Not In Kansas Anymore

New Years: The Other End of the Earth

2007-12-31T08:31:00.000+08:00

Penobscot Bay, from Caterpillar Hill (click on photo above for better view)

New Years is a time when we are more aware of endings and beginnings. And so I have come to the end of this story.

We Buddhists know that only this moment is real, the rest is memory and illusion and hopes and "just our idea". (The hard part is remembering that in each moment.) I have so many memories of this year. Reading back over the notes I made about it in this blog, there is a lot that wasn't included, and maybe some things that should have been left out. But it is what it is, and I hope you've enjoyed it and that it's made you think.

As for me, I'm ending this year both an entirely different person and perhaps more comfortably the person that I always was.

Everything changes, and after being in Maine only 11 days or so, I would say the Coast of Maine is a temple to that principle. The sea air and weather change minute to minute, the smells vary from conifer to dirt/earth, to fish guts to fresh clear wind which is the smell of nothing at all. A day here has no end or beginning, but is part of a recurring cycle as tides come in and out, sun goes up and down, clouds blow over; always the same yet ever different.

Our own sea change continues, but hopefully at a slower pace. I will start my new practice this week. More new beginings, but with a difference: this time there are no endings foreseen. Time will tell. Already I feel the slower rhythms of Island life, as I learn to wait patiently in the Post Office, while the Postmaster and her customer compare earrings received as Christmas presents; as people stop to chat in the middle of the street; as I pick up a hitchhiking clamdigger in an early morning snowstorm. Time is slower here. And that is ok.

We began being lost and changed. We went to the End of the Earth. And now we have returned, to the Other End of the Earth. No matter where we go, we are standing on the Edge. And that is as it should be. Looking out from the hill above Stonington; over the waves, wind and sky spread before us; Vicki and I talk about all the islands we might explore. Each new moment is a seed, pregnant with possibilities, as we walk backwards into the future.

I began this blog with a quote from Robert Charles Wilson. I will end with another, from Spin, the book I started on the plane ride home and just finished last night:

"A transition is only a door...A door into a room. A room you've never been in, though you might have caught a glimpse of it from time to time. Now it's the room where you live; it's yours, it belongs to you. It has certain qualities you can't change- you can't make it bigger or smaller. But how you furnish it is up to you."

Terra Incognita

2007-12-25T04:43:00.000+08:00

Maine is a polar opposite of Derby, in more ways than one. We are almost exactly 180 degrees of longitude around the globe, and 30 degrees closer to the pole. (“Dig a Hole to China " in Stonington, and you come out halfway between Perth and Antarctica.) Tuesday night we arrived here in the dark, after a 9 hour drive, the last 2 hours down icy back roads. Maine had a huge snowstorm the day before, with up to 2 feet of snow in the northern part of the state. It has been cold and windy. When we arrived we walked around the town a bit looking for a hot cup of tea, and felt frozen after 10 minutes. It was hard to see much in the dark. But when we opened the curtains at the Inn on the Harbor Wednesday morning, this is what we saw:
Relocating to Maine has been a leap of faith. It’s been a bit scary, but this type of leap is also something we've already done several times this year, so it’s a familiar scariness. I don’t know any other doctors who have signed up to join a long term practice without ever physically visiting the community. More importantly, I don’t know any whose spouses would willingly decide to settle someplace they have never been. But Vicki has always wanted to live on the Maine coast, and this opportunity has just seemed to “click” into place, ever since the recruiter put us onto it. We learned a lot about the community in advance from the videoconference last June, and over the Internet. But it’s great to finally be here on the ground and meet everyone in person.

One of the best things to fall into place is our accommodation. A retired local doctor and his wife have gone to South Africa for a year or so and kindly rented their brand new house to us, until we can find a place of our own. This place is only a mile out of town, on a beautiful forested point, overlooking a rocky cove. It is so quiet and peaceful here. At night, the only sounds are the wind in the trees, and an occasional sound of the foghorns in the distance. The other evening, a red fox walked across the snowy front yard, 15 feet away from the dining room window.

Wednesday Vicki and I joined the staff of Island Family Medicine for their annual holiday luncheon, sponsored by the local Community Board. When I walked into the office, the manager greeted me with a hug and the exclamation “You really are real!” One of the board members introduced himself as “your first patient, for 8 AM on January 3rd”. The Island Medical Clinic Board is currently adding space and remodeling our office. There are workmen everywhere running saws and placing drywall. It’s really great to see the community having ownership of the medical services on the island, and I’m looking forward to working with them.

Vicki and I are now homemaking again. In the last year we deconstructed and sold our Cedar Rapids household; organized and "decorated" the house for our holidays in Florida; cleaned and arranged in our first house in Derby; and then cleaned, furnished, painted, repaired and decorated our final home in Derby. We are getting pretty good at this, although we agree we are tired of setting up house. We both feel ready to settle down for a long time.

In the meantime, our daughters have both arrived this week and we retrieved Vicki’s mom from north central Maine where she has been visiting her sister and other family. We Christmas shopped and visited L.L. Bean to buy warm clothing and thermal underwear. We found a Christmas tree and the girls decorated it with paper cranes and an origami star. The snow is melting a bit, but today the sky is blue, and the sun shines on the deep green water. Everyone here has been very kind and welcoming. Our faith in the kindness of strangers is reaffirmed, this Christmas Eve.

The purpose of music...

2007-12-19T22:52:00.000+08:00

This is an example of what I'm talking about...

In this mornings newspaper:
New York Philharmonic to break ice in North Korea

Pak Gil Yon, the North Korean ambassador to the UN, sat next to orchestra leaders at the news conference {...}, saying the orchestra's visit would "surely deepen the understanding and cultural relations of the two countries."

Excess

2007-12-19T11:32:00.000+08:00

Our hostess gave us a hug and a little kiss goodbye this morning as we left the White House, on the last leg of our journey to Maine. We’ve been staying here the last 4 days to hear our daughter Leah’s chamber music and solo recitals at SUNY Stony Brook. The White House is a high-end B&B on Long Island, and includes a room with remotely-operated fireplace, a Jacuzzi so large we could swim laps in it, and a shower for two with no less than 6 thermostat-controlled nozzles. Add to that luxury the exquisitely Christmas-decorated lounge and common rooms, and the gourmet breakfasts with wonderful coffee and the New York Times and Wall Street Journal, and we definitely are not in Kansas anymore..

Long Island could be called the land of Beemers, Benz’s and Bentleys. This densely populated chunk of sand sticking into the Atlantic is so palpably rich you could feel the hum of money while driving down the streets.

My senses were overwhelmed. Everywhere we saw huge houses; some overlooking the Sound can only be described as palatial. We took Leah out to one of her favorite restaurant, the Cheesecake Factory. The menu is so huge it came in a spiral bound notebook of 20 pages. The patrons were all huge (as in obese) and it’s easy to understand why. A simple salad plate was the size of the platter I used to carve our Thanksgiving turkey. Vicki mentally counted the calories in the 3 courses ordered by the table next to us, and figured it was over 3000 calories for the meal. Later, Leah dragged us into Macy’s and the mall, looking for sparkly earrings. The place was packed with shoppers, even at 9 PM, a cacophony of voices, carols and products competing for our dollars. A great many of the stores, such as Sharper Image, or Swarovski Crystal specialize in only selling things nobody really needs.

We spent some of our days here in “support role” for Leah as she prepared for her performances. This included tidying and dusting her apartment, throwing her laundry in with ours at the local Laundromat, and grocery shopping. After Woolies in Derby, we are overwhelmed with the mile-long produce aisles (not to mention shopping carts that have wheels that don’t wobble). There are so many choices; our brains are exhausted by the time we reach the checkout lines.

The flip side of all this wealth is that there is abundant tax money for services. Americans make the most noise of any people on Earth about hating their governments, particularly for “excessive taxes”. But driving around the Eastern U.S., we’ve noted the many services tax dollars provide, which are underappreciated. The Interstates are smooth, sanded, and well-maintained. The Pennsylvania Turnpike had emergency call boxes every mile. In Ohio we valued the clean rest stops, attended by mentally-handicapped people who were clearly proud of their work and their ability to be productive. When traveling, we could easily get reliable weather forecasts, and feel secure knowing that our flights were routed by rested, well-monitored air traffic controllers. While we are careful not to attract a speeding ticket from the police, it’s nice to know police, and fire and ambulance are immediately nearby if needed. New York and Long Island have the most amazing infrastructure of any place on the planet, with so many bridges, railways and buildings. And there is consumer protection, so that a building in the Bronx lacking heat is a major news story, attracting help for the poor tenants from government agencies that fix the problem while tracking down the slumlord. Finally, there is the clean, crisp SUNY Stony Brook campus, its Medical Center towering above the trees, a center for learning and culture.

Leah played her pieces with energy and intensity, and we were very proud of the progress she has made in the year since we last heard her play. In the past she and her sister and I have discussed her art and its place in the world. This week’s concerts, and some conversations we had about her new role as a violin teacher fro small children, led me to reflect on her training. Leah’s teacher in High School, Doris Preucil, had a “violin genealogy” on the wall of her studio. Doris’ teacher was at a terminal branch on the tree, which could be traced back, student to teacher for over 300 years.

Violin performance is not a skill that can be learned from a book or watching a video. It is an oral and physical history that must be passed from master to student over long training and with practice. I have seen the havoc wreaked on Aboriginal culture by the removal of just one generation. The truth is that the performing arts of Western civilization are also just as fragile. Remove one generation, and music and dance would never recover.

Compared to fundamental utilitarian vocations, such as medicine or civil engineering, some people might be tempted to criticize the arts as “non-productive” or non-essential to society. But while sewers are critical, and healthcare may relieve suffering, how do we interpret and find meaning in our lives without the arts and our culture? Surely societies that support so many excesses, should find some resources to support the arts, which nuture our spirits.

Ice Storm Passage

2007-12-14T22:37:00.000+08:00

In the last week we traversed the continent of Australia twice (from North to South, and from West to East); flew over the largest ocean on the planet; crossed North America by plane to Ohio; and yesterday drove 650 miles to New York City and Long Island.

We had to beat the ice storms in order to hear our daughter Leah's recitals, at Stony Brook on Long Island this weekend.

We've been watching the weather maps all week as storms barreled out of the Midwest into the Pennsylvania. Yesterday morning my folks woke us and suggested that we leave earlier, as another storm was coming. So we jammed everything into my little red car, and took off East, in an icy cold rainstorm.

All day we watched the thermometer in the car register 33 to 34 degrees, as we skirted the southern edge of the storm on I-70. We crossed the Muskingum River; the Ohio, the Monongahela, the Youghiogheny, the Susquehanna. As we drove up into the mountains, the road ascended into the foggy overcast. The sun came out briefly and the trees sparkled with hoarfrost as ragged clouds blew up out of the valleys. We listened to Norah Jones, NPR and an mp3 from the New York Academy of Science, a liguist discussing what language tells us about human nature.

Night fell, and we stopped for a bowl of chili and a map. We decided to "press on", hoping to cross the bridges in New York late at night. This was a calculated trade off: less traffic versus the stress of night time driving. But it paid off. We hit the George Washington Bridge and fly through the Bronx, onto Long Island in about 20 minutes. Another hour and we gladly take the last, smoke-filled hotel room in Stony Brook and collapse. Thirteen hours, but we are here.

Between Parallel Worlds

2007-12-11T02:48:00.000+08:00

My first sensation is the smell of roasting turkey. Slowly I’m aware of having a cold head and shoulders. The quilt weighs on my chest. I snuggle down into the comfy warm spot and snooze a bit longer. But the diffuse grey light sneaks in through the slats of the blinds and I have an intense desire for a huge cup of coffee, so I get up. I deliberately look through the window to reset my pineal gland to morning. Out of the fog, a bright red cardinal appears to grace the lawn,

I’ve had 9 hours of sleep. Our trip home took 49 hours door to door. We had 22 hours of air time. On the endless Saturday, we saw two sunsets, had two short sleeps, two sunrises, a shower in Sydney, a spit-bath in L.A., and so many snacks and meals they all blur together. A two and a half hour delay in Sydney required rebooking all the U.S. fights. We rerouted through St. Louis, that Purgatory of airports, landing in Dayton at 10 PM. Still Saturday. We slurp down a bowl of stone soup and hit the sack.

This morning we wake at my parents’ farmhouse in Troy, Ohio to fog and drizzle. I can barely see the cornstalk stubble beyond the window. We are in some misty limbo, between worlds, our internal clocks out of whack, wide awake at 2 AM, yawning at noon.

Vicki says we’ve fallen through the wormhole into another world. She is right. A few days ago I was in Ngallagunda. Now I am struck by the sudden appearance of Christmas decorations everywhere, the humming background cadences of the “Little Drummer Boy” in all the airports here. The toilets in St. Louis have automatic paper towel rolls that sense your wet hands and spit a sheet of paper on your palms.

My family has decorated, too. The living room is dominated by my folks’ traditional monster tree, grown at the end of the farm lane, and decorated with ornaments, some from my Dad’s childhood. There are poinsettias and greenery everywhere. Today is Sunday, and it’s my Mom’s tradition to have my brothers’ families for dinner when we visit. She put the turkey in at 6 AM and made stuffing, Czech dumplings and sauerkraut and gravy, sweet potatoes, green peas, seven-fruit salad, and cranberry jello. My sister-in-law brings pecan pie, and there is pumpkin as well. With whipped cream. It is Thanksgiving late, and Christmas early, and my family with all our foibles and peculiarities, faults and strengths gather at the table. It is a home to come home to. I know I am very lucky to have a place to land.

Later we put on long pants, waterproof high-top boots, long-sleeved shirts, possum-knit gloves and coats and knit hats and walk around the frozen bean fields, our feet crunching through the snow and frozen slush. We talk about our trip. Riding the plane so long became a hypnotic, almost hallucinogenic experience. By the last hop, Vicki and I were giggling hysterically as we wiggled our numb bums into the narrow commuter jet seats. We talk about Michael Moore’s film “Sicko” which we both watched on the trans-Pacific flight. While I enjoyed the guerilla theatre of the film, what has stayed with me is not the indictment of the U.S. health insurance mess, but the point that a society is judged by how it cares for the weakest and poorest of its members. Vicki and I talk about the importance of being nutured. I have been nutured by my family, by the RCS, by DAHS, by so many mentors and organizations over the years, and in turn have tried to nuture my students and coworkers. The friends, students, and patients I have seen over the years with the most troubles have all suffered from lack of nuture and social support.

The plea at the end of the film goes round my brain: “Maybe we should all care a little bit less about ourselves, and a little more about each other.” Sounds like Christmas to me.

Change of plan...

2007-12-08T07:30:00.000+08:00

Now 19 hours since we left Derby. Goodbye Derby Pool and frangipani and ibis and boab trees...

We hit Sydney at 0630 local time and are on the list for exit row seats. Pray for us!
[Reminds me of Jimmy Carter on Prayer: "Sometimes God says 'Yes' and sometimes He says 'No' and somtimes he says 'You've got to be kidding.'"]

Best thing so far: getting SHOWERS in the Sydney International terminal. Free. Why don't all airports do this?

Worst so far: Our LA flight is delayed 2.5 hours or more, so we will have to rebook all the domestic U.S. flights once we get to there... And the weather looks terrible..

This feels a lot like when I have been a patient in surgery. Everything is out of your control, there are unexpected delays, you know its going to hurt, but you just have to bite the bullet and tough it out.

Maybe this will just be the price to pay for a White Christmas?

Ok, Here's the Plan (Subject to Change Without Notice....)

2007-12-06T17:01:00.000+08:00

Flight - Qantas Airways (QF) - 1929 Friday, December 07, 2007

Flight 1929 Non-stop
Class of Service: Economy (O)
Depart: Broome Airport (BME)
Friday, December 07, 2007

Arrive: Perth Arpt (PER)
Terminal 2 21:00
Friday, December 07, 2007
Flight Service Information
Equipment: Boeing 717 Flying Time: 2:30
Meal Service: Dinner
In-Flight Services: Non-smoking

Flight - Qantas Airways (QF) - 518 Saturday, December 08, 2007

Flight 518 Non-stop
Class of Service: Economy (V)
Depart: Perth Arpt (PER)
Terminal 2 00:15
Saturday, December 08, 2007

Arrive: Sydney Kingsford Smith Arpt (SYD)
Terminal 3 06:15
Saturday, December 08, 2007
Flight Service Information
Equipment: Boeing 747 Flying Time: 4:00

Flight - Qantas Airways (QF) - 107 Saturday, December 08, 2007

Flight 107 Non-stop
Class of Service: Economy (V)
Depart: Sydney Kingsford Smith Arpt (SYD)
Terminal 1 12:00
Saturday, December 08, 2007

Arrive: Los Angeles Intl Arpt (LAX)
Terminal 4 06:30
Saturday, December 08, 2007
Flight Service Information
Equipment: Boeing 747-400 Flying Time: 13:30
Meal Service: Lunch, Refreshments
In-Flight Services: Movie, , Audio programming, Duty free sales, Non-smoking

Flight - Qantas Airways (QF) - 3163 Saturday, December 08, 2007
Flight 3163 Non-stop
Class of Service: Economy (V)
Depart: Los Angeles Intl Arpt (LAX)
Terminal 4 10:00
Saturday, December 08, 2007

Arrive: O'Hare Intl Arpt (ORD)
CHICAGO
Terminal 3 16:05
Saturday, December 08, 2007
Flight Service Information
Equipment: Douglas MD-83 Flying Time: 4:05

Flight - American Airlines (AA) - 4193 Saturday, December 08, 2007
Flight 4193 Non-stop
Class of Service: Economy (V)
American Airlines Confirmation Number: MXBTJJ
Depart: O'Hare Intl Arpt (ORD)
CHICAGO
Terminal 3 17:20
Saturday, December 08, 2007

Arrive: Dayton International Airport (DAY)
Terminal Not Available 19:30
Saturday, December 08, 2007
Equipment: Embraer RJ140 Flying Time: 1:10

Estimated Total Trip Time 42 hours if no travel delays..
But hey, only 5 cabin briefings!

The Wet Season

2007-12-06T06:39:00.000+08:00

I'm looking down over the Kimberley on my last flight to Ngallagunda. Its starting to rain here, and the dry, sere, brown country has turned a deep silvery green. The gorges gleam reflected blue and green as deep pools fill. Our pilot jinks our little dragonfly of a plane between fluffy cumuli now, as Jesus rays stream down through the morning cloud layers.

The Kimberley, at the end of the earth, collects the flotsam and jetsam of humanity, washed up on the huge tides. The radio station here, 6DBY is no exception, playing the most eclectic collection of tunes I've ever heard. When was the last time you heard Rod McKuen or Woody Guthrie on daytime radio? I listen to the National Indigenous News and a hokey, country Christmas song about Santa in a pickup.

But this morning, as occasionally happens to all of us, I'm sure; they play a song that fits my mood and thoughts perfectly. I haven't heard this in probably 25 years, but the perfect harmonies of this old Crosby, Stills and Nash song resonate in my soul, as we prepare to leave. I hear, for the first time, the message: about taking chances; about living in the moment; about taking a deep breath, and as the Quechua believe, looking forward into the past as we walk backwards into the future.

Look around me
I can see my life before me
Running rings around the way
It used to be

I am older now
I have more than what I wanted
But I wish that I had started
Long before I did

[Chorus]
And there's so much time to make up
Everywhere you turn
Time we have wasted on the way
So much water moving
Underneath the bridge
Let the water come and carry us away

Oh when you were young
Did you question all the answers
Did you envy all the dancers
Who had all the nerve
Look round you know
You must go for what you wanted
Look at all my friends who did and got what they deserved

And there's so much time to make up
Everywhere you turn
Time we have wasted on the way
So much water moving
Underneath the bridge
Let the water come and carry us away

And there's so much love to make up
Everywhere you turn
Love we have wasted on the way
So much water moving
Underneath the bridge
Let the water come and carry us away
Let the water come and carry us away
-Wasted on the Way, Crosby Stills Nash (and Young)

Not in Derby Anymore

2007-12-03T20:31:00.000+08:00

O let America be America again-
That land that never has been yet-
And yet must be.
-Langston Hughes

What you need is sustained outrage...There's far too much respect given to authority.
-Molly Ivins

Vicki has been happily bouncing around the house the last week, singing. “Only x more days” has been the mantra as we count down our time here. With 40 C. heat on the back porch it does not seem like December at all. Only 18 days until Solstice.

A year ago this last week we said goodbye to our house and moved on. Last year’s December we were headed to New York City, then Florida, and finally here. That was a long time ago. I look back at the repetitive, routine of working in Cedar Rapids for 15 years, and events and faces all run together in my memory. In contrast, this year has been long, with so many new experiences burned as waypoints on the path

When people ask why we are “going back,” I say, “This was my ‘gap year’, just taken a bit late…”

Then they wonder, “How did you like your time here?”

I answer. Interesting. Eventful. Challenging. Satisfying. Frustrating. Revealing. Unanticipated. Heartbreaking. Beautiful. Horrible heat. Vast. Intense. …

I could go on and on with adjectives. How does one begin to describe a Continent? I know only one little corner, one Western edge of this land. People tell me “Not all of Australia is like this...” and I’m sure that is true. It’s a big place and complicated, so I naturally have mixed feelings about this country. I never could have anticipated all this year has been. It reminds me of the story of the trip to Italy, turning into Holland.

Sometimes the racist, boozy, provincial, blokey, unaccountability of it all makes me want to scream. Compared to Australia, New Zealand is the goody two-shoes kid; sensible, practical, always pulling up her socks and coming in out of the rain. While the Ozzies are the naughty little brother, skinned knees, covered in mud and a lost look, and sometimes a bruised eye. Compared to his sister, this is a country that needs your love, and patience, until it gets its act together. But I’m comfortable with Australians, who have much in common with us Americans—believing in Fair Dinkum, a Fair Go, and exhalting the “battler”. I believe in them. I know they can do it. Both our peoples have to reconcile our values and beliefs with the truth on the ground.

There are things I don’t miss about the U.S. I don’t miss parents abusing their kids at Wal-Mart, the pervasive materialism, the degradation of the natural world, too many lawyers, demanding consumerism, racism, the death of the spirit. But after this year, I also see my country with new eyes. Those lawyers keep the cows off the roads, and defend civil rights. Commerce makes it possible for every kid to be able to afford crayons. And competition leads us to expect customer service and quality. Americans report they attend church at an astounding 47% rate (but lie about it at a rate of 2:1). I wonder if this reflects some sort of spiritual yearning? And while America still has a lot of racism, we have come a long way since I was a kid. And we can and do talk about it.

So I am homesick for all of it, the good and the bad. I miss my country. I have been an expatriate long enough to feel the yearning to be someplace familiar. Like the sea turtles, imprinted to return to their natal beach, feel the tug of the Earth's magnetic field, pointing them back where they originated, I am pulled North.

Suffice it to say that I came for a geographic cure, and the teaching job, which had many joys and was about what I expected. The RCS faculty, the local doctors and the people at DAHS have been great and I cherish these friendships. The Kimberley I could never have imagined in my wildest dreams. I’ve tried to describe it, but like the Grand Canyon, you have to sit on the rim to get it.

Vicki and I accomplished many things. To judge the value of those accomplishments on some arbitrary scale means little. I think we both feel satisfied with what we did, which in the end is all that matters.

When we began, we were undergoing a sea-change. It’s still happening, but I think we are starting to grab glimpses of the result. Visions of walking through snow again, of evergreens. Christmas is coming, and it will be good to join that season of new birth within the depths of winter.

And I have decided I would like to mark this year by making a change in name, to mark the change in me. I began this blog posting as “Charles”. Because in Australia the name “Chuck” has humorous connotations, this year, I’ve used Charles as my given name everywhere. I am Dr. Charles Zee at DAHS, and Charles at the RCS. At the RCS end of year dinner, the Professor referred to me as “Chuck” and it just didn’t seem to fit me anymore. Vicki says maybe it's because I’ve finally matured (and she can call me anything she wants). But I like "Charles", so I’m going to ask other people to call me that from here on out. (“Dr Z” would be ok, too.)

A week or so ago, I dreamt that the night before our flight, it rained and rained, and all the Fitzroy River plain was 2 meters deep, a vast brown lake. Dead cows and bloated roos floated by; the boabs, green-leaved and yellow-flowered, protruded from a vast still waters. Our 4 Wheel Drive was halted where the road disappeared into the muddy murk. Oh, we were so sad and so upset.

And then I remembered. No worries. “We are not in Kansas anymore”. We need only click our heels three times. Because we are ready to go home.

Bragspot.com

2007-12-02T12:14:00.000+08:00

I just have to brag a bit. Derby meets Lake Woebegon.

The Derby Lads, those loveable larrakins, all scored at or above the mean on their Final Exams.

I am so proud of them!

International Finance

2007-12-01T07:43:00.001+08:00

The American stock market is volatile. Interest rates are going up in both countries. The Aussie dollar has gained value, from 0.82 against the US dollar up to current 0.88 (giving me a nice raise this year). I don't pretend to understand it, but I did come literally face to face with it this morning in the shower.

I am on my last razor blade.

So do I buy another pack here, or wait and try to scrinch by this week on the last blade?

I'm partial to the Gillette Fusion Power razors. Expensive, but a nice shave. I do think the vibrating razor is superior.

Here in Derby, a pack of 4 blades goes for the astonishing price of AU$ 27.00 at Woolies. Explains why there are so many bearded men in the 40 degree C. climate!

In the U.S., current price is $17.99 for a 4-pack (at the most- some places are cheaper).

This converts to $17.99 x 0.88 = AU$ 20.44.

An 8-pack in the U.S. goes for as low as $17 on Amazon.com, but usually about $25 in stores, or $25 x 0.88 = AU$ 28.00 /2 = AU$ 14 per 4 blades bought as an 8-pack.

Bottom line, razor blades are much cheaper in America, even factoring in the weak U.S. dollar....

EXCEPT, the last word comes from Vicki. She doesn't want me grizzly. So she'll buy the blades here. IF they have them in stock at Woolies, which is never a sure thing...

This is just a trivial decision, compared to trying to decide when to transfer my earnings internationally, what to do with my "Super" (retirement money) left here in Australia, etc. What a headache! Makes me glad I'm in Medicine and not in International Business.

Mento Meditations

2007-11-30T20:51:00.000+08:00

I munched on the Mento and a small hard lump started to roll about in my mouth. Bad candy, I thought, and spit it into my hand, only to see the amalgam gleam in the white enamel. Second molar I’ve fractured here in Derby, bookends to my year, and one more little reminder of my mortality. Another trip to the kindly overseas-trained Derby dentist who sets a temporary filling (at no charge). So we go, creaking and cracking and limping into the long slide down from midlife.

“Why be upset about it?” Vicki says, “There’s nothing you can do about it. It could be a lot worse!” And she is right. By my age, her father had survived a major heart attack, CHF, and a bypass with experimental ventriculoplasty. It’s “just my idea”, as the Buddhists say, that I should somehow escape the vicissitudes of aging and disease. I wonder that my idea is even more strongly incorrect because I’m a doctor. I have practiced my detachment to the point that I won’t believe disease can happen to me. Especially since I take fairly good care of myself. Oh well, as the t-shirt says, “Eat right, exercise hard, live well, and die anyway…”

Our travel health insurance coverage ends the minute I step back onto U.S. shores next week, so we’ve been trying to figure out how to avoid becoming one of the 50 million or so uninsured U.S. citizens. Health insurance for my new post won’t cover me until January, so there is a month gap. This is not a big worry for little creaks and cracks, but we don’t want to risk suffering a major car crash or slip on the ice without coverage.

I contacted several people who recommended short-term health insurance. These policies are non-renewable beyond 6 or 12 months, and are designed for people between jobs. Just Google the term and tons of sites come up wanting to sell you a policy.

So I gamely spent an hour or two reading about this product on the web, and obtaining various quotes. Its almost as much fun as making airline reservations, there are so many combinations and permutations. First question is where do I live? I guessed I could pick any state I can make an argument for: there would be Iowa, which I left this year; Ohio, location of my mail drop at my parents, or Maine, ultimate destination. I decided to try Maine. Found a nice catastrophic policy at a cheap cost, and started answering questions.

Now it gets a bit dicey. There are “7 questions” one must answer “NO”, or you can’t be issued short-term insurance. Some are obvious- “do you have cancer?” But do I have “degenerative joint disease of the knee?” At first I use my doctor brain, and think, yes, because I had knee surgery for a torn cartilage. But then I rethink it with a consumer’s brain. I fell in the boat and hurt my knee, and after my surgery I walked 53 km over a 1000 meter mountain and back in New Zealand. So I decide I don’t really have DJD, and anyway, I’m not looking to stick the insurance company for a total knee surgery this month. So OK, we answer all the questions “NO”, put in our credit card number and hit the SUBMIT button. (This in itself is pretty scary, as the application obtains birth date, SSN, and enough details for any identity thief to have great fun. I am surprised that there are not a lot of phishing sites set up to collect this information from the unwary.)

Forty-eight hours later, through the miracle of email, my application is REJECTED. No reason given. But my guess is that it’s the MIB in action again! No, not the Men in Black, but the Medical Information Bureau (or some other ethereal insurance data base) which has recommended because of my age and past claims, I am unworthy of insurance at this low, low price.

So I stayed up late one night and called Anthem Blue Cross in Maine, to ask about an individual (non-short-term) policy. Maine is one of the few states that require all insurance companies to insure all comers, without exclusions. But it turns out there is a catch- you must live in Maine for 60 days before you are eligible. So no joy with Blue Cross (which by the way would have cost over $1000 for a month of coverage for the two of us, IF we were eligible).

However, the Anthem guy was very helpful and did steer me to another short-term company, Assurant, which has a different set of exclusion questions. So I tried again, and this time was approved for a short-term policy, $1000 personal/$4000 family deductible, 80% copay (up to $10,000), lifetime max of $2 million coverage. This cost $350 for the month. But, God forbid, if we should get hurt, at least we won’t be bankrupted.

As many criticisms as I could make of the Australian health care system after this year, this experience does bring home one major difference in which the Australians are far ahead of the U.S. No one in Australia has to worry that if they have a head injury, or come down with leukemia, or choke on a piece of steak, their life’s savings will disappear into the black hole of healthcare.

This is just crazy. We Americans should tell our congressmen to support The United States National Health Insurance Act (HR676)

Universal Medicare coverage would give every American citizen a “fair go” (as they say here in Oz).

Thanksgiving Day

2007-11-23T21:23:00.000+08:00

It is the end of the Rural Clinical School year. I am in Perth for meetings and exams, saying goodbye to all our RCS students as well as my fellow RCS Coordinators. And I am a happy man. I have so much to be thankful for. I won’t list everything- it would take me all day. But after living in Australia for a year, Thanksgiving Day has a special poignancy.

Click to see Album

Frozen turkeys in Perth run about AU$ 38 for a 12 pound bird (AU$ 69 for same size in Derby!), so we opted to have “Thanksgiving Breakfast” Friday morning at Miss Maud’s Swedish Buffet downtown. With time differences, it was still evening of Thanksgiving in the U.S., and we both love breakfast, so this seemed perfect. Miss Maud’s is in the Swedish Hotel, and has already been decorated for Christmas. It was very charming. We enjoyed Swedish pancakes, wonderful breads and fruit with muesli. While we were relaxing, the couple next to us overheard us talking and struck up a conversation about Australia. As soon as we open our mouths here, anyone can guess we are American. (But to be politic, they ALWAYS guess “Canadian” first, because apparently our Northern neighbors are quite offended to be lumped in with us Yanks).

These nice people wondered how we liked Perth. But as we talked, it turned out they were Kiwis. Not only that, they were just back from visiting New Zealand. And to top it off, they were from Winton. Not only FROM Winton, but both BORN there.

Which brings me to the soon-to-retire Head of School, my boss this year, Campbell Murdoch, and his theory of causality. Campbell tells me that he deeply feels that things don’t just happen by coincidence. Certainly one of the things I’m most thankful for this year, is the opportunity to work for Campbell and be part of the wonderful team of RCS faculty. This opportunity came about due to a “chance” meeting he had with our mutual friend and former Winton practice nurse, Dawn, when a plane was delayed in a New Zealand airport 18 months ago. She told Campbell of my interest in Australia, gave him my e-mail address, and the rest is now history. {picture of Campbell, in center at right, with Port Hedland MC and students}

Campbell and Annie visited us in Derby midyear, and have been concerned and supportive of us all year. I’ve realized how much I’ve missed talking with an older, wiser, doctor in recent years. As I age, opportunities to talk to someone like Campbell become more rare and precious. (I’m not sure he was very happy with my expressed appreciation of his ancient wisdom.)

Although I don’t see the other RCS Site Coordinators and Faculty daily, we have regular meetings, and communicate with daily e-mail, and fortnightly video conferences. The 5 central meetings we’ve had this year provide enough opportunity for personal interaction that I’ve made great friendships among the faculty. I am thankful for all that I have learned from them. This extends from a basic understanding of medical education in Australia, to tips about Aboriginal health, to understanding the rules of “footy” and cricket. They have also been very interested in what I have to say. And, they have been most patient when I’m sure I’ve put my foot into it and said something offensive or off-target.

I believe it is unfortunate that so many American doctors lack experiences in foreign medical settings. I very much admire my faculty friends for their diverse backgrounds and the experiences they bring to the RCS. Like the local doctors in Derby, many of them are OTDs, and bring an international perspective to the RCS’s medical education from places such as England, Scotland, and South Africa. One is a Rhodes Scholar, and all have fascinating stories to tell. Added to the RCS’s home-grown faculty, who often have extensive overseas experiences in places like Papua New Guinea, the RCS fields a strong team. All of them have been or are practicing country doctors. As I helped with the OSCEs in urban Perth yesterday, and met the suit-and-tied Urban UWA faculty, I was struck by what a different bunch we RCS teachers are with our relaxed, blue-jeaned, practical, at-the-coalface approach to medicine, and to people in general.

Campbell talks about the RCS as being a family-friendly organization, but it is much more. It is a true family, engaged in the generative process of raising our “children” to be good doctors. And today I am thankful to have been accepted into this family this year. I will miss them so much. Vicki and I cannot bear to really say goodbye to them, so we leave them with invitations to visit us in Maine for “lobster rolls and whoopee pies” (a tribute to the kind of humorous innuendo that Campbell so enjoys).

The Professor has built a great team by including people in a meaningful endeavor that is larger than themselves. He does this with humility, humor and joy. He possesses a charisma I’d heard about from many people in Winton, but had to experience to fully understand. I see Campbell accepting and acknowledging the value, beauty and worth of every human being he meets. (This is how he gets away with a kiss and a hug with all the women, without ever getting slapped.) And he and I are both very lucky to be supported by strong, patient women, who have been willing to go places that most doctors’ spouses would never consider. Fate has provided Campbell with his Annie, and me, with Vicki; and I know that, of all things in our lives, we are both most thankful for that.

Campbell, as he leaves his 5 years as Head of the RCS, admonished us with his “two rules” for success. First, “don’t ever become respectable” because respectability deprives you of the ability to grow, progress and change life for the better. And the other rule is that when others tell you “you must do it this way”; or worse, “it can’t be done”; tell them to “bugger off”. (To get the full effect, say it again—this time in a deep Scottish accent… “BUGGER OFF!”).

A few weeks ago I wrote about fate, but spending a few days with Campbell and the RCS faculty has made me rethink my attitude. Certainly fate exists and must be dealt with. But I find myself more positive about it this week. We can deal with fate by building relationships with people who center on positive, generative endeavors. By doing this, we imbue our lives with meaning and purpose. And for this, and the opportunity to learn this from the RCS, I am forever thankful.

Walking Away From Perth

2007-11-22T21:26:00.000+08:00

Perth is beautiful in the early summer. We are here for my last RCS faculty meetings and the students’ Final OSCEs. Flying in the other day we looked down and saw huge blooming clouds of purple jacaranda trees. The roses are all in bloom and the cities has a fresh-scrubbed feel, like it’s straight from an early morning shower and shave. Steel towers soar over their reflections in the Swan River and no one is seen sleeping in the meticulously manicured parks or wandering homeless in the streets.

Andrew, one of the Coordinators, currently practicing in Kalgoorlie, is hitching a ride with me back to the hotel, when we get to talking about this. He and his wife practiced in Derby over 10 years ago. “When I first came back to Perth” he says, “for two weeks I just wanted to open the window and shout at everybody ‘Don’t You Know What is Going on Up North?!’ “. He found the contrast between the communities so outrageous that he could hardly stand it. It is a larger culture shock to travel from Derby to Perth than it would be to go to China or India, because the two places are such universes apart.

Vicki and I observe Perth through very different eyes, compared to last January. This Sim-perfect-City is just as beautiful, clean, neat and tidy as it was then. I’m sure its one of the most pleasant and comfortable cities on Earth, with its cool green spaces, tidy urban planning and gorgeous Indian Ocean beaches. But we both feel we could not be comfortable living here anymore, knowing what we know now. It is a moral conundrum. I am reminded of Ursula LeGuin’s little story, The Ones Who Walk Away From Omelas. In that moral fairy tale people live in a perfect village, in peace and prosperity. But this perfection is maintained by an unbreakable magic spell, which requires one small child to live in hideous degradation in the deepest basement of the town. The dark power of this child’s misery prevents the entire town from sliding into chaos, filth, pestilence and mayhem. Everyone in the town learns this is the case when they come of age. And from time to time, a lone figure will walk away from the town, never to return.

The place they go towards is a place even less imaginable to most of us than the city of happiness. I cannot describe it at all. It is possible that it does not exist. But they seem to know where they are going, the ones who walk away from Omelas.

LeGuin poses the question: “Are you, the reader, one who would also walk away?”

This is a question I can’t shake, as I walk around Perth, with the dust of Derby still on my shoes. How might I walk away from Omelas? And am I sure, really sure, that the spell is truly unbreakable?

Valedictory

2007-11-17T14:00:00.000+08:00

As a teacher in the RCS, I have a wide variety of roles. Foremost, I am the coordinator of the students’ learning, organizing their clinical attachments to the wards, clinics and remote sites and working to get them to the bedside as much as possible. But at various times I’m also a mentor, friend, colleague, preceptor, examiner, spirit guide and at times, a bit in loco parentis. Which means, either “in the place of the parent” or “in crazy parent mode”, I’m not sure which.

When people here have asked me about the differences between medical students in the U.S. and Australia, I have noted that the students here are very young. Most of the UWA RCS students begin medical school at age 17, right out of high school. Some have come back at older ages, but most have little life experience compared to a U.S. post-graduate. In fact, at the Jarlmadangah weekend last February, only 2 out of 17 students were able to well articulate “why they wanted to become a doctor” after 4+ years of study. Medical school in Australia is heavily subsidized. Compared to the rest of the world it is damn near free. (The low tuitions can be deferred to built-in interest-free loans, and graduates move on to full-salary post-graduate training placements, unlike the U.S. where Residents are paid at about 1/4 of usual salaries. In addition there are many scholarships and loan-forgiveness schemes as well.) Many of the students are eligible for Centrelink (welfare) subsidies while they are full-time students. In addition, RCS students receive free housing, transport of possessions and their own cars to remote sites, use of the RCS 4WD vehicle (free petrol included) “for educational purposes” and an additional stipend for the costs of rural living. They receive free airfare to and from their sites, and one free trip back to Perth for the Options study period mid-year. Student housing comes with free high speed internet, a complete library of medical books on site, as well as unlimited access to all University Library electronic books and journals. All their cases, lectures and slide talks are downloadable from the medical school web site. Student houses, generally some of the nicest in any remote town, are fully equipped, including TVs, stereos, DVD players, and modern kitchen and laundry appliances. The Port Hedland house even has a swimming pool. Gardening services are provided by the site—students don’t even have to mow the grass.

I spent this last week doing last minute tutorials with my RCS students, who have Final Exams this coming week. I’ve also welcomed my replacement coordinator, just arrived from the U.K., as well as supported our new Resident doctor who has been here one week. Last weekend the RCS students took us out for dinner, gave my assistant Jane, and me some lovely parting gifts, and came to a farewell reception we held for them at DAHS.

Finishing up my student teaching has led me to reflect quite a lot, because, after 20 years of having students in one form or another, I plan to take some time off from teaching for at least a year or two. In their individual exit interviews, the RCS students all expressed great appreciation for the year, and commented on how much they’d grown and improved as self-directed learners. All three of them commented in one way or another on Aboriginal health, the gist being that “before this year, they thought of Aboriginal people as being very different, but now they see they are just people with common human problems, complicated by different backgrounds”. Hearing this spontaneously from each of them has to have been one of the high points of the year.

While it is easy to teach shoulder examinations, the role of the folic acid cycle in Wiernicke’s encephalopathy, and stepped care plans for asthma, it is much harder to teach the personal and professional side of medicine. I can only do that by modeling, discussing cases, and providing environments where “transformational learning” might occur. At the end of the day, my goal as a teacher is not to produce “good-enough doctors”, but to nurture doctors who are good at what they do and good as people. I hope all the RCS students graduate with as much empathy, compassion and kindness as they possess smarts. Maybe more. One can always learn the smarts.

Without going into details, my students’ final leave-taking was not without its major bumps, causing a bit of consternation around here this week. Other concerning incidents have occurred this year across the RCS and also among the 6th-year students. For example, one 6th-year student's mother called the Medical School less than 10 hours after her arrival in Derby complaining that her 23 year old daughter’s hospital quarters were dirty and had cockroaches. This occurred in a community where many people live outside in the parks, or 15-20 people reside in one family house. In fairness, I have concerns about all medical students—not only in Australia, but in the U.S. as well. The stats show that more and more, the privileged are recruited into medicine, while fewer students with rural and social disadvantaged backgrounds become doctors every year. [be sure to read the "Response from Australia" on the link above]

So I have been wondering, do the students generally appreciate all the advantages they receive? Do they truly know how lucky they are to have this education, and all the material, not to mention personal and professional, support they enjoy?

Much of this week, my thoughts have gone back to the shy, teenaged Aboriginal girl from the desert beyond Hall’s Creek, who after 3 days on the Leeuwin trip in July, finally got up the courage to talk to Vicki, and shared her dreams of becoming an astronaut. She has been handicapped by birth and circumstance—such aspirations are forever out of her reach. How much would she give to trade places with any one of our medical students in the RCS?

Last January on the first day my students arrived in Derby, Vicki and I made supper for them and talked about the year ahead. Vicki talked about the importance of hygiene in the tropics—that kitchens and baths must be kept clean to prevent disease, that hygiene must be much more of a way of life here in the heat, due to risks of bugs, parasites, and skin infections. And I asked them, when on the wards or in the office, to wash their dishes. Because students and doctors are not special people, they should show humility, respect for co-workers and self-regulation by cleaning up after themselves, and not expecting to be waited upon. (And of course, behind my admonition is one of my favorite Zen koans: Student: “What is the way to enlightenment”? Master: “Go wash your rice bowl!”)

What do I want to see in the next generation of doctors—the people who will take care of me when I am old and sick and dying? Like everyone, I want a doctor who is kind and caring. A doctor who walks the talk, who takes care of herself with discipline and self-regulation, because she knows she herself is the tool that facilitates healing. I want a doctor who not only washes his own bowls and cups, but one who sees the wider problems, the big picture. So maybe, if I had to do it over again, I would assign, near the beginning of the year here in Derby, a reading and discussion of LeoTolstoy’s little treatise about poverty and morality, “What Then Must We Do?”

It is a hard question. It is what we must teach our children, the next generation, to whom we are leaving a world in trouble. How do we privileged doctors relate to our less privileged patients? How does the developed world fairly treat the undeveloped under Kyoto protocols? How do we as rich Westernized countries deal with poor, war-torn nations? It is a question of self-control, self-regulation, self-discipline and self-denial. Where do we draw the lines for acceptable and expected behavior? I don’t have all the answers.

But despite the bumps here at the end of the year, I leave teaching feel satisfied that at least I have asked the questions of my students. And I know that they have heard what I am saying.

A Fate-full Flight

2007-11-11T15:29:00.001+08:00

I am on a remote flight up the Gibb River Road, when the last patient comes into the clinic. She has been dealing with domestic violence at home for quite awhile, and requests that I fly her and her 4 preschool children back to Derby on the plane. The smallest is a nursing infant in her arms. She tells me her partner has often threatened to kill her. And this morning, he told her to get everyone out off the house. She has no relatives in the community or any place to live.

The local area nurse is concerned, but doesn’t really know what to do. I listen to the young woman for awhile; give her the message “No one deserves to be treated this way”, talk to her about the safety of her kids, explore her perceptions that she has no options. I ask her to wait a bit, and phone the Aboriginal Corporation for Women’s’ Assistance service in Derby. No one answers the telephone. The emergency mobile number gives me the message that it is “no longer in service”. And there are no police services on the Gibb River Road. (Heck, there are no police in Derby after 5PM. If someone is being murdered down the street, you may call and get Broome Police dispatch, who will send someone around in the morning.) In desperation I call our Social Emotional Well-Being (SEWB) counselor at DAHS and talk to her. She thinks she can find the Women’s’ Assistance worker, so I wait a bit.

During all this, the partner comes back to the clinic and asks my patient and the kids if she would like him to fix lunch for them? They all troop off together. While I’m waiting for the SEWB call back, I eat my own PB&J. I’m worried. How would I feel if I fly off and something bad happens? Yet the single-engine plane is very light, and it’s really not appropriate to carry the infants without proper seating. (It’s a hot and very bumpy day up there.)

The SEWB worker calls back: “No joy”. I’m on my own. The patient comes back after lunch and seems less anxious. I review her options again. I talk to her about coming to the clinic to make a police report if she feels in imminent danger. She doesn’t want to do that now. I talk about having the traveling counselor see her when they come up the Gibb in a few weeks. She’s pretty sure she doesn’t want that either, but I prevail on her that I will put in the referral, and she can always decide she is ok later. She seems satisfied and leaves. I wonder, was this just a ploy for a flight to Derby? Is she just conflicted and unhappy and needing someone to talk to? Has my advice helped? Have I misjudged the situation in any way? The cultural divide never has seemed so wide.
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The season is changing. Besides the daily 40 C temperatures, we now have clouds, and afternoon flights require tight seatbelts to avoid hitting my head on the up and down drafts. We fly home at 8500 feet, just beneath the flat bottoms of fluffy cumuli. It has rained 2.5 cm up the Gibb, and I again look down into remote gorges with huge white waterfalls. The rainfall has stimulated the grass and things are green in the Gibb, although still sere and dry in Derby. One community puts a herd of horses out on the schoolyard to “cut the grass”.

It is Spring here, but that makes no difference to the ubiquitous dogs in the communities. They have puppies all year around. Here is one of our nurses, Mary Jane, a Sister of Mercy, with a new pup.

Which brings me to the issue of sainthood. The Remote Area Nurses (RANs) in Australia are excellent candidates in my view. Whether they are religious or secular, they live and work in many remote Aboriginal communities. They are essentially on call 24/7 for any accidents, of which there are many. And they do the best they can, with help only from RFDS by phone or hours-away flights. They know the people in the community, and do their best to educate them to do the right things. But they need tremendous patience to see that advice ignored day after day, year after year. And they risk “payback” from families if there is misperception about any adverse outcome in the clinics. It is not a job for the fainthearted. They are heroes in my eyes.

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I was thinking about heroism on my flight home this week. Lately I’ve heard a lot of stories from people who have been faced with insufferable situations. A mom adopts a child who develops homicidal thoughts and actions towards her. My patient with children is stuck in a situation with domestic violence. A family is faced with institutionalizing their autistic kid. A patient is diagnosed with cancer. Usually these are problems involving birth, life, love and death.

Several of my correspondents have intimated that my motives for this year abroad have been similarly heroic and altruistic. This feels very false to me. As we turn into the last 4 weeks here, I have looked back to my first post on this blog, a year ago. We were in a metamorphosis at the time. A sea change. Not a choice.

What is the choice when facing an impossible unsolvable problem? There is no choice. One just gets stubborn and pushes on through as best one can.

Yet, from the outside, there is a tendency to ascribe noble aspirations, heroic qualities to the people involved in the story. Only in fairy tales do we find heroes who choose to face danger voluntarily. In fairy tales the hero wins, despite all odds. Contrast them to the great myths, where Fate controls the outcome, often to the hero’s detriment.

When I was 17, I talked to one of my first physician mentors about the Lord of the Rings books, which I had just read for the first time. He commented that their cult status (at that time) was due to the well-written human qualities of the Hobbits. So I am reminded of one passage in the books, where Sam breaks the 4th wall in the narrative, and speculates that later generations will “tell heroic stories about Frodo and his faithful gardener, Sam”. He notes that the storytellers won’t relate that he and Frodo were in a situation where they just did what they had to do.

Fate and destiny certainly rule here in the Kimberly. People here seem to live in the present more than Westerners. The future is uncertain, uncontrollable, inevitable. The little boys I see here in the clinic hold still for me to look in their ears, poke sticks down their throats, give them injections. As 3 and 4 year olds, they are already stoics.

I think we Westerners fool ourselves about controlling our lives. We can try to choose who to be with. Where to work. Try to find pleasure by finding satisfaction in our actions, whatever they are. But our choices are limited. In the end, things happen, and we must grow or die.

And as I fly over these ancient rocky landscapes, I reflect that they will never transform into rich farms, great cities, or green golf courses. Fate holds sway.

Aboriginal Health Summit

2007-11-07T20:02:00.000+08:00

I’ve not been feeling very well for about 6 weeks now. First I had the flu, and sinus infection. Getting over that, I developed pain in my right shoulder. This impingement got so bad that I’ve had to stop all swimming with my arms. I am reduced to kicking with the float boards which is very frustrating. And to top it off, in Port Hedland I got bitten by sandflies, and about 4 days later developed a serious case of papular urticaria. The itching has been so bad that I sleep only by taking 50 mg of Benadryl and taking an ice pack to bed with me. The antihistamine makes me hung over until about noon each day. So I am not my usual perky self. The good news is that my students passed their OSCE’s. This week we are having final tutorials before they leave Derby next week for final exams in Perth.

Last week was the Aboriginal Health Summit in Broome. I stopped and attended for a couple of days on the way back from Port Hedland.

Two talks caught my attention.

First, a talk by an architect, Paul Pholeros talked about housing and health in Aboriginal communities. The prevailing Australian prejudice is that “Aboriginal people are given free houses that they don’t take care of, and in fact actively destroy”. Even my hairdresser here in Derby repeated this attitude to me this week. The truth, based on surveys of 5232 Aboriginal homes, is that only 10 percent of 91,819 items in these homes were damaged by overuse, misuse, abuse or vandalism. A much bigger problem is that 70% of repairs were needed for shoddy or incorrect initial construction. The remainder of problems were due to the harsh Outback environment. Outside of urban areas, most water in Australia is very high in mineral salts, which results in rapid corrosion of tap seats, for example. In one community, 40 of 76 hot water units fitted in a government program were leaking due to a manufacturing fault, yet warranty claims were not honored. In essence, government housing programs put in very expensive housing- up to $AUD 400,000 per Outback home- which goes to the lowest bidder and results in a sub par construction that does not last. As a result, in many Aboriginal communities, only 33 % of homes had a working shower, only 55% a functional toilet, over 90% had unsafe electrical systems, and over 95% did not have a functional kitchen where food could be stored, prepared and cooked. Is it any wonder that poor nutrition, skin diseases, and diarrhea and respiratory diseases run rampant?

Mr. Pholeros is part of a project in South Australia called HealthHabitat. They go into a community and teach the local people to survey, then repair the problems. His plea was that it is much cheaper to build homes correctly the first time, and provide local people with skills, tools and supplies to maintain the homes. Their program focuses on improving housing to promote the Nine Healthy Living Habits. Just fixing the water systems in one community saved $AUD 67,000 in water bills and over 100 million liters of water in this arid country.

Unfortunately, in 2006 the Minister for Indigenous Affairs could not account for how more than $AUD 2 BILLION had been spent on housing in the previous decade.
Perhaps a new government will spend the money more wisely? Mr. Pholeros has been researching and writing about these issues since 1993. He is the soul of persistence.
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The second story was about an Aboriginal community, Baryulgil, in New South Wales. These people were able to keep their land and preserve their culture. They were even lucky enough to find jobs on their land, mining a valuable natural resource. Unfortunately, this resource was asbestos. A similar story unfolded in Western Australia around Wittenoon and Roeburn. The presentation was focused on efforts to gain the communities’ trust. In one community, the son of the chairman went to University and studied anthropology and oral history collection. He has been hired to interview the old peoples’ stories about the mines, in order to collect data for compensation. This is needed, because the company that ran the mines, James Hardie, suffered “mysterious fires” that burned only the file cabinets containing the personnel health records of the miners. Also, the original chest x-rays of all these workers were sent off for review by the company, and also “disappeared” from the face of the Earth. While a settlement was negotiated two years ago, the company has not paid a cent yet to victims. When I shared this story with my mentor, Dr. David Atkinson, he said, “The irony around Aboriginal health never ends.” Barristers plan to bring new test cases to the courts.
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Finally, the newly released draft drinking guidelines for Australia are getting a bit of press here. Most of the controversy is not about the science or safety of the guidelines, but whether they are "realistic".

Elections, Ozzie Style

2007-11-04T14:39:00.001+08:00

I am relaxing at the pool at the students' house in Port Hedland, after a long day doing OSCEs and talking with Stephanie, who asks, "What do you think of Hillary?"

It turns out her boyfriend is a law student and obsessed with U.S. politics. They both watch "The West Wing" but admit they understand as much about American politics as they do "gridiron". I tell her I feel out of the loop, living in Derby. We only see little snippets on World News Australia on SBS. We saw Hillary getting pounded at the debate by Obama and Edwards this week, but I have not had the opportunity to read much or understand any candidates’ positions. And since we are not returning to Iowa, I don't feel the need to make the effort just yet. I explain to Stephanie about the Iowa caucuses. And she answers my questions about the current Australian election. Or at least tries hard to. To me, it’s a bit like trying to understand the arcane rules of cricket.

John Howard, the current Prime Minister, dissolved his government 3 weeks ago, and has 3 more weeks of campaign before Election Day. Howard is a Liberal, which here, means really a conservative. He has been in power for 12 years. And I do mean in power. Under the Australian parliamentary system, the government with the majority (or a coalition with the majority) chooses a Prime Minister, who appoints members of the lower legislative house as Cabinet Ministers. So the legislative branch of the government also becomes its executive branch. This means they can run the country however they like, as their majority will pass any law or support any policy of the "executives". Imagine if the party controlling the U.S. House of Representatives automatically won the Presidency every time, and you will get the picture. No vetos. No fights between the Congress and President over legislation. (Oh, yes, I forget, we had that in the U.S. under Bush until the Democrats returned the country to a saner form of government last year!) So the genius of our Founders is revealed. They understood the need for checks and balances to keep the government from doing crazy things.

Australia has a different flavour to its democracy. The party in power gets things done alright. And after awhile, variable in time, the public gets sick of them and replaces them with the other party. This year, that looks to be Labour, who might be analogous to the U.S. Democrats, except that labour unions still play a role here, and Labour does not have the natural pull for the affluent and well-educated people that the Democrats traditionally held (but maybe not any more?). I am no political scientist, that is for sure, and I suspect that trying to draw analogies is like saying, "kangaroo hold the same place in the Australian ecosystem as deer in North America, except that they tolerate dry climates much better, oh and they have their babies without placentas, carry them in pouches, and don't have to worry about large predators once they grow to adult size". Things just don't cross-map well.

Add to that the smaller parties. The most important one seems to be the National Party, a rural issues group especially strong here in WA, which is in coalition with the Liberals. There are also the Greens, Family First, Australian Democrats and many others. The Greens hold 4 seats in the Australian Senate, and are contenders there for controlling the balance of power. (The Senate, as in the U.S. contains the same number of members from each Australian State, and is intended to balance the representation of the Lower House, which is proportional to population.)
I have to smile at the names of the many minor parties here, including the Australian Fishing & Lifestyle Party, the Four Wheel Drive Party , HEMP (Help End Marijuana Prohibition) , the Lower Excise Fuel and Beer Party , the unfortunately defunct Sun Ripened Warm Tomato Party, the Non-Custodial Parents Party, and the What Women Want (Australia) party.

Finally, add to this broth, the requirement that voting is MANDATORY for all Australians and that voting is preferential, and it makes for a confusing and fun time. All Australians face a fine if they don’t vote in the upcoming election. And this week, blinded judges picked numbered balls twice to assign positions on each ballot. The ballots themselves are paper and huge. And because they require each voter to number every single candidate in order of preference, I understand most Australians pick up a “cheat sheet” from their party of preference to copy in the voting booth. This means, that even if the Greens have no chance of taking a seat in a district, say, Bennelong where the Prime Minister is standing for re-election, their recommended preferences may make a huge difference in the ultimate winner. And there is a chance that Mr. Howard’s party might win the election while he loses his own seat in his Sydney suburb. This would catapult the unloved Peter Costello, his current Treasury Minister, into prematurely becoming the next Prime Minister. Counting the votes, all done on paper ballots, is very complex. Wikipedia has a good article on preferential voting in Australia if you are interested in the details. And, you can imagine that interpreting opinion polls and their possible significance takes an advanced degree in math and statistics.

The campaign so far has been blessedly free of the 24/7 attack dog TV ads we are accustomed to in the U.S. Instead, we have had one debate between Mr. Howard, and Mr. Kevin Rudd, who is the current Opposition leader. And there are a series of sound and video bites daily, as each leader visits the marginal seats and makes the usual promises to provide education, safety and a chicken in every pot.

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Each party has made some funny gaffes, most notably Tony Abbott, the mafia look-alike Liberal Health Minister browbeating his female Opposition counterpart, being rude and labelling her statements as “bullshit”. And Labour’s Environmental Shadow Minister, former rocker Peter Garrett, was caught on camera joking that if his party won the election they “would just change everything [they’d promised] anyway”.

Both parties have promised to pursue some sort of rapprochement with the Aboriginal and Torres Strait Islander peoples, although what, how and when remains well undefined. The Liberal PM clearly has no intention of saying “Sorry” to the Indigenous people, believing that would open a can of worms: i.e. the government might then have to actually do something to redress the situation. Mr. Rudd is more cagey, saying that his new government would take more responsibility, but not really spelling it out much either. And both Federal politicians have made moves and threats to take over the hospital systems currently run by the States, again with no firm long-term commitments spelled out.

It will be fun to see what happens. The election is 2 weeks before we leave the country, and currently it’s too close to call. My Australian co-workers are mostly very apathetic about it. There is a widespread belief that it doesn’t much matter which party wins as it will make little long-term difference. That sentiment is certainly a very familiar one that needs no cross-cultural explanation.

Odds and Ends

2007-10-26T21:25:00.000+08:00

The last two weeks we've both been under the weather. I caught the flu and felt really rotten for about 3 days, then started to feel better, then got sicker again. I posed the problem to my students: purulent nasal discharge, right sided facial pain, + face pain on bending over, and "double sickening" over 10 days. Classic history and signs for sinusitis. It was so bad I actually took a sick day last week. (Not to be confused with a "sickie", which is Australia is a common practice of abusing a sick day to escape from work. And also not to confused with American "sicko" which has entirely different connotations.)

I believe I took about 4 sick days in the 14 years I worked in Cedar Rapids, so this was really unusual for me. I had to beg off my Wednesday flight, which meant that Cyril flew up to Gibb in my place. As always happens when one takes call as a favor to a colleague, a man collapsed just down the road, and was lucky enough to be only 10 minutes from the clinic. He was having a heart attack and at one point had a pulse of 23. I met this gent the next day in the hospital and he realized that he beat the reaper. He had his MI on the ONLY day a doctor or nurse was in the Community, he was close to the clinic and had someone who could drag him in, the ECG machine and other equipment sort of worked (always a problem up the Gibb), and the RFDS had a plane only 2 hours away and was willing to divert and let Cyril fly back as the flight surgeon. The chances of the stars aligning in such a fashion are rare in the Outback- he is one lucky man. And I was so glad I didn't try to fly with a clogged up, fuzzy head. Another stroke of luck for him that I wasn't on duty!

About the same time Vicki also came down with the flu. So we have been snorting and coughing at each other now for a couple of weeks. To add to the fun, one of the two aircon units in the house has busted. The replacements for these very old units are sitting on the back porch, but waiting on the workmen to come from Broome to install them. And the Kimberly is heating up now. Our back porch thermometer has hit 40C (102 F) daily this last week, so the aircon business is hopping. We took the bed apart and moved it into a room with a remaining working unit, and are praying that the cranky machinery can hold out till the workers get to us.

This week is the last week of instruction for the RCS students. My RCS guys have been in review mode for the last 2 weeks as we prepare for their OSCEs. They will have OSCEs in Port Hedland on Monday, so we all drive the 766 km on Sunday, then drive back on Tuesday. The exams are 7 minutes each, among 8 stations, with a minute between stations. They will walk up to the door, read a precis such as "A young mother brings in her 5 year old who has a fever and a large swollen gland beneath the jaw (see picture). Explain to her what the problem might be, and outline your diagnostic and treatment plan." Then the student walks through the door and performs the skill.

My guys have justifiably high anxiety, because the problems could be anything they have seen in the entire year, from reading an ECG or x-ray, to delivering the bad news of a terminal diagnosis, to demonstrating how to deliver a stuck baby. However, this type of exam should better predict later performance as a physician. Once they complete the RCS OSCEs, they have two more weeks to study, and then will join the Metro Perth students for final written examinations as well as a last round of OSCEs in Perth.

The written exams are NOT multiple choice, but the more traditional British-style exam, with questions such as "Discuss the differential diagnosis of urinary incontinence. Detail the optimum diagnostic algorithm, and discuss treatment for the most common problems." Vicki and I will fly to Perth for an RCS Coordinators meeting and I will help with the OSCEs there as well.

So we have been spending the last two weeks trying to fill in the gaps for things the students haven't seen here in the Kimberley. This mostly includes advanced cancer cases, cancer screening, musculoskeletal medicine, complicated gynecology, endocrinology, and advanced obstetrics.

And despite the heat, it is Spring here in the tropics. My tomatoes continue to produce. We have had wonderful papayas from trees in the yard, and the mango's should be ripe in a week or two. The frangipani are blooming and their heavy sweet fragrance hangs in the air when I come home in the evening cooling. I am enjoying the rainbow lorikeets and black cockatoos each day, and savoring the time left while anticipating the coming contrast to silent, snow-covered Maine.

Alcohol Guidelines Revisited

2007-10-18T18:43:00.000+08:00

(see Sept. 22nd post below)

From last Sunday's Australian:

"The nation's top health advice body is set to call time on our obsession with grog by slashing by up to two-thirds its recommended limits on how much people can drink before putting themselves at appreciable risk of illness or injury.

The draft guidelines advise men and women to drink no more than two standard drinks a day. For children and adolescents under 17, pregnant women and those breastfeeding or planning a pregnancy, avoiding alcohol altogether is "the safest option". "

Read the full story at: http://www.theaustralian.news.com.au/story/0,25197,22577560-2702,00.html
The draft guidelines can be read at: http://www.nhmrc.gov.au/consult/index.htm I found Part A: Section 4 with its public health information about "Drinking in Australia" very interesting.

Previously I'd sent the the Sept. 22 "table" as an email to all the RCS Faculty and Students. The reaction was varied but interesting. With follow-up flurry of emails after this weeks news, its been quite a discussion.

One fellow faculty member claimed that "if you tell the blokes 'only 2' they'll just ignore you as its unrealistic." I've countered with the fact that research shows primary care doctors can make a difference with as little as 10 minutes of brief counseling on a couple of visits. For the evidence see : http://www.annals.org/cgi/reprint/140/7/557.pdf

This revision of Australian Guidelines for Safe Drinking is a good start at dealing with a very large problem.

so Cheers! and happy SAFE drinking!

Proud To Be An OTD

2007-10-14T17:47:00.000+08:00

When I was a 3rd year med student my intern used to refer to patients to be discharged as OTD- or "out the door".

Here, it means Overseas Trained doctor. In Australia OTDs are an issue because they make up 30% of the workforce. In the 80's the government decided the way to control medical costs was to train fewer doctors. They cut training posts in half, which led to the current severe shortages of doctors and nurses. In addition, the chronic underresourcing of hospitals by state governments has led to events such as the recent uproar in New South Wales where a woman miscarried alone in an ER toilet after waiting 2 hours just to be triaged. Of course, this kind of thing probably happens all the time in the U.S., but because of the abundance of lawyers, hospitals are held accountable and work to prevent such horrors. Or at least pay for their mistakes. Here, it becomes an election issue, which is ironic, because health care is a State responsibility. But the Prime Minister and his Opponents are threatening to take over health care because of public discontent.

OTDs have become an issue in politics as a side issue to service inadequacies. Several years Australia had a doctor who killed a large number of people through bad practice. Jayant Patel, Queensland's "Dr. Death" was an OTD who was not credentialed properly by the Queensland Medical Board, but this case has tainted the reputation of all OTD's in the public mind. So there is much discussion in the press about foreign trained doctors and perceived problems in language, culture, and knowledge base.

Add to this the case of Mohamed Haneef, an Indian-trained doctor who was detained incommunicado by the authorities for 5 days under anti terrorism charges after the bombings in the U.K. this year. One of the bombers was a distant cousin. But after an exhaustive investigation the police were forced to drop charges. Never ones to admit error, the government nevertheless cancelled his visa and deported him back to India. He was greeted there as a hero wrongly persecuted by Australia. By all accounts he was a good doctor in Queensland and is missed by his colleagues. Inquiries from Indian doctors for Australian jobs have subsequently dropped by 80 % .

Last week the Rural Health Network sponsored a social dinner for Derby doctors and their families at The Point restaurant. As I looked around the tables, I was struck that we were the U. N. of medicine. The Hospital's Senior Medical Officer is one of two Australian trained doctors in the room (the other is a temporary Pediatrician). The SMO is the youngest doctor in the room. Besides working full time as a GP/Anesthetist, she is expected to supervise and direct medical care at the local hospital. Yet as far as I can tell she is not supported by the WA Country Hospitals with the time nor staff to do this.

Who are the doctors we SMOs support? Starting at the hospital, Chris is a tall, dignified Nigerian doctor, trained in GP/Obstetrics in Ireland. His wife, our pregnant Paediatric registrar, worked in the hospital caring for sick children until she herself delivered last week. Duncan is from Papua New Guinea, a single parent of 3 kids, he did over 200 anesthetics last year in addition to clinics and inpatient work. Eric, from Singapore, climbs mountains and makes delicious chili mudcrab. He has extensive experience in emergency medicine and Aboriginal health from working in the NT. Gowri is a Tamil from Sri Lanka, happy to have escaped the violence there. The students love him for his supportive teaching. Finally my friend Arvind, from India, is a lovely, gentle pediatrician who has worked all over the world, including experiences in the war zones of Ethiopia.

At DAHS, where I am SMO, Cyril is a devout Buddhist doctor who spent 6 months as a teenager in Burmese prisons. His crime was being a leader in the medical student association during the time of the 1988 demonstrations. He got out, came to this country, learned English, and finished med school. He just passed his RACGP exams and will leave soon to study palliative care. Lilley and Charles are a Malaysian couple in their 60's. They have a son living in Melbourne. They worked in Aboriginal Health in Kununnura for 2 years before coming to Derby. Finally, Marina, our DAHS GP Registrar emigrated from Irkusk in Siberia and is retraining here. She came to Australia for a better life for her daughter, who now lives in Perth.

All these doctors, like me, are granted visas restricting their practice to "areas of need". In other words, only places so poor, remote, and/or underresourced that Australian doctors don't want to be there. Many of them have spouses and children who must deal with the isolation, lack of family and cultural support, and poor schools in rural towns. Additionally, in Derby there is the added stress of the cultural collision between European and Aboriginal peoples.

And all OTDs must deal with the inevitable homesickness the results from being an expatriate. About 10 years ago I read My Own Country: A Doctor's Story, Abraham Verghese's powerful description of his life and adaptation to being an OTD caring for AIDS patients in America. But I don't think I ever really had a chance to understand how it feels to be away from your native country for a prolonged period of time until this experience. And Australia, while having many similarities to the U.S., also simultaneously feels like a very alien planet. I strongly suspect that all the OTDs here suffer similar episodes of missing their own places.

Yet despite these challenges, the Derby OTDs do the best they can for their patients. Daily they try to bridge the cultural gaps. They apply their knowledge and hands humanely. The wide array of training they bring might not make it easy for them to pass the written RAGCP exam. But they have immeasurable and invaluable skills and memories that help them adapt to practice here. And in some cases, as in undernourished infant needing IV access or a woman having a vaginal breech birth, OTDs have the experience that young, city-trained doctors could never have.

I have learned a lot from my association with these fine doctors and their families. It is a shame that they suffer discrimination and exploitation on the basis of their OTD status. Australia's gain is under-appreciated, although it comes at great cost to these doctors' home countries.

So it is with humility that I join their ranks, firmly in the back row, and say, "I am proud to be an OTD!"

Windjana Gorge and Tunnel Creek

2007-10-06T14:21:00.000+08:00

It's the Queen's Official Birthday, October 1st here in Western Australia. Actually, it's not really her birthday which is April 21st. And it's not her Birthday anywhere else in Australia except Western Australia. The rest of the country celebrates on the 2nd Sunday in June which is the beginning of snow season. The Governor of WA sets the holiday for this state, which just coincidentally happens to be the Monday after the biggest sports weekend of the year- the Grand Finals for the Australian [Rules] Football League, and the Australian Rugby league- held on Saturday and Sunday, respectively.

Windjana Gorge

CLICK PHOTOS TO SEE ALBUMS
Because we are not into celebrating a history of colonization, or watching the impacts of sweaty men on the playing fields, we decided it would be more appropriate to visit Windjana Gorge and Tunnel Creek.

We had planned to visit Windjana Gorge for a long time but had put it off for various reasons. I'd read that this was a sacred spot, but actually walking in this place brought home its magical nature. This is an area with deep spiritual historical significance to the local Aboriginal people.

Windjana Gorge is a chasm where the Lennard River cuts through the Napier range. For centuries it was a holy place to the Bunuba people. They believe that the spirits of their unborn children rested in the permanent waterhole beneath a giant boulder. And the people did not live in the Gorge despite its abundant wildlife. For them it was a place of life and power; it was the place they laid their dead, wrapped in bark, in the cliffs.

So in the 1860's, when cattlemen invaded the country, enslaving the men, raping the women, and moving cattle into these sacred places it sparked resistance. Jandamarra, a Bunuba man, turned on the police who were enslaving his people, and waged a guerrilla war for over 3 years. He led a battle to protect the Gorge and hid out in Tunnel Creek. Vicki and I read his story in Jandamarra and the Bunuba Resistance and we are here to visit these battlefields on the Queen's Birthday holiday.

We left the house at 0630, and bumped up the Gibb River Road to the turnoff to Windjana. It is a very hot day, forecast to hit 40C. By 9 AM we are on the track up the gorge, with camera and water bottle. We walk through a narrow crack in the rock-the gateway to a magical world. A cloud of butterflies rises out of crevices in the rock walls and flutters about our head. The trail is listed as 7 km round trip. Vicki took off at her usual blistering pace and within 45 minutes was out of sight. I lagged behind, stopping to photograph the wonderful birds and wildlife. The gorge is magnificent, with red rocks radiating both heat and power. The cries of the cockatoos and other birds echo within the canyon. The still green water reflects the cloudless sky and freshwater crocodiles swim lazily. But it is hot. After a couple of kilometers the trail rises and runs close to the cliff base. I see there is quite a distance to the end of the gorge still. I come upon Vicki who is sitting on a rock, not looking so well. She is overheated and starting to get a bit nauseated. I make her drink most of the water and sprinkle some on her hair. By this point the Gorge is like an oven, with the sun higher, and reflecting off the rock walls, the water and the sand. Out of the shade the sun feels 20 degrees hotter. I am reminded of the old movies, where parched men slog across the desert seeing mirages, as we run out of our water and are still a kilometer away from the car. We keep to the shade and take it slowly. The last 100 meters across the parking lot are torture, but we open the car, turn the aircon on high, and guzzle more water from the esky. It feels great, but we are parched and just sit there for 20 minutes, nibbling on our peanut butter sandwiches for the salt. Even prepared, it is so easy to get heat exhaustion in this country, I can understand how many people die just meters away from their vehicles.

We drive down to the Lillimilura Police Station. This is where Jandamarra's conscience finally led him to start resisting. The only marker here is to the policeman he shot. And while it's true he shot him in his sleep, he did it only after severe and prolonged provocation. Later in his guerrilla war, he and his men tried to drive the settlers and police away with psychological warfare- raining rocks down from the heights on top of the police station at night, stealing the cops' food and weapons- when they could have very easily massacred every policeman in retaliation for enslaving their families. It is ironic that the only monument in these national parks is to the white man. One of my medical students told me this made him so angry, that when he visited he pissed on this marker. From the stains it is clear he was not the only one. I like to think I am too civilized- but the truth is I'm just too dehydrated- to join in. But I mentally applaud those who do.

Tunnel Creek

CLICK PHOTOS TO SEE ALBUMS
Twenty-nine kilometers down the road, through dry, scrubby, rocky hills and boabs, we come to Tunnel Creek. We put on our wading shoes, and again enter a sacred place through a narrow cleft in the mountain. It is amazing: dry, cool, very wet- a cave full of life. There are small fish in the water, and a colony of large flying fox bats hanging from the ceiling and from a tree outside. Water drips from the flowstone and stalactites overhead. We walk on through, using our little crank flashlights. Just as it gets so dark we can't see anything but the narrow beams, a glimmer of light appears ahead, and we come to the middle, where the tunnel has opened to the sky. The dark to light transition happens again after walking past this area to the far end- but here the water from the cave flows out into a lovely creek with water bugs, little fish and kookaburras in the gums overhead. It is remarkably cooling- the yin to the yang of the Gorge.

We complete the loop by driving through the Bunaba people's current lands. These resemble nothing more than a post-nuclear attack landscape, with burned over rocky soil punctuated by blackened, twisted trees. It is awful country. A sign to one of the communities has a cow skull hanging on it. It is a relief to regain the Great Northern Highway and drive the two hours back to Derby.

I am struck by the lack of Aboriginal involvement in these Australian National Parks. Imagine the Little Big Horn monument without Native American input and presence. It is a sad legacy. Here in Australia, Ned Kelly, a lowlife criminal, is admired, while Jandamarra is still seen as a terrorist, instead of the freedom fighter he truly was.

Sound and Word Bytes

2007-09-30T09:43:00.000+08:00

I slip into the water. Vicki and I are the first ones into the pool. This often happens because we are waiting when the doors open. She wants her lane, #6, and as they say here, "first in, best-dressed". I take lane #3, walking right into the cool water, push off and breast stroke the first 25 meters. It feels great on this 104 F. day. The surface of the water is glassy, still and reflects the brilliant blue of the Australian sky. I love being first one down to the end, first to break the surface tension.

Today (as usual) I'm listening to eclectic stuff. A little Paul McCartney, Over the Rainbow by Izzy Kamakawiwo Ole', Podrunner techno music at 148 beats per minute (good for 20 laps), DragonPage Cover to Cover podcast about how to find old, out of print books on the Internet, and Aretha Franklin singing "Think!". I do this with my SwiMP3 headset, a birthday gift several months ago from my folks. This is a funny device that charges off my computer USB port and carries 256MB of music or podcasts. I think its the best thing since sliced bread to combat the boredom of cranking out 66 laps every day. I just load it with stuff I have on my computer. It is very simple, has only 3 buttons, and I turn it on and just go. The sound is fair, and I think it would be better if I had better hearing. Its not like listening in my car after all, because there is splashing, water moving past my head, and oh by the way, I have to breathe which means noisy bubbles blowing out my nose and mouth. This interferes a bit with the bone conduction of the sound. Music seems best if I know the piece, as my brain will fill in the missing notes or lyrics. Bach's Chaconne, for example, works in the water, as I know the piece well. Spoken word is harder to get. The recording needs to be high quality. Men with deeper voices are better in my ears, and if I backstroke or sidestroke I can follow most conversations. Dr. Karl's Great Moments in Science is great; Slate Explainer and the poetry in Writer's Almanac are much more difficult to follow. I do get a lot of funny looks when I strap this thing on. I think it kind of gives me a bit of a Captain Midnight look.

A week of so ago I was listening to Cover to Cover and heard about DailyLit.com. This is a great website for those of us who always meant to "read that Great Book" but never got around to it. The idea is simple: pick a book, enter your email address, and the site will send you a 1 minute chunk of the book every day (or MWF, or once a week or whatever you want). They have tons of the classics, but also some contemporary literature that the authors have released from copyright restrictions.

Vicki had never read Moby Dick, and I last read it when I was 12 so I'm sure I never really understood it from a very deep perspective. We've both signed up for Moby, and are on part 10 (of 252). Its great. And very appropriate for travelers planning to settle in New England. I also subscribed MWF to Down and Out in the Magic Kingdom, a modern novel by Cory Doctorow. These are a great break in my day, and just the right amount. Like a piece of Whittakers wonderful chocolate, best consumed in small bites.

Many Dimensions

2007-09-26T20:58:00.000+08:00

Vicki picks me up from the Derby Aerodrome, hot and sticky after an hour and a half in the plane returning from the remote community flight. All I can think of is getting into the shower as quickly as possible. I detest feeling dirty and germy. I can’t help it. I dump my backpack on the back porch, and strip off my clothes in the 38 C. heat so I won’t carry vermin into the house.

I’ve worked with poor people all my professional life, and I hope I have a small inkling of the psychology and environment of poverty. But most of the time, I have seen “the poor” in EDs, my own office, or the hospital or residency setting. I’ve made more than a few house calls over the years, so I’m not shocked anymore. But visiting an entire community is different. There is no place to rest your eyes; nowhere I am not confronted with the stark reality of my patients’ lives.

We fly in to the dusty airstrip in a GA8 Airvan, a very light, high-wing, single engine Australian-built plane. One of the old men in the community drives the 5 k to the strip in a battered ute to fetch us. The truck has a homemade wire bench on the bed, which is loosely attached. We pitch our many bags and boxes in the back. We have to bring everything from meds to band-aids to our own scales. The four of us: pilot, RFDS nurse, health worker, and I then clamber up and sit hip to hip for the bumpy ride to the community center.

The “center” itself is just a big dirty room with a beat up table. There is a kitchen counter which has hot and cold water. There is a dirt encrusted shower room, and around the back, the loo which has no toilet seat and rivals the worst service station johns. Four months ago when I was here the cockroaches were so bad, they were crawling into my doctor bag and all over the files within seconds of my setting the items on the small desk. DAHS threatened to cancel clinics unless the place was cleaned up. The community did a spit and swipe and bug-bombed the place, which helped for awhile, but now the insects are returning. The cockroaches always win in the end.

We set up our gear and I dive in to see patients. I review the older peoples’ chronic disease files. We drew bloods 2 weeks ago, and some are doing well, some need their meds adjusted. The RFDS nurse spends a lot of the morning filling dosette boxes, those clever little plastic devices that set up a weeks worth of meds. Many of the patients speak poor English, so these are essential. I see a child with ringworm of the scalp and head lice. The mom is trying hard, but only had topical antifungal cream, which won’t kill the fungus at the roots. I only have adult strength Griseofulvin, but we work out that she can whack the tablets in half with a knife and a hammer. A gent I saw two weeks before shows me that his extensive pyoderma- boils that reminded me of Job’s sores- has improved, although is still not completely gone. A teenage boy got in a fight 4 days before, knocking out the lower teeth of his opponent, and now he has pus coming out of the human bite he sustained on his middle finger. It’s not bad enough to require the hospital yet, and I hope some high dose Augmentin and wound care might do the job. The last man is young, in his 30s, and has just moved to the community. He seems lost and wants something to help him sleep. I pull him into the back of the center’s not-so-private office, and he admits he is thinking of walking out into the bush and hanging himself. We talk about that, I express concern as best I can across the cultural gulf, start him on some antidepressants and make a referral to community mental health. God knows when they will get a worker out to him. I only know one community mental health worker, and blonde, white Sara is not someone this bloke will be able to easily talk with. He promises to come to the next clinic in a month at least. I hope confessing his black thoughts will help. I’m uneasy, but I’ve done the best I can.

I work right along. “Who’s next” I keep asking the nurses. Part of it is a desire to be efficient, but another part is just revulsion at the working environment and a wish to get the hell out as soon as possible. Prepared this visit, I’ve brought my own towel and dry handwash. I wash my hands as often as I can, but I have to touch the equipment as well as the patients. Everything is a fomite here.

At one point in the morning I step on the back porch and see 3 brilliant blue kookaburras on a branch in the back. But when I turn around, there are piles of trash, scattered cans, garbage bags, rusted machinery, paper, wire, horse manure and dog poo everywhere. It looks like some of the yards I used to see in my grandparents Appalachian community when I was a kid. I remember my parents encouraging me to actually see the poverty, if for no other reason, to appreciate what I had.

But this is poverty in more than one dimension. Financial poverty is the least part of it- as the people get CDEP and pension payments. There is emotional poverty and pain, related to the stealing of family relationships and structure. There is educational poverty: the older generation grew up on stations and never knew school; and now their children and grandchildren are truant and no one cares. With no training, there is vocational poverty, so that the annual cattle muster is the only work event providing any self-esteem, for 1 week a year. There is a spiritual poverty here, where life is out of whack, and the traditional owners of the land are no longer its protectors or custodians. And the end result is a poverty of hope. The people here live in the moment because the past is full of pain, the present is uncontrollable, and the future, unimaginable.

I realize the people in this particular community are mentally not "running on all cylinders". (Thank God not every community here is like this.) Combined effects of deprivation, isolation, racism, cultural loss, diseases, and too much grog leading to loss of neurons have done their damage. It’s not something I can fix on a fly-in. All I can do is really try to be with them in the moments when I visit. And I feel guilty, because a shower sure feels good afterwards.

"More political than scientific in nature..."

2007-09-22T20:32:00.000+08:00

It looks like I will have to grow wings here soon, as the Royal Flying Doctor Service locums "no showed" for this month, leaving the two RFDS docs here very stressed. This means they have no time to help with our remote clinics, leaving it all to DAHS doctors. Last Wedsneday I went back to Imintji, and next week I have two flights, Yulumbu and Dodnun, and then a flight the week after next as well. It is really starting to heat up here- it was over 100F several times in the last week. The tin box airframe of the planes becomes a furnace sitting in the sun on the red dirt strips while we do our clinics, and I sweat from the heat on takeoff and then freeze when we hit 9000 feet and it cools off. I sat on the porch at Imintji store eating my lunch, and a willi willi blew around the corner, dust flying and pulling the trees sideways. The clouds, absent for the last 5 months have returned and the humidity is ramping up as well.

The Imintji trip did have a bit of happy news, in that the patient we organized to see the psychiatrist was actually hospitalized, and started on meds. An adult in the community who has known her for her entire lifetime, has given her a job with lots of structure. Getting up in the morning for meaningful, daily work; quitting ganga and taking some medication has had a wonderful effect. So while mental health is a real problem for remote communities, it's nice to see that some community caring can make such a difference.

The RCS students have been more focused on tutorials, and getting all their assignments done. E-logging of cases is due by the end of the month, so suddenly the computer records of the cases they have seen has become more important. They also wish we could cover everything in the next month before exams. We have been focusing on Paeds and GP this week, and will review some O&G in the next 2 weeks.

Yesterday in the clinic we saw a gentleman who desired some medicine for a rotton tooth. Turns out he is a heavy drinker. Thursday was "payday" when the Centrelink (welfare) payments are made. Typically there will be 50 people at Woolies waiting for the "bottle shop" to open to buy grog. This gent had consumed 4 "casks"- these are also called "balloons" for the silvery linings of the 2 liter wine boxes, seen blowing around town the next day. After 8 liters of wine he was not running on all cylinders, but we were amazed that he could even walk.

I have been talking with my students about social attitudes towards drinking, and asking them to reflect on how these affect health care. We found some great international comparative statistics on the Wikipedia, which I've abstracted into the table below. I'll paste in the quote from the Wiki page, and let you, dear reader, reflect and draw your own conclusions...

From: http://en.wikipedia.org/wiki/Recommended_maximum_intake_of_alcoholic_beverages

This article summarizes the recommended maximum intake (or 'safe limits') of alcohol as recommended by the health agencies of various governments. These recommendations are highly varied, reflecting the fact that they tend to be more political than scientific in nature. The recommendations are distinct from legal restrictions that may apply in those countries. Therefore, consumers need not follow the recommendations of the country in which they happen to live and are free to choose those of another country.

Here's my table:

Country	Drinks per day	Drinks per week	Std Drink size (g)	Max per day (g)	Max per week (g)	Rec OR Calc'd g/w	Legal BAC
Australia	6	28	10	60	280	280	0.05
Italy				40		280	0.05
Japan	2		19.75	39.5		276.5	0.03
Portugal				37		259	0.05
Denmark					252	252	0.05
New Zealand	3	21	10	30	210	210	0.08
Ireland		21	10		210	210	0.03
Spain	3		10	30		210	0.02
Hong Kong	4	21	1 glass wine/pint beer)			210	N/A
Netherlands	3		9.9	29.7		207.9	0.05
USA	4	14	14	56	196	196	0.08
Canada	2	14	13.6	27.2	190	190	0.08
UK	4	21	8	32	168	168	0.08
Switzerland	2		12	24		168	0.05
Austria				24		168	0.05
Czech Republic				24		168	0
Finland		15	11		165	165	0.05
Sweden				20		140	0.02

For a further exercise, check out the international recommendations for permissible alcohol intake in pregnant women. I can't believe that some countries still believe it's ok to drink while you're pregnant!
http://www.icap.org/PolicyIssues/DrinkingGuidelines/PregnancyTable/tabid/254/Default.aspx

Medicine, Moose and Me (ur, I mean...Us!)

2007-09-17T22:12:00.000+08:00

I just had to steal that title above- its from a talk given by one of our RCS students who just returned from an Option in Ontario, Canada last month.

Headline:
Stonington
Island Family Medicine hires new physician

Now that it official, I can announce our plans for January 08. We are moving to Maine, where I will be joining Island Family Medicine, in the beautiful seaside town of Stonington. Well, I assume its beautiful- that's what everybody tells me. I have never been there!

Vicki and I were married in Maine back in the time of the dinosaurs, and have returned regularly to visit family, and enjoy the views from her cousins' homes in Belfast. We had always talked about moving there one day. So beginning last year, I chatted with a recruiter from the Maine Medical Recruitment Center, sponsored by the state hospital association. We talked about what I was looking for in a practice, and the type of community we would like to join.

Once we arrived here in Australia, we began to explore the options in more depth, and the practice in Stonington really seemed to fit. Several months ago, we scheduled a videoconference interview. This took some planning, due to the 12 hour time difference. We turned on our machine at 7 pm and said "Good morning" to the people in Stonington! We talked for over an hour, and things just seemed to click.

We are both very excited about the move. Vicki is anticipating lupines, pie contests, blueberries, bell buoys and lighthouses. Both of us think snow sounds great (101 F today!). I am looking forward to returning to a full time private practice. I know the people of Stonington will have much to teach me about their community. I'm hopeful I can apply some of the theory I have been teaching my students for so many years in a real practice again. And we are looking forward to joining a very interesting community- at least that's how it seems reading the local paper!

I have long been a believer that when a door opens to a new life, or new experience, best to just take a deep breath, and like the pelican, fall. [Jan 2,2007]

Its going to be great.

Read the article in the Island Ad-Vantages newspaper here: http://www.islandadvantages.com/ianewsfeature1.html

Yulumbu Again, Hospital Dedication

2007-09-15T20:55:00.000+08:00

Another week gone by here in Western Australia, and although it is SPRING here and patients are coming in with allergic rhinitis and asthma flares (more from the dust now that the Dry season has hit its stride) it still mentally feels like FALL to me, as I see things starting to wind down. We have made our plane reservations to return to the U.S. and there are only 84 days left. (It was good that we made them when we did two weeks ago- as the trans-Pacific legs were already starting to fill up. School (summer) holidays and Christmas coincide in Australia, and essentially the entire country will shut down in December, I am told.

The good news is that I have hired my own replacement for DAHS and the RCS. In checking references for another doctor we were trying to hire, one of the referees wondered if I "knew of any good jobs working in Aboriginal Health" in the Kimberley. One thing led to another and it appears we have hired a young British woman to take my place here. We are very hopeful she will arrive by end of October so I may train her for a month before we leave.

My students are starting to feel the pressure, as exams begin the last week of October for them, with finals in Perth in mid-November. We are working to fill in the gaps of any subjects they feel they might have missed, which at this point they have decided is "all of them!". Procrastination is a universal attribute, although it was not enough to prevent two of them from spending a week with the Orthopaedic specialist in Kununnura. That left me with one 5th year, and a 6th year student last week.

Last Tuesday the flight rotations took me back to Yulumbu for the first time since April. The small community, very remote, in the Tablelands area of the Kimberley did not look much better, but with water now, they had cleaned up the community room we use for visits. Many people are traveling this time of year, before the rains return and lock them into their communities for 5 months. So instead of 20 kids and 10 adults, there were only about 6-7 very old (that means 50-60 years old) people, a few teenagers and smaller kids in the community. We did "diabetes clinic" for most of the adults, talking about diet and exercise and the importance of taking tablets. One of the innovations I have instituted here is an integrated care plan summary, called a GPMP (GP Management Plan). Setting up these flowsheets has made it much easier to keep track of labs, meds and observations in patients charts. Using the flowsheets really helps in remote clinics, where the doctors and patients rotate around so frequently.
.
One old lady in Yulumbu showed me her new wheelchair with pride. She had fallen into the fire and suffered a bad burn on the leg, but while in the hospital, was fitted with a chair with tires that are wide- they look like a mountain bike tire. This allows her to wheel her chair all over the dirt tracks in the community and get around for socialization. She was quite happy with it.

We also admired the two large King Brown snakes the boys in the community had dispatched the day before. They were hanging in a tree- to what purpose I'm not sure I understand. But they were quite impressive.

The rest of the week was the usual mix of teaching and practice, with the added visit of Mr. Jim McGinty, WA Health Minister, who dedicated the new wing of the local hospital. This despite the fact that the landscaping has been bare red dirt now for 8 months, which the patients and visitors have been tracking in all over the new floors and rooms. We contrasted this delay to the new community school in Jarlmadangah, where the elders put in a sod playing field around the school, at great community expense. They were quite proud of that foresight, which has protected their new school building from the current ubiquitous dust and soon-to-be sticky mud (come Wet season).
Central planning for the hospital has also provided it with new rooms and equipment, but serious personnel shortages. Two weeks ago the entire Kimberley region, from Broome to Wyndham had no surgeon on call for 5 days. This meant that any orthopedics fractures, appendicitis, serious trauma, etc all had to go directly to Perth (at least 10 hours transfer time) without surgical consultation. Derby still has no staff Ob/Gyn, despite being a regional birth center with >240 births a year and rising- something much applauded at the dedication. And the current hospital staff is overworked, and stretched thin with night call and ED responsibilities. My sense is that the community is pleased to have the hospital still here in Derby, and happy that it wasn't downsized in favor of a larger facility in Broome (220 km away). .

Vicki and I have enjoyed a couple of weekends at home. We are both still swimming every day- she notched 100 25m laps today- and enjoying the tropical garden in our backyard before it gets too unbearably hot. It has been over 100F here twice this last week, but so far the humidity has stayed in the lower ranges. However, we can feel it heating up, and have had to use the air-con some days just to get the bedroom cool enough to sleep. I'm hoping to make one more sight seeing trip, to Windjana Gorge, before the buildup gets too far along. We had planted tomatoes, which have come on full, and my papayas and mangos are starting to really grow quickly. The ripening of fruit in the spring here also contributes to the mix-up of my Northern Hemisphere mind thinking it is fall here in the South

Not a good place to go insane...

2007-09-05T21:19:00.000+08:00

Things have been "crazy" the last two weeks, and I'm way behind on writing. Our daughters left 10 days ago, and we've been busy since.

Two weeks ago today we flew to Imintji up the Gibb River Road. This is a long day, as the flight lands on the airstrip at Kupungarri and we have to get in the Land Rover and drive 70 km down the GRR to the Imintji community. DAHS and Jurrugk Health Services run a remote clinic. I saw the usual assortment of sick kids and chronically ill adults. But a patient was brought in from another community. This young person's mum wanted me to "send x to the place you go to get off the ganja" (marijuana). "What place is that?" I asked her. "Like where you go to stop drinking.." she said. I did a mental status exam and discovered the patient was actively hallucinating and had not slept in a week. This teenager had been yelling all night and throwing rocks around the community. This in itself is not unusual in Aboriginal communities where a lot of people drink, so for family and friends to bring the patient into the clinic was alarming. Now this is a difficult logistical problem so far out in the bush. We spent a couple of hours on the phone talking to Mental Health in Broome and Derby. I happened to know the visiting psychiatrist was coming to Derby in the next week, so I was able to book her in. Then came the question of travel to Derby. This is about a 5-6 hour drive down the Gibb River road. The local nurses had already organized another patient to go in the community vehicle, so that was a possibility, if everyone could stand to ride together. I flew out, leaving the details in the Remote Area Nurse's capable hands. Thank God for these great ladies, who live and work among the people out in the bush. (The appointment was ultimately kept, after a couple more frantic phone calls when the patient arrived in Derby and the local system somehow did not have an appointment with the correct person.) The patient was treated and we will see how it turns out. {click on thumbnails below to open web albums}

Imintji

On the way back, we put down at a very remote station to see a young girl suffering from anorexia nervosa. She and her mother had come back from Perth a few weeks before, and it had been arranged for us to stop and weigh her and interview her weekly for awhile, with phone calls back to Perth to aid in management. The staff were mustering several thousand head of cattle, who were waiting in pens for the trucks. We could see the plumes of dust from the air for 50 miles. The station however, was a green oasis with duck ponds and lilly pads, tucked into some rocky outcrops in the Kimberley. It was several hours drive by dirt track just to reach the Gibb River Road. We popped in and I incidentally saw a worker who had dropped a metal can and avulsed a toenail. Start antibiotics and the flying RN will check it next week.

Last week I was off to the RCS Scientific Meeting in Geraldton. This in itself is an odyssy, as I flew OzJet from Derby to Perth, stayed overnight, and took the early flight back north to Geraldton. There is no other way to get there from Derby, and few connections.

The first day was our Site Coordinators meeting, in conjunction with a meeting of the administrators of ALL the RCS's across Australia. There is a lot of variation among Rural Clinical Schools, with many of them in the more populated NSW and Victoria states sending their students to small towns within 30 minutes drive of Sydney and Melbourne. This is not quite the same as living hellandgone in a place like Derby or Esperance. It seems the WA Rural Clinical school is the model for the rest of the country in our support for our students, and having the students in the country for an entire year of medical school.

Australia restricted their medical student slots in the 80's and 90's, resulting in their current severe shortage of doctors. This policy was predicated on the supply-side theory that if there were less doctors, there would be less medical care, which would cost less. Unfortunately, people continued to get older and sicker and the population has been growing steadily. So now the number of medical students has doubled. The graph looks like a tsunami, and there was much discussion at the meetings about ways to train this tidal wave of students, soon to be young post-graduate doctors. Because the urban clinical experiences have always been well subscribed, rural placements will have to fill the gaps.

Friday was spent in an Anesthetics workshop. I have to admit I chose this topic because I have taken or taught the others (Wound care, suturing, OB ultrasound, Advanced Obstetrics) SO many times, I thought I'd take a workshop in something I knew little about to avoid boredom. Not the best strategy in hindsight. The speaker was knowledgeable but disorganized. He had computer troubles, and all his equipment was in boxes that he was forever rummaging through. Not something that would inspire my confidence if he had to put me to sleep. His audience was quite mixed, from students to "Procedural GPs". In Australia, because of the shortages, many rural doctors take additional training in Obstetrics, Surgery, or Anesthetics. And I have no objection to adequately trained generalists doing procedural medicine- heck I did C-sections, appendectomies and spinal anesthetics myself in the 80's.

But one doctor told a story that made my hair stand on end. Because of the distance, many psychotic rural patients are heavily sedated and kept in rural emergency rooms in Western Australia, sometimes for days, awaiting transport. There is only one secure psychiatric hospital in Perth. Local doctors tell me even psychotic patients in the city sometimes have to wait 5 days, sedated and sometimes intubated (tube down the trachea), in an ED before getting a bed at Graylands Hospital (really, that's the name of the hospital!) . Now we were discussing drugs and anesthetic procedures for this situation, and a doctor told a story of using a particular drug which caused too much respiratory sedation. The patient had a respiratory arrest, and unfortunately coded and died. This is terrible enough, but what was most upsetting for me as a foreign observer, was the attitude that, "oh well, this is rural medicine, these things are going to happen because this situation occurs so often". Over and over I find that the acceptance of second class care for rural and especially remote Australians is taken as just a fact of life. Unfortunately this has really made me appreciate U.S. lawyers in a new light. They may drive up the cost of care, and the system is surely not very fair and just, but also, one gets what one pays for (and is responsible for).

The last two days of the long meeting were spent listening to scientific papers. Some of these were very interesting, and some, not so. Like any meeting. Listening to these papers, it is clear to me that regarding rural and Aboriginal Health, Australia is in a time (to quote Franklin Roosevelt) "when certain historic ideas in the life of a nation have to be clarified".

Geraldton

As for me, Vicki and I only have 94 days left before we leave Australia. I have a lot to do to help my student finish, to complete my projects at DAHS and train my replacment. But you can be sure I won't lose my mind over it. Not in this environment.

3310 Kilometers

2007-08-18T15:17:00.000+08:00

Today I'm catching up on blogging for the last 2 weeks because our daughters have been here visiting. We took this opportunity to see some more of Western Australia. Here are some memories of the trip. I've uploaded a lot of pictures, and I'll give some text "snapshots" of our trip.

Aug 6 & 7: We started in Broome for a few days. Vicki and I saved the "tourist stuff" for the girls visit. We visited the Willie Creek Pearl Farm on Sunday,

Willie creek pearl farm

and woke early on Monday to do the famous camel ride on Cable Beach. This is high tourist season in Broome (its Winter here!) so the classic evening rides were all booked. We took the 8 AM ride, which I think has definite advantages. The morning was cool and crisp, the beach absolutely clean and fresh from the recent tide. We were surprised at how gentle the camels were. They have big brown eyes and huge eyelashes, and are fuzzy like a plush toy.

Broome Camels

Aug 8th: We leave early and drive all day to Cossack, south of Karratha. Cossack is a "ghost town", the first pearling settlement in WA. The shire runs a backpackers hostel there which is clean and very nice. We arrive at dusk, in time for a walk on the beach and a swim. Vicki and I walk through the small cemetary. We are both moved by the Japanese graveyard at the back. All the graves are arranged pointing back to Japan. "Such a desolate place, and such a long way from home for these young men to die. Their poor families!" says Vicki.

Cossack

Aug 9: Another day on the road. We begin the morning with breakfast in Cossack. As I am washing dishes, the sink faucet begins to leak. I tap it to make the water hotter and the entire faucet head shoots off, water geysering 8 feet into the air, drenching me and the room. I put my hand over the metal socket, both cold and scalding hot water shoot out. I feel like I'm in a Three Stooges movie as I holler for help. Of course there is no shutoff below the sink- my family has to run around and find the host to turn off all the water in the place. We mop it all up eventually. First time I've ever completely washed the communal kitchen before leaving.

The drive is long. Vicki does most of it- she likes being in control and says I am a distractable driver, which is probably true. We listen to radio, talk, the girls snooze. We snack too much till we're actually sick of Arnott's biscuits (hard to believe) and gummi bears. Toward afternoon, the country changes from scrubby bush to fields of sand dunes. We start up the peninsula to Exmouth and see skinny sheep. Come into Exmouth at suppertime, do some laundry, and run out to get Chinese food before collapsing.

Aug 10-12 Ningaloo Reef. We stay at the Ningaloo Reef Retreat, in tents. This was a great choice. Its an "eco retreat"- meaning tents, and "Nature-Loo" toilets and only 20 liters of water per day, for the end of day rinse off. However, the spot is one of the most beautiful places any of us have ever seen. All the meals are included, and the young guides supply us with snorkel stuff and wet suits and show us the wonders of the reef. There are no words to describe it, it is just dazzling. There are turtles and sharks and sea snakes and a billion brilliant fish.
We soak up the sun, listen to the wind, watch the roos come within 5 meters of our tent. We have nibbles at sunset and watch for the green flash. At night, the Milky Way extends from one horizon to the other- it is completely dark and moonless, but we can see the path in the starlight. (The Milky Way is amazing in the Southern Hemisphere. From these latitudes, we are looking into the center of the galaxy.) I wonder if there are other coral reefs on other worlds out there somewhere. Vicki says "if there are other worlds, they would be poor worlds without turtles...."

Ningaloo Reef

Saturday Vicki and I walk about 7 Km round trip into Mandu Mandu gorge and back. The rocks here are ancient seabed and conglomerate.

Ningaloo Reef 2

Aug 12: My 54th birthday and we, sadly, have to leave Ningaloo behind. We roll out after breakfast, and hit the road to Exmouth, stopping to stock up on food and arrange accomodation in Tom Price, a town named after the president of Kaiser Steel. Its another long day on the road in the car, and I am glad we booked ahead. Tom Price is a mining town, but we are impressed because it is a Tidy Town award winner. No garbage on the streets, clean public areas, a lovely library and park in the center of town. This shows the potential of WA, if only communities would pull together, and put the riches of the mining boom to good use.

Aug 13 & 14: Karajini National Park. We've gotton a line on a newly opened eco-retreat here which is having a 1/2 price sale for visitors from the Kimberly. So we forego the swags on top of our rig. Spend the night in another tent, this one inhabited by the largest spider any of us have ever seen in the wild. I unfortately cannot move him outside so have to incur bad karma by dispatching him. But not worth a bad bite or allergic reaction this far away from civilization. We visit several of the gorges in Karajini, but love Joffre the best. It is a 5 minute walk from the eco-retreat and we have it all to ourselves.

Karajini

The afternoon of the 14th we drive to Port Hedland. This town has a huge mining boom. We have booked a campsite well ahead, which is a good thing, as the lady at the caravan park takes 5 phone calls in 5 minutes as I check in, turning people away. We break out the swags for the first and last time. They are miserable. Vicki and I cram into one together and she goes to sleep in the car at 3 AM. There are dense clouds of gnats, the Port is noisy all night, the bathrooms are covered with dead bugs, and I have to get up in the morning for a teaching session as Visiting Professor for the Port Hedland students the next day. It is not a good night.

Aug 15: Teaching session with the Port Hedland girls is fun. We cover the knee and lower extremity exams. My girls check out the visitor center, get lunch and we are on the road headed home (about 600 km) by noon. Last long drive. The girls sleep, Vicki is bored driving, we jointly do crossword puzzles together... Finally we roll into Derby at about 7:30 PM. (The last 1.5 hours in the dark is very slow, on cow-alert!)

Total: 3310 KM in 10 days.

From the Art Show

2007-07-28T14:56:00.000+08:00

I mentioned the Kimberley Art Contest 2 weeks ago. We bought some of the art at the exhibit, and Vicki brought it home Monday.

This is Turtle Nesting Cycle by "Wossie" Hunter. Wossie is an artist who lives and works in One Arm Point. He was on my Watch on the Leeuwin trip, and showed us this work on his cell phone camera. The Bardi people at OAP have an intimate relationship with the turtles, protecting their nesting beaches, and hunting them in semi-traditional manner (they use outboard motors now) for food. This painting encompasses the entire life cycle of the turtle. It is in our living room, and the longer we look at it, the more we see, and the more we like it. See detail to the right:

"Myalls Bore." This photo is of the longest watering trough in the Southern Hemisphere, which is located just out of town in Derby, near the Prison Boab Tree. It was used during the cattle drives to the jetty, to water the huge herds brought through Derby.

My personal favorite, this little photo is of a Restless Flycatcher, called the "Scissor Grinder" due to its raspy call. This was taken at the jetty we think on the edge of the mudflats...

It wasn't until we got these home that we realized the common theme to them all. We didn't plan it that way: after all, we only had an hour to decide what art in the exhibit spoke to us.

Can you see the common theme?
Hint: look for the evanescent, reflecting the eternal.)

A Day in the Office

2007-07-23T23:04:00.001+08:00

I kept track of one day in the office at DAHS recently. Like the Gibb, it is run on the "British" model of consultation. I have my own room to see patients, with a computer and basic equipment. The staff put the charts in the box on the door and I see the patients in order. There are no appointments. I call my own patients, and do all their vitals. However, at DAHS if I get really busy I can often talk an Aboriginal Health worker into drawing some bloods or finishing the opportunistic screening, which helps.

Here is list of one busy day:

· I start the day with two little kids, 10 months and 4 years, with acute conjunctivitis. We use cholamphenicol eye drops here, a drug that has been virtually banned in the U.S. due to a rare risk of bone marrow damage. However, I looked it up, and its never been associated with eye drops. Here in the Kimberley, bacterial infection is so rampant that we use antibiotics much more aggressively.

· Next is a bearded dude in his 40s who needs refills of his BP meds. I saw him a few months ago and tried to get him to quit smoking with patches. He’s down to 5 a day, and would like to have a go with the Zyban, which I prescribe.

· A 10 month old has nocturnal cough for a month. There is a family history of ?asthma and lots of smoke exposure. We’ll try a short burst of Prednisolone for reactive airways disease.

· A very obese (150+ kg) diabetic comes in with a second attack of ankle gout in a month. I put him on recall to try to get Allopurinol started once we get it settled.

· A young man comes in right behind him ALSO with a sore ankle. I think, “It can’t be two cases of gout in a row!” but it turns out it might be. He was told he had gout before. I’m not so sure on exam what it is, except the spot anterior to his fibula is sore and swollen. We decide to settle it with ibuprofen and see what happens.

· 5 year old brought in by mum who notices “his head stinks”. I smell the fuzzy-grape odor of Pseudomonas. When I take off his cap, his hair is matted with a solid, thick skullcap of dried pus and he is covered in head lice. Mum says this only started last Thursday but nobody believes it. The kid has swollen glands and a little bit of fever. I start oral Augmentin and get the Health Worker to shampoo him in the office and remove as much crud as she can. We will rewash his hair daily this week until he is better.

· A one-eyed old man comes in wanting copies of his records for when he travels. I notice he is very short of breath, and find his COPD is really flared up badly. He hasn’t really noticed it much- he always runs an O2 sat of about 90 and refuses to use home oxygen. I give him his 3rd Prednisolone burst in 3 months and flag the drivers to drag him back to DAHS in 2 weeks.

· 30-something local woman who drinks a lot brings in a huge abcess under her arm. I take 45 minutes to set everything up myself, I&D it to drain the pus out, pack it, start her antibiotics and pain meds and arrange another call back. I get to clean up the mess myself and sanitize the room after each patient, which I tell myself is a good Buddhist exercise in humility and being in the moment.

· A break for lunch. I do a few admin things and run home. Vicki has painted the living room this morning. White of course. We sit outside and have avocado and salami sandwiches in the beautiful garden. She enjoys the little water fountain we placed in the pond this weekend.

· After lunch an intoxicated fella has the drip from not using condoms. He tells me his contact, and I have him take a ZAP pack (Zithromycin 1 gram/Amoxycillin 3 grams/Probenecid 1 gram) in front of me. Cultures to the lab and instructions to go and, if not “sin no more”, at least wear protection.

· Pregnant European woman has headaches at 16 weeks. Seen at hospital twice but not happy about explanations. Multifactorial but we sort it out and start exercises and sleep hygiene. She hasn’t started Antenatal Care, and we try to get that organized.

· Middle aged man with previous sinus surgery has congestion and drip for 5 weeks.
An x-ray taken at beginning of month was filed without being seen by the ordering doctor. I apologize for this. He is understanding, I explain my concerns, start antibiotics and urge him to keep his ENT appointment.

· Young guy working “out bush” comes in with men’s business concerns. We discuss that a circumcision won’t solve his sexual dysfunction problems. But reviewing a handout from the Internet and starting some medicine might help a lot. Finally a chance to practice medicine on a 21st century problem, and not an infection from the 1920s or earlier…

Festival of Fun?

2007-07-22T22:10:00.000+08:00

More snapshots from an interesting week.

Our local doctors finished up our 6 months of "small group learning" with a visit from the podiatrist. She talked about leg-length discrepancy. Turns out most of the population has one leg 1 cm longer than the other. My left leg is 2.5 cm longer, which probably explains why I've walked like a duck my whole life, and why I am always tripping with that left foot. The nice thing for the docs here is that by having an organized group they get 30 continuing education points from the RACGP. We focused on community resources this first 6 months. We'll take a break and then finish the year reviewing core topics like CHF and asthma.

Early in the week I started breaking out in a red rash on my wrists and ankles and itching at night. I told Vicki in our first month here that we would not get through the year without a visit from scabies sarcoptei. I am surprised it took this long. We lathered each other up with the permethrin cream and she washed all the laundry. We'll do a repeat this week. Die, bugs die!

Vicki's little 8 year old friend has been visiting a lot lately, as its school holidays now. Hannah has never heard of Harry Potter. Not a clue. And she is way behind U.S. kids at reading. It makes us sad. It also is another evidence of how Derby is the End of the Earth (or at least the last stop before Kandiwell, the True End!)

The library here has a very small kids section. And there are very few books with Aboriginal themes or anything culturally appealing. Vicki took Hannah to get books, because only adults with a proven local address (you have to bring in a bill showing you really live there) can have a library card. Kids aren't allowed to have their own card. Hannah took out a DVD on fairies and mermaids. Made in Australia, it features porcelain-white women dressed in pastel wings and glitter, singing songs about flowers and seashells. She loves it. But for a kid with Aboriginal heritage, I wonder what it does for her already confused identity?

I ordered books online from an Australian bookstore, only to get an email back that they were back ordered until the end of August. By the time the Post gets them here, I will be on my way home. I cancelled the order and re-ordered on Amazon.com, and will have my daughters bring them to me when they come next week. They have also promised to bring Harry Potter along.

Last Wednesday I flew out to Kuppingari (up the Gibb River Road) again and saw 17 patients in one day. That isn't much until one considers the flight time lost on each end, and that I do absolutely everything, including all the vital signs, drawing my own bloods, writing up all the slips, dispensing my own meds from the little pharmacy and instructing the patients in everything. I was exhausted when I got back and went right off to bed.

This weekend brought the end of the Boab Festival, which climaxed in a night of bands and drunken revelry, with loud hootin' and hollerin' until all hours of the mornings. The town has been full of locals and tourists, and we've seen the ambulance make a lot of runs. Many of the locals also light campfires in their front yards in the evening which makes the town smokey, and is a bit of a worry as a fire hazard.

Pictures from Boab Festival at Mowanjun, and Xavier & my trip birdwatching...

Boab Festival Week

Have you been drinking?

2007-07-17T21:12:00.000+08:00

"Have you been drinking?" the Shire worker asked the Aboriginal man and woman who walked into the Civic Center just in front of us. "You can't come in if you've been drinking."
The woman turned away, but the man said, "No, I haven't been..."
"Yes I think you have!" said the man, "You can't come in." Reluctantly, (but also clearly inebriated) he turned away also.

A woman worker appeared from the left, and pulled us aside.
"Come in", she said. "There's no charge tonite. Please sign in, and here are your three free drink tickets. Enjoy the show and the buffet."

What is wrong with this picture?

We had been excited to attend last weeks Boab Festival Kimberley Art Competition, in no small part because we hoped to purchase a painting by the Aboriginal man who was our guide on the Leeuwin trip. And I think we were stunned and shocked as the above scenario unfolded.

Yet we believe it is symptomatic of what is happening in Australia today.

The big national news here (notwithstanding scares about terrorist doctors) has been the Howard government's "intervention" in the Northern Territory to rescue Aboriginal children from child sexual abuse. After 8 years of doing nothing, with the election looming, Mr. Howard has sent Federal Troops into small communities in the N.T. to take control of the communities. And this week, there has been a firestorm in nearby Halls Creek, Western Australia, where a dozen men and teenagers have been arrested for having sex with underage (<16) girls as young as 11. (We have seen many family members from Halls Creek visiting Derby relatives this week as a result.)

This has been a brilliant political move- after all, who can oppose stamping out child sexual abuse?- but some say it is a cover for abrogation of Aboriginal land rights, and to take the focus away from the current government's lack of progress in improving the lot of Aboriginal children.

What is immediately apparent to us is that the policy is inherently racist. There is no equal push to detect and treat child sexual abuse in European communities. In fact, the diversion of social workers and resources to Aboriginal communities might be giving a free pass to non-Aboriginal child abusers. It is easy to go into a remote community with the Army and look like something is being done- but whether there will be a sustained push to improve the conditions that predispose to child abuse and neglect is another story.

The original report (that so embarrassed the government that they HAD to do something) said that "rivers of grog" were a major factor leading to child sexual abuse in Aboriginal communities. And the Government has indeed declared Communities "grog-free zones", which their soldiers will enforce (causing the heaviest drinkers to relocate to nearby towns and cities).

But the problem is deeper than that. The son of the Premier of Victoria this weekend was drink driving and wrapped his car around a utility pole, putting his best friend in the ICU with head and facial injuries. This is not the first time this teenager has been in trouble over alcohol. He will receive a small fine only, and some points on his license. His father has been quoted as saying, "I really don't think he has a problem with alcohol."

It really all comes back to accepting responsibility and consequences.

Which brings me to several conclusions.
1) As we've said before, the average Australian (90% of whom live in the big cities) has no clue about conditions of poverty and despair in Aboriginal communities.
2) But if they do have an opinion, what we hear is that its the fault of "drunken Aboriginal people on the dole".
3) Yet ALL of Australia tolerates levels of drinking that are far higher then we are used to, and with even fewer consequences than we see in the (overlawyered) U.S. (not to mention Scandinavia or New Zealand)
4) If you are drinking, what happens to you depends on who you are are and the color of your skin.

One of my students this week mentioned how shocked and guilty she feels about the situation here in her own country. But she feels inhibited about speaking out, afraid she'll be perceived as racist.

In our discussion, I pointed out that the Government should and could intervene in a non-racist way. No matter what color you are:
1) Children should be made to go to school, with truant officers and consequences for parents who don't educate their children.
2) Any child at risk of abuse should have a family investigation, and support and intervention as needed
3) Welfare should be a temporary situation, with training and job placement an expected outcome in a short term of several years. (If only Nixon could go to China, then only Clinton could declare "welfare should not be a way of life".)
4) Dole payments should be vouchered, like Food Stamps, so they can not be spent for alcohol, gambling or tobacco.
5) Alcohol intervention programs should be funded and available to all who need them.
6) All communities should be encouraged to pursue economic development with equal resourcing.

At this point let me emphasize that these are good policies for the U.S. as well. Certainly we could add health-care equality to the list as a specific U.S. problem. And we have our own share of racism in places like Hurricane Katrina/New Orleans/ South Side Chicago and many other cities...

Yet amidst all this social distress in the Kimberley, there are real moments of beauty. We sat in the outdoor movies last Friday, with about a million local kids under a spectacular dark starry sky, watching Spiderman 3. There were at least 4 brilliant shooting stars during the picture. And early Sunday a student and I went birdwatching, enjoying a dozen brolgas, and a flock of huge white pelicans in the local lakes.

Derby, Western Australia, often makes me feel like when I was a kid with a friend down the block, who gets into trouble a lot. Sometimes he is mean to me, and he is always in the Principal's office; but on occasion, often enough to tantalize, he can be a really sweet kid, who has so much potential, if only he could just change his attitude, and come right...

Leeuwin

2007-07-08T19:36:00.000+08:00

The full moon shone brightly over the beach and its breaking waves, as the taxi headlights showed the silvery reflections of the crew's life jackets. My flight from the Medical Coordinators' meeting in Fremantle had been 40 minutes late, and then I had been stranded at the airport for another hour waiting for a taxi on a busy Friday night in Broome. The special beach pickup had been arranged by another RCS faculty member, and I had not wanted to inconvenience the ships crew. So it was with relief that I stumbled out of the cab with my single bag and walked down onto the sand. We wrapped the bag in plastic and waded into the sea. Just as I reached the zodiac, a huge wave came in and all hopes for a dry pickup vanished in a wall of water. Laughing, we hurled ourselves into the boat, and headed the mile across the sea to the Leeuwin. The wet arrival was compensated by my first view of the ship at anchor, masts lit from below, riding the moonlit sea.

We signed up to join the Leeuwin cruise at the suggestion of a friend in the RCS. Leeuwin is a Tall Ship, its major mission is educating young people. It's a member of the Australian Sail Training Association. The idea is to put diverse young people together on a Tall Ship for leadership training. From the ASTA website:

Sail training is an outdoor adventure activity for young people. Its purpose is not to teach young people how to sail. It is principally to help them learn about themselves, to discover hidden strengths and talents, to understand the value of others and of working as one of a team. It requires an individual to confront many demanding challenges, both physical and emotional. It is an activity that inspires and develops self-confidence and responsibility, an understanding and acceptance of others whatever their social or cultural background, and a willingness to take a calculated risk. For many it can be a life-changing experience.

Our particular voyage, Broome Leaders, included 29 teenagers, aged 13 to 19, and 5 adults plus ships crew. The kids were from various Kimberley communities: Broome, Derby, Mowanjun, Halls Creek, One-Armed Point, Mandurah, and one from Kalgoorlie. They were about half of European and half of Aboriginal descent. We were bound for Sunday Island, at the mouth of the King Sound (see map).

The Bardi people, the traditional owners of the Dampier Peninsula and many of the islands of the Buccaneer Archipelago gave permission for the trip. Wossie, a Bardi man in my Watch, was our guide.

The first day out we spent literally "learning the ropes". We were divided into 4 "Watches" which worked as teams. Watches set and furl sails together, and take rotating shifts running the ship. You can bet that taking the 0400 to 0800 nightwatch on a sailing ship was a novelty for many of these teenagers. Add that to 35 people sharing 4 toilets, bunk rooms with 4 to 6 in a cabin, and a small deck with no place to hide and you have an intimate experience.

We also learned to climb rigging, with safety harnesses. And there was the ultimate challenge: climb to the top of the 33 meter mast and read the plaque at the top. The climb is steep, and near the top the rope ladder so narrow that I can barely fit my toe into the rung. The tip of the mast is swaying back and forth in the ocean swell, and the narrow ladder twists- suddenly I understand the meaning of the phrase "twisting slowly in the wind".

Each day began at 0630 with music playing throughout the ship. We had morning yoga and exercises. An educational director led both games and informational sessions. We spent a fair amount of time on deck just enjoying the sunshine and the wind. The kids were especially good at spotting wildlife- sea snakes, dolphins, whales, a couple of hammerhead sharks, turtles and schools of tuna. I was amazed by the flying fish- which actually do appear to fly 10-15 meters over the waves.

Night watches were spectacular, with the soft hum of the ships engines, and slap of sail and water against the hull, the huge starry sky overhead. We enjoyed moonrises and sunsets. An unlisted aspect of the voyage was being outside most of the time, working with nature to sail the ship, living the rhythms of the sky and sea.

Dawn of the third day and we were at anchor off Sunday Island. In 1899, several "beachcombers" encouraged members of the Bardi tribe to settle in a mission on the island. This isolated community lived a mostly traditional lifestyle with limited interaction with mainland people until the late 1940s, and was finally closed in the 1960s. The children were forced to move to Derby for schooling, and the elders ended up in One Arm Point. Later many of the younger people moved from Derby back to One Arm Point, but today there are still many family connections between the One Arm Point mob and the Aboriginal communities here in Derby.

We launched the dories from Leeuwin and landed on a beach on the Northern part of the island. This area has rock formations unlike an I have ever seen. It is a conglomerate of small quartz crystals, like coarse rock salt, and very sharp to slide over or sit upon. The tides there are huge. Vicki and I climbed to the top of the rocks and spent an hour or so watching sea turtles feeding just offshore on the reef. Around the corner standing waves were forming as the ocean rushed into King Sound. Despite the tide rising at a rate of about a meter an hour it didn't seem to bother the turtles any. We all had a short swim, with "croc watchers" posted on the rocks around our beach. We took turns being the most seaward "bait" swimmer. I did a bit of swimming with goggles- the tropical fish were abundant.

After lunch we took the dories around and climbed into the central valley of the island to view the ruins of the mission. While it is a special place to the local people, it is also a sad one. The valley is essentially rock- so hard and with so little soil that even septic tanks could not be built. Everything has gone to ruin except a few tin shacks. Its a sad legacy after 100 years.

Earlier one of the boys from One Armed Point spent an hour telling me about learning to hunt turtles, dugong and fish with his grandfather. He clearly was skilled and enjoyed living the traditional lifestyle, as much as is possible in the modern world. Cape Leveque and One Armed Point communities now survive with tourist campgrounds and operate boat charters as a way of earning a living.

We found the young people to be a study in contrasts. One one hand, some of the Broome kids were very worldly, and some of the Aboriginal kids had met Michael Jordon and were fans of the latest hip hop songs. Yet they were simultaneously naive and much less mature than the teens we are used to. At age 17 to 19 many are "just starting to think about what career I might want to have" as one young lady put it. One girl from a remote community confessed to Vicki that she "wanted to be an astronaut". Another told me her plan was to become a mechanic and work in NASCAR. Many of the Aboriginal kids are clearly caught between two worlds, with no good options in either the White world or their own homelands.

We spent Tuesday sailing back from Sunday Island, around the Lacepede Islands, a group of formerly-guano encrusted sand spits that the United States briefly tried to claim from Australia at one time. This bit of trivia led to the quip that, "as usual, the United States wants everyone else's shit", to which we could only smile. Tuesday night we had a Ship's Opera, complete with musical acts, acrobatics, humorous skits and songs. I presented a short lesson on "How to Talk Like a Pirate", complete with red bandanna and eye patch.

We were all pretty tired by debarkation Wednesday morning, but there was also a sense of accomplishment. As the Voyage Certificates were passed out, each person said a bit about what they learned on the trip. We had begun the trip with an interest to see the coast, the wildlife, and the beautiful Archipelago. But we will remember the journey most of all for the young people we met. We wish them well, and hope we contributed some small thing to their life's voyage.

Click the picture below for more photos:
>

Leeuwin

Men's Pit Stop: Courtesy of the Kind People of CRMEF

2007-06-24T16:02:00.000+08:00

When I left my teaching job at CRMEF last December, the Residents, Faculty, Staff and friends threw a going away party, and instead of a gift, took a collection of monies for me to use in some community health education projects here in Derby. This was a wonderful gift that greatly touched my heart. So when the opportunity came up to do a Men's Pit Stop here in Derby, we jumped at the chance.

The idea is based on research that shows, in the U.S. at least, that 88% of men have looked under the hood of their car in the last year, while only 60% have had any kind of health checkup.

So to get by around the problems of coming to a health clinic (full of women usually) for care, we take the care to the men, in the form of a "Pit Stop". In a short time the blokes can travel around each station, and get "run their car (body) through the pits".

We use automotive analogies for the various stations. For example, the Fuel Mixture station is a finger stick blood sugar test, and the Fuel Additives is a short alcohol abuse screening questionnaire. Exhaust is smoking, Shock Absorbers is emotional stress screening, and Radiators and Spark Plugs are "Men's Business" (safe sex, STDs, prostate, urine flow problems, etc.)

I've spent the last few weeks adapting this concept, originally developed in the Gascoyne and Pilbara regions of Australia to the Kimberly and Aboriginal Health concerns. Vicki helped me order "Pit Crew" shirts in the colors and with logos containing found in the Aboriginal Flag. We built "Work Orders" which each man carries through the pits on a clipboard. At each station, they are marked "Roadworthy" or "Work Needed", and at the end the doctor reviews it all and slaps either a Yellow Temporary Registration or Blue Certified Roadworthy sticker on the guy's shirt.

This last week we placed posters all over town. My 3 students and I each took a turn on the local radio station, 6DBY, at the noon program to explain the Pit Stop and talk about one or more aspects of good health practices for men.

Friday morning, the big day, we set up on the lawn in front of the Shire offices and opened for business. Our drivers cruised around town all day and gave men lifts to the Pits for checkups.

I was the "cleanup batter" at the end of the chain, and I learned a lot, spending the entire day doing motivational interviewing. Men here have little or no idea of proper nutrition, and underestimate the dangers of smoking.And all Australians, black or white, drink too much alcohol. James spent the day giving "DrinkCheck" questionnaires, and said that he had never understood what "one standard drink" was until doing the station. He really liked the chart in the government pamphlet- although it reminded me a lot of the aircraft identification charts my mom used as a plane spotter during WW2.

The turnout was rather sparser than we hoped, but we did cycle 19 men through the Pits, and had several alarming findings, including a gent with previously unknown severe proteinuria, and several with hypertension and high blood sugars. We had hoped for over 50 men, but our timing may have been off. (We set the date for a Pay Week when many people would be in town- however, Friday may not have been the best day because Centrelink pays out on Thursday and many of the men had been up all night drinking and partying the night before.)

But the great thing is that the concept is now all set up for DAHS, and we have all the materials and run through it once. We will plan on setting up more Pit Stops later in the year, and we've scheduled a time to take it "on the road" up the Gibb River Road in September, to the Aboriginal Communities there.

And as Narelle and I agreed while doing the extensive planning- if we find just one man with a preventable disease or death risk that we can change, then it is all worth it.
Click the photo below to see the album:

PitStop

Worlds Best Ice Cream Bar?

2007-06-24T14:23:00.000+08:00

But Dangerous! Note Warning Label!

A Day at the Races

2007-06-20T19:19:00.000+08:00

Another week flown by and its raining here, in the middle of Dry Season! After over two months of clear blue sky sunny days- so much so that Vicki would joke by going to the window and saying "I wonder what the weather is today- Oh my, another blue sky day!"-we've had two days of dark cloudy overcast and rain. In fact, its rained so much the Gibb River Road has been closed and my flight to Ngallagunda was scrubbed this morning due to a soggy runway. This wouldn't be a bad thing, except its not the hot rain of January. This morning the temp was 50 F when we awoke, so it feels a lot more like New Zealand weather. And we don't have the clothes for it. And no heater. All the space heaters walked out the door of Retravision this last weekend- the locals are complaining of the cold. We bought a small quilt for nights. Down in Sydney and the Hunter Valley they are having "massive floods", so we can't complain. ("Massive" is the most overused word on the TV here- Vicki and I laugh whenever we hear it.)

Last weekend was Race Weekend here in Derby. We puttered around on Saturday and went to the Races in the afternoon. This was some of the sorriest horseflesh we've ever seen. Definitely not Keeneland. It was an orgy of beer drinking and punting. One of the U.K. med students hit a Trifecta and won $120, and my boys reportedly did pretty well. When people ask me this week how I did, I've said "I lost my shirt!" which gets a funny look. Not an Aussie idiom I guess. We had a good time watching the people as much as the horses. At least there was also a funny hat contest.

Sunday the horse races were followed by the mudcrab races. These were sponsored by the local Fishing Club. At least half of the crowd seemed to be tourists. Anyone may buy a crab, put a name on its back (girlfriends/wives/de factos were popular!), and enter it into a race. Again, beer and betting were rampant. Between the races, bush poet Murray Hartin recited a rambling rhyme about a jackaroo riding his swag on an airplane named "Turbulence".

Saturday night we ate some of those mudcrabs. One of the doctors at the hospital, Eric is from Singapore. He and two of the local pharmacists, Andrew and Cameron caught a mess of mudcrabs and invited us over for a taste. They cook them by breaking them up and popping them in a wok full of peanut-chili sauce. Over rice they are delicious.

Two more weeks until the end of the term. I've been working with the staff like crazy to help organize the Men's Pit Stop for this Friday. We will set up on the lawn in front of the Shire offices and do quick health checks for men all day long. I just hope it stops raining tomorrow!

Click the pic below to see the races:

A Day at the Races

More snapshots

2007-06-12T21:34:00.000+08:00

Last week the SEWB worker and I make a home visit. An elder is in the hospital in Perth with cancer, and things don’t look so rosy. No one from this large family is with her, as she’s been there for weeks getting treatment. Fran has called a meeting for anyone who wants to come. I grab the file and we drive across town and pull up in front of a small house. It is hot and dry and shady. Legions of kids have frustrated any green thing’s chance of growing in the front yard, which is now inhabited by 8 small dogs, each with their own cool hole in the dirt. We sit on old plastic chairs and overturned milk bins, 10 adults in a circle. We start reviewing what people know, which is not much. I try to explain what I know from talking to the Perth doctors that morning. We go around and around. It is like the archetypical discussion in Ten Canoes about what happened to the wife- we go around the circle and say the same things over and over in several ways. People hear different things- some hear that the elder will die soon, others wonder if she’ll be able to walk “and would a wheeled-brace help?” when she comes home soon. We go around until the questions run out. I have few answers and I'm talking to people who rarely think of time in the same way I do. The family decides they will send two people if PATS will pay. They come to the office later and I fill out the large yellow forms. We later find that PATS will only pay for one person to travel, but I’m not involved in that family talk circle.

The paediatricians have invited 6 medical students from the U.K. to spend their summer experiencing medicine in the Kimberly. They talked to the hospital administrators but not to any of us at DAHS or the University. My students find out a week before these Year 4 students arrive from England. This ignites many hours of discussions with the paediatricians, development of a roster and negotiation of “attachments” for the students. In the end I cooperate and help the Paeds guys in order to preserve our teaching ties and not have my own RCS students penalized. I like the Paeds specialists here in Derby, and they are good teachers for my students. I just wish they had talked to us before inviting a so many students into a small place. After all, there are only 8 beds on the Paediatric ward. Today I get a letter from the University of Notre Dame (in Freemantle, WA) that they are bringing 82 students up on a tour of the Kimberly in August and September and that I should RSVP for their seminar. I walk around DAHS for 10 minutes, cooling down, before sitting down and writing an email. I wonder if clinics and hospitals in Hawaii or Colorado have troubles with this kind of junket.

Stopping into the BP Colec for a “coffee, white, with 2 sugars” (for A$2) on the way to Jarlmadangah, I notice the cigarettes in the rack behind the counter have wonderfully explicit, gross warnings on them. We should do so well in the U.S.

Saturday Vicki's little friend 7 year old Hannah comes over to visit and we end up taking her and older brother Colin to the pool. The water temp is getting cool- 24 degrees C. - and she is blue and shivering after only a few minutes. (She reminds me of the waif in the poster for Les Miz.) The kids have a great time however playing tag on the lawn, on the slide, eating peanut butter sandwiches and just being kids. I fall asleep on the grass and they amuse themselves by throwing paper airplanes at me until I finally rouse. What simple fun!

Sunday morning we read the paper on the back veranda. It is much dryer and pleasant these days. We agree that sometimes the best "tourism" is just being in a place.

Monday I go to Jarlmadangah by myself. Halfway there I run out of radio, and belatedly realize the DAHS car I'm in only has a tape player. Who listens to cassette tapes anymore?! Its the first time I've been alone with my thoughts for quite a while. Maybe 6 cars pass me the entire 110 km. The landscape slowly slides by until the Grant Ranges rise up, out of the plain.

I take a lunch break outside the trailer-clinic at Jarlmadangah. A black kite is slowly hovering above the house across the road. Sudden he drops like a missle into the earth and comes up with a lizard, which he gulps down. Not like a red tail at home: he just shoots down into the ground. Amazing.

After the clinic, on the way back, I stop and walk 100 yards through the bush to climb up the rocks a ways and record the 360 degree view...

{click image to download and enlarge it in viewer: can you find my car? Can you see why you should NEVER leave your vehicle in the outback if you get stuck, and certainly NEVER leave the road?)

This thing was in the pool today. A giant water bug. At the end of my lane. It was at least 7 cm long and could swim like mad. Locals call them "toebiters" (but say they don't really... ?)

Snapshots

2007-06-05T21:09:00.000+08:00

Diary of a Week in Practice.

• Flight out to Ngallagunda again. This time the place is full of patients, and the nurse from Dodnun even drives a bunch down to see me from that community. One baby has a swollen forearm, and I have to decide if it can wait a few days for a drive down the Gibb River Road for an x-ray or not. Another patient has back pain. I demonstrate the history and exam for my student, Michael. He is leading the tutorial on back pain 2 days later, so this comes in handy.

• Harriet, the Rural Clinical School researcher, who visits all the sites comes on Thursday and interviews everyone at our site. The students chance to say how awful everything is, but they surprise me and seem very pleased so far. Harriet did her undergraduate degree in Theology but decided she wanted to do something useful so became a medical researcher and statistician. She is a wonderful listener.

• We drive to Broome for the WACRRM Kimberly meeting. There is one radio station in Derby, 6DBY. Once you get 20 km outside of town it fades out. On the car radio, for the next two hours, you can scan around the dial in both AM and FM and never find a station. There are few places on Earth one can still do this. In preparation for these long car trips, I have been downloading podcasts. We listen to “Roadtrip” from This American Life, WA Reloaded from the ABC ("A" as in Australian) and The Writer’s Almanac with Garrison Keillor.

• Saturday morning one of the speakers, an older GP is enamored with his “low-intensity” laser. He spends 70 minutes of his 90 minute lecture time showing us grayscale electron micrographs of the structure of human muscle spindles and their innervation. Then he describes how he uses the laser. He holds it against a sore spot for 2 minutes and the patient tells him they feel better. I can only think of my daughters laughing over the “Sharks with Lasers” in the Austin Powers movies, or of the famous cartoon, “…then a Miracle occurs”. During the Q&A he is unable to explain the physiology of how it works. In the Men’s room, all the doctors agree we are still skeptics. I am still looking up the literature.

• Sunday morning I swim in the hotel pool, than arrive at 0730 to learn how to implant Implanon. It is slick, much easier than Norplant. Not that this will be much use to me at DAHS, where
Aboriginal women will only see women physicians, for cultural reasons.

• Monday I am back on the road to Jarlmadangah. This time I have a new arrival, a 6th year student who is one of the very few Aboriginal medical students. She has family ties to the Kimberly. She is related to some of the people we see. I am heartened to see her sit down in the waiting room and just yarn with people. Aboriginal people need Aboriginal providers.

• Tuesday morning its bedside teaching at the hospital. I do this on Tuesdays and Thursdays. It’s “teaching without a net”. I look at the patient list on the general ward and pick something to talk about. Extemporaneously. The students usually have to go do a history and part of a physical exam, so its “learning without a net” for them also. Among other people, this particular morning there is a patient with a spontaneous pneumothorax, so we see her and review her x-rays, and how to read a chest x-ray in general. The nearest CT scanner is 220 Km away in Broome, and is an older model. There is no easy, fast way to diagnose a pulmonary embolism in the Kimberly.

• Wednesday I work in the office all day. My students have videoconference in the afternoon, and one of them has driven 2.5 hours (one way) to Fitzroy Crossing for their Cardiology clinic. I worry about him hitting a cow while driving home with the sun on the highway at sunset. The 6th year student sets up across the hall from me and we shuttle back and forth. This is helpful as our Registar, Marina, is sick today, and two of our doctors, Charles and Leeli are on annual leave, so we are very short-handed. The flu is going through town, so I see a lot of people with cough. I should probably get my “autumn” Southern Hemisphere flu jab, as my “autumn” Northern version has probably worn off by now.

• Thursday is teaching day again. I attend the hospital doctors “Discharge Rounds”. The Social/Emotional/Well-being worker and I visited a patient the day before at her home. The hospital called the SEWB worker to pick her up, and the nurses took her out in a wheelchair with all her things, including some big boxes of medical supplies and her “machine”. Nevertheless when we called for a Discharge Summary, we are told that she had “absconded” from the hospital, therefore no Summary is available. I bring this up at rounds- the hospital doctors are also very understaffed. It turns out the doctor caring for this lady had to go to Broome for a meeting, and the covering doctor was unaware he had promised the patient she could go home. So much for the unplanned exodus, which is now called a “negotiated absence”. Some communication problems are Universal.

• However, going to D/C rounds has helped the Hospital/DAHS relationship a lot. As in most relationships, if we don’t talk to each other, misunderstandings arise. The hospital doctors are all Overseas-Trained Doctors, like me. Australia takes advantage of us by restricting our visas and licenses to rural and remote practice only. Essentially, if you are an OTD, you must serve your 5 years in Hell before being allowed to practice anywhere else. And many of the OTDs are specialty-trained. One has certification as an OB-GYN in the U.K. but will never be allowed to practice that specialty in Australia. He will be forced to be a GP-OB; that is a country doctor who delivers babies and does Caesarians. They work long hours, take too much call, have little or no staff support in the hospitals, and then if things go wrong, the state Hospitals let them take the fall. I have found a niche in being the “University” teaching doctor for them. They need support. The week before we had a lot of questions about metformin use in diabetes, renal failure and pregnancy. I have time to look this stuff up, call Royal Perth, and synthesize a “two-minute drill” email which I send around to all the Derby docs and my students. I enjoy this Academic Detailing.

• Friday and it’s a flight to Kandiwell again. Of all the places I’ve been this one truly feels like the End of the Earth. Probably it’s because of the 65 minute plane flight over the rugged, uninhabited, drowned coastline of the Kimberly, followed by the swoop onto the rocky airstrip among the palm trees. Today there is air traffic however, and tourists flying into the strip to swap from planes to helicopter over to Mitchell Falls. We wait at the strip for an hour as the people in the community seem to have slept in and forgotten us. They finally come and I spend the day seeing mostly kids with huge smiles. They have mostly nothing and are quite happy. They are also very shy, not seeing many outsiders. I have never seen such trusting children, who willingly open mouths wide for me to see their terrible tooth decay. Even the infants hold perfectly still while I check their ears. Many of these kids are rostered into the Dental schedule for general anesthesia to repair really rotten 6 year old molars. This despite signs of fluorosis on some teeth. I wonder if there is fluoride in the water supply here.

• Saturday, long weekend and I’m happy to stay home. One of the docs from Fitzroy is in town and rings me from Woolies- he’d like to have a chat about a job at DAHS next year? I go down to collect him and his family. There are no street numbers in town- he would never find our place. While he is finishing his shopping I pop into the liquor store to buy a bottle of wine for tomorrow. The place is jammed on Saturday afternoon. 12 beers cost A$28. Both European and Aboriginal people are stocking up for the weekend. A large, orange butterfly flits about in the store and lands on the wine bottles. I wonder why all the labels extol Nature, with pictures of animals, mountains and trees?

• The Professor, Campbell Murdoch, Head of School, and his wife Annie come up from Broome on Sunday for a social call. Vicki prepares a wonderful lunch ahead of time on Saturday- so for Sunday dinner all I have to do is throw the steaks and veggies on the grill and we are ready to eat in 15 minutes. We give them the “Tour of Derby” and finish by having Vicki’s low-fat chocolate cake, with frosting made of Whittaker’s dark chocolate. Yum. I really enjoy talking to Campbell. He is a wonderful storyteller. After we swap a lot of tales, he says, “Being a GP is like being a solid rock in the ocean, you just have to let the waves wash over you….” I tell him one of the things I miss by getting older is not having even older doctors around so much anymore to listen to. And one gets tired of being the tale teller. He graciously takes it as a compliment.

• Monday morning and it’s the Queen’s Birthday in the rest of the country, but not in Western Australia, where it is somehow Foundation Day (and the Queen will have to wait until October for her birthday). Anyway it’s a Holiday and everything is closed. We get up early and Vicki takes me out to the lakes and the brumbies. We see 7 brolgas and hear their haunting calls. On a whim we take the turn out onto the mudflats with the 4WD. The sky is huge, blue, mostly empty. We can see smoke rising in the distance- it is dry season and there is always a fire now somewhere in the bush. It’s still hot, and a shiny rock will set the spinifex on fire, it is the natural way of this ecology. But it does ruin our leaving the windows open at night, to have the smoke and soot drift in on the wind. But that is emblematic of Australia, occasional bad smell in the midst of intense stark beauty.

Kandiwell 2

Vicki writes:

2007-05-30T21:46:00.000+08:00

The pool is closed on Mondays, so my friend Doris suggested that she would show me the lakes. Of course, I thought a walk would be a healthy alternative to swimming laps, but Doris assured me it was too far and that she would secure a 4WD vehicle for our little jaunt. Since Doris is German, I knew we would leave promptly at 8 AM, as planned. It was a breezy, cool morning and in no time we were out of town, heading towards Broome. At the 20 K marker we turned towards the marshes on a barely distinguishable track. After slowly bumping over the hard-packed pindan, we suddenly came to a large expanse of water out in the middle of the bush.

The water was colored by the large purple water lilies and miniature white “frenzies.” Hundreds of ducks glided over the water, while off in the distance a pair of brolgas raucously engaged in what appeared to be a mating ritual, wings wildly flapping as they hopped about each other. White cranes perched in the eucalypts; ibis and egrets delicately picked their way through the water. The cacophony of birdsong was overwhelming. It was too much to absorb all at once; focusing the camera helped to focus my mind, even though I detest taking pictures. Doris, behind her camera on a tripod, told me to “just shoot; something will come out.” As I clicked away and listened to the birds I suddenly heard the distant drumbeat of hooves. We both looked across the lake but couldn’t see anything. Suddenly, a herd of brumbies galloped from the tall, brown grass and headed straight towards us. We remained still and let them come. They were clearly curious and totally unafraid of people. They stopped abruptly within a few meters of us. They were fat and sleek; as beautiful a bunch of horses as I have ever seen. The Uruguayan gauchos of my childhood would have been ever so eager to catch them. Suddenly, a loud neigh came from across the water. In unison, the horses lifted their heads, listened intently, and then, as one, galloped back to join the loner.

With Doris at the Lakes

Click picture above to see the brumbies!

In Lennard Gorge

2007-05-22T20:42:00.000+08:00

Last week we rented a bunch of videos and one that i nabbed was the 1959 Cold War film On The Beach from the novel by Neville Shute. Vicki had mentioned that she had never seen the film, although she had read all of Shute's books. The film is about Australia, and focuses on a young couple- the young man is in the Navy. Shots of downtown Melbourne, dominated by bicycles and horse-drawn buggies gradually introduce the fact that a nuclear war has killed everyone in the Northern Hemisphere. Australia survives, but everyone is destined to perish in about six months when the radioactive dust in the atmosphere reaches the continent. In black and white, with Gregory Peck, Ava Gardner and Fred Astaire, the film is a classic about the response of people to the inevitability of their own extinction.

Saturday morning we arose early, as I had organized an "official RCS field trip and tutorial on 4-wheel-driving" for my students- i.e. a picnic to Lennard Gorge. This was a 184 Km jaunt up the Gibb River Road, the first time we had been up that highway. We took two vehicles having been warned that it is not uncommon for people to lose 2 or 3 tires to sharp rocks in the outback. Since one of the students has a vehicle that matches the RCS Nissan Patrol, we can "share spares" if need be. Michael and Owen made the supreme sacrifice of getting up early on a Saturday morning and putting off their studying for a day.

We got started a bit after 7 AM for the trip. The first 74 Km of the highway is "sealed" or paved, but this is using the term generously. About 20 Km out of Derby the paved part becomes one lane down the middle with 1/2 lane wide gravel shoulders on each side. One needs to keep a sharp lookout not only for cows, but for oncoming vehicles. Fortunately traffic is light- we saw only 21 other vehicles in an entire 400+ km trip.

First stop was the Lennard River crossing where we took a leg stretch, had a snack and admired the river bed with its smoothly worn stones. Shortly thereafter we found some emus on the road. Crossing the Napier Range, we encountered Queen Victoria's Head and could not resist making our own Queen Victoria strike a pose! [Click picture for enlargement]

After this the road rises up over the King Leopold range, with spectacular views of land that seemingly goes on forever, with no fences, no cell towers, or power or phone lines in view at all. There is no obvious sign of human habitation or even transit beyond the gravel road. This is the only time I can remember ever seeing such an unmarked landscape in my lifetime. For Vicki, its the first time she has seen anything like it since the pampas of Uruguay when she was 12.

Another hour and we turn off on a very rough 4WD track for the 8 km ride to the Lennard Gorge carpark. We pack up and put on hiking boots. Its a solid uphill kilometer walk to the top of the hill, then a rocky scramble down a stream bed of round red boulders to the top of the gorge. The Lennard river is roaring by now, and we climb down into the cool of the gorge and find we are the only ones here, with a deep green pool and beautiful waterfalls. By now we are very hot from the hike, so we change into bathers and climb down into the water. Its a great swim, against a stiff current, to the base of the waterfalls. We sit on the rocks under the falls, float on our backs and admire the eagles soaring overhead between the red rocks, and just enjoy the magic of the place. The rocks are so smooth, but hard granite shot through with white veins of quartz. This cleft in the Earth must have taken a million years to cut- especially since the river only runs during the wet.

We sunbathe on the rocks and eat our lunch. I review the 32 points to remember about driving a 4WD in 5 minutes and give the boys the handout: tutorial finished, and its time for another swim. This time Vicki peeks over a rock on the way into the river and finds herself face to face with a 2 foot goanna. It is unafraid, and lets us get a foot away. It opens its mouth, and I am close enough to see its tiny teeth and black tongue. Even sans glasses, I admire the speckled camouflage pattern of its scales.

2 PM and we have to leave this place. I have developed a great appreciation for the hundreds of thousands of miles of barbed-wire fence in the American landscape, if only because they allow us to drive at night without fearing for our lives if we encounter a cow. There are cows on the road all the time, and the last sunset hour, as we tiredly near Derby is an effort in concentration and frustration, as we have to stop frequently to clean bugs off the smeary windshield so we can keep a sharp eye peeled. But we only see one roo scamper past and are soon home safely. (Click the picture below to open the photo album:)

Lennard Gorge

Sunday we are so tired we sleep in till 9, but then clean the car and the house windows while we are at it. We walk out to the jetty- its King Tide Day, with tides up to 11.5 meters this week, the highest of the year. There is a celebration on the jetty with food stalls, art auction and booths. The local Aboriginal kids are climbing up on top of the ore-conveyor and jumping 8 to 10 meters into the swift, crocodile-inhabited currents around the jetty, laughing with delight; not an adult in sight.

But life is short, especially compared to the age of the Earth, the Deep Time it took to carve Lennard Gorge, to create the waterfalls. I reflect about On The Beach, which I believe is not so much an anti-war movie, as an existential commentary on all our shared fates. "What would you do if you knew your time was very limited?" Swimming in Lennard Gorge, I realize I am also On The Beach. We all are.

Eurovision

2007-05-15T17:05:00.000+08:00

Vicki and I stumbled onto the finals of the Eurovision Song Contest, broadcast here on SBS on Sunday night. We hadn't planned to watch it, but had seen the documentary, Finland, Zero Points the night before, and our interest was piqued.

The most watched non-sports broadcast in the world, Eurovision has been an annual rite since 1956. In a nutshell, every European country (and some that are not like Israel) may send only 1 song/group/act to perform in the contest. After all the acts are done, each country may vote for the best act- but no country may vote for themselves.

What was fascinating was the wide variety, and sometimes surreal character of the contest. No boring cookie-cutter American Idol stuff here. Finland hosted this year due to the success of monster hard rock and roll group Lordi last year. (The winning country becomes host the next year.) And Lordi are literally "MONSTER" rock, dressed as demons that would make the meanest orcs in Lord of the Rings go crying for mummy. We especially loved the pyrotechnic effects, such as fireworks erupting from the ends of their guitars as they sang "Hard Rock, Hallelujah" to open the show.

The show continued with a variety of eclectic acts. The Boznia-Herzegovina act was ethereal, the Irish showed up with a predictable nasally out-of-tune Celtic singer backed up by drum and tin whistle (and ended up bottom of the list, where they belonged.) The Bulgarians did "The Ten Tenors" onstage, to great effect. The French were very odd and outre as predictable. The U.K. band Scooch performed a very campy "Flying the Flag" number which was fun.

In the end the voting came down to the Russians, Serbia, and Ukraine. The Russian girls did a very rude number which would have made Brittany Spears blush. Dressed in black they sang

Oh! Don't call me funny bunny
I'll blow your money money
I'll get you to my bad ass spinning for you
Oh! I'll make it easy honey
I'll take your money yummy
I've got my bitches standing up next to me

Truly the West has had a bad influence on Russia.

The Ukraine featured a drag group who looked as if they had fallen into the mills at the aluminum wrap factory. This act would have made millions in Miami Beach. It made the Sisters number in "The Birdcage" look positively straight. They were quite popular with the crowd and consistenly high in the voting.

But even before the voting began, both Vicki and I pegged the Serbian singer, Marija Šerifovic, as the best act of the night. This only 22 year old, plain-appearing woman has a beautiful, powerful voice which communicated the emotions of her torch song so wonderfully, that we felt her pain and grief acutely, even though it was in Serbian. When we looked up the lyric, it was no surprise to find lyrics matching the longing in her song:

MOLITVA (PRAYER)

Music by: Vladimir Graić
Lyrics by: S.M.Mare

I'm wide awake
An empty bed drives my dreams away
Life melts like ice

Disappears in the twinkling of an eye
I'm losing my mind,
Pushing reality out of sight
Our lips are touching softly
You're the one I believe blindly

I walk around like crazy
Falling in love frightens me
Days are like wounds
Countless and hard to get through

Prayer...
It burns my sore lips like a fire
Prayer...
Thy name is something I admire
Heaven knows just as well as I do
So many times I have cried over you
Heaven knows just as well as I do
I pray and live only for you

I can't lie to God
as I kneel down and pray
You're the love of my life
That's the only thing I can say

We held our breath during the voting, cheering for Marija to win. We were so happy for her and for Serbia.

This was 2 hours of plain fun, and I have to wonder why I've never seen it on American TV. A quick search of Google, TVGuide.com, and Yahoo.TV on U.S. sites shows no articles or schedule times. Maybe I'm wrong and it was shown on BBC-America or something- (leave a comment if you saw it on TV in America!)

But if you missed it, you can still see it due to the miracle of the Internet. You can see her amazing performance in Helsinki here. Or at least go to her website and hear Maria sing Molitva. You will enjoy it.

Perception Leads to Reality

2007-05-13T12:51:00.000+08:00

We are enjoying a special treat, the Weekend Australian this morning. We especially chuckle over Phillip Adams weekly column, one of the funniest (yet also scathingly sarcastic) being a few weeks ago- see http://www.theaustralian.news.com.au/story/0,20867,21591643-12272,00.html for a rude but right on read. Like a modern Mark Twain, he is calling his country to heed the better angels of their natures in the area of tolerance and fair go.

This is interesting in comparison to an abstract that popped up in my PubMed medical literature surveillance robot for "Oceanic Ancestry Group"[MeSH] AND Aborigin*". An article from the British Journal of Social Psychology, [Volume 46, Number 1, March 2007, pp. 191-204(14) Authors: Leach, Colin Wayne; Iyer, Aarti; Pedersen, Anne (who are from PERTH) ] titled

Angry opposition to government redress: When the structurally advantaged perceive themselves as relatively deprived has the following abstract:

We examined (structurally advantaged) non-Aborigines' willingness for political action against government redress to (structurally disadvantaged) Aborigines in Australia. We found non-Aborigines opposed to government redress to be high in symbolic racism and to perceive their ingroup as deprived relative to Aborigines. However, only perceived relative deprivation was associated with feelings of group-based anger. In addition, consistent with relative deprivation and emotion theory, it was group-based anger that fully mediated a willingness for political action against government redress. Thus, the specific group-based emotion of anger explained why symbolic racism and relative deprivation promoted a willingness for political action against government redress to a structurally disadvantaged out-group. Theoretical and political implications are discussed.

In English, what these authors are saying is that inequality in Australia, the U.S. and other developed countries is perpetuated by inaccurate perceptions. The dominant (White) electorate wrongly believe that minorities do not share their values and have unfair advantages over them, even though the society is quite clearly structured in their [Whites'] favor. The authors then say:

"...we expect group-based anger to fully mediate a willingness for political action (symbolic racism -> group relative deprivation-> group-based anger-> action willingness)......

....the notion of inverted relative deprivation may help to explain the
continued appeal of political movements that are fiercely anti-government and antioutgroup.

In the last 15 years, parties such as One Nation in Australia, the British National Party in the UK, the National Front in France, neo-Nazis in Germany and Austria, and ‘white power’ movements in the United States, appear to have increased their numbers and influence by appealing to white people’s relative deprivation-based anger (see Fraser & Islam, 2000; Wrench & Solomos, 1993). All of these parties gained some support among disenfranchised members of the white majority by portraying their ingroup as relatively deprived to immigrants, asylum seekers or other structurally disadvantaged out-groups."

Which brings me to the lapel flower I bought this week. May 26th is National Sorry Day. Of the residents of Perth studied in the article above, over 68% did not believe the Australian government should indicate they are sorry for the past injustices inflicted on Aboriginal people. So it makes sense that the first step must be education and increased awareness of the facts of Australian history. Sorry Day is only 9 years old. Perhaps by wearing Sorry Day flowers and confronting the misinformation about fairness and deprivation, people on this oddly-shaped continent may begin to reconcile. Also something to think about next Martin Luther King day, when we are back home again. As Michael Shermer outlines in this months Skeptic column, ending self-deception is the beginning of wisdom.

A Lazy Derby Saturday

2007-05-12T18:39:00.000+08:00

0750 AM: We stayed up watching silly TV till late Friday, so this morning slept in until 8AM. But then we had to get up when the last "retic" (lawn irrigation) station switched on. This makes such a loud, vibrating noise beneath the bedroom, the raised floor of the house acting like a huge loudspeaker, that we are driven from the room.

0815-0930: Coffee and apricot muesli with passion fruit yogurt on the back veranda. It is cooling off a little at nights, although the days here are still peaking in the 92-98 F range. We sit on the back porch and listen to the birdsong, which has changed as new migrant birds come into this tropical area for winter. The unseen dawn choristers in the garden are very loud and sing continuously until about 9 am when they suddenly all cease. The frangipani in the back yard are still blooming vigorously, and their fragrance fills the morning.

0930-1100: Vicki got an email from our daughters to call them. We talk for about an hour. She bought a phone card at the newsagent in town which runs $0.0502 per minute for calls to the U.S. It is probably cheaper for us to call family in the U.S. than it is for them to call each other. Vicki's brother Bill is visiting Leah on Long Island, and Liz has come down to attend her sister's Masters Violin Recital. Leah will graduate with her Masters in violin performance next week. We are very proud of her, and sorry we can't be there. We talk about their plans for summer work. Its obvious the three of them are having a great time together.

1100-1200 AM: The pool opens. We swim, I do a kilometer of laps, Vicki churns out 1.5 klicks. It is a beautiful sunny day, and we manage to get done just as the children start to fill up the pool. We agree we enjoy watching the black kites, and butterflies drift overhead while we backstroke.

1200-1300 PM: Showers and dress. Vicki has a snack; apple and peanut butter on bread. I have a few pieces of Whittaker's chocolate- "Special Dark" and "Cashew". We have been looking for Rum Raisin but have not been able to find it in Australia.

~1300-1500 PM: Errands in town. I go down to the Tourist Information center to find some maps and info about driving up the Gibb River road. I'm interested in places to drive out and do some day hikes and picnics, now that the weather is improving. I get information about some local gorges, only 2 hours drive away up the gravel road, and also a good place to swim. "There are Crocodile Warning signs there" the woman says, "but everyone swims there anyway". "When was the last time someone was eaten there?" I ask, and to my amazement, she turns to the older woman at the Center and repeats my question! "I can't remember any, but a boy did report seeing a crocodile there last month. But no one's been eaten".

I go to the Blockbuster, which in Derby has quite a nice selection. I rent an Australian romantic comedy, a sci fi movie, a classic ("On The Beach"), and "Garden State". Vicki is bound to like at least 1 out of the 4. A stop at the Newsagency and I nab the Weekend Australian- something to read on the veranda on a Sunday morning. And then a run out to Woolies, where I am on a search and destroy mission for Magnum ice cream bars. They are out of the really good ones- the chocolate ice cream covered by chocolate bars. (Today's blog is brought to you by CHOCOLATE- you can see why I have to swim a klick a day!) I settle for a box of 6 mini-bars. Woolworth's is not too crowded, except for the liquor store which is doing a booming Saturday afternoon business. As I leave, a flock of rainbow lorikeets are flying over the parking lot, making a racket. On the way home, I notice a flock of about 30 black ibis on the footie oval. These birds probe the grass with their long bills- they are huge and identical to the ibis seen in Egyptian art.

3PM and its time for a little read and a nap. I am taking a break from reading Australiana and Aboriginal literature, and relaxing with Robert Charles Wilson's Darwinia. We nap for about an hour in the heat of the afternoon. Its hitting the high 90's but we are trying not to run the "AirCon" now that its less humid. We give up and turn it on for an hour when it becomes stifling.

5 PM: We are both starving after our swimming. At Woolies I've nabbed some Chevap (Serbian sausages) which we threw on the grill with onions, red peppers and potatoes. Supper on the veranda and we stuff these ingredients into Pitas with cabbage/carrot cole slaw. Yum.

6:30 PM and we watch SBS World News. This has become an evening habit as we can not get a daily newspaper here. The papers have to be shipped up from Perth and they are a day late at the minimum, and there is no home delivery. SBS is the "alternative" government-funded station, which shows the most eclectic programming I have seen. Its a mixture of old movies, great news programs, documentaries, Aboriginal programs such as "Going Bush" and "Living Black", and hour-long foreign language news (in Italian, Chinese, French, German, Greek, and a smattering of Eastern European countries). Their radio broadcasts cover 68 languages, but we only get three radio stations in Derby: 6DBY which is local within 30 Km. of town, and is mostly country, oldies, and on weekends footie games; ABC-AM Local Radio, and a station from Port Hedland called Spirit which doesn't always come in. 6DBY does have the National Indigenous Radio Network, which often has an interesting view of the national and local Australian news and politics, and is worth listening to.

7:30 PM and I'm checking email and blogging a bit. We watch TV here a few evenings a week- guilty pleasures like Desperate Housewives, McLeod's Daughters, Heroes. I am disappointed that I've not found any Australian produced programs that have captured my interest. (The number one program here, on Channel 9 is Home and Away, a soap opera in which the recent Logie winner, Kate Ritchie, has been playing her character for over 20 years, since she was 8 years old.)

8:30 PM Vicki is a fan of Inspector Lynley, a BBC crime program based on the Elizabeth George novels. He is a hunk, and he drives a nice car. England looks very cold. They have foggy salt marshes where we have hot, dusty mudflats.

10:30 and off to bed. For the first time we keep all the aircon off and open the windows, even leaving the overhead fan off. This is cool and comfortable for sleeping, but we listen to the myriad canine population of Derby howling all night long. Sometimes being half-deaf has its advantages. Oh well, I have cleverly reprogrammed the #6 retic setting for 8PM in the evenings, so we are able to sleep late on Sundays from now on...

No Solar in A Sunburned Country

2007-05-10T21:31:00.000+08:00

This picture is not in Australia. That's the problem. We recently saw an article on the SBS news about a new solar power tower, in Seville, Spain. We are constantly hearing on the news here that Australian citizens produce more greenhouse emissions per capita than any people on Earth. So it is interesting to hear the Australian government come out with a new budget which emphasizes carbon sequestration for coal plants (essentially pumping the CO2 from the smokestacks back into the ground). John Howard has also floated the idea of widening the use of nuclear power.

This in a country where, at least up here in northern latitudes, it is still hitting 98 degrees daily at the end of autumn. This sunburned country would be a natural place to use and develop solar power in a big way. One article quotes a leading scientist who states that "the amount of solar energy that hits Australia alone in one summer day alone is about half the total global annual energy demand." Yet this same scientist, who has worked on solar power for 30 years, left Australia for the U.S. in January of this year.

The vast majority of people here seem to me to be taking global warming seriously. I hope the mood has become more accepting back home in the U.S. At a time when both our countries should be concerned about both energy independence and maintaining the environment for our children and grandchildren, we should all be writing our legislators and demanding that more R&D and subsidy money go into solar power (and wind and energy conservation).

And how does this impact indigenous people? A report from the U.S. Worldwatch institute details how the Lakota people are using solar power to cut down the degradation of their reservation and conserve money. Generating electricity from their own lands also fits cultural ties to the land as the source of life. Many Aboriginal remote communities, such as Kandiwell, rely on solar power because they are off the grid. A few have built larger power stations. But perhaps this would be an industry that would be non-polluting, friendly to the land, and a source of jobs and income for Aboriginal people, with a little kick-start from the powers-that-be in Australia?

But what really got me thinking was an article discussing the difficulty of finding really ancient Aboriginal archaeological sites. You see, the problem is that 40,000 years ago, before the last ice age, when Aboriginal people likely first came to Australia, the sea levels were 20-100 meters lower than they are today. That means all the coastal sites, where the First Australians likely settled are now deep underwater.

If the climate scientists are correct and the ocean rises another 25-50 meters in the next century due to global warming, all of Derby and many miles of the beautiful coastline I posted photos of (in the Kandiwell folder) will be submersed. And this would include a lot of traditional lands for Aboriginal people all over Australia.

For a more critical review about solar power in Australia, read this article as well.

FARTs

2007-05-06T20:19:00.000+08:00

Last week we spent in Broome, for the annual Formative Assessment in Rural Training, or FARTS as Professor Campbell likes to call them. This being "tourist season" in Broome, kind of like winter in Florida, accomodation was hard to come by, so the Rural Clinical School ended up putting us into the pricey Cable Beach Club Resort, across the road from Cable Beach.

Cable Beach is rated the #2 beach in all of Australia, the continent with the best beaches on the planet. (#1 is Esperance according to the poll, but its rather cold there now in late autumn.) There are 10 meter tides, which means at low tide, I had to walk about 1/4 mile over the wet surface from the dunes to the water's edge. This was great as the fine sand was patterned with wonderful radial geometries made by 1 inch long crabs, interspersed with long random snail trails laid down by tiny welks. The turquoise Indian ocean was very warm and seemed much saltier than the Gulf in Florida. It was rather a shock to stay at this resort for 4 nights after living so long in dusty, mudflatted Derby. We also felt a bit guilty about the cost, when we are surrounded, both in Broome and Derby by those who have so much less. A conscience is a terrible thing.

The 4 days included two exam days, and two workshop days. My students were pooled with the 8 students from Broome, and the 7 from Karratha and Port Hedland, for a total of 18. Monday was devoted to OSCE's, or "Observed Structured Clinical Examinations". We faculty ran 6 stations, and each student had to complete them all. Each station was 15 minutes, and the student comes to the door of the room, reads a short precis, and then has to perform the task. Half of the stations had an actor, and the student is instructed to do a brief interview, and demonstrate a skill. For example, the student interviews a patient with fatigue, tiredness and 10 pound weight gain, then must explain the possible diagnoses, outline a plan to investigate, and interpret the thyroid tests given at the end. This type of exam tests skills that students will need in everyday office practice. My case was of a young pregnant woman, who (18 times) asked the "doctor" to explain what they "were feeling for when you push on my tummy, how will I know when something is wrong, when should I go to the hospital?" Listening to this 18 times makes for a long day.

Tuesday the students had a day long Paeds workshop, and we had a local Medical Coordinators meeting, debriefing from Monday, and putting finishing touches on our Wednesday workshops. Vicki and I took a beach walk north up to the "nudie beach" in the morning, and on the way back, crossing some rocks, I slipped and caught my ankle in a crack and fell hard, right on my face. It was fast and frightening, and I ended with a couple of gashes in my shins, but otherwise no major damage except to my dignity. (My daughter Liz when told about it summarized it in engineering terms as "high center of gravity + gawky = fall"). Tuesday evening the students and faculty all went out to dinner together.

The next day we ran 9 stations in rotation for "quick clinical workshops". I ran a double station, teaching pneumatic otoscopy and how to use the tympanometer. These are crucial skills in the Kimberly, where ear disease among children is rampant. (I have never seen so many draining ears from infected, perforated eardrums in such a short time in my entire career.) Other stations included knee and shoulder exams, some patients with heart murmurs, and a case of pediatric trauma. (Our dummy child got her foot bitten off by a crocodile before it drowned her- the students eventually learn to look under the bandage once they stabilize her.) These are great fun, and we mixed the students from different sites together to make it more interesting for them.

Thursday was the Long Case. This is an hour long exam where the student is asked to do a complete history and focused clinical exam on a real patient, while I watch and score. Each of us had 4 patients, which again makes for a long morning. We only let the patients be interviewed by 2 students, or they become stale and bored with their own stories. One of my patients had rheumatic heart disease, and the other had obvious lung disease, with a few twists. I found it interesting to see the variation in skill which each student had in approaching the patients. And at the end of both Long Cases and OSCEs, we also ask the patients to rate the doctors "bedside manner" and give them that feedback.

We quit Broome immediately after the Long Cases and drove back to Derby. Vicki and I enjoyed Broome and the students. I felt the social support was helpful to combat the isolation of living and working in such remote places. But ultimately were happy to come back home to our friendly, quiet little town.

Click the image below for pictures of the gardens, and also for StoneRage, a shop that imports wonderful art and furniture from Indonesia.

Broome_MayDay

All Over the Place

2007-04-27T21:26:00.000+08:00

Last week I had a flight up the Gibb River road to the community of Kupingarri. This remote community is on the Kimberly plateau, near the Mount Barnett Roadhouse. For the last 10 years or so, there has been a full time nurse in the community, staffing the clinic. Because its affiliated with Jurrugk and DAHS, there is an emphasis on preventive care, although that doesn't keep the locals from eating the ice cream and junk food stocked at the Roadhouse. The environmental health worker for the Shire of Derby flew out with us to inspect their water and sewer systems. He found them very satisfactory- a huge contrast to my Yulumbu flight. The clinic as you can see in the pictures [click it for slideshow] is clean and relatively modern. I saw a wide variety of children and adults on a very busy day.

Kuppinjari

We turned around on Friday and drove to Broome, taking the late night flight back to Perth for the WACRRM meeting (see blog entry below). It was a very nice conference on Men's Health, and I was pleased to find an emphasis on Aboriginal health.

Perth WACRRM Meeting

I attended talks on mental health, nutrition, ear health and infection, and a review of "Brief Interventions for Blokes". Vicki found me a nice sport jacket which I wore to the Conference evening dinner & dancing entertainment. We did a bit of browsing at the bookstores and had some nice walks in the brisk "cold" (55-65 F) autumn weather.

Returning from Perth Sunday night, my colleage Cyril drove us back to Derby in the dark. Although we saw many cows, often in the road, we managed to avoid any close encounters. We spent the drive listening to Cyril's story. Son of a university professor in Burma (Myanmar), he was a medical student and involved in the human rights movement of Aung San Suu Kyi. Now 36 years old, he spent 6 months in their prisons for being the president of the student body and demonstrating for human rights. All of his family left Burma, but he had stayed behind hoping to finish his medical studies. After his prison term, he emigrated to Australia and finished medical school here. He is now a Registrar, training to get his GP "Qualification". (This is similar to being a Resident in the U.S. except that GP training is onsite, in a working practice, supervised by older, more experienced GPs.) A devout Buddist, Cyril has been called to medicine to relieve the sufferings of others. He plans to go on to study Palliative Care next January after he finishes his term at DAHS.

I spent most of this week, except for Anzac Day, at DAHS seeing patients, although yesterday had a flight to Ngallagunda (the first "g" is silent), a beautiful community farther up the Gibb River road. This was the first "slow" clinic we have had, with my time spent seeing only one very old woman, and doing a bit of talking and teaching with the nursing staff. [Click picture below for slideshow]

Ngallagunda

Ngallagunda is high on the plateau, up over 500 metres altitude. The community as been well laid out, it has a Catholic school and also has a full-time nurse, Mary Jane, who staffs the clinic. The dentist was also visiting yesterday, so many of the children and adults were up at the school having their teeth examined. In a week of so, those that need care will travel south to Kupingarri where the dentist will haul in a dental chair and do tooth repairs for a few days.

Today is a day of rest, with a swim in the pool, a few home repairs, and getting ready to go to Broome. We will spend next week with the students from Derby, Broome and Port Hedland all in Broome for FARTS (Formative Assessments in Rural Training)- essentially midterm exams that don't count for a grade, and do some workshops for the group of 18 while they are all in one place. I will be teaching about ear health, and pneumatic otoscopy and tympanometry. The RCS has booked us into the pricey Cable Beach Resort. It is tourist season, and hard to find inexpensive accomodation in Broome.

I must admit to feeling a bit whipsawed, going between Aboriginal rural communities and the Western high tech ambiance of Perth and Broome on such a reciprocating schedule. It certainly brings home the disparities in wealth and housing here. Its hard not to feel both guilty and lucky to be able to do this. Vicki and I are both looking forward to the beach, as we have not yet dipped ourselves in the Indian Ocean.

Click the pictures below a "you are there" 360 degree movie of a beautiful Ngallagunda morning. Listen for the birds, and the children on the swings.

Anzac Day in Derby

2007-04-25T21:43:00.000+08:00

We woke up at 4:30 AM to go down to the Civic Center for the Anzac Day Dawn Ceremony. Today is a national holiday in Australia and New Zealand, commemorating the landing at Gallipoli in the First World War, where over 10,000 Australia/New Zealand Corps (ANZAC) men died in a futile attempt to invade Turkey.

Here in Derby, the Police, Fire Brigade, Scouts and some veterans made a predawn parade through the streets to the War Memorial on the lawn in front of the Shire Offices. About 200 people stood in the darkness for the service, which included prayers, a short address, songs, the national anthems of both countries, and finally the Final Post, the Anzac prayer, and closing with Reveille.

Most of the crowd were European descendants, although there were a scattering of Aboriginal people present. After attending Anzac Services 2 years ago in New Zealand, we had been curious to see how Anzac Day was celebrated in the Kimberly, in this land where the indigenous people do not speak the name of the dead or look at their pictures. The SBS News tonite had coverage of the first-ever Aboriginal Anzac Day Parade in Sydney. My medical students were not aware that any Aboriginal people had served at Gallipoli, but the truth is that Aboriginal people have served Australia since the Boer Wars. It is hard to tell exact numbers, because they were required to deny their Aboriginality by passing as white, or Pacific Islander or Maori in order to join up. But current estimates place about 500 Aboriginal soldiers at Gallipoli and over 5000 serving in WW2, with more serving in VietNam, the Solomons, and now in the Middle East.

The Anzac service is meaningful and poignant. We arise at dawn, as traditionally soldiers were awakened before dawn to stand watch, it being the favored time for the enemy to attack. The grey light filters through the boab trees, turning crimson on the horizon, mixing with the words of remembrance, and the haunting sounds of bagpipes, and finally, the call of the bugle.

Winston Peters, the Foreign Minister of New Zealand spoke at Gallipoli today, and we found his words chilling. When talking about the needless loss of ANZAC troops due to failures by their British leaders, he said:

" "They were to learn that courage and natural ability cannot compensate for failures in planning, leadership and logistics."

It is sad to contemplate that 92 years later, similar mistakes have been made in the Middle East by our own country and our Australian and British allies.

Also from Winston Peters' speech:

"After the war, it was Mustafa Kemal Atatürk, a divisional commander at Gallipoli and later founder of the Turkish Republic, who paved the way for reconciliation.

His generous words, which are engraved on the battlefield here and on the memorial to Atatürk back home in Wellington, continue to have resonance for New Zealanders and will never be forgotten.

'In remembering the suffering and loss on both sides, let us commit ourselves to working for a world where differences between nations can be resolved without resort to war.

That is the way that we can best honour the men who fought and died here.' "

The ANZAC Dedication:
For the Fallen
by Laurence Binyon

They shall not grow old,
As we that are left grow old.
Age shall not weary them,
Nor the years condemn.

At the going down of the sun,
And in the morning,
We will remember them.
We will remember them.

Off to Perth for the Weekend

2007-04-20T13:23:00.000+08:00

We are taking a 4500 km jaunt to Perth today for the weekend. I will attend the WACRRM meeting on Men's Health, and Vicki gets to come along. WACRRM pays for the airfare and pricy rooms at the Sheraton, and all I pay for is the tuition. This is a great program WA has to support both rural doctors in their education, and also their families by reducing isolation. (If we had kids there is a family weekend program for them in Perth.) Vicki and I have a list of things we need to purchase, and on Saturday night we will attend the "Star Studded Extravaganza", whatever that is. Hopefully we can show off some of what we've learned at our ballroom dancing classes.

Over Easter I took a bunch of photos of "downtown" Derby. Click on the Goanna below for a tour of the shops and places of note in our metropolis.

Derby Easter 4/2007

It Made A Difference to That One...

2007-04-18T22:15:00.000+08:00

Last month I read Michael Shermer's always excellent column in Scientific American. He was discussing happiness, and makes the point that "happiness is better correlated with satisfaction, than with pleasure. .[because].. Satisfaction is an emotion that captures the uniquely human need to impart meaning to one's activities"

Tuesday morning I called the local CAT office to follow up on the dead bore at Yulumbu. As a result of our phone calls, CAT had a team flown out to the Community on Monday and had the well fixed by early afternoon. I also learned that the local Shire (government) staff have been alerted and are going to work with CAT to be sure that if vital services like power and water are interrupted for repairs, that standby or temporary equipment will be available so remote communities do not have to go without.

Throwing stars makes me happy...

Yulumbu

2007-04-15T11:41:00.000+08:00

A short week here after the 4 day Easter weekend. Many people are still "gone bush" and there is no school for 2 weeks, so the kids are out and about and people have gone visiting. Because it is autumn here (the Ozzies give me a very funny look when I call it "Fall"!) we are giving flu shots like mad. However, with the time of year we are having our first outbreak of respiratory viral illnesses, so I've seen a lot of sick kids and adults this week. A lot of people come in to be "just checked out" and get the Section 100 (free) medicine that an Aboriginal Health Service dispenses. Here in remote Australia, a package of 24 500mg generic paracetamol (equivalent to Tylenol) runs about A$ 5.00. Mums particularly have concerns about small children with fevers, as well they should, given the historically high death rate from sepsis for Aboriginal children. And then there are very high rates of ear infection, with it being very common to see ruptured eardrums draining pus in small children. The theory is this is due to high carrier rates of streptococcus bacteria species in the nose and throat, which invade during every viral illness. So we end up prescribing a lot of liquid Amoxycillin antibiotics.

But beyond treating sick people one by one, and doing opportunistic preventive care in a systematic fashion, a rural and remote doctor occasionally needs to become a public health officer.

Friday I was rostered for a remote flight out to the sister communities of Tirralintji and Yulumbu. These communities, about 35 km apart across the Fitzroy river are about 350 km due west of Derby. So we flew out of the Derby Aerodrome around 0730 and landed at Tirralintji first, where the morning was spent giving flu shots and doing some routine checkups. The people at Tirralintji told us that their relatives at Yulumbu had no water- their "bore" (well) went out around April 1st. In fact, two of the teen aged boys had walked across country and swum the crocodile-infested Fitzroy to visit their Tirralintji relatives after this happened. Otherwise the two communities had been cut off from each other completely for the entire Wet season.

We loaded up the plane again and took the 20 minute hop to Yulumbu, which is situated right on the river. Yulumbu has 23 people living in the community, 9 of them are small children and 4 are teenagers. One woman is pregnant. Most of the adults were older and a few very old (for Aboriginal people), with many medical problems. This community has historically found hygiene to be a challenge, but now all of them had now been without running water for 2 weeks. They had been carrying drinking and washing water out of the Fitzroy, which besides having crocodiles, is in the middle of cattle country. And overheated cows are fond of standing in the small streams and pools in the area, and contributing a nice load of manure into the water. It was clear that the people did not have the resources for- and therefore had not been- boiling all their water. The RFDS nurse and I were very concerned to hear that the estimate for repairing the bore pump was "sometime after Anzac Day" (which is April 25th). This would mean almost an entire month without water for this community, and surely this was an outbreak of dysentery just waiting to happen. The cost for a new pump was A$5000 so CAT had recommended that the old pump be pulled and repaired because it would save $2000.

Gail got on the satellite phone and called the Center for Appropriate Technology (CAT) office in Derby who told her that "the contractor was on annual leave for a week and there wasn't much that could be done". So she asked me to call them back. I explained that I was on the ground in the community, that the hygiene situation was terrible, how many small children were around, and that my assessment was this was an urgent health crisis. They told me they were "not aware the situation was so serious for so many people and they would see what they could do". They are on my call back list for Monday morning. We will see what happens.

It just strikes me that there is so little concern about this situation in wider Australia, at a time when the earthquake/tsunami relief for the Solomon Islands is on the news nightly. Australia has donated A$3 million for relief there, but can't find $5000 for a new pump for its own people. And $A5000 is a good deal when you consider the cost for each chartered fortnightly flight to the community was over A$3000. One RFDS evacuation for a dehydrated shocky child will be many times the cost of a pump.

Yulumbu

Click picture above to see the album.

"24/7" is Bad For One's Health

2007-04-09T16:33:00.000+08:00

An amazing thing has happened to me recently. About a month ago I started noticing that I was getting dizzy and lightheaded when standing up suddenly from gardening or stooping over. A quick check of my blood pressure showed it was running about 105/70, so I quit my 12.5 mg of Atenolol. So far the BP is hanging in there at 112-118/80-85 range without medicine.

Now, I have been taking BP medicine for over 14 years. Hypertension runs strongly in my family. When we went to New Zealand 3 years ago, I lost about 10 kg and started walking more, and was able to cut down from my then 50 mg dose to 25 mg. I lost more weight in early 2006 and cut down from 25 mg to 12.5 mg daily. But my weight has now been stable for the last year, I am exercising and eating about the same.

The only explanation I can come up with is that I am sleeping better. I now get at least 8 hours of uninterrupted sleep every single night, usually getting up only one time to the toilet. I did a PubMed search yesterday, which confirms that this may have a significant effect. Last year a huge study on health and nutrition showed that short sleep is associated with hypertension. There have also been Japanese studies of shift workers showing more severity and faster progression of hypertension.

Usually we doctors think of lifestyle changes as weight loss and low salt diet and exercise, and neglect to talk to our patients about adequate sleep. But I am more convinced than ever that our 24/7 world, epitomized by 24 hour Wal-Mart in the U.S. is really bad for cardiovascular health. For me especially, the many phone calls and night calls I have been doing the last almost 30 years of medicine have not been healthy. I am convinced there are also a lot of not-so-obviously-obese people out there who also have sleep apnea and terrible sleep hygiene causing high blood pressure and vascular disease.

And this does not even take into account the other good effects of adequate sleep, which for me include better energy, more upbeat mood and an easier time "living in the moment". So when considering recent events like flying cows and bogged aircraft wheels, I don't feel especially stressed.

One social difference between the U.S. and both New Zealand and Australia are the limited shopping hours. Most everything here closes at 5PM daily, except the groceries which might stay open until 7 pm. This leads to busy noon hour shopping, but most people do not work late shifts or night hours, except for "emergency personnel" and hospital staff.

Certainly this gives me great pause when considering returning to a busy call schedule when we come back to the U.S. It should make all of us think twice about the work schedules of key people in our society: not just doctors and nurses, but aircraft and auto mechanics, police and fire personnel, and even factory workers and the poor guys behind the counter at 7/11 at 1 AM. We all may pay a terrible price for being "24/7".

Easter

2007-04-08T12:31:00.000+08:00

It is Easter break here in Australia, and pretty much everything is shut down for this next two weeks. Good Friday and Easter Monday are national paid holidays. Easter also kicks off the start of 2 weeks of school vacation as it is end of the autumn term. So many people are taking annual leave, and Derby is a bit of a ghost town as many Aboriginal and local people have "gone bush" as they say here. The big activity this weekend is a fishing tournament.

Vicki and I have joined the local pool and have begun swimming laps every day. Yesterday we camped out in the shade of a huge palm on the swimming pool lawn and read and dozed the morning away. Unfortunately the pool is closed except for morning lap swims today and tomorrow.

Despite the stats that say Australia is overwhelmingly Christian, most of the emphasis on Easter has been on chocolate. Australia is said to have the highest per capita consumption of Easter chocolate in the world. At dance class Thursday night, we all had to bring a chocolate egg and put it in a basket for an egg exchange. Cadbury's holds the major market share, although the Lindt dark chocolate bunny has been biting their ears off in recent times. Despite reading about the Easter Bilby (instead of bunnies, which still have a bad rep in Oz), we did not see any in the Kimberly stores. Vicki and I still prefer the Whittaker's (New Zealand) chocolate bars. She likes any of the dark bars, and I could eat an entire block of the milk chocolate/hazelnut at any one go. These are hard to find, but I've tracked them down in Cole's in Broome. Unfortunately, we have been unable to find the Rum Raisin block so far on this trip.

Today Vicki is cooking up lamb for Easter, and a surprise dessert. She quite enjoys cooking I believe, although is having a bit of an adjustment to using the gas oven with its huge yellow flames visible at the back.

She also decorated with an egg tree. This was interesting, as we can only get natural brown hens' eggs here. She uses plain food coloring and tried a bit of wax tracing for designs. They are hung on a fruiting branch from one of our palms around the house. The results are a quite "earthy" egg tree, which is a rather nice effect. I have really enjoyed her creativity and artistic sense. Next to them she has placed our collection of carved and painted boab tree nuts. These are works of art done by local people from Mowanjum, and are quite unique to this area.

For the Easter Gallery, click on the picture below:

Easter Egg Tree

Its a Long Way to Perth When You're Hurt

2007-04-06T17:48:00.000+08:00

Wednesday morning Derby Hospital doctors, and DAHS doctors met with the Royal Flying Doctor Service (RFDS) doctors for our monthly case review. This month we discussed the care and transport of victims of a rollover accident 40 km outside of Derby. The RFDS doctors were particularly interested in talking to us about patient transport from their perspective, so we may better understand what to expect when we call for a "Miracle Flight".

First, let me say again that Western Australia is BIG. It is hard to convey how big it is in words. This map may help (click on it for better resolution):
It is about 2300 Kilometers from Derby to Perth. This is about the same distance as from Chicago to Phoenix, AZ in the U.S. From takeoff in Broome, on a jet, it is a good 2+ hour flight time (and we always have an in-flight movie!)

Now the RFDS does not have jets. (I'll get to that below). They fly twin prop Beechcraft Kingairs or similar planes. The planes are fitted to take one very high needs patients (e.g. unstable, ICU level, ventilated, etc.) or sometimes two stretchers stacked up if both patients are lower care level.

The facts about evacuation from Derby:
• Best in-air time from Derby to Perth is 4.5 hours.
• However, at least ONE refueling takeoff and landing is required.
• With load-up and offload times at each end, minimum evacuation time door to door from Derby Regional Hospital to Perth hospitals is thus 8.5 hours.
• However, if the patient must be transported at "sea level" cabin pressures, this means the pilot must follow the coast, because inland airstrips are over 1000 metres altitude. Low level flights have much lower airspeeds and a longer route. This means up to 3 to 5 refueling stops. These flights may take from 12 to 15 hours.
• BUT the CASA rules (based on sound science) only allow pilots to fly up to 12 hours (14 hours if in the middle of a "mercy flight"), then they need a 12 hour rest break.
• There are only two pilots and two planes at Derby base right now.
• Often they try to coordinate a swap of pilots or planes by having a crew fly up from the south and meet them halfway, usually at Meekathera, which is about 1000 km from Derby. This can only happen if there is another crew available from one of the other RFDS bases.
• Thus, if an evacuation leaves the Kimberly, the doctor and crew are usually gone for 30 hours.
• Right now there are only two RFDS doctors at the Derby base.

In the case of the local rollover accident, there were 7 injured persons. One was very minor, 3 required hospitalization here in Derby, and 3 ultimately required evacuation to Perth for a variety of serious injuries. One of those patients was hemodynamically unstable (i.e. could not maintain blood pressure and circulation well). As you can imagine, this presented a serious triage and transport problem.

The situation would not be so serious if the Kimberly hospitals were not so under-resourced. Despite the name, "Derby Regional Hospital", the designated regional hospital for the area is in Broome, 220 km away. Derby is supposed to have a full-time surgeon on site, and a full-time OB/Gyn. Since I have been here we have had neither, and I understand this is not unusual. The gap has been plugged by hiring locums surgeons who come for 2-3 days every month. Clearly this is OK for booking elective procedures like tubal ligations or circumcisions; but it does nothing to help deal with trauma, which is quite common in the Kimberly. So the local GPs do the best they can. (We do have 2 "GP-OBs" who can do C-sections, assisted by the 2 "GP-anesthetists".) But if someone comes in bleeding internally, there is only one surgeon in the Kimberly, and he is in Broome and quite overworked as you can imagine. With 27,000 people in the West Kimberly, one surgeon is hardly sufficient.

There may be many reasons why there are no surgeons based in this remote town. Lack of amenities, schooling opportunities for kids, family distances, lack of career opportunities for spouses- in fact, all the factors that make it hard for any rural community to attract doctors are all in play here. But one factor is fixable and that is reimbursement. I heard on arrival here that the Hospital lost the opportunity to hire a 1-year locums OB/Gyn over a difference of a few thousand dollars. This type of funding problem has a measurable impact on access to services for the community. The current referral wait time for a colposcopy (follow-up test) for a pap smear showing pre-cancer cells is over 4 months. A general surgeon here in Derby would be quite busy with not only elective surgery, but regular cases of wound care, abscesses, orthopedics and fractures, appendectomies, and could provide some roster coverage for Cesareans, spreading the load out and making it easier to recruit GPs.

Our discussion with RFDS was originally supposed to be a review of the decision to evacuate the unstable patient to Broome first for stabilization, before moving on to Perth. But is developed into a wide-ranging discussion among the doctors about everything from communications problems, to triage, to community barriers to seat belt use (its hard to buckle up when you are riding in an overloaded 1970s vintage ute that barely has seats). We discussed RFDS needing jets, but that is really not the answer. For one thing, it does not solve the pilot rest problems very well. But the bigger problem is that it requires a quantum leap in support staff and services, including technicians who can maintain jet engines. This is a big issue in country with severe labor shortages, and especially a problem in the Kimberly. For example, there is only 1 licensed plumber for Derby and the West Kimberly, and great concern over his upcoming retirement.

I have suggested that we doctors as a group compose a letter to the Minister of Health for Western Australia, expressing our concerns over the lack of manpower in the area hospitals. Certainly the more things we could handle locally, the easier triage and transport would become for RFDS. And this would be a better use of current infrastructure and local funds. (Maintaining a trained surgery support staff costs money no matter how often they are used.) We will see what becomes of it.

For myself, I am going to be very careful not to hit anymore cows.

Today's News: Oxfam Australia Says Aboriginal Health Worst In Developed World

2007-04-02T23:13:00.000+08:00

Figures compiled by Oxfam and the National Aboriginal Community Controlled Health Organisation (NACCHO) show the gap between indigenous and non-indigenous life expectancy in Australia is approximately twenty years compared to seven years' difference in New Zealand, Canada and the US.

There are some success stories in the report- see the example of DAHS on page 16!

And the local press responses:
Abbott admits to 'inadequate' Aboriginal healthcare.

Lolly cash would fix black health

Kandiwal

2007-04-01T12:51:00.000+08:00

Another Wet Season storm rumbled in the distance, the sky darkened ominously, and the smell of imminent rain came on the wind. Looking at the landing gear half buried on the runway, I wished I had thrown a spare set of underwear in my pack, because it looked like we might be here for awhile.

It had been a pretty long week. I'd begun by flying to Perth for the quarterly Medical Coordinators meeting. All 18 site coordinators met with the staff of the Rural Clinical School, and our Head, Campbell Murdoch to review this year's progress to date, plan for upcoming assessments, and deal with concerns and issues. The meetings took two days, but required 4 days of my time, there being no way to get from Derby to Perth either in time for a morning meeting, or on the flip side, home after a 3pm adjournment. The trip involves driving the 220 km from Derby to Perth, then logging 4400 kilometers of air travel from Broome to Perth and back, finally driving back to Derby. My plane home on Wednesday was delayed 4 hours in Perth, so I didn't arrive in Broome until after 4 pm. This is what led to my "Close Encounter of the Bovine Kind", (as Dr. Atkinson called it). And the week was only just begun.

Friday I was due to fly to Kandiwal for a remote clinic, having been scrubbed the week before. This Aboriginal community is 350 Km north of Derby. The indigenous people who originally lived in this are from the Wunambal language group. They lived on the Mitchell Plateau of the Kimberly from time immemorial, but were removed in 1942 (due to fears of Japanese invasion) to the Kunmunya Mission, and finally to the Mowanjum community, located 10 Km outside of Derby. In the 1980s many Aboriginal people moved back from relocation sites to their ancestral lands. Kandiwal is a community that resulted from such a return to the land. There is a nearby airstrip, built by a mining company that has prospecting rights to aluminum deposits in the area. The Aboriginal people have been trying to reclaim their land rights to the entire area for many years, and are concerned about the impacts of proposed mining, tourism, and other activities upon their ancestral home.

We got up early and were at the airport at 0630 AM. The medical flights to Kandiwal are organized by the Royal Flying Doctor Service, which provided our flight nurse, Gail. DAHS provides the Aboriginal Health worker, Shelly and the doctor, me. Gail had all the medical equipment packed. Because the site is so remote, she brings a flying pharmacy, all kinds of bandages, a cold Esky for vaccines and medicines, and all the medical equipment we need including baby and adult scales for weights. The Kandiwal community has only a small number of adults and a large number of kids, so we packed everything needed for child health checks and sick kid visits. Gail has been a flight nurse for a long time, and was completely organized when Shelly and I arrived with the charts. I only had to bring my medical bag and a backpack with lunch. Truly "no worries".

The flight up was smooth, and I spent the time watching the land and sea slip by below. The flight path went north over the Kimberly coast, which has to be one of the last true wildernesses left on Earth. There are no roads into the area, and the tidal rips and whirlpools are said to be the worst on the planet. For an hour and a half we flew over mudflats, mountains, and scrub plateaus lacking any signs of human impact. The geography is unique- some of the oldest rocks on the planet, over 1.3 billion years old, worn and weathered to flats, and nubbins of hills, and remnants of mountains. The community car met us at the field and took us the 5 Km to the community. We spent a busy morning and early afternoon seeing patients and handing out balloons to the kids. Then we packed up, and returned to the airfield, reloaded and taxied to the end of the runway, where the plane suddenly stopped and lurched to the right. Our embarrassed pilot shut down the props and we trooped out to examine the problem. A quick try at pushing the plane out of the mud was futile, and our hosts had already left the airfield. The pilot and I decided that perhaps we could dig a ramp forward out of the hole and drive the plane out of trouble. The field was mostly gravel, and we seemed to have found the one soft spot on the entire runway. He found the nosewheel pullbar, and I walked out into the bush and found a large tree branch, which we used to dig and scrape away the mud in front of the wheel. Then with the plane unloaded of the 3 of us passengers, and the rain minutes away, the pilot revved the engines to full power, released the brake, and slowly, centimeter by centimeter the wheel moved up the ramp and we were free. We piled back into the aircraft, and as we shut the doors, the rain pounded onto the aluminum skin. The pilot gunned the engines, we shot down the runway and out from beneath the storm, and I vowed to at least bring a toothbrush, if not a shovel, on my next remote clinic flight.

For larger, detailed views, click ON THE PICTURES in the blog above. For more photos, click this picture below:

Kandiwal Trip

Examples of what I'm talking about...

2007-03-28T22:13:00.000+08:00

I'm back home in Derby.

The good news: after more than 8 weeks, we finally have a broadband connection at the house. The order went into Telstra for a phone and broadband ADSL connection on January 23. Today it is live, finally, after many phone calls and finally intervention from the DAHS CEO pulling strings. It wouldn't be so bad except in the middle of the whole FUBAR situation the president of Telstra was on the morning news explaining that connecting remote and rural doctors and medical centers in the North of Australia was "their highest priority". Pity the poor bastard at the bottom of the list.

The bad news: driving home tonite, it had just gotton dark and started to rain and I hit a cow. I had already slowed down and suddenly a whole herd was standing out in the road in the rain, and even pumping brakes like mad I couldn't stop or steer around them. I am ok, but poor cow- I had to call the police to go back out the 20km south of Derby to put it out of its misery. Thank god for the "roo catcher" on the front of the Patrol- it is all dented in. Sorry cow. I am never going to hear the end of this from the other Dr Charles at DAHS, who refuses to drive at night, saying, "its just blood on the road" whenever you do. He was right.

Finally, all of the above is of miniscule importance compared to the following article. My problems are trivial. If you wondered why I've taken time and effort to blog about Aboriginal Health and DAHS, then read this:

From: Aboriginal Health System Needs Revamp

Monday Mar 26 19:29 AEST
A report into the death of an elderly Aboriginal patient, who died when he was left alone at a remote airstrip in the Northern Territory, has warned of more tragedies unless urgent action is taken.

The 78-year-old indigenous elder was flown home to Kalkaringi, about 600km south of Darwin, on August 21 last year after being treated at Katherine District Hospital.

The man, who was almost blind and could not walk unaided, had no escort on the chartered flight and there was no one to meet him when he arrived.

The man, whose name can not be used for cultural reasons, was left at the airstrip and his body was found in nearby bushland one week later, after police had abandoned their search.

A month after his death, the NT health department vowed to tighten transfer procedures.

Rather than just faxing the details of patient itineraries to their local clinics, the department said it would now follow up with telephone calls as well.

But an independent investigation into the man's death - commissioned by the Health Department and the Katherine West Health Board - warned on Monday of more deaths under the current system.

"Under existing arrangements, and in the absence of a centralised coordination process around the Patient Travel Scheme (PTS), the potential for further adverse incident ... is considered a high risk," the report said.

Despite the fact there are about 8,000 patient transfers - mostly by plane - to small, remote communities each year, investigators found there was no system of checking to make sure people got home safely.

The report recommended improving communication with remote clinics and insisted pilots never leave a patient alone at a remote airstrip.

"There are gaps in the communication processes around the operation of patient transport to and from the remote communities that need to be addressed as a matter of priority," the report said.

It also recommended the NT government recruit Aboriginal clinical staff at Katherine Hospital and other regional health services.

NT Health Minister Chris Burns welcomed the findings, calling the death "a tragic incident that should never have occurred".

"The system failed this man," he said.

"I am deeply sorry this happened and for the distress caused to the man's family."

At the time of the man's death, his niece Josie Crawshaw-Guy accused the health department of "hard-core, systemic racism".

The death prompted the Australian Medical Association (AMA) to call for a royal commission into the state of Aboriginal healthcare in the territory.

Checks have revealed at least one other case of a bungled patient transfer investigated by the NT coroner in the past three years.

In early November 2001, a 67-year-old man with dementia and severe acidosis and hyperkalemia - too much potassium in the blood - was put on a bus from Darwin hospital to Katherine without an escort.

He was later found by relatives under a tree dressed in his hospital pyjamas near the tourist information centre in Katherine.

His only possession was a bus ticket and the man died in Katherine Hospital from acute renal failure three weeks later.

Recruiting in Perth

2007-03-28T08:08:00.000+08:00

I'm leaving Perth this morning, after being here for 3 days for Medical Coordinator meetings, and a recruitment fair for 4th year students. Monday night each RCS site had a booth a the University Club, where we hosted an information session for next years potential Rural Clinical School recruits. The turnout was great, with over 130 attendees looking at our 62 slots for next year. My Derby Lads sent along a disk of their photos which I played on my laptop at the booth, amongst the travel brochures and giant boab nut Vicki picked for me from the Derby golf course.

Derby Lads Recruiting Photos CLICK ON PICTURE TO SEE ALBUM

The most frequent question from students was, "Does Derby have a nice beach?". Oh well, despite the wine and hor d'oerves served, these are very young people. The flip side, as you can see from my Lads photos, is they are full of energy, which is fun. Check out the picture of the snake- it generated a lot of interest!

I've enjoyed the two days. Its been great to hear about the other sites, and discuss ways we can improve out students's experiences. And it is worth the trip to Perth just to listen to our Head of School, Campbell Murdoch tell his rural practice stories, and watch him schmooze with the students.

DAHS

2007-03-26T23:12:00.000+08:00

Friday we woke up to booming thunder and heavy falls of warm rain. This was a concern as I was rostered to fly out at 0645 AM to Kandiwal. The Derby Aboriginal Health Service partners with Jarrugk Health Services to provide physician clinics in remote communities in the Kimberly. Vicki drove me and one of the 6th year medical students out to the aerodrome in the rain. The tides were exceptionally high, and salt water was lapping out of the mudflats into the marshes at the edges of the runway as we arrived. While we watched the sky clear to the east, word came that the runway in Kandiwal had also received a heavy wetting, and was too muddy to land on that morning. So the mission was scrubbed and rebooked for next Friday. I returned to the office and saw walk-in patients the rest of the day, and prepared for my trip to Perth this week for the quarterly RCS Coordinators meeting.

Both Derby AHS and Jarrugk are Aboriginal Community-Controlled Health Services (ACCHS). The medical care situation for Aboriginal people in the Kimberly is complicated and has taken me awhile to sort out. Aboriginal patients in most of Australia have three choices for healthcare services. First, there is the State health system. All Australians are entitled to medical care through their State hospitals and Community Clinics. If admitted to a State hospital, the care is generally free or very low cost. While there are private hospitals in the major cities like Perth, they generally do not do charity care. If they bill Australia Medicare, the patients are responsible for the difference in private billings, which is usually quite substantial. So private hospitals are an option only for Aboriginal people who have integrated enough into the Western mainstream to acquire private health insurance.

The second option is GP care. All Australians are encouraged to have a GP who provides them care, covered by Australia Medicare (which covers all ages in Australia, not just the elderly.) Unfortunately, there are widespread shortages of GPs in Australia, especially in rural and remote areas, like the Kimberly.

The last option for Aboriginal people is to seek care at an Aboriginal Medical Service (AMS). The first AMS was founded by volunteers in Redfern in 1971. Initially AMS received no government funding. The governments’ argument over the years has been that they provide a perfectly good healthcare system through the State hospitals and clinics, so why should they fund AMS’s? So for a long time the first AMS were funded by donations and staffed by volunteers. Some of the first AMS actually received large grants from charities in Germany who were concerned about the plight of Aboriginal people!

AMS’s recognize several principles. First, they are community-controlled, run by a board of local Aboriginal people. In this way they are much like a local school board or hospital board in the U.S. and may vary in performance depending on local leadership and vision. But given the history of Aboriginal people, community control is essential. One must recognize that these are a people whose lives were controlled, until very recently, by “Protectors” who decided where they could live, who they could marry, and whether or not to take their children away from them. Many Aboriginal people were removed from their homes for leprosy and remanded to Sanitariums, causing great family and social disruption. And with the legacy of discrimination in Australia, every Aboriginal person can tell you stories of family members maltreated in State hospitals, often recently. In fact, for a long time there existed a “separate and unequal” system of “Native Hospitals” run by the States. Even Aboriginal people with money and health insurance were turned away from the general State Hospitals and sent to the Native Hospitals where care was clearly second rate. So you can understand why ownership and control of their own health delivery system is a very big deal.

Another important component of AMS’s is their staffing by local and Aboriginal personnel. DAHS is fortunate to have many well-trained Aboriginal Health Workers (AHWs), as well as nurses. The Health Workers are Aborignal people who have undergone training similar to what an “LPN” or practical nurse would receive. They work in the Clinic as a first point of contact for Aboriginal patients, taking histories and helping triage. They often operate independently from physicians and may follow sets of standing orders to provide patient services. For example, they perform a large number of wound care visits and dressing changes.

Finally, Aboriginal Medical Services have a different focus than the State system. State hospitals and clinics are generally problem-oriented. They see illness, wounds, accidents, alcoholism and its effects as short-term problems to be “treated and streeted” for the most part. While they do provide childhood immunization clinics and some preventive services, this is not their main focus. In contrast, AMS primary purpose is to improve the health of Aboriginal people as measured by less illness and lower death rates. We do this at DAHS by providing opportunistic screening. Every time a patient presents, the front desk prints out a sheet of overdue services from the Ferret computer system. We have a full-time worker who enters results and services rendered into Ferret, keeping it up to date. Thus, when a patient presents with an ear infection, I am likely to be prompted to get a urine sample to test for STDs, renal failure and infection; draw blood to screen for undiagnosed diabetes and check for high cholesterol, and counsel the patient about smoking, alcohol abuse and diet. You can see this expands a 10 minute visit into a 30 minute one, at least. But having the Aboriginal Health Worker to prescreen the patient and begin some of those services helps me get the job done. And frankly, without a health service structured to provide the time, teaching and support for patients, none of these services would get done. The AHWs provide a lot of support and continuity. For me as the physician, they also provide much background information. Because they live in the community, they can often fill me in on what they know about family problems, legal difficulties, terrible housing situations, drug and alcohol problems, etc. AHWs also understand the cultural barriers, such as skin group problems, and “Men's Business” vs “Women’s Business” that can get in the way of providing needed services.

DAHS is really well focused and administered for this mission. I am very pleased to be part of the organization, and it is a great place to learn about Aboriginal health. I saw my first case of leprosy this week, and the staff were really supportive in getting me the materials and help I needed to assess the case. And we also booked the patient into the Women’s Clinic day so we can catch up on her other health needs.

For me the Aboriginal Health part of this job is much more challenging than the student teaching. Lately when considering the overwhelming needs and problems of Aboriginal people, I have been thinking of Loren Eisley's famous story of the dancer on the beach and the starfish, and it keeps me going. “I can help that one.”

Jarlmadangah

2007-03-18T12:46:00.000+08:00

The wind blew the rain horizontally through the slats of the outdoor shower stall. I dropped the soap dish cover and it was gone in a flash, caught in the air jetting past my feet. The flimsy stall walls shook, and the thunder boomed from 360 degrees, echoing back and forth between the high canyon walls of Jarlmadangah community. Lightning broke the pitch blackness with actinic flashes showing branches, leaves and muddy dirt flying across the canyon floor. The rumbles from above shook the earth. I stepped out of the shower and was immediately wetter.

This happened on our 2nd night in Jarlmadangah. My three medical students and our Registrar, Marina, joined with 8 students from Broome and their faculty for a 2 day Aboriginal Health workshop in this small community of about 150 people.

Jarlmadangah is 150 km southwest of Derby. We drove out about 100 km on the Great Northern Highway, and then took a gravel road south. Twenty km down the washboard, an unmarked right turn took us through low scrub inhabited by the occasional group of cows. As we twisted and turned through the scrub, the rusty cliffs of the Grant Range appeared on the horizon, and before we knew it, we were driving between rocky walls into a 30 km long sheltered canyon. We arrived at midday in 100 degree heat in time for a welcome lunch in the small Clinic building.
This consists of two small prefab trailers, with a room built between them serving as a waiting room. The clinic has air-conditioners, but they were laboring. (Also, the community generates its own power. When I worked the Clinic in Jarlmadangah the Monday before, we lost power for 20-30 minute intervals four times during the day. In 20 minutes, a metal trailer becomes an oven in that heat.)

Our hosts were John and Annie Watson, his son Anthony, and the rest of their extended family and community. John and Annie were among the founders of Jarlmadangah. John was born on the Mount Anderson station, where Jarlmadangah is sited. He worked on the station most of his young adult life, only to be fired in the 1970s when the Australian government declared that employers had to pay equal wages to Aboriginal people. This led to mass displacement of people who had been born and lived their entire lives on remote stations, as employers could no longer afford to keep them as employees. Many stations also became economically nonviable as a result of this legislation. The law of unintended consequences prevailed. John and Annie went to live in Looma community, but became unhappy with many aspects of that community, including widespread alcohol use. John had also been active in the Aboriginal land rights movement. After many years, Mount Anderson station was placed in Native Trust and he and Annie founded Jarlmadangah as a drug and alcohol free community. (Despite the Native Trust designation, the people living in Jarlmadangah still do not own or have clear title to their land. This is a concern as there are potential minerals beneath the land, and no guarantee that the government will not displace them again.)

Annie had been trained as a nurse in Perth, and worked for many years in Looma for the state health system. She chafed under rules that kept her in the clinic consulting room 40 hours a week and forbade her from using some of her time to teach and pursue community health and prevention activities. She felt she was just patching up diseases and problems that could have been prevented with community-wide approaches. So when setting up the clinic in Jarlmadangah, she affiliated it with the Derby Aboriginal Health Service (DAHS) which encouraged her to take a community health approach.

We learned these things over the weekend mostly by sitting and talking together. In fact, the main activities of the weekend workshop were simple. We toured the school and parts of the community. The students played extensively with the children. For many hours we sat in a circle in the classroom and listened as John, Annie and Anthony explained their lives and views. I was very proud of all the students for the way to listened generously to the stories and histories of the community. We had meals together outside on the lawns in front of the school. And late Saturday afternoon we all piled into Land Rovers and drove out 15 km across the canyon to climb up the rocks to a sacred waterfall and spring.

I can’t relate all the stories we heard here, but maybe I can give a small example. One of the conversations began with discussing concerns about HIV and sexually transmitted disease. STDs have historically devastated Aboriginal communities, and syphilis is still endemic in the Kimberly. As Anthony discussed community STD prevention activities, the thread suddenly veered off and we went into a discussion of skin groups and long explanation of this traditional Aboriginal concept. Skin groups are a group each person is born into—always different from the skin groups of the parents. Skin groups are intimately bound up into rules in the Aboriginal culture. These rules, among others, famously forbid direct face-to-face conversation between a man and his mother-in-law and her relatives. Intimate, personal information (such as medical concerns) is only to be shared with someone in your own skin group. And the groups also closely govern funeral rules, initiation rites for boys and girls, and even choice of mate. You are not allowed to marry anyone from your same skin group. And each Aboriginal language group and community has variations and different names for the skin groups. The discussion then swerved into a long explanation of funeral rites and customs. They explained the tradition of never speaking a dead person’s name and putting all their photographs away (which explains why many Australian television documentaries begin with a warning that “the following programs include video and photographs of deceased persons”). Finally, after about two hours of wide-ranging storytelling, the conversation came back to STD prevention and the importance of teaching Aboriginal children their culture and heritage as a method of preventing STD spread. This was a fine example of non-Western, circular story-telling structure, and I found it very effective at tying together many concepts. I believe physicians working with Aboriginal people should be aware of this circular structure. The concepts of “chief complaint” and “history of present illness” do not fit neatly into this construction. One huge difference between working in an Aboriginal Health service versus the state health system is that we are given more patient-contact time, and the assistance of Aboriginal Health Workers to encourage patients to tell the stories of their illness, and of how their lives intertwine with their illnesses, in this circular style.

Jarlmadangah is a small community. They declared themselves alcohol and drug-free, and they have a reputation in Derby as “strictly enforcing” that policy, with the implication that physical and public humiliations might be used if necessary. But they have a belief and pride in their culture and a conviction that passing on their heritage is vital to their survival as a people. And, it is clear that the major focus of the community is their school, and its 47 pupils. They are justly proud of what they have built, and their efforts to preserve and pass on their heritage.

Some days I feel very discouraged when I think of how difficult and impossible the problems of Aboriginal healthcare seem, and of the institutional and cultural barriers. But I am glad to have experienced Jarlmadangah. It has helped me not only understand these problems from a different point of view, but also gives me hope and optimism. It serves as an example of that philosophy found in many cultures, but encapsulated in the Jewish proverb: “It is better to light one candle than curse the darkness.” Thanks, Jarlmadangah, for hosting us.

More pictures are here:

Jarlmadangah Feb 07

"Arsenic... Would Have Been A Loving Kindness"

2007-03-10T21:51:00.000+08:00

In many countries we have taken the savage's land from him, and made him our slave, and lashed him every day, and broken his pride, and made death his only friend, and overworked him till he dropped in his tracks; and this we do not care for, because custom has inured us to it; yet a quick death by poison is loving-kindness to it.
-Mark Twain, commenting on a story he was told about an Australian settler giving arsenic to his Aboriginal neighbours, in their Christmas Pudding

The Natives were not used to clothes, and houses, and regular hours, and church, and school, and Sunday-school, and work, and the other misplaced persecutions of civilization, and they pined for their lost home and their wild free life. Too late they repented that they had traded that heaven for this hell. They sat homesick on their alien crags, and day by day gazed out through their tears over the sea with unappeasable longing toward the hazy bulk which was the specter of what had been their paradise; one by one their hearts broke and they died.
Twain, on the fate of the Tasmanian Aboriginal people

For Valentine’s Day Vicki gave me a collection of Mark Twain’s essays about Australia, from the book Following the Equator. He visited this Continent a little over 100 years ago, near the end of his life. Remembered today chiefly as a great humorist and for his novels, he is less remembered for his virulent anti-Slavery views and his opposition against racism in all it forms.

Twain was widely read and an astute observer or character. It is sad therefore to read his essays. Vicki and I find them as true today as they were 100 years ago.

We have been learning about Australian history. The earliest explorers declared Australia “terra nullis”, meaning “no one lives here”, despite there being a population estimated at 250,000 to 1 million.. Aboriginal and Torres Strait people have inhabited Australia for at least the last 45,000 years- the longest inhabitants of their territory of any people currently living on Earth outside of Africa.

Aboriginal people, during their long sojourn, developed a culture and indeed a physiology well adapted to living in this dry, hot land. Their culture is so bound up with the country they live in, that they see themselves as belonging to the land (and not the other way around.) The land gives them everything they need, and in return, they are caretakers of the land. Unfortunately, the clash of cultures resulting from Colonization was disastrous to these people. As detailed in the book Guns, Germs, and Steel, native cultures around the world were at a disadvantage when meeting Western Civilization. The lack of exposure to cows and centuries of East-West trading made them excessively susceptible to diseases like TB and smallpox. And the “high technology” of Europeans, expressed as guns and alcohol, finished the job of decimating the population.

Aboriginal people were therefore viewed as being a “dying race”. Overt racism also gave colonists license to mistreat and virtually enslave the survivors. Aboriginals were not seen as people until the 1970s, and their welfare was administered as part of the government department responsible for the entire flora and fauna of Australia- essentially part of the “Department of Fish and Game”.
To make matters worse, a systematic program of removal of children from Aboriginal families, in an effort to “breed out the black” was carried out in the 20th Century (as you can see in the movie Rabbit-Proof Fence), ending only in the 70s. The effects of the Stolen Generation are still being felt in Aboriginal communities and as one person told us, “this still hurts us”. I have met patients who never knew their parents, being removed from the home and raised in Christian orphanages, cut off from their culture and heritage.

The results, in a nutshell, are that Aboriginal people have some of the poorest health in the developed world. It took us only a few weeks to discover that many of the distinguished “old men” we saw in town were actually much younger than us. They just look 20 years older, due to poor health and very hard lives.

Aboriginal people don’t suffer the diseases of advanced age, like Alzheimer’s very much. This is because they usually don’t live long enough to become demented. The average life expectancy for an Aboriginal man is about 59 years at birth- which is 20 years less than for other Australians. In the Kimberly, Aboriginal people have high rates of death and disability from cardiovascular diseases, diabetes and kidney failure. I have seen many young people- from children to those in their 30s with severe hearing loss and chronic draining ear infections. And overcrowding- read lack of available decent quality housing- leads to high rates of common infections including parasitic diseases, skin infections like impetigo and lice, and severe diarrheal illness in infants and small children.

This is all over a background of disadvantages in education, employment and a “fair go” at life as they say here. Consider these facts:
• Indigenous unemployment is almost five times the national average. A January 2004 study by the Australian National University's Centre for Aboriginal Economic Policy Research found that labour market discrimination is more likely to manifest in an inability of Indigenous individuals to secure a job, rather than in being paid low wages
• Aboriginal households on average earn about $200 less per week than non-Aboriginal households.
• Aboriginal people are half as likely to have completed schooling and only about 40% are employed.
• Indigenous people are 14 times more likely to be imprisoned than non-indigenous Australians
• Indigenous people also suffer higher rates of crime. A 2001 study in New South Wales found that Aborigines are 5.5 times more likely to suffer domestic violence, 3.4 times more likely to suffer assault, 2.8 times more likely to suffer sexual assault, and 2.5 times more likely to be murdered.
• The Aboriginal infant mortality rate is 2.5 times that of the rest of Australia, with the rate in the Northern Territory four times the national average. Moreover, the number of babies of low birth weight is double the non-Aboriginal average and actually increased over the late 1990s. The figure is higher than those for Ethiopia, Senegal, Mexico and Indonesia.
• Suicide, which many Aboriginal languages have no word or concept for, has risen from the one of the lowest rates in the world to one of the highest in the last 25 years.

In the face of these medical problems, the Australian government was recently found to be spending A$ 225 per person in the non-Aboriginal population, compared to A$ 74 for each Aboriginal person.

Add to this an attitude toward these problems, as exemplified by our taxi driver, the first day we arrived in Australia. He asked why we were here and when told our plans to go to Derby, he commented, “well, they really different and primitive up North- I don’t think they are quite human, you know?” And he was serious and unfortunately not alone in this belief.

As an American, partly a descendant from Colonial ancestors, I am certainly not claiming any moral high ground when looking at these problems. This is just the milieu I am working in. And not everyone is ignoring the problem. More than 30 of Australia's key medical and social welfare groups say Indigenous Australians are dying because of a lack of political will and action and have called on the government to change course. I write about it as background for the next topics I will write about: Jarlmadangah, and DAHS.

Cyclone Season

2007-03-09T21:01:00.000+08:00

Its been raining the last 3 days. We had 16 mm of Rain since 9 AM today. Its high tide, and the mud flats are covered with chocolate water. Mostly we have just had rain and some wind- the brunt of this stuff went south and hit Port Hedland. I have a meeting in Perth on Monday, but we'll see if the planes are flying at all in the next few days... Wore long pants to work today for the first time- it was a chilly morning: 68 degrees on the back porch at 7 AM. Many of the patients are not coming in (they have no cars) so the drivers have been busy picking up people. Vicki's had to knock off her keen gardening and catch up on reading. Overall, good days to take naps, as one of the Aboriginal Health Workers said yesterday.

Last night we enjoyed the second week of dance classes, free and sponsored by the Shire of Derby. These are in the small community center and great fun. About 24 people attended, maybe 1/3 of them "unattached" and just there for fun; in age from ~12 to 50's. We danced the Barn Dance, slow dance, salsa and mambo, and some the teacher made up. Most of the dances are "progressive", meaning one dances one cycle and then the woman moves around the circle to the next guy. Great fun.

Michael Posted This to the UWA Listserve...

2007-02-28T15:27:00.000+08:00

Hello from the Derby Mob.
Seeing as everyone else was showing of their newspaper articles we thought we would join in and show you our FRONTPAGE Article. Thats right FRONTPAGE. Now before you say Derby must suck because they put us on the FRONTPAGE, it doesn't we are just super cool. And when your super cool in a town thats so hot you are a FRONTPAGE news item.

Derby Lads Signing Off.

Medical Students To Spend a Year in Derby

Three medical students from the University of Western Australia have arrived in Derby to begin working at the Regional Hospital and Derby Aboriginal Health Services (DAHS). Fifth-year medical students Owen Milne, Michael Patton, and James Stacey will spend 2007 building their clinical skills as part of the University’s Rural Clinical School (RCS).

Dr. Charles Zelnick, their Site Coordinator is also newly arrived in Derby. He will work half-time as a consulting doctor at DAHS in addition to supervising the new students. Dr. Zelnick arrived in Derby two weeks before the students. One of those weeks was spent in Kalgoorlie where he and the 62 students in the RCS underwent Orientation, including a mock disaster exercise which involved retrieving car crash and plane crash “victims”.

The Rural Clinical School is funded as part of the Governments $830 million Rural Health Strategy. The aim of the School is to get students out of the city for a large portion of their training, in hopes they learn the attractions of country practice, and reduce the shortage of rural doctors. Derby students will spend time on the hospital wards in Paediatrics, Maternity and Women’s Health, as well as General Practice. They will see patients with local doctors both in the hospital and at DAHS. A strong focus of their training will be to work with Aboriginal Health Workers and get out into the community to learn about resources they may use to help local people. The Derby students will participate in teleconferences from Perth, and will have some joint workshops with their 8 fellow RCS students who are based in Broome.

The three young men all grew up in the Perth area, but have been keen to come to the Kimberly to broaden their experience. Their supervisor, Dr. Zelnick, is from the United States, where he worked as a country doctor for ten years in rural Washington State. “It was a small town of 3000 people, mostly farmers.” he said. “But the surrounding hills were covered with sagebrush, and we often heard coyotes howling at night.” Zelnick spent the last 14 years teaching postgraduate doctors and medical students in Cedar Rapids in the state of Iowa. After working a 6 month sabbatical in Winton, New Zealand in 2004, he was recruited to work in Derby by the Head of the RCS, Professor Murdoch, who had also worked in Winton. He is accompanied by his wife, Vicki.

“Everyone in Derby has been so welcoming and friendly”, Zelnick said. “We are sure the students will have a great experience here, and hope some will eventually return to settle in the Kimberly.”

How hot is it?

2007-02-27T11:57:00.000+08:00

Stranger in a Strange Land

2007-02-25T21:35:00.000+08:00

Simplicity is making the journey of this life with just baggage enough. –Charles Dudley Warner

We’ve been in Australia for 6 weeks now, and although we are “settling in”, it remains an adjustment.

Things have been quite busy for me at work. My 3 students have arrived and begun their training. Their basic didactic teaching is familiar, but I don’t know the local doctors, the hospital routines, or community resources, not to mention Australian medicine and customs. So it’s been a steep learning curve for all of us, but we have been making steady progress.

Also, two weeks ago Vicki and I moved into a different house. DAHS gave us the opportunity to move to another house a block away. This home features a huge tropical garden. Besides the wonderful smell of frangipani trees, there are two water ponds, bamboo, and coconut, papaya, and banana trees. The house has a wonderful long veranda in the back, and a very shady yard. Vicki and I have spent quite a bit of time painting two rooms, cleaning and tidying up and moving into our new quarters. These quarters are certainly some of the best in town, certainly a lot better than what the majority of my patients live in, and we feel very lucky. I have been doing a lot of home repairs because of the labor shortage in the area- e.g. there is only one licensed plumber for the entire Kimberly.

The weather remains very hot, and the townspeople say it’s the “driest Wet” season they remember. We’ve had some amazing thunderstorms, but little water. Daily temperatures have been above or close to 100 F. with a lot of humidity. So we’ve been walking early in the morning, getting out at 6 AM and watching the sunrise. We have several favorite routes; out to the Wharf and back, around the racetrack at the golf course, and a route along the edge of the mudflats where we routinely see wallabies and parrots, which we’ve enjoyed a lot.

On Valentines Day Vicki made us a lamb dinner, and I made her a plumeria lei like she used to have in her Hawaiian childhood.

But behind all this is our adjustment to rural Australian and Aboriginal life here in the far north. When unpacking, Vicki found the quote above, which speaks volumes. Besides downsizing and leaving possessions behind, I am making a conscious effort to leave the baggage of my preconceived notions behind. I am not really ready to write about culture and community here in Derby- it may be a long time before I can do that well and fairly. We just haven’t been here long enough. I don’t know the hidden rules and expectations. So while I can’t help but have a lot of impressions, I try to let them go. It is what it is. I can only say that I am glad for the support I get from my co-workers at DAHS and the RCS as the patients have a lot of medical problems and are very challenging.

Tomorrow morning I go out on my first “remote clinic”, driving into the outback to a community called Jarmadangah. My students and Vicki and I join the RCS students from Broome next weekend for an Aboriginal Culture workshop in this same community, so I am looking forward to this trip.

If you’d like a taste of Aboriginal culture, I highly recommend the movie “Ten Canoes” which is out on DVD here in Australia. We watched this wonderful film this weekend. The people are from Arnhem Land, 1000 km from here, but the red dirt, the hunting for bush tucker, and the people’s approach to life seem similar to this area in many ways.

For most recent photos, go here:

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It's Different in Derby

2007-02-05T20:50:00.000+08:00

We've been in Derby for a little over 3 weeks now, minus the week we spent in Orientation in Kalgoorlie. Although it’s only been a short time, so much has happened that it feels a lot longer. My students arrived a week ago Monday, and we welcomed them with a steak barbeque, with salad, and chips from the local Takeaway. We finished with American-style banana splits, as novel to them as the daily cricket matches on the telly are to us. They have settled in well to their studies at the hospital and DAHS (Derby Aboriginal Health Service). We have been staying in a nice house provided by DAHS, but have been given the opportunity to upgrade to another place with a wonderful garden and beautiful veranda, just around the corner. Vicki and I spent this last weekend painting the kitchen and master bedroom: white of course...

But despite all this, I know we are still in the first impressions stage. And my first impression of Derby and the Kimberly, is that everything is INTENSE. When we first stepped off the plane from the South (twice in two weeks!) the heat hit us like a sauna. The sunlight is piercingly bright- we have to wear our “sunnies” everywhere. We walk early in the morning to avoid the baking 38-40 C. heat. From complete darkness, in minutes the sun slams over the horizon. At that moment, the quiet is suddenly broken by a cacophony of birdsong and the flutter of rainbow wings in the trees. The earth itself is extreme, this ancient landscape thrusting upwards in rust brick termite mounds. Boab trees have immensely thick trunks and dark green leaves. Ghost gums, white barked, provide contrast. Bugs are huge, a grasshopper, larger than my hand, dive-bombing me out of a frangipani; giant beetles appear and walk across the floor of my Consulting Room. The tides fluctuate 10 meters, boiling up the sound in standing waves of caramel-colored water. A ship riding in to the wharf on the tide grows from a small dot on the horizon to running up on the beach in 15 minutes. The sky is huge. Cloud bases float at high altitude and build into the stratosphere by late afternoon. Wind blows off the King Sound strongly enough to push land-sailors to high speeds on a mud flat Sunday afternoon. Some days thunder rumbles like an earthquake, shaking the building before unleashing a twenty minute torrential downpour. Immediately after soaking the soil, the sun returns to steam the town, and vapors rise from the puddles. At the end of the day, 4 layers of clouds take it in turns to glow golden crimson in an 180 degree sunset. As if that was not enough, the full moon bangs over the horizon, huge, orange and upside down. INTENSE.

You can see it here:

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