It took just two days for me to recognise that being Director of Sexual Health for an area the size of the state of Victoria was a task beyond any one person. However well committed, my small team and I could make little impact on the sexual health of an entire region.
Indigenous Sexual Health
The late afternoon sun was bright. Sweating at the top of a rickety flight of steps, I was conscious of feeling uneasy and well out of my comfort zone. Despite repeated knocking, no-one came to the door, but I could tell the dilapidated Queenslander was occupied because all the windows were open. As I stood there uncertainly, a plane came in to land, seemingly just metres above my head. The house was about 800 metres from the airport under the direct flight path.
Bowing my head against the deafening roar, I retreated down the stairs. At the back of the house, I found an old Aboriginal woman retrieving washing from the line.
‘Hello, Aunty,’ I said uncertainly, ‘I’m a doctor from the hospital. I’ve come to see Tyrone.’
She nodded, showing no surprise.
‘Sure, he got bad sickness.’
‘Can I see him?’
‘He upstairs on his bed – in the front.’
She pointed to the back stairs, but made no attempt to accompany me.
‘It’s OK to go on up?’
She nodded again as she turned back to the washing line.
I stumbled up the stairs. It was dark inside. I made my way through a kitchen and what seemed to be a living room. A closed door stopped my progress, and I knocked tentatively. No response. I knocked harder and called out, ‘Tyrone, it’s a doctor come to see you. Can I come in?’
Still no answer. The house rattled as the next plane thundered overhead. How do I get myself into these situations, I thought?
The call had come that morning from a nurse called Laura on a remote community on Cape York. By reputation, Laura was an excellent nurse but she was said to have little time for doctors. On the phone, she didn’t waste words with me. For a year, Tyrone had been a trainee Indigenous health worker in her clinic; bright, reliable and trustworthy. Recently, he’d become unwell, but was reluctant to tell Laura about the problem and had refused to see the visiting doctor. His work had deteriorated, he seemed to have some difficulty walking, and he’d started taking days off.
‘I knew he was gay, Doctor, and suspected it might be a sexually transmitted thing.’
‘Why wouldn’t he tell you then? He knew you well.’
‘I don’t know, but soon he didn’t need to. One day I knew for sure what the problem was.’
‘How was that?’
‘The smell. It’s a give-away.’
‘Sorry, you’ve lost me.’
‘I came on him one afternoon in the back store-room where he’d been working for an hour with the door shut. The smell was overpowering. He’s got donovanosis. The shame of it has got to him.’25
‘So, what did you do?’
‘I told him I knew, and that he should see the doctor on his next visit. He refused. I knew he had an aunty in Cairns, so I booked him on a plane and said if he stayed with his aunty I’d see to it that he got proper treatment down there.’
‘So will he come and see me?’
‘No, you’ll have to go and see him.’
‘It would be better if one of my Indigenous health workers visits him at home and brings him to the clinic.’
‘No! I’ve told you. It’s all a matter of shame. You’ll have to keep the health workers out of it.’
‘But I’m hospital based. I don’t do house calls these days.’
‘Well, you’d better start.’
‘How am I, an old white doctor, supposed to relate to a young Indigenous man overcome with shame?’
‘He’s gay. You’re gay. I don’t see a problem.’
‘Surely that’s irrelevant, Laura.’
‘Have you got your pen handy? Here’s his aunty’s address. Tell him Laura sent you.’
With that, she’d terminated the call.
Now, here I was at a closed door. I hesitated, then went in. Aborigines call donovanosis ‘dead dog disease’ because of the smell; how appropriate a name, I thought, at the overpowering stench that filled the darkened room. I could make out a body facing the wall, lying on a mattress on the floor. Despite the heat, he was covered with a heavy blanket. I knelt down beside him, found a hand and felt his pulse, which seemed okay. I explained who I was and that Laura had sent me. He made no reply.
‘Would you just tell me about it, or let me see the sickness, Tyrone?’
He squeezed my hand but shook his head. He remained otherwise immobile. What to do? I racked my brains as minutes passed in silence. He didn’t seem to mind when I kept hold of his slim black hand. I came to a decision – it was against good medical practice, but I would have to treat him blind.
‘I’m going to the kitchen for a glass of water, Tyrone. Then I’m going to give you two tablets to take. I’ll come back in one week and give you two more. In time, they will make you better.’26
He sat up enough to swallow the tablets and finish the glass of water. I could see he was a good-looking boy. I took his hand, gave it a squeeze and left, promising to see him in a week. I realised he hadn’t said a single word.
All week I worried. I talked to Barbie Brayshaw about it
‘I’m just treating him on hearsay evidence. I don’t like it.’
‘There is that smell, David. You’ve done the only sensible thing. I think it’ll get easier.’
Next week I didn’t bother with the front door. I found Aunty in the kitchen and she waved me through. I knocked and went in to Tyrone. Just as before, he was lying on the mattress on the floor.
26 A new treatment for donovanosis had been studied in 1995 by my colleague
Frank Bowden in Darwin. 1g of oral azithromycin weekly for a minimum of 4 weeks was shown to be better than all previously used daily antibiotic treatments. Genitourinary Medicine 1996; 72(1):17–19.
I knelt down and took his hand. He turned and looked at me, smiling shyly.
‘How do you feel, Tyrone?’
He actually spoke, and said, ‘A bit better, Doctor.’
‘Will you let me examine you today then?’
He kept hold of my hand, but shook his head. I talked a bit more, but he wouldn’t respond. I got water, handed over two more tablets and watched him swallow them. I promised I would be back in a week.
Next week, I found Tyrone sitting on a chair in his room waiting for me. The air smelled sweeter and Tyrone seemed to have gained some confidence. He smiled and took my hand. ‘Today, much better, Doctor.’
His voice had a lisping lilt. That afternoon we held a stilted conversation, although he still refused an examination. He told me he’d had the problem for more than six months. It had started with sores around his anus and had gradually spread forwards to one side of his groin and the base of his penis. As he wouldn’t let me examine him, after watching him swallow two more tablets, I left, promising to drop in again the following week.
On my fourth visit, I was amazed to find Tyrone waiting for me at the front gate. He said the problem was better and he could now walk without pain. As I gave him another two tablets and watched him swallow them, I made a suggestion: when I came next week, would he come back to the hospital in the car with me? There would be no-one else at the clinic. Maybe he could show me how it was healing and let me take tests for other STIs. He said he would think about it.
On my next visit, Tyrone agreed to accompany me to the hospital. In the car, he became excited, almost garrulous. He let me examine him in my office at the hospital. I had seen only one or two cases of donovanosis before: once when I was visiting a clinic in India,
and the other time in a young woman on the obstetric ward at Cairns Base Hospital, soon after my arrival in the region. Tyrone had ulcerated areas from the right side of his groin all the way back to behind his anus. The extent of it shocked me. How had he borne it? Althou
gh good healing was taking place, I thought it would be a few more weeks before the ulceration was completely resolved. A PCR swab test confirmed donovanosis when the result came back a week later.27 An HIV test was negative and he had no other STIs.
I continued visiting Tyrone. For nine weeks all told I kept up treatment, probably a week longer than necessary. I wanted to be sure he wouldn’t relapse in future. On my last visit, he said an emotional goodbye to me, but I was glad to see he had acquired a cheeky grin. A day or two later, he flew back to his community, scarred but healed. I confess I felt a twinge of regret. I had come to enjoy my weekly visits to my reclusive patient.
I wish I could claim that my eleven years as Director of Sexual Health led to an improvement in the disastrous state of Indigenous sexual health in Far North Queensland and the Torres Strait Islands. The prevalence of common STIs (gonorrhoea, syphilis, and chlamydia) was much the same when I retired from the position as when I commenced, and I have to admit disappointment.
I can only make three claims from my time there.
Firstly, the loathsome disease, donovanosis, also called granuloma inguinale, disappeared from our region in those eleven years. This was the result of a Commonwealth-funded eradication programme initiated by Federal Health Minister Michael Wooldridge. We participated in it wholeheartedly.
Secondly, there were no outbreaks of HIV/AIDS in any of the Aboriginal or Torres Strait Islander communities in the area. We saw only one or two sporadic and largely unexplained cases of
27 PCR: polymerase chain reaction. A recently developed test for donovanosis in
Northern Australia.
late-presenting AIDS on Cape York, which did not result in ongoing transmission. I doubt my team or I can claim credit. It was more by good luck than good management that significant numbers of cases of Indigenous HIV infection did not appear in those years.
Thirdly, after a couple of cases of congenital syphilis (i.e. syphilis in the new-born) found in 1993 and 1994, there were no more congenital cases in the region throughout my remaining years of full-time work. I think this good outcome was achieved by excellent cooperation between my team and the obstetrician, Professor Michael Humphrey, and his antenatal team throughout the Cape and the Torres Strait.
I can claim that my team and I did our best with the resources available to us. In my first six months in the job, I visited every Aboriginal community on the Cape York Peninsula. I had a couple of trips to Thursday Island and Saibai Island, from the shore of which I was able to look across the water at the coast of Papua New Guinea. In the communities, I met and talked with remote area nurses and Indigenous health workers to learn about the problems they faced. On Thursday Island (TI), I talked with legendary Dr Peter Holt, much loved and long-serving Medical Superintendent of TI Hospital. I can sum up our conversation thus: ‘You ask about STIs in the Torres Strait, David. Oh, I leave STIs to these young people here.’ And, in answering, he waved his hand at the little TI team of white male nurse and two female Torres Strait Islander health workers.
He was right to do so; my sexual health team were keen, and knew how to talk to young Torres Strait Islanders at their own level. They worked tirelessly to provide preventive education, to screen young people for infection, to treat promptly and to contact trace. It was the size of the problem that defeated them. We would have needed four times as many such teams in the Torres Straits and on the Cape to have had a significant effect on STI rates.
The Indigenous health workers on my Cairns team travelled frequently to all the communities on Cape York to educate and support local workers. Every six months, we ran week-long courses in Cairns for the ever-changing population of remote area nurses and health workers, updating them on health promotion, diagnosis and treatment for STIs, and basic facts about HIV infection.
The crux of the matter was clearly evident. Faced with the health problems they dealt with every day and night – diabetes with its complications, chronic cardio-vascular and kidney disease, trauma, alcohol-related harm, and life-threatening infections – remote area nurses and health workers put sexually transmitted infections and sexual health way down their list of priorities. They had no option. There wasn’t time in their busy professional lives for anything except treating the most obvious, symptomatic STIs. Even today, success stories in Indigenous sexual health are rare.
Work in Cairns
Barbie Brayshaw (the HIV clinic nurse) and I managed all the HIV patients at the hospital clinic. Paul Stephenson, the clinical nurse consultant, worked in the community, visiting sick AIDS patients at home and liaising with the local Queensland AIDS Council staff and volunteers, with whom we maintained excellent relations.
Some people innately understand sexual health, without having undertaken any specific training in the field. They possess the requisite empathy, they know how to be tactful, they have an ability to set patients at ease, they can counter guilt and shame and, in their speech and body language, they engender trust. Barbie Brayshaw and Paul Stephenson were just such health professionals and it was a pleasure to work with them.
Sadly, more than half the HIV patients I met when I first commenced work in Cairns died of AIDS before the end of 1996,
including the gay bashers and the young woman who lived on Thursday Island. A couple of patients suicided. Despite this attri-tion, the number of HIV patients seeking care at the clinic steadily grew. There was a small number of new infections acquired locally, but most new patients were imports from ‘down south’ (as Cairns residents referred to anywhere south of Townsville). Even some of my Melbourne patients migrated north to Cairns. It wasn’t surprising. If you are diagnosed with a potentially fatal illness, why shiver in Melbourne or Sydney when you can be warm all year around in Cairns?
In response to repeated lobbying and the effort of writing and submitting business cases, Queensland Health gradually increased the number of staff positions at the Cairns Sexual Health Service, to keep pace with the steady rise in the number of HIV/AIDS and other sexual health patients.
An extensive hospital redevelopment took place in the years 1999 to 2001. In late 2001, the clinic moved, from the inadequate quarters it had occupied, to a stand-alone site on the hospital campus. Largely due to Wally Smith’s assistance, the new clinic was a renovated red-brick building that used to be the medical superintendent’s quarters. To generations of hospital staff, the house had always been called ‘the Doll’s House’. It seemed as good a name as any for the new sexual health clinic.
By that time the staff had increased to one extra doctor, a trainee medical registrar, two receptionists, a clinical nurse consultant with three additional nurses, a psychologist, three Indigenous health workers and a Sexual Health/HIV Regional Co-ordinator whose remit was to oversee sexual health issues throughout Cape York and the Torres Strait. I now had the luxury of a team of thirteen, all in the Doll’s House, under the same roof. The number of HIV/AIDS patients the doctors and I were caring for had increased to 250.
My work in Cairns was not all HIV/AIDS and Indigenous Sexual Health. The clinic served patients with the whole gamut of STIs. Cairns was a popular holiday spot with a high turn-over of tourists, including many young back-packers, some of whom stopped over in South-East Asia, running a risk to their sexual health en route to Australia. We diagnosed plenty of symptomatic infection in the Cairns Clinic – gonorrhoea, chlamydia, herpes, and syphilis – it reminded me of my early years at the MCDC.
One afternoon during 1994, I had a notable phone call.
‘I’m sorry to interrupt you, David,’ said Wendy, the receptionist, ‘but there’s a very angry man on the phone. He insists on speaking with you at once.’
I was surprised. Wendy usually had no difficulty handling awkward phone calls.
‘Put him through then, Wendy.’
A belligerent voice came down the line. There was no attempt at preamble or common courtesy:
‘Are you a specialist?’
‘Yes, I’m a specialist i
n sexual health.’
‘I hope that means you know about VD?’
‘Yes, I’m familiar with sexually transmitted infections.’
‘Well, when can I see you privately?’
‘You can’t. I don’t see private patients. You are welcome to come to this clinic at the hospital, any afternoon, like anyone else in the district.’
‘I’m a busy man. I can’t be wasting my time hanging around hospital clinics.’
‘Suit yourself. Your other option is to see a GP.’
‘I’ve seen my bloody GP already – twice in two days. His treatments haven’t worked. The man’s a fool. He knows nothing about this stuff.’
‘Look, I’m in the middle of a clinic. If you can get here before 4.30pm, I’ll see you, but you may have to wait until I get through the booked patients. Otherwise you must go and see another GP.’
‘There’s no other private specialist in town?’
‘No. I’m it.’
‘It’s most unsatisfactory.’
‘Tell that to your MP. I’m putting you back to our receptionist. If you decide to take up my offer, Wendy will give you instructions how to get here.’
At 4pm, I took a look into the waiting room. Seated beside the remaining two HIV patients sat an overweight, impatient-looking, red-faced man of about thirty-five. I didn’t require Wendy to tell me that ‘Mr Belligerent’ had arrived. I took my time over my last two patients, then I invited him to come in. Disregarding my out-stretched hand, he looked around the pokey office with distaste.
‘Good God, what sort of a place is this?’ he started out, ‘Those two fellows you’ve just had in – they look like they’re out of Belsen.’
‘They’re both very unwell, I’m sorry to say.’
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