicine in Central Australia is not like going to another country it is more like going to another planet; it is so different and thus incredibly interesting.

By far our longest stint was at Urapuntja, Utopia; it is located on the Sandover Highway about 250 km from Alice Springs. The “Sandover “boasts only a single 16 km strip of bitumen along its substantial length. The rest is sandy in good weather but impassable with slippery mud and dangerous washouts after even modest rain. Prior to going, RAHC provides a forum and very useful educational package online for the clinical issues we were to face in remote practice. RAHC also provides a driver and vehicle for the Utopia job, delivering nurses or doctors to locations safely, which is not always easy in the weather and road conditions of the NT.

The communities we helped service are all Indigenous. The health problems include; chronic skin infections, diabetes, hypertension, unbelievable amounts of renal disease (beginning even in teenagers), auto immune disease (lupus in particular), social problems, anaemia, severe bacterial infections, results of domestic violence, and not to forget, sexually acquired infections; we are always on the lookout for syphilis especially in young people. The general guide to all treatment and management is the blue book, the current CARPA manual, a distillation of medicine tailored around the limitations and practicalities of remote practice. It is a well thought out guide which is generally pretty sensible, but it is still no replacement for being innovative, up to date and imaginative in dealing with the myriad of people and their complex multiple morbidities.

We stayed for a month at a time, and each time we built up a greater body of experience not only of the medical problems for which we were primarily employed but also the social issues, the incredible natural beauty right outside our houses, the changes with each season and relearned the ability to work with a team in addressing both chronic and acute problems. I have talked with Bush Nurses, Elders, Aboriginal Health Workers and long term locals about the problems we all face in the bush. In fact, this essay is a distillation of all these discussions. The medical problems are acute and chronic; the former can be straightforward illnesses or can be highly complex with the need for managing serious electrolyte disturbances, septicaemia and the like. The chronic diseases often require multiple medications, frequent monitoring both clinically and biochemically, enormous education, helping people who are notoriously poorly compliant, have poor school education, endemic deafness, poor command of English, and where disease rather than health is increasingly regarded as the new normal. The child without the discharging ear or with clear uninfected skin is the abnormal one in some communities. Are we helping these people? Without any doubt, the answer is yes. There have been vast improvements in child mortality, and in achieving greater longevity despite a burden of morbidities, due to the medical and nursing care supplied by the health workers in community settings.

However, if I could choose between building a modern clinic in a remote, unserviced part of Australia and providing adequate, abundant clean water, I know which I would choose. It is impossible to wash when the water supply is poor. Facial washing, not antibiotics, is the best preventative strategy for trachoma. The contribution of all the health workers I have met is enormous, their passion, their commitment, their knowledge of their communities is inspiring. However, the social factors are powerful forces always working against further widespread improvement.

There are all sorts of causal relationships between society, culture and health. Teasing out these relationships can give an idea where I think efforts need to be directed. Firstly, the antenatal, uterine environment must be optimised to give new Aboriginal babies normal healthy organs and the necessary reserves of iron and nutrition. Antenatal traumas extend from alcohol abuse, high levels of smoking, persisting iron deficiency, missing antenatal visits, prematurity, mothers who already have kidney disease and diabetes, to generally poor maternal nutrition. There are very few formal studies of these issues in Aboriginals.

The cultural norm in many families in Utopia (but far from all) is that children are the last fed in a family; they turn up at the clinic famished. One child, I saw who was a visitor to Utopia, had not eaten for a day, and had a prolonged apnoeic and asystolic spell aggravated by his hunger. The parent's excuse was that they had been too busy attending a football carnival to chase up some food, any food for their children. Alcohol is a sporadic problem in Utopia due to being a dry area, but gambling is an endemic problem. Gambling there can totally consume some family incomes making purchase of food and the basics of life impossible.

The men eat first, the children last. Poor child nutrition compounded by early and frequent

diseases, including; ear infections, trachoma, chest infections, rheumatic fever, too often leads to a huge burden of ill health even before children get to school. The Utopia Clinic is particularly imaginative in developing new strategies to educate and encourage young mothers to turn this around, and though this is an untested approach, they should be applauded for moving out of the medical model and embracing community in a new way. There are also several government programs that address these issues. Once at school, the children get regular meals, regular washing, and in short, simply do many of the things a family should be doing, but cannot for all sorts of reasons. However, school attendance can be poor, due to education having a much lower priority than the whims of the child, not attending during the months of football carnivals, the cultural expectations about Sorry Business (a heartfelt community usually grieving for months that stops the normal operation of a community), and the really low emphasis on getting an education. Some talented children do get support, they may be encouraged to go to school by a grandparent or mother or father, but this can still be fractured by domestic violence, serious health problems, deafness, and the belief that attending to community norms is more important than achievement as an individual. Despite these difficulties, all around Australia, many young Aborigines are taking advantage of the many financial incentives to be educated and enter trades and professions. The quality and enthusiasm of the Aboriginal health workers I have met is extremely high. But the awesome isolation, the sheer remoteness of many of these communities makes reliable work for most young people and access to services which we take for granted, difficult to obtain. Utopia is great for Art and is some ways, a very traditional lifestyle (though not hunter gathering any more) with the older people rich in language and bush hunting skills but despite some studies showing otherwise, the social and health profile of the area is truly appalling despite the tremendous efforts and commitment of the health staff.

We have also worked with Central Australian Health Service (CAHS) using RAHC as the organisers for the interstate travel and accounting procedures. CAHS provides doctors to remote communities on a rotating basis, so there is a lot of driving and air travel. Based on my experience, I would suggest having some Pink Floyd CDs and good sunglasses for the drives. When flying always have access to some noise cancelling headphones.

My impression is that, the places with the best health profiles, are those where the mastery of English is good, there is access to better food, where the majority of men have jobs, where the number of Aboriginal Health Workers is greater, where there is no alcohol allowed or at least strictly controlled, where the elders are healthy and respected, and where basic hygiene is possible due to working, installed bathrooms and toilets. There is ample evidence that Aboriginal people can see what the problems are and what to do but some infrastructure is beyond what they, as communities, can provide.

I have not talked about the spiritually inspiring Elders, our incredible experiences of nature, wild thunderstorms lighting up the skies, the meetings with wild animals, caring for an injured falcon, the photography of delicate native flowers, me playing Villa Lobos Preludes over grasslands of spinifex, a brilliant moon out-shining all the stars in the sky, the wonderful relationships with other health workers and the many terrific, hardworking, talented Aboriginal people I have met and worked with. And it is all these latter aspects which make working in Central Australia so rewarding. We do help people here in Central Australia but the solutions to the fundamental determining forces that shape their lives and lead to poor health, are largely out of any doctor's hands.

There is so much more to learn and talk about. The work is very interesting and challenging, with many opportunities to expand your medical knowledge into third world diseases; including, Rheumatic Fever, HTLV, Meliodosis, severe renal and endocrine disease especially Diabetes. The RAHC team keeps in touch during all of the placements; it is an organisation which fosters a supportive and interested relati

Monday, 20 March 2017