essay: Utopia

Utopia#1                                                                                                       14.11.2014

It’s not such an ironic name really – pretty spot in the Central Desert, miles from anywhere else.  I tried sending a few mobile phone pics but the home wifi didn’t like them, so might try a few with the iPad later on.  This part of Utopia, an area maybe 80k across, is Urapuntja – a broad flat red spinifex plain, lightly wooded with white-trunked gums and mulga scrub.  There’s our clinic, a tiny school out on the road, and about 10 houses, about 100m apart and scattered through the scrub – that’s it.  It’s about 10k to the Arlparra store, and we are about 300k n/e of Alice Springs, turning east onto the slippery red Sandover “Highway” about 60k nth of Alice.  I get food by online order and pickup from Woolies in Alice, and the water is from a bore, though it is being replaced and water is being trucked 10k from Arlparra, where the diesel generator that supplies our power is also located.

Getting here last Sunday was a bit trying – nice clear flight to Alice, and the red starts near Coober Pedy; beyond that it’s all red centre.  Picked up at the airport by Gail our clinical manager, and we shared the drive to Utopia, but half way back she realized she’d forgotten the CEO Linda’s grocery order, so back we went.  The trip then became 600k rather than 300k, and it was dark by the time we arrived.  Nearly hit one goanna but no roos to be seen; hunted out locally, apparently.  The 2br house seemed quite newish and spacious, clad in corrugated iron, but TV and wifi not working (now they are) so had to wait 24 hrs to unpack and move in, in case had to move to another house. Rather tired anyway so made dinner and went to bed, with work next morning.

Hours more gentle here than the standard NT PS 8-4.  Enough hardship already!  so it’s 9-5, very wise.  My house is about 400m from the clinic, so walked to work through the red sand past big flocks of galahs and a few corellas.  Chilly overnight, and quite cool some mornings – had to wear a jumper early, which surprised me after the Top End, but by mid morning it’s 40+.  Nice helpful clinic staff – Gail and Linda (‘CEO’ and midwife) are the 2 senior nurses, with 3-4 young ones who do a lot of driving around to homeland settlements. We have six big Hilux vans, 1-2 of which are loaded up with all you need to do a mobile clinic.  Thursdays are my day to go with them to do a clinic at Arlparra, held underneath the grandstand of a big roofed basketball area.  I worked in the tiny kitchen with my laptop atop the microwave.  Exam couch and 2 chairs filled all the space, along with many small sticky flies (apply the Rid next time, stupid), and numerous camp dogs wandering in and out (the vets are coming to euthenase or sterilize most of them next week – the dogs, not the flies unfortunately).  The store closes from 10-2, so we had an influx of patients at 10 and most of them disappeared at 2.  There are visiting specialists in small teams from Alice.  For the past 3 nights I’ve shared house with a pleasant young neuropsychiatrist – interesting chats at night about what the ###! that is – and me trying to appear as sane as I could.  He left yesterday, so now it’s just me and geckos of varying sizes – some of them very big – enough to make me wonder as I go to sleep whether their appetite for flesh extends beyond smaller geckos.

The people here are all fullbloods, no mixed race to be seen so far.  A lot of them have little English, especially the older folk, and a good number of these oldies still live in bark humpies.  It’s said that health stats are better here than most other parts of NT, probably because of a tradition of independence.  They were never fully dispossessed of / alienated from their land and the elders have refused significant town/admin facilities, though there’s a shire office and bigger school at Arlparra.  However the usual chronic severe diseases abound, especially diabetes which seems to afflict most adults older and younger. It’s a dry community but the grog still gets in; alcohol-related problems are less common, though yesterday I sutured a stab wound from a drunken altercation. The clinic here has 4 consulting rooms where the nurses and doctor consult, and is quite well equipped with the usual little pharmacy of free meds, etc.  The locals are fairly taciturn or shy, and one quickly gets used to the absence of civilized niceties like please and thankyou. As in other parts of NT, it probably takes some time to get their trust.

Today Saturday AM before the hottest hours I drove about 10k (more with a few wrong turns) to the Sandover River.  It’s a forever dry bed about 100m wide – flowed once in living memory and a few people drowned; not used to swimming out here. Nice place for a walk though, but soft red sand made it taxing in the heat and I headed back to the Hilux after a k.  Not much else to do here but read, though the clinic has a little gym!!  No need for a sauna.  So expect a few more emails, if I can think of anything else to say.

Utopia #2

After my 2nd week here, I feel another meandering email coming on.  It has been a week for the historians and others like me of ‘mature age’, with the death of Gough Whitlam at a hypermature 98.  An impressive life to reflect on, he was one of the big names for my generation, an example of inspired, progressive, visionary but flawed leadership – but the flaws seem small in the overall package, especially in comparison with our national leaders of recent times.  More prosaically, I’ve just been out hanging out the washing on an old Hill’s hoist – by the time I got back to the start the first hangings were almost dry.  It’s warm.  The view from the clothesline, looking out across a vast red spinifex plain with azure sky and white gums, is inspiring.

One of the joys of working remote is that you can catch up on reading.  Have just finished a really good book on dogs (!) “Inside of a Dog” by American behavioural scientist Alexandra Horowitz- a ‘must read’ for doggy people.  Well written and scientifically based, it explores the way dogs see and interact with the world, and the way our two closely adapted species interact; and it’s full of anecdotes about her own much-loved mutt.  I wish I’d known some of this before – would have been a better parent to past dogs! Shall try to be much more sensitive with Lulu, a delicate child.

This place is more remote than most other locums I’ve done, and not just in distance.  The people are less town-oriented, living a bit more independently of white culture, and quite a few speak little English.  In the past week I’ve been out at surrounding small camps (3-bore, Camel Camp, Tomahawk, Soakage, Soapy Bore, Arlparra Store) from 10-60 k distant, doing little clinics with a couple of nurses.  We might set up in an open shed, or a 9m square room with aircon if the  settlement has a dedicated ‘clinic’.  There are vast numbers of dogs, often in packs ( one of the nurses was attacked and bitten recently), and herds of 20+ feral horses wandering about.  I carry a big stick if walking about.  The dogs of course are a hygiene problem and source of scabies (infected scabies is a cause of deadly or crippling heart and kidney disease), and locals often sit about in the red dust.  Each camp has a few small basic unattractive houses on a baked red open common and is heavily strewn with rubbish, old car bodies etc; at least a part of the problem is poorly organized  rubbish collection.  Some houses have TV, but many lack  basic amenities.  The scenes are suggestive of abject poverty, underlying the very poor health that these people suffer.  So although Urapuntja where I am staying is quite attractive, Pilger’s film was certainly a true depiction of the camps where most Utopian locals live.

A few other thoughts about remote outreach work.  Most of it is done by small teams of 2 nurses, who are generally very efficient at what they do – rapid routine health checks with blood tests.  They are often not great at diagnosis, which is less of an emphasis, and not really their training (cf GPs who should be pretty expert at diagnosis and management).  The nurses stick to Carpa – an excellent how-to health manual designed by NT experts.  So the locals have good health checks and need to because there are heaps of diseases to try to mitigate, but not good personal medical care of the type that many other Australians enjoy.  The nurses vary from dedicated long termers to agency nurses on short 2-3w placements, taking advantage of big regional remote pay allowances; some of the latter have no training in or knowledge of ‘cultural safety’ – better ways of relating to aboriginal folk.  One young NZ nurse I worked with this week was flying home to Dunedin every 3 weeks, paying off her mortgage quite quickly, and was pleasant but way too bombastic.

Other aspects of remote work need thought BEFORE  you face the situation.  For example this week I found myself in a small crowded room with a local who was speaking very loudly and aggressively right in the face of one of the nurses.  My hearing being what it is (along with his rapid accented speech) I didnt quite get the gist of it but it wasn’t looking good.  The natural tendency of some old blokes like me is to consider physically restraining the offender (he was quite big and strong, and I may have an exaggerated opinion of my waning physical abilities), but one is in a small minority, so I decided to just stand very close, and after a little while he calmed down and left.  Then I had a good think about what I’d do if it ever got uglier.

The other things that happened this week reminded me of the office politics of remote work.  One concerns the nearest health centre about 100k distant. Apparently the white manager there is longterm and has links with the local community.  He has been behaving in a ‘my way or the highway’ style, alienating many visiting health people and causing many of the locals to travel to Urapuntja for their care.  The health centre board has been trying to get rid of him, but he is hanging on.  In my own clinic yesterday, one of the drivers asked me for a checkup – I asked him to see the nurses first as that’s the routine.  Then I found his manager (white mechanic married to the CEO) in my face saying Jason wants a check-up; I said I’d asked him to start with the nurses as usual.  The manager got huffy and said he was above the nurses.  I then thought maybe this Jason has an std and needs a male to check him, so I started to say OK to the manager but he threw up his hands and marched out in high dudgeon.  Later after I’d seen sicker patients I checked Jason who had just had a sniffle for 2 days.  On further discreet enquiry it became clear that the mechanic manager has a little empire maintained in part by telling his workers they can have instant access to the doctor.  So one needs to know the local rules, and recognize the Colonel Krantz types in remote spots.

A time-consuming part of my work here is reviewing and acting on the countless routine health assessments /blood tests done by the nurses.  There’s a great backlog of this computer ‘paperwork’ as Urapuntja hasn’t had a doctor for a while, and often doesn’t.  A doctor’s review is necessary to get the substantial medicare payment for each checkup.  It’s actually quite interesting work at times because of the embedded info and insights.  For example there are large numbers of deserted or widowed mothers, and men here quite often have 2-3 wives (‘bush wives’), some of whom are effectively deserted.   The resulting kids are often cared for by grandparents, uncles and aunties, often passed around.  The following is an example of how frustrating bureaucracy can be, especially in places like this.  Not only does the clinic get a medicare payment for each detailed health assessment; it’s federal grant funding is proportionate to the number of health assessments it does.  The Commonwealth can also use ‘not enough check-ups’ as a way of closing down small health centres. This is a real catch 22 for aboriginal community health centres (managed by local boards): the newly arrived doctor is often busy with clinical work, struggling to find time to do the reviews of accumulated health assessments and medical test results.  The other type of (non-private) health centre servicing remote NT is state government-run.  For them a remote DMO (district med officer) sits at his computer eg in Alice Springs, just as I do, and churns through all their backlog of health assessments, keeping their numbers up and hence their funding.  So amid other hardship, remote community health centre managers are often tearing their hair out with frustration.

Enough typing, too much local bureaucracy.  I’ve just finished an orange Penguin “The Big Sleep”, the quintessential detective novel by Raymond Chandler, read in a few hours and a lot of fun.  About to start a big tome by my old friend Joe Camilleri.

Good luck to Lec and Cat moving in to their new home in the coming week.  Looking forward to seeing it and very much to another fine meal at Dear Liza.

Utopia #3

C’est moi, encore une fois!  Another Utopian week gone by, a bit undermanned because 3 of the nurses had an unpleasant gastro virus with high fevers, and one resigned.  Then Stephen McIntyre the head nurse and his wife Kym the receptionist came back from holiday, so we are up to full strength again.  I did a little clinic with Steve at Atheliye, the nearest of the bores only a few km from here.  We weren’t busy so chatted away and he told tales of Afghanistan and East Timor, where he’d worked as an army medic.  I was reviewing a health check on one teenager whose mother had died and whose father was useless; she’d been in trouble and nobody was caring for her.  There are quite a few orphans and virtual orphans and apparently Atheliye is a bad place to be one, as nobody seems to care enough to look after them.

The following is a longer account of Utopia, enlarging on much that has been said already, so only read the rest of Utopia#3  if interested.

Utopia, a locum’s view:

Situated on the edge of the Central Desert in the hot red centre of the country on the Sandover track about 300k north east of Alice Springs, the Utopia area is quite different from Yirrkala in the Top End, last year’s locum.  There are of course no sea breezes, so daytime temperatures in October/November are often over 40, and there’s not a drop of rain.  The Sandover River 10k from here is a dry bed 100m wide, and has flowed maybe once in recent times, in 2009, and a few local people drowned.  Why would you learn to swim in such a place?  Most people in Yirrkala lived in reasonable little houses. Here a few small ugly houses (each with up to 10 residents) cluster in far-flung rubbish strewn camps around artesian bores, and quite a few people still live in bark humpies, especially the old folk.  It’s said that historically, Utopians were never completely dispossessed of their land; are less town-oriented, more self-reliant and have resisted significant western facilities.  There are scattered small schools, and just one trade store between here and Alice; and Utopia is a dry community in the other sense, so alcohol fuelled violence is much less of a problem than in Alice.  There’s no public transport other than the occasional irregular demand-dependent bus to Alice, but those who want alcohol can clearly get it, or may just camp in Alice for indefinite stretches of boozing.

The health-worker settlement around Urapuntja Clinic has neat little houses widely spaced on a vast red spinifex plain.  I walk the 400m to work each morning past flocks of galahs and corellas, wheeling and shrieking once disturbed.  Clear blue skies and white gums in the shimmering heat make it pristinely beautiful, contrasting with the surrounding bores where local people live in what looks like abject poverty.  Each comprises a cleared, baked red rubbish-strewn common bordered by dim little dwellings and car bodies – accurately depicted in John Pilger’s recent film. There are vast numbers of skinny dogs and cute pups – the former often in packs, aggressive at times; and roaming herds of feral horses, looking healthy enough.  There’s little work available, and the scenes bespeak a depressed culture, relating in part to colonial dispossession; and to gross systemic failure by our community to help these folk to a better life after so many years of white dominion.  Some may choose to live this way in the red dust and heat; many, for example, dislike the aircon which we need to survive.  But there must surely be a better balance; the present ongoing one seems skewed towards the worst aspects of what white dominion has achieved.

For a 5-week locum, it’s impossible to get to know the locals, probably hard even for the longer-staying health workers.  The local folk are all full-bloods, often shy rather than unfriendly (respond to a smile), and quite often have poor English – especially the un-schooled older people.  So communication is partial, eye contact fleeting, and at every contact one feels the gulf between our cultures.  There’s a confusing riot of names; most people have a traditional name and an anglicized one.  Surnames are often taken from where the individual was born, especially if around one of the old cattle stations, so Sandover is a common surname around here; but there are also lots of Jones, Mortons, Purvises and Clubs.  Christian names are often a creative build on white or biblical ones – Kirklen, Roshaina, Renisha, Doreena, Danico, Shalanta, Reynella, Shirleena, Dezeriah and Laquwisha were on yesterday’s list of patients.

The health stats for Utopia are said to be among NT’s best, perhaps because of a more traditional less town-oriented lifestyle.  This isn’t obvious in day-to-day clinical work, where the usual chronic severe diseases are the norm, and many people die young with diabetes, chronic kidney disease and cardiovascular disease, and complications of rheumatic fever.  Syphilis is still a common blight almost unheard of in white communities for nigh on a hundred years.  Many adults smoke and are obese, often morbidly so, especially the women.  The poverty-related causes are obvious – poor, high fat/sugar tradestore diet, and under-education, and it’s too bloody hot to exercise. All overweight adults ( and some normal weight folk) get type 2 diabetes, with that unfairly added genetic tendency (?thrifty gene hypothesis), and then all the complications. The transition from fit and beautiful little children to overweight adolescents and obese adults is as depressingly common as in other parts of NT.  There’s a healthier group of older folk, some in their 80s and even 90’s, whom I’ve seen in other areas – the old stockmen around Kalkaringi for example.  Moe commonly women here, they are old and thin, don’t smoke, often live in a humpy with a traditional lifestyle distant from trade stores; still hunt their food, though kangaroos are pretty much hunted out around here.

Most health care in Utopia is carried out by small teams of 2 nurses visiting the surrounding bores up to 70 k distant from the clinic at Urapuntja.  They might work from an open shed, or a tiny 3mx3m one room ‘clinic’ with aircon, if there is one. Their most important work is efficient conduct of routine health assessments / blood tests, with a Communicare template on a laptop and scaled-down clinic resources carried in big plastic boxes, including one of basic medications.  The aim is to pick up chronic disease early, but teeth, education, living conditions, and most things relevant to health are quickly assessed.  They also work like GP’s, diagnosing and treating, but with variable competence, and using the famous Carpa manual; after all it’s not their training.  They refer bigger problems quickly, and all evacs are by air – so nurses are quick to phone the DMO in Alice to negotiate a flight.  They work in very isolated and often difficult situations; relatives are quick to anger over poor outcomes, even if the patient has been doggedly non-compliant or following the advice of his ‘bush doctor’ ie magic man.  They may be dedicated long-termers, or short term often younger ‘agency’ nurses.  Both may in part be motivated by higher remote pay rates and allowances, in part by wanting to contribute in an area of great need.  The former may have a partner working here too, or may be single or in a distant marriage that survives or necessitates only occasional contact.  Their local knowledge is impressive.  The short-termers are very variable, from impressive to out of their depth and anxious, without much understanding of ‘cultural safety’ – how to relate well to the locals.  One young nurse resigned this week just 2 weeks after arriving.

Sometimes Utopia has a doctor, whose role in part is to review and sign off these accumulated health checks.  Itemized medicare funds follow only after a doctor’s review, and each health centre’s federal grant funding is also tied to the number of health checks submitted to medicare. So there’s lots of essential ‘paperwork’ for the hapless visiting locum.  Doctors in these places may also be longer-termers, competent experienced professionals who enjoy remote work; or they may on occasion be incompetent, perhaps working remote where they are less subject to scrutiny by peers.  The doctor before me was here for a couple of years, but won’t be back.  He alarmed the other health workers by ordering cheap Indian Viagra on line for all the local men, and wasn’t interested in seeing children or women!  The nurses felt he was incompetent.  A locum doctor has to establish his/her competence quickly.  He’s not here for long, and first impressions endure.  That should be easy enough, though not necessarily, as in his first week he may be struggling with unfamiliar software, and local rules which nobody mentions, as well as a completely new population group and surrounding geography.  The other health workers are generally friendly and supportive, but not always.  There can be a ‘you sink or you swim’ mentality, and there’s that subtle nurse v doctor thing in some places; with some individuals not subtle at all, and of course there’s just one doc and several nurses.  Perhaps this is heat-induced paranoia, and maybe I’ll be evacced soon in a straight-jacket.  It is one of the more challenging locums, and I feel fortunate that it’s not my first.  There’s no social life, so weekends are ok as long as you can amuse yourself (writing long boring emails).

As in most other NT locums I’ve done, I have a nice house to rattle around in, and this one has reasonably functioning wifi – a first – and a free phone!  The bore water is a bit smelly – said to be drinkable but I’ve been sticking to the big casks supplied. Food is ordered online from Woolies in Alice, and picked up by any staff having an Alice weekend.  Last week only half my order was handed over, so I was anticipating a hungry week ahead; but fortunately Steven and Kym returning from leave picked up the rest.  I greeted them like long lost family.  So that’s my take on Utopia at mid-term.  Despite the above ‘mots justes’ I’m enjoying it, but 5 weeks is about right for me.

 

 

Utopia#4

Well, it has been quite a week.  The ‘good thing’ that happened was that one of our drivers brought to me a goanna he’d killed – poor beautiful thing.  I thought maybe he was offering it to me to cook, but he really just wanted to show me.  I was suitably impressed.

Then a not so good thing happened.  A white woman came in as a patient. She’d previously had a fight with Stephen, the head nurse, so he warned me briefly that she could be difficult.  She was short, fat, about 55 and unsmiling.  I listened to her and checked her bp, got her a 2week emergency supply of medication, and politely explained that it was policy for waged non-aboriginals to be given a script to take to a pharmacy, not free ongoing medications, and said that her consult and 2w emergency supply would be free.  She then said it was an unfriendly clinic and left, no voices raised, everything polite.  She worked for the local shire and clearly had expected to get lifetime free meds, as the blacks do.

She put in a verbal complaint to her boss who happened to be at a conference in Alice with our ceo and clinical manager.  Next thing we get a furious email from our ceo saying what do we think we are doing refusing treatment to anybody.  She made a big tactical mistake by shooting from the hip from afar, rather than ascertaining the facts back here on the ground.  All the nurses are most upset by this email and there’s talk of a mass walk-out.  Stephen resigns!  A few of the agency nurses are just finishing up, so that leaves me to deal with the issue when the managers come back today.  I’d already made a brief accurate account of the consult which I gave them on their return last night, and today just before close of work the ceo gave me the written complaint. I’d sat down with her and had a heart-to-heart before she returned to work this morning, as it seems clear to everyone except the managers that the patient is a vexatious liar.  This was confirmed when I saw the complaint – completely inaccurate, full of lies and defamatory.  Calls me a racist among other things.  Beautiful!  The ceo had been talking about a full meeting of the board, but now I think she’ll follow my advice and hose this down.  It has brought many staff grievances to a head.  I have crafted a reply to the complaint, which I’ll type tomorrow and send you – so you get the full unadulterated flavour.

Another thing that has come out is the grievances that accumulate against managers in these small places.  Management isn’t easy but these little remote spots tend to breed an insular outlook, and small things seem big.  And these 2 managers seem to have been managing staff poorly – bullying behaviour etc.   The last week will go quickly, probably just as well.  Something different in Utopia each week!

Utopia#5

The last week here has been fairly typical, although for me still a bit affected by the unpleasantness of the ‘Nona’ business last week and how best to deal with it.  I hope she will retract, because while not wanting to go down the legal path, I feel she should not get away with defamation, let alone making up a pack of lies in her complaint.  We had one day with three air evacuations – one a sick middle-aged diabetic woman, and a fellow with a deep hand infection needing surgical drainage/washout, and then a five-year old with a high fever, one of twins who both suffer a rare immune deficiency syndrome and are very vulnerable.  Our clinical manager was air-evacced out at the weekend by the other nurses without even asking me to help; she had diverticulitis which I probably would have managed here quite easily.  Because they often work without a doctor, and don’t have doctor skills at diagnosis and management (work out of a manual) they are very quick to order air evacs, at great cost.  On the other hand, the locals are weakened by chronic illness (esp diabetes, chronic kidney and cardiovascular disease) so they may ‘go bad’ quickly. Nobody seems concerned about the cost of air evacs (“free”), and anyway the locals can be very angry if they feel more should have been done.  So it’s tricky.

The next day was very quiet as apparently all the locals had left for a big community meeting at Ampilawadja, something to do with land royalties for fracking!!

Suddenly at 7pm a big change of plans, have to get out with 12 hrs notice, leaving tomorrow Wednesday 7am not Saturday!  Apparently builders arriving unexpectedly and they need a house; also with staff shortages nobody to drive me to Alice on Saturday, but they have to go in tomorrow to pick up a sick staff member from the hospital, so will take me to the airport.  A bit of a rush to clean up and pack up.  So should be back in Melbourne Wednesday night, 3 days early.

 

 

 

 

 

 

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