A Doctor's Dream

by Buddhi Lokuge

  And most importantly, he said, the gearbox between the motor and the drum was steel, not plastic like in the electronic brands. Even a load of several blankets didn’t cause the Westinghouse too many problems. Instead of the motor or gearbox failing, there was a very simple, cheap and easy to replace clutch. It was a safety feature that he could teach someone to repair in ten minutes. The other two parts that would fail eventually were the pump and the timer, which were also plug in, plug out parts. You did not have to be an electrician.

  Because the Westinghouses lasted so long there was a good spare parts market. It was a machine built to last and built for punishment. It was made in the United States. It was more expensive, but given the lifespan and ease of service, it was really the only option in the long term. It was the only machine he looked for in the tip, the only machine he serviced and the only one worth bringing to the region for our program.

  I was sold. To find a great solution to the washing machine dilemma all I had needed was to find someone who had lived in this environment most of their lives, and had an unusual obsession for manual Westinghouse washing machines.

  Next Bruce took out the Yellow Pages and called the Westinghouse head office in Melbourne to speak to a sales clerk. He was as keen as I was to get this project up and running. But a few minutes later he put down the phone and shook his head.

  ‘They don’t make the manual model anymore. Nowhere in the world. And production has moved to China.’

  17

  ISLAND HOPPING

  The first two days at Umbakumba on Groote Eylandt started awkwardly. I was there to do simple skin checks; the nurses had to perform ear, eye, blood and urine checks. When the children arrived for school screening, they moved efficiently between stations but it seemed like I was always standing in the way.

  When I spoke to Tanya that night I noted dully that I had been asked to go to the Milingimbi healthy skin day the following week so I would only be home for the weekend. And I would have to spend those two days preparing for the next steering committee meeting.

  ‘Why don’t you change the meetings to every six months?’ she suggested.

  Lawrence had been pushing for more reporting but as it was I was spending every waking moment on the scabies program, including keeping Sam in the loop with painstaking detail, often several times a week. Changes happened slowly so extra reporting for the steering committee would only replicate the reports I was already producing and I had been clear that I would begin by implementing existing treatment protocols better, not by trialling new ones so we were not waiting on new protocols.

  I had convened a medical working group of experts from Northern Territory Health and Miwatj in order to update the clinical guide for scabies and crusted scabies treatment protocols, with the aim—in part—of introducing ivermectin. This update would become part of the Central Australian Rural Practitioners Association remote medical practitioner’s Standard Treatment Manual but that, too, was a long-term project that could take months or even years.

  Tanya reminded me that despite decades of work on scabies nobody had eliminated scabies as a public health issue in remote communities. So since it had only been a couple of months since we had decided to create our own program with One Disease she thought I could afford to take the pressure off myself to have solved the problem already.

  Some of the scabies programs that had been run previously may have worked had they not ended before they had the chance to look at ways to adapt and deliver better outcomes. Most of them had no room to pivot and become more relevant to the context. They had an action focus, imposing by doing, rather than a reflection focus, learning by doing. A reflective focus means admitting that we don’t know everything and we may make mistakes but we are committed to learning. We brought a reflective focus to the table but it meant we were swimming against a riptide. A humble program run by people determined to learn how to do something truly valuable for communities in the area of scabies, even if that meant taking ten years to treat ten people, was much harder to pitch to donors. If I couldn’t provide Sam with enough impressive-looking ‘evidence’ to keep the steering committee supportive and convince donors to get onboard for the long term the program would fail, just like those before it.

  When I finally spoke, my tone was lifeless.

  ‘Promise me you’ll never let me take on something like this again. And let’s focus on just getting ourselves out of this mess.’

  •

  When I arrived on the island of Milingimbi the following week, Elizabeth had already put her camp of extended family houses on notice. There had been a flurry of activity the day before, so houses and yards were sparkling and the kids were shining from head to toe.

  Strong women. Elders. Traditional owners. When they speak, others listen. What makes them leaders is pretty much the same as for leaders anywhere—a mix of situation, status that comes from being born into the right family in the right place at the right time, and personal character. Every culture admires its version of leadership skills, the ability to connect people, to read situations, and to network. And a touch of fearlessness is important.

  Elizabeth of Milingimbi was a leader. Completely at ease no matter whose company she kept, she was always calm and utterly herself. And she was fearless.

  Being averse to exertion she had taken to technology like a duck to water and worked her half-broken Nokia like a Wall Street banker. Although she was busy, Elizabeth had suddenly decided that another healthy skin day was in order for Milingimbi and had again suggested that Oliver should organise a visit for some of the health workers from surrounding communities to see how things were run.

  By the time I arrived, a team of Yolngu men and women from neighbouring communities, including Talisha from Gurrumu, had assembled in Milingimbi.

  Elizabeth took over and together we worked our way slowly around the community. Even with Elizabeth’s inimitable force it was sometimes difficult to build a critical mass. It must have taken incredible fortitude for Talisha to organise and follow through with a healthy skin week all of her own.

  Elizabeth pulled out her megaphone and sat in a common area on a large woven mat with the scabies storyboard and a flip chart beside her. Here there were groups of houses without fences that formed a kind of community within the community, and Elizabeth was able to gather quite an audience for her scabies story. Soon an animated discussion began and I saw, for the first time, what an ideal healthy skin day looked like.

  But in other parts of Milingimbi it was much harder to draw an audience. Elizabeth pushed gently but if there was little engagement she soon moved on.

  Healthy skin days had run since early 2000, and Elizabeth had re-invigorated them in recent years. The community was familiar with the work. Though there was much more engagement and interest than I had seen at Yalambra previously, I was not sure how many people were likely to use the creams—and this was the best-case scenario. This was what a healthy skin day looked like with a strong, fearless leader and lots of support. Elizabeth bellowed for attention and my mind returned to the present. I was here to learn, not to ruminate.

  •

  Tanya and the children left the town of Nhulunbuy for the first time since they had arrived more than two months earlier after they dropped me at the airport for my flight to Milingimbi. Tanya longed to bank over the azure sea, land on a dirt strip and then fly on to the next place but her licence was no longer current and a few short flights between communities would cost about the same amount as a return airfare to Paris. She watched my small plane taxi and take off, and gazed after it until the kids grew bored.

  As they drove past the turn-off to Katherine, which was some ten hours and three creek crossings away by dirt road, she slowed the Troopy. They would have run out of diesel before they reached the next service station and they had no food or camping equipment but it was the perfect time of year to cross the Goyder and she hadn’t realised how much she wanted to get out of the strange bubble that was Nhulun
buy. Instead she turned right, towards Yirrkala, to visit a real Yolngu community for the first time.

  What she found there were more permanent and appropriately designed houses, with breeze-ways and verandahs and louvre windows. And tents pitched on the verandahs for families that couldn’t fit inside the overflowing houses. There was a modern-looking school with a fluctuating attendance of between 100 and 600 students, staffed mostly by balandas, several offices all staffed mostly by balandas, an even more expensive IGA than the Nhulunbuy store with an eclectic mix of items ranging from tents to strawberries and run by balandas, and there was an art gallery full of expensive, exquisite art, run by balandas.

  The children quickly tired of the artwork and sat in the gallery’s theatre to watch four animated Yolngu stories play on repeat while Tanya walked down the stairs to look at the over three-metre tall Yirrkala church panels.

  When the Methodist mission in Yirrkala decided to build a new church, Narritjin Maymuru thought that Yolngu art should be right up there beside the altar. The large masonite panels were begun in 1962 and were the result of some extraordinarily sophisticated negotiations.

  Sixteen artists came together to map the creation stories of Yolngu country and the Yolngu claims and rights to land at a time when outsider interest in the area was increasing. Bauxite had been discovered and it was a good time to remind both outsiders and each other of the sacred heritage of the Yolngu. As much as anything, perhaps, it was also a time to formalise and prepare diplomatic relations between the clans. The age-old rules governing interactions and travel had been tested in new ways since the missions had thrown together large groups of people from clans that would never have had to live together under normal circumstances.

  Those in touch with the outside world had guessed that the Yolngu might need to learn how to form a coalition. The church panels were a diplomatic coup, representing layers and layers of complex information that had never been gathered together in one place before. Deciding what could be displayed on the panels must have taken thousands of hours of determined negotiation and they are impossible to fully comprehend for anybody without a deep understanding of the Yolngu kinship system.

  The message was not lost on Kim Beazley Snr, who suggested a bark petition to protest the proposed mining operations. The bark petition was followed by the Supreme Court Gove Land Rights case Milirrpum v Nabalco Pty Ltd (1971) 17 FLR 141, but the bauxite mine went ahead. The Yirrkala elders then launched another court case in an attempt to keep alcohol off their land but once again they lost and the Walkabout Hotel was allowed to sell alcohol in Nhulunbuy.

  Many Yolngu literally walked out of the area in disgust. The Gove land leased for mining was deserted almost overnight by Yolngu, who returned to their homelands where they could protect their children from destructive influences. In 1976 the Land Rights Act recognised the Yolngu as the legal owners of east Arnhem Land and, as it is private land, outsiders require permission to enter. But the mining lease was excluded from the provisions of the Act and the bulldozers continue to dig up the earth and the grog shops continue to operate.

  Tanya drove back to Nhulunbuy deep in thought. She stopped at the supermarket and waited in the shortest line, eager to get home to put our youngest to bed. In front of her was one Yolngu woman with a trolley full of soft drink cans, chips and two-minute noodles. Perishable food was of little use since it was unlikely to even make the hot car trip back to a homeland several hours away, let alone survive without refrigeration in the days beyond.

  Once the woman had emptied her trolley she reached behind Tanya without looking up, and pulled the next trolley in line towards her. A young woman pushed it forward and then joined some friends behind her with another full trolley. As the cashier worked her way steadily through a neverending collection of groceries, the young woman sent her friends off for still more. Tanya moved to a long line of balanda shoppers, each with just one trolley.

  •

  By the time I returned from Milingimbi I had once again decided that there was no point in us being in Arnhem Land. Real scabies control required real systemic changes, not medical fixes.

  ‘Can you do me a favour?’ Tanya asked. ‘Can we talk about it after you come back from camping?’

  I had a bunch of friends from university days who went camping each year. It took us several hours of driving into the mountains on dirt roads before we would leave our cars and tote all our supplies in with backpacks, crossing freezing rivers and trekking several hours to a remote campsite. This annual ritual was all just an elaborate excuse to step out of our daily lives and catch up: mountain men for a week or two.

  ‘I can’t go this year. I’d have to fly out in two days and I just have too much to do, especially if I am going to leave the program.’

  When Tanya spoke her tone was measured. ‘As much as I have any right to insist you do anything, I would like to insist that you go on your camping trip as planned.’

  It was very rare for her to be authoritative about my affairs. I didn’t reply, wondering how I could justify being away for two weeks. We hadn’t heard much more about the operations manager job from Oliver. He was still waiting to find out about the Yirrkala position and I had given up on that sliver of hope. We had been speaking to a number of other prospective managers but so far nothing looked hopeful.

  When the day of departure dawned I woke up and began to pack mechanically.

  The flight was that evening and, since I hadn’t cancelled it, it was easier to simply catch the plane than to make a decision. I rifled through the house for what little camping gear we had brought up and decanted powdered milk, tea and sugar into ziplock bags. By lunchtime I was showing the children how I put a garbage bag into my backpack and then packed my clothes inside it so that if I fell into the river, or got rained on, my clothes would stay dry. Soon they were giggling as I pretended to be a clever Samba deer, sniffing out the hunters before they got close.

  When the bus arrived to take me to the airport that evening I turned back to give one last wave to my family and mouthed ‘thank you’ to Tanya. She nodded and waved me off, relieved to hand me over to my old friends for a fortnight.

  Half an hour later she saw my number come up on her phone.

  ‘Oliver is thinking of taking the job. Sam must have worked his charms on him!’

  Tanya grinned. ‘Offer him our house, car, whatever he needs.’

  Oliver was in a Department of Health house and there was a good chance he would lose his accommodation if he changed jobs, and with a pregnant wife and a young child he was not in a position to deal with uncertainty.

  ‘Really? Can I?’

  ‘Of course. Whatever it takes.’ Tanya didn’t think Oliver would be thrilled to move into our house; his house was built slightly more appropriately for the climate and had a little covered outdoor space, as well as a lawn and a shady mango tree. But at least it meant they had options.

  ‘Also I told Sam that I was struggling and he has agreed that the Sydney team will take all the admin and logistics off me.’ The new CEO of One Disease, Jennifer McClaren, was on the job and she was a quick study. There would be no more writing up minutes and job descriptions and monthly updates as well as trying to get the fieldwork up and running.

  ‘Better go. The flight is boarding. Love you!’ I turned my phone off and shoved it deep into my bag. There was no reception in the high country; no way I could check emails, send reports, front up to a steering committee or organise anything whatsoever.

  Tanya had high hopes for the camping trip. She loved my old mates: a tough Wagga wheat farmer with an artsy intellectual side; a sensitive electrician; an accident-prone pharmacist; a founder of a London private equity firm; and the guru, a passionate teacher and farmer from the Hunter Valley in New South Wales who seemed to have the answer to all of life’s hard questions. Their common sense and compassionate humour would help me see things in perspective. In their company, she knew, I would stop agonising and decide either to pu
ll out or continue. She wasn’t sure which she wished for.

  I dug my phone out first thing the following morning in Sydney and called her again.

  ‘Tan, I’ve got it! All I needed was a bit of quiet time on the plane to think and the penny dropped; it all became so clear. So I’ve rewritten the plan and sent it off to Sam! He can look at it over the next two weeks while I’m away. So it’s done!’

  The operations plan that we’d been trying to fashion since I first asked Tanya to write it from her parents’ house, and that she had rewritten one afternoon in Nhulunbuy, was finally finished. Or the first draft was finished, at least.

  ‘You know what’s funny? It is not too far from what you wrote a few weeks ago.’

  ‘What do you mean?’

  ‘I mean there is a lot more detail now, with the right jargon for donors and medical experts and so on, but the focus—concentrating on the worst-affected houses and crusted scabies—is just the way you imagined it.

  ‘It will win support from gatekeepers like Rhonda and the other clinic managers because we’ll be reducing their workload, and people like Jilory, community leaders, will see the benefit of the program since they are all acutely aware of these particular houses and it will help people realise that healthy skin is possible.

  ‘And, whatever else, kids like Yinarri will get their lives back rather than suffer continuously with the pain and stigma of being covered in scabies and sores.’ I laughed.

  Tanya did not.

  ‘Without even getting out into the field you knew exactly what to do. Very wise, Tan!’

  ‘Actually it was hundreds of hours of listening to you recounting every moment and every thought and every problem of your every single day.’

  ‘We make a great team,’ I said, triumphant.

  •