A Doctor's Dream

by Buddhi Lokuge

  While I was out of contact Tanya busied herself with the garden and in the afternoons she made the daily pilgrimage to the pool.

  One afternoon she found herself chatting to a friend who had decided to leave Nhulunbuy.

  She was a nurse who worked in Yolngu homelands and was tired of organising medical flights and specialist visits only to have people not turn up. Not that she blamed them, she said; they had different priorities and we just couldn’t understand why they wouldn’t prioritise their health like we do.

  ‘They probably can’t understand why we try to prolong our lives at any cost,’ she said philosophically.

  ‘But the other day one of my co-workers was sick of all the humbug because she had a whole lot of family staying with her for a funeral, and nobody was cleaning up after themselves and they wanted her to drive them here and there and finally she snapped and said: “You can’t treat me like this. I’m not a ngapaki!’’’ She pulled a face. ‘That just said it all.’

  ‘What’s a ngapaki?’ Tanya asked.

  ‘A white person. Well—a balanda. Non-Yolngu.’

  Tanya raised her eyebrows.

  Oliver was right, there was always a reason; for everything anyone ever does there is always a reason, but there was no way they could expect to understand the decisions other people made. Tanya could barely decipher her own motivations at times, let alone those of a group of people whose complex kinship system was as integral to them, as basic to their understanding of life, as numbers were to the health-coveting ngapaki.

  •

  My stress dropped to zero out in the mountains. Most of my friends hunted while the guru and I fished. He couldn’t understand my anxiety.

  ‘Just do your best to help your patients and let someone else worry about all the rest.’

  That was basically what my sister kept reminding me. I knew they were right, yet the systems of funding and research and development work were all set up to ensure I did my best for the donors, not the patients.

  When I got home to Nhulunbuy I went straight back to the long list of work that had been waiting for me.

  Tanya’s face fell slightly when she heard me launch right into the challenges ahead but she kept her voice upbeat. ‘Any news on Oliver?’

  ‘Oh, Oliver has been thinking about the program already. He’s going to start early next year maybe.’

  •

  I had given up mending bridges with the Northern School of Medical Research (NSMR), so the next time Graham called I pushed harder for the latest scabies results of the Galiwin’ku ivermectin trial. Screenings done during the second mass drug administration, twelve months after the first mass dosing, showed scabies rates had more than doubled from baseline.

  Scabies was a complex, multi-factorial infectious disease and to think that there was a magic-bullet fix was fantasy. And selling that kind of dream would take resources away from the slow, hard work of finding ways to reduce the burden of the illness on affected families and communities. Indigenous health did not need more of the same.

  I stayed up until five o’clock in the morning researching and fine-tuning the operations plan I had drafted before I had gone camping in the Victorian mountains. There was another steering committee meeting coming up in a week.

  The clinic nurse at Gunyangara, just up the road from Nhulunbuy, had asked for my help with scabies since there had been a funeral and the clinic had seen a rise in scabies presentations. I drove out after a few hours sleep to the small, highly educated and wealthy community. Gunyangara was home to a lot of well-known artists and very mobile residents. It tended to have a lower rate of scabies than other communities and the population was generally less tolerant of it, so I was excited to have been invited to bring the program to the community. This was how it was supposed to work.

  But before the day’s end I saw that it would not be a simple exercise to run a healthy skin week in Gunyangara. I could see myself standing forlornly out the front of each empty house, nobody else in sight. Or worse, facing the offended glares of people who did not appreciate being treated like ignorant peasants. By the time I dropped into bed that night I was already beginning to feel the panic that had become the familiar forerunner of the healthy skin days.

  •

  I woke the following morning after a few hours of broken sleep to grab for my phone. Through sleep-blurred eyes I saw Graham’s name flashing on my screen and I tapped at it, grunting into the microphone.

  It took me a few moments to understand what Graham was telling me.

  When I stumbled out into the loungeroom the children were all seated around the table playing with a pile of forks with paper puppets stuck in the prongs. I frowned at the noise and they paused to look up.

  ‘Look at my Feeling Spiders!’ the oldest shouted.

  ‘Mm.’ I turned to Tanya, who had been fine-tuning a learning program on emotional intelligence for children. I wondered vaguely if her program would work for me, too.

  ‘Graham is leaving NSMR. Now I feel like rewriting the whole operations plan,’ I moaned.

  ‘What! Why?’

  ‘Well, now that Graham is leaving I can see it was too defensive. I wrote it as though I was arguing the case directly to him. And now he won’t even be there.’

  Tanya groaned.

  ‘Just watch your Feeling Spiders, Papa,’ my daughter advised me.

  I picked her up. ‘You’re right. I’m not scared of those Feeling Spiders. Did you know it’s been six weeks since Papa went to Gurrumu for the healthy skin day? How would you all like to drive out to Gurrumu with me tomorrow to do the follow-up screening?’ I grinned at Tanya.

  18

  RETURN TO GURRUMU

  The three-hour trip to Gurrumu was almost completely flat, yet the landscape changed suddenly from sparse, dry eucalypt forest to unearthly white-barked trees packed together like soldiers, then wet, dark rainforest gullies, then grassy plains. On and on it went, the kaleidoscope of ecosystems lining the corrugated red-dirt road. It was the first time Tanya and the children had been past Yirrkala since they arrived three months earlier.

  The locum house in Gurrumu was fully furnished, solid and much more comfortable than our Nhulunbuy park cabin. All day long tiny planes were landing and taking off from this community of just 1000 people.

  I visited every Yolngu house in Gurrumu with Talisha, the Aboriginal health worker who had helped me do skin screenings six weeks earlier.

  Something had shifted for me since my last tumultuous visit to Gurrumu. Perhaps the culture shock was beginning to wear off. The differences, frustrations and complexities were being balanced by the people and the possibilities and now as Talisha and I walked door to door doing skin checks I started to see how healthy skin days might fit into the scabies program, even with their limitations. This time we were not asking people to cover themselves with cream or clean up their houses and I began to enjoy the work.

  In most of the houses there was at least one family per bedroom and sometimes more, with tents creating a sense of privacy within the rooms. But the houses were hot, chaotic and overcrowded so the living area was typically outside. Outside one house was a 4WD with no wheels, leaning towards the house, its roof-racks serving as a cupboard for the family that lived in the tent on the verandah.

  About one-third of Gurrumu’s dwellings housed the small balanda contingent, often just one or two people in a well-maintained two- or three-bedroom home. The young teacher, who had been behind the toothbrush holder workshop, had set up one bedroom in the house he share with his wife as a nursery, thoughtfully furnished and freshly painted, while they waited for the birth of their first child.

  For Tanya and the children there was nothing to do but wander around. It seemed they weren’t the only ones without a purpose in what felt to her like a run-down all-inclusive tropical resort whose guests had been there for so long they had grown tired of the amusements.

  Outside the ALPA, a cooperatively run general store, mooched women as ta
ll and thin as the unearthly models that stalked the New York catwalks. They wore colourful skirts and T-shirts and moved very slowly. And inside the ALPA store a packet of biscuits cost almost $8, a price intended to subsidise the fresh produce.

  A steel shed the size of an aircraft hangar served as a community centre. When Tanya arrived there she met a woman in a bright shire T-shirt who ushered them in and set up the children at a table on the big enclosed basketball court. The shed was lined with airconditioners and their table was plonked right underneath one and they were supplied with textas and paper.

  At eleven o’clock on Wednesdays and Fridays the shire held activities for unemployed or disadvantaged folk. For two hours, twice a week, sport, music and a sense of purpose could be found in the community centre. Four or five lanky young men straggled in and set up a band. When a few younger boys wandered in for sport, music and a sense of purpose they were shooed away to go hang out aimlessly someplace else.

  The earnest shire woman was in a bind, she told Tanya. The younger boys were probably better off here but if she let school-aged children stay she would be encouraging truantism.

  At the end of the day the shire woman would return to her empty house with its neat garden, a working car parked out front and no rubbish lying around or tents pitched anywhere. She was not unaware of the realities of the community but she came from a different world and ran a program designed and funded by that different world. Even when she could see that her program had set up a paradox there was little she could do about it. She had come to Gurrumu to help and when people had come to take advantage of that help she had turned them away because there were other balandas, in another balanda system (the school), offering what the balanda world had decided was more important than sport, music and a sense of purpose: an education. And those children had no power to choose just as their parents had no power to choose between the hundreds of programs each year designed to help the Aboriginal population.

  Tanya watched our youngest daughter scribbling furiously. Her brother had told her she was supposed to colour within the lines so she had taken a texta and destroyed the page. It was more important to her to assert her sense of agency than to follow her brother’s rules.

  At one o’clock the community centre was locked up again. The young men, Tanya and the children all strolled back outside to resume wandering around. As they reached the door the shire woman shouted: ‘Don’t forget your big stick!’

  ‘What for?’ Tanya called back.

  ‘The dogs. Packs of dogs sometimes attack people. And never walk outside the town after dark, not even with a big stick.’

  ‘Oh. Okay.’ The children’s eyes were wide.

  Our middle child was an avid collector of anything shiny, mechanical or curious and the ground in Gurrumu was a storehouse of treasure. There were car parts, bike parts, wrappers and drink containers, old pens, rusty tools and unidentifiable pieces of every kind of material. He found a bike wheel and sent it rolling it down the road, running straight in front of our Troopy as Talisha and I drove back to the clinic for lunch.

  I leaned out the window. ‘Not a single case so far.’

  ‘No scabies? At all?’ Tanya asked, bending down to pick up something.

  ‘Nope.’ Talisha was shaking her head proudly. She had organised the healthy skin day; it had been her first and she had been nervous but today she had smiled each time we left another scabies-free household.

  I reached out and took what Tanya had picked up, showing it to Talisha. ‘Isn’t this one of the toothbrush holders the young blokes made a while ago? That was a great project!’

  ‘Yeah. But nobody was allowed to screw them into the wall. So. No good.’ She tossed it out her window and a puff of red dust rose from the road where it landed, and spread lazily on the still air.

  That evening we went for a walk down to a bright plastic playground behind a brand new demountable building with a cross on it. The church overlooked the ocean and a motley band of girls flew up from the water’s edge and began to ask each of us what our names were. Tanya and I left our children playing with their new acquaintances while we walked down to the beach. The mirror-still water was turning a deep purple as the sun set. Mangrove trees reached out of the surface for the sky. The night-time wildlife was starting its chorus and it was the kind of magical moment that might just lure an unsuspecting adventure seeker to move to remote Arnhem Land.

  Before long all of the children drifted back to us, one of the local girls draping herself over my shoulder so that she could look at photos on my phone. As it got dark we got up to go but one of the younger girls held out her arms to Tanya, who picked the girl up and threw her into the air. The child squealed for more. I groaned—the mosquitoes had started to bite and we would not get away without giving everyone a go.

  After the girls had peeled off to wherever they were going for dinner, I noted that one of them had active scabies on her hands.

  ‘I thought you weren’t seeing any here.’

  ‘We weren’t. But we haven’t seen those kids yet.’ I looked down towards the houses where the girls had run.

  ‘Do you think we’ll get it?’ Tanya asked.

  ‘Probably not.’

  ‘I thought it was really contagious.’

  ‘Yeah . . . that’s what people think. Our understanding of scabies isn’t that great, really. Nobody knows exactly how the medications work or why some people seem to have greater resistance when they use sorbolene cream, or tea-tree oil. Or why some people are more susceptible than others. I’ve been around scabies every day for the past few months and have never got it.’

  19

  PREVENTION

  The following day Talisha and I continued the follow-up screening. In one house there were three single sisters who were caring for their dozen or so children, having lost the men of the house to heart disease, a car accident and a younger woman. This household had been just coping, held together by a strong old matriarch. When she died, the household finances and routines fell into a heap and then two of the mothers took to playing cards and gambling all night, sleeping until late afternoon.

  As Oliver said, there was always a reason. Now their children rarely attended school and were often covered in lice and scabies. The clinic had begun noting Failure to Thrive on their records.

  There were three houses in Gurrumu in similar circumstances—front yards and houses strewn with garbage, dirty nappies and cigarette butts, and countless visitors crowding the overflowing houses.

  These households had not engaged at all with our healthy skin day six weeks ago—and they might have housed up to 80 people between them. It was looking as though the whole community could be scabies-free with commitment from these three households. This was exactly the situation where ivermectin could be disruptive. In a chaotic environment such as these houses it was near impossible to organise everyone to get together and apply cream all over and not wash it off again until the following day. A simple pill was likely to improve compliance substantially, clearing scabies out of households that had not had a break from it in years. I resolved to get ivermectin available and in the treatment guidelines as a priority.

  Everybody in Gurrumu knew about those three houses. One community elder with a lot of experience working in the school and shire commented that those families were descendants of families that had had less influence within their traditional clans. This was not just inter-generational disadvantage but ancient prejudice, she suggested.

  As it was they didn’t seek help and they didn’t engage when help was offered. But the scabies mites shared themselves among Gurrumu’s children even where householders followed the strictest regimes. So the patterns became clouded. And when Talisha, Oliver and I cleared the rest of the community of scabies six weeks ago, the remaining reservoir was exposed.

  To Tanya, this was exciting news. In her world view this meant our job had just become simpler and more focused, our patient load much smaller and a low scabies rate that
much closer. To me things appeared ever more complicated. Even getting rid of scabies had the potential to further entrench social exclusion and reinforce the fact that these families were ‘problem households’. It seemed that having a small proportion of society firmly stuck at the bottom of the heap was a universal issue that only needed fixing when the problems of the bottom few began to infect the higher ranks.

  At the next house there was a man sleeping on the lounge and the woman who answered the door said bluntly, ‘There is no scabies here.’

  Talisha explained politely that we were screening children under five years old in each house to make sure everyone had healthy skin and healthy bodies. I watched Talisha shift awkwardly and realised how difficult her job was here. There were relationships in Yolngu culture that prohibit certain kinds of interactions and I had no idea what calculations and negotiations were going on in her mind as she approached each new household.

  She entered tentatively as one of the women of the house mixed flour and water into dough and cooked it on a gas stove on the floor. A child walked past and I saw immediately that he had scabies. The woman asked us to leave.

  As we walked towards the next house a fifteen-year-old girl came running after us and asked us to come back and do the screening. Everyone we checked in that house had active scabies.

  ‘She seemed a sensible girl,’ I noted once we were outside again, remembering the fifteen year old who had called us back.

  Talisha grunted. ‘She used to be a good girl, going to school every day. But now she stays up all night while her mum gambles. Her mum thinks she’s good luck.’

  In Niger we fed children to keep them from starving to death while we developed longer-term interventions, such as education and agriculture programs. Here, too, we had to find the middle path, a third way, that would take the best of bandaid medicine and the best of community development and public health and provide true support to populations for their immediate as well as long-term needs. Here Lawrence and I agreed: at some point it becomes impossible to excuse inaction.