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