GROWTH FALTERING

The cat­a­strophic de­cline in the health of in­dige­nous chil­dren in re­mote ar­eas needs med­i­cal an­swers, and a hu­man touch, writes Ni­co­las Roth­well

The Weekend Australian - Review - - Books - Ni­co­las Roth­well is a se­nior writer at The Aus­tralian.

In Jan­uary 2009, at the height of the Kim­ber­ley wet sea­son, in the crowded chil­dren’s ward of Derby hospital, pe­di­atrics pro­fes­sor John Boul­ton came face to face with a tall, thin Gurindji stock­man named Coolibah. It was a tense en­counter, one that changed the lives of both men.

Ill-health had brought them to­gether. Coolibah’s three-year-old grand­son had just been evac­u­ated by the Royal Fly­ing Doc­tor Ser­vice for treat­ment of a se­ri­ous med­i­cal con­di­tion. Boul­ton saw the child a week later for a checkup at Halls Creek, then drove Coolibah and his grand­son back to their out­sta­tion, Ganyinyi, 100km away on Louisa Downs.

“As we headed west on the long drive and started talk­ing,” writes Boul­ton, “we soon found out that we were the same age and Coolibah re­sponded warmly to this co­in­ci­dence. He told me about hav­ing been taken away when he was a baby, and his deep sad­ness at not even hav­ing a photo of his mother. I told him how ashamed white peo­ple were now about past poli­cies and prac­tices of child re­moval.”

Their con­ver­sa­tion gave Boul­ton much to re­flect on. Coolibah was strik­ingly re­silient and had an open cast of mind. He was op­ti­mistic in the face of con­stant ad­ver­sity. The two men struck up a friend­ship; it strength­ened. Boul­ton, who was al­ready im­mersed in a deep study of Abo­rig­i­nal child health, now found him­self pre­sented with “an ex­tra­or­di­nary op­por­tu­nity to gain a glimpse of the life of an Abo­rig­i­nal man in all its pro­found dif­fer­ence”. He lis­tened to his new com­pan­ion and learned.

Boul­ton has now placed Coolibah’s story at the heart of his re­mark­able new book.

Abo­rig­i­nal Chil­dren, His­tory and Health is both an em­blem­atic story of the fron­tier in north­ern Aus­tralia and a guide to the hid­den, per­sist­ing causes of in­dige­nous dis­ad­van­tage.

Coolibah was brought up with other Abo­rig­i­nal chil­dren on Spring­vale sta­tion, given scant school­ing and sent out to the stock camp when he was 11. There he was beaten mer­ci­lessly by one of the boss’s sons. Life there was so hard he ran away when he turned 18 and worked on sta­tions across the east Kim­ber­ley and Vic­to­ria River Dis­trict. He moved be­tween Water­loo, Lim­bunya and Kirkim­bie; he rose to be head stock­man on Ruby Plains. One of the lo­cals there still re­mem­bers that when Coolibah was in the sad­dle, “it was as if man and beast were one, it was a sym­phony of move­ment”.

He mar­ried in those years; there were chil­dren, the first of whom died. The mar­riage broke down; he raised his sons alone; there was a drink­ing phase: “One time I woke up look­ing at the sky, and knew I was in trou­ble: I got off the grog then.” An­other mar­riage and five more chil­dren; his sec­ond wife died and he found him­self alone with a de­pen­dent fam­ily. He set up at the out­sta­tion and tried to get by. A com­pen­sa­tion pack­age of $5000 came through: rec­om­pense for be­ing taken away.

But al­ways the ob­scure hurt from his child­hood years lin­gered on. Even­tu­ally a re­searcher from the Na­tional Archives un­earthed a doc­u­ment with his mother’s de­tails and con­nected him with his rel­a­tives. Aged 65, he was at last able to meet up with some of them at a fu­neral in Ku­nunurra: “They told me that my brothers and sis­ters never for­got me, and were al­ways ask­ing af­ter that lit­tle pic­caninny who was taken away. My brother Felix, who lived in Port Keats, and Smiler, who lived in Tim­ber Creek, are both dead now, same as my three sis­ters.”

Dis­per­sion; the obliv­ion of lost ties: a life summed up. Boul­ton steps back to bring in the fac­tors an­tecedent to this tale: he looks far back to colo­nial times and be­yond in his quest for an­swers to a sim­ple-seem­ing ques­tion: what hap­pened to the Abo­rig­i­nal peo­ples of the north? What made the com­mu­ni­ties of the Kim­ber­ley and Top End what they are to­day?

So­cial and med­i­cal re­searchers con­trib­ute sup­port­ing es­says to but­tress Boul­ton’s ba­sic, rad­i­cal the­sis: that “struc­tural vi­o­lence” is at the heart of things; Coolibah’s world has been so buf­feted and dam­aged by out­side pres­sures that it has all but fallen apart; and a long his­tory of op­pres­sions, pri­va­tions and pro­hi­bi­tions is now “em­bod­ied in bad health out­comes”.

The ev­i­dence point­ing to a great dis­rup­tion is laid out clearly in Boul­ton’s ar­gu­ment: for some 2000 gen­er­a­tions, Abo­rig­i­nal peo­ple lived sus- tain­ably healthy lives on their iso­lated con­ti­nent, yet to­day’s re­mote com­mu­ni­ties are at high risk of sub­clin­i­cal mal­nu­tri­tion. Their tra­di­tional lands have been trans­formed and many of their tra­di­tional food­stuffs de­stroyed; they have been sub­jected, within liv­ing mem­ory, to vi­o­lence and strict con­trol regimes; above all, their so­cial ar­chi­tec­ture has been turned up­side down. Dur­ing pre-con­tact times chil­dren were few and highly val­ued, and were raised not just by their mother but by a range of helpers. To­day the age pyra­mid is re­versed; chil­dren are ev­ery­where and the older rel­a­tives needed to help rear them are in scant sup­ply.

The up­shot is the phe­nom­e­non of “growth faltering”, a term Boul­ton places at the cen­tre of his work. Once doc­tors used to re­fer to this prob­lem in child de­vel­op­ment by the neb­u­lous term “fail­ure to thrive”, but it is noth­ing ab­stract. It can be tracked, it can be quan­ti­fied. Growth faltering oc­curs from the sec­ond half of in­fancy on, when the child’s rate of growth falls be­low nor­mal be­cause of an in­suf­fi­cient in­take of wean­ing food, at the very time in its de­vel­op­ment when it is be­com­ing mo­bile and needs more en­ergy. Once the child has fal­tered, the con­se­quences are long-term: a path­way to­wards early on­set di­a­betes and heart dis­ease has opened up. But the faltering is iden­ti­fied and di­ag­nosed ex­clu­sively by med­i­cal prac­ti­tion­ers and con­strued in purely med­i­cal terms. It may be a per­fect mea­sure of poverty’s im­pact on child health, yet its deep roots in struc­tural in­equity are “hid­den in plain sight”.

So, too, is the bale­ful legacy of the fron­tier past and its long-term ef­fect on the in­dige­nous pop­u­la­tion, so­cial struc­ture and sys­tem of be­liefs. The Kim­ber­ley was the last re­gion of the trop­ics to be set­tled; its wild ranges and thick veg­e­ta­tion pro­vided cover for a long guerilla re­sis­tance that lasted al­most into the 20th cen­tury. Boul­ton is a scholar of this dark his­tory, and de­scribes the process in al­most clin­i­cal terms:

De­pop­u­la­tion from the north­ern Kim­ber­ley ranges oc­curred through a com­bi­na­tion of co­er­cive ag­gre­ga­tion of peo­ples on pas­toral sta­tions; spo­radic ex­tra-ju­di­cial killings of Abo­rig­i­nal men liv­ing in the bush; mas­sacres, such as in the vicin­ity of For­rest River mis­sion in 1926; the forced ex­ile in chains to far-away pris­ons of men for cat­tle-spear­ing for food; and the re­moval of large num­bers of peo­ple be­cause of lep­rosy.

These strate­gies emp­tied the coun­try. In the north­west Kim­ber­ley the pop­u­la­tion halved in every decade from first con­tact un­til 1950. At Kun­munya mis­sion in the early 20th cen­tury, deaths were twice as fre­quent as births. Across the Ter­ri­tory bor­der, the Vic­to­ria River Dis­trict was a “death­scape”. In 1880 the Abo­rig­i­nal pop­u­la­tion was some­where be­tween 3000 and 4200. By 1939 it had dropped to 187, a greater than 95 per cent loss of peo­ple.

Much of this dev­as­ta­tion was caused by killings and by star­va­tion and sick­ness con­se­quent on habi­tat de­struc­tion. But other, more elu­sive, fac­tors also played a part. Men and women felt doomed; they too fal­tered and failed to re­pro­duce or thrive. Here is Ger­man scholar An­dreas Lom­mel, writ­ing of his ob­ser­va­tions from the north Kim­ber­ley in 1938: “Ev­ery­where the re­sult of the slight­est con­tact seemed to be a fall­ing birth rate and a dis­in­te­grat­ing so­cial or­gan­i­sa­tion. It ap­peared that the news of mod­ern cul­ture alone was suf­fi­cient to de­stroy the Abo­rig­ines’ con­cept of the uni­verse.”

The low point was the 1940s. Since then there has been a spec­tac­u­lar re­bound in the in­dige­nous pop­u­la­tion of the north, with para­dox­i­cal re­sults.

At Wad­eye, the for­mer Port Keats mis­sion on the Bon­a­parte Gulf, the pop­u­la­tion was sta­ble around 300 in 1950 but rose sharply from then on, to 766 in 1971 and to 1400 by 2001. It is about 2500 to­day and is pro­jected to reach be­tween 3600 and 4000 within 15 years.

Such is the pat­tern in many of the high­growth com­mu­ni­ties of the re­mote north. Jobs and hous­ing are in short sup­ply, school at­ten­dance re­mains poor, drugs are the cur­rency of daily life. For par­ent­ing, the im­pli­ca­tions are ev­i­dent. Chil­dren are hav­ing chil­dren of their own: men and women find them­selves grand­par­ents in their 30s. The tra­di­tional in­dige­nous pat­tern of assistance in parental care be­comes un­work­able when the num­ber of chil­dren so

greatly ex­ceeds the num­ber of adults in the com­mu­nity. Even a mother op­er­at­ing in a sta­ble re­mote area home strug­gles, given the seden­tary na­ture of com­mu­nity life, the de­pen­dency on shop-sourced, high-cost food­stuffs and the fierce com­pe­ti­tion for ac­cess to wel­fare funds.

The de­tails of the new so­cial land­scape are dis­qui­et­ing. Many preg­nant women in the Kim­ber­ley con­sume al­co­hol and are them­selves mal­nour­ished; many ba­bies are ill-fed dur­ing key stages of their de­vel­op­ment. Abo­rig­i­nal ideas about chil­dren, de­rived from tra­di­tional life­ways, of­ten con­flict with West­ern med­i­cal rec­om­men­da­tions for in­fant nu­tri­tion.

As it hap­pens, much in the present health pro­file of the con­tem­po­rary Aus­tralian bush has par­al­lels in Euro­pean his­tory and the plight of the un­der­class in places such as Wales and the Bri­tish mid­lands dur­ing the early Vic­to­rian age. We know a fair amount about poverty’s im­pact in the newly in­dus­tri­alised so­ci­eties of the mid-19th cen­tury, and we also know what re­forms were even­tu­ally leg­is­lated to over­come it and im­prove child health.

Once new laws came in, the era of wel­fare and com­pul­sory ed­u­ca­tion dawned, hous­ing for the poor was built, pub­lic san­i­ta­tion was taken in hand. The re­sult was a dis­tinct “health tran­si­tion” be­tween 1870 and 1920: a rapid fall in the in­fant mor­tal­ity rate and a rise in all mea­sures of child health through­out the West­ern world.

That tran­si­tion has not oc­curred in re­mote Abo­rig­i­nal Aus­tralia. If one ex­cepts the im­prove­ment in the in­fant mor­tal­ity rate as a re­sult of ba­sic hospital birth-care prac­tices, many of the key health sta­tis­tics re­main spec­tac­u­larly poor and a range of novel dis­eases has en­tered the pic­ture. The most telling in­dex is the rel­a­tive one: the con­di­tion of bush chil­dren when com­pared with their main­stream, metropoli­tan coun­ter­parts.

“De­spite the ef­forts of gov­ern­ments to im­prove child health in re­mote com­mu­ni­ties in north­ern and cen­tral Aus­tralia over at least 30 years,” writes Boul­ton, “the rel­a­tive risk of pre­ventable dis­ease and early death has in­creased in re­la­tion to ur­ban chil­dren of all iden­ti­ties.”

Chil­dren in the Kim­ber­ley are 10 times like­lier to die in the post-neona­tal pe­riod (28 days un­til the end of the first year of life), as are chil­dren from one to five years old. The cri­sis has many causes. Some tra­di­tional so­cial pat­terns are ill-fit­ted to the con­text of mod­ern com­mu­nity life; some of the be­havioural codes that once con­trolled Abo­rig­i­nal so­ci­ety have been aban­doned and noth­ing fills their place.

But the more alarm­ing el­e­ments in the back­ground may well have a hered­i­tary com­po­nent, Boul­ton ar­gues, through the com­plex mech­a­nisms of epi­ge­net­ics, and thus stand be­yond easy mod­i­fi­ca­tion.

Growth faltering is viewed to­day by evo­lu­tion­ary bi­ol­o­gists as a nat­u­ral adap­ta­tion to a poor nu­tri­tional en­vi­ron­ment: reg­u­la­tory hor­mones in the body kick in, the tempo of phys­i­cal de­vel­op­ment in early life slows down, a stunted adult is the con­se­quence.

Boul­ton, draw­ing on ideas from the dis­ci­pline of “life his­tory the­ory”, then reads the ev­i­dence to sug­gest a long-term shift in the Abo­rig­i­nal body on the chang­ing fron­tier: “The con­se­quences of sev­eral gen­er­a­tions of nu­tri­tional con­straint in early life has been to re­duce stature be­low that de­scribed for Abo­rig­i­nal peo­ple at the time of con­tact.” He finds the mark­ers are all there: re­duc­tion in height, lower mus­cle mass, a ten­dency to­wards midriff fat de­po­si­tion.

Growth faltering also has a down­stream im­pact: if it de­vel­oped as an evo­lu­tion­ary trick, well cal­cu­lated to en­hance sur­vival in harsh con­di­tions, it be­comes dam­ag­ing in the mod­ern con­text. A child ill-nour­ished in the womb or early in its life then sud­denly ex­posed to the high sugar, high car­bo­hy­drate diet of a re­mote com­mu­nity fam­ily is bound for early re­nal fail­ure and early death. A “nu­tri­tional ghetto” — one without walls — has trapped the vic­tim and wrecked all prospects for healthy life.

Bleak car­tog­ra­phy! Boul­ton’s de­scrip­tion of the med­i­cal fron­tier re­flects his long ex­pe­ri­ence on the Kim­ber­ley front­line and his par­tic­u­lar com­mit­ment to treat­ing foetal al­co­hol spec­trum dis­or­ders in the Fitzroy Val­ley.

There are plenty of dis­tin­guished doc­tors and med­i­cal aca­demics who give lec­tures about in­dige­nous health, col­lect Abo­rig­i­nal art from eth­i­cal sources and con­trib­ute to fundrais­ers for re­mote com­mu­nity dial­y­sis ma­chines.

Very few though, spend a decade of their lives like Boul­ton, driv­ing on dirt tracks out to Balgo and Billiluna to care for ail­ing chil­dren, or bunk­ing down in the ship­ping con­tainer bud­get rooms at Fitzroy Cross­ing for weeks on end.

Every sen­tence of his nar­ra­tive breathes in­tel­lec­tual cu­rios­ity and em­pa­thy with his pa­tients in the hec­tic, highly coloured re­mote com­mu­nity world. Like many spe­cial­ists con­fronted by the med­i­cal dis­as­ter un­fold­ing in the north­ern trop­ics, he lays great stress on per­sonal con­nec­tion.

Health goals and tar­gets can be es­tab­lished and pur­sued, sta­tis­tics end­lessly re­cited, gaps part-closed, but Boul­ton is con­vinced true progress on the fron­tier can be achieved only through “an ad­di­tional emo­tional com­mit­ment to one’s pro­fes­sional work”.

Medicine thus be­comes a moral jour­ney through the wide, des­o­late wastes of post­colo­nial time and, at the end of all the sci­ence and di­ag­no­sis, emo­tion is what re­mains, the last, the hu­man card:

This is the in­gre­di­ent that we as in­di­vid­u­als can con­trib­ute to mak­ing a dif­fer­ent fu­ture for Abo­rig­i­nal chil­dren so that they are not ground un­der the wheels of the road-train of the global econ­omy like other In­dige­nous peo­ples in rapidly de­vel­op­ing na­tions, but are reared as fel­low cit­i­zens whose unique life view en­riches us all.

Abo­rig­i­nal Chil­dren, His­tory and Health: Be­yond So­cial Deter­mi­nants Edited by John Boul­ton Rout­ledge, 238pp, $67

An over­crowded house­hold in Her­manns­burg, west of Alice Springs, far left; John Boul­ton with Coolibah, left

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