MTT to MD in 30 years—A human metamorphosis: Dr Roy Scragg, OBE, MD, FRACMA, MPH
Based on an address at Adelaide Annual PNGAA Lunch 11 November 2007
My mind still holds the big picture but many who worked with me tell stories I’ve long forgotten. In Liverpool, England, the other day Peter Pharaoh, who completed the lipiodol/cretinism Jimi study in 1970, reminded me that his first follow up patrol found only 60% of the injected women. I was not satisfied with this proportion and wrote, ‘try again’. On the next patrol, he found 90% but I still wasn’t satisfied, so out he went yet again and got 99%. He, thereby, was able to be the first to prove that iodine deficiency of the mother caused cretinism in the foetus from conception. Pharaoh was one of many who sought and obtained answers to the health problems of PNG and in so doing became a world renowned epidemiologist and the Professor of Tropical Medicine at Liverpool.
In 1947, I first considered working in Arnhem Land and was interviewed by JB Cleland and NB Tindale. However, my contemporaries were going into the army in Japan and medical officer in Papua New Guinea sounded more interesting. Through my church connections, I had heard a lot about PNG and met people who had been evacuated from Port Moresby. I arrived on 19 August 1947 to join the existing 12 doctors for the 21-month tour and worked at Lae then Sohano and in and out of Rabaul relieving Bruce Sinclair.
In this review of my 27 years in PNG, I have defined five eras—Epidemic, War, Curative, Preventive and Independence—and within these eras I have described events in Medical Research, Treatment, Prevention and Education. The expectation of life at birth is a broad measure of the quality of health services, and in each era heading I have shown my estimate of this statistic for the country as a whole during that era.
Epidemic era, 1880-1941: Expectation of life 25 years
The epidemic era started when the first European vessel brought people with diseases new to the country. In April 1880 the first western doctor, Dr Goyon, arrived with the First Marquis de Rays expedition to New Ireland to establish the capital of Nouvelle France which included all PNG and the Solomons. As the Rabaul settlements had no doctor, he was called to do a placental removal for Mrs Danks at the Duke of Yorks Methodist mission. Later, Goyon ignored the Marquis and got settlers away from malaria ridden New Ireland to Australia.
The five doctors with the 1898 Cambridge Anthropological Expedition to the Torres Strait wrote six anthropological treatises but produced only one page in the British Medical Journal. Epidemiology started with the studies by Robert Koch of malaria in 1899 followed by Breinl of dysentery in 1913, Cilento of depopulation in 1920 and in the 1930s by epidemiologists from the Australian Institute of Tropical Medicine, Townsville, and the School of Public Health, Sydney, who studied skin, bowel and venereal diseases.
Just the presence of a doctor was of value to the Europeans but doctors rarely visited villages and for many years all services were limited to the towns. The German doctors trained illiterate village men to be medical tultuls (MTT) but only a Supervising MTT gave arsenical injections (NAB). The first doctor to go into the community was Walter Strong, Chief Medical Officer Papua. He initiated the training of patrolling native medical assistants and in 1934 sent primary school leavers to Sydney for further training.
The Rockefeller hookworm campaign included PNG, and patrols used NAB to treat but not cure yaws but prevention was minimal. The only effective medicines were quinine and NAB until the first sulphonamide, M & B 693, became available in 1939. Eric Wright, as a medical assistant, used it to try to control an influenza epidemic that killed about 12% of the Woitape people in 1939-40.
In 1972, on Yule Island, I unearthed books recording family (Status Animarum), births (Baptizorum) and deaths (Defunctorum) kept by the priests of the Catholic Mission by date starting in 1875 including the Mekeo from 1885. An analysis of these books show deaths exceeding births in most years due to frequent epidemics of measles, whooping cough and influenza reported in the Annual Reports for Papua. Study of records in New Guinea also show a decline in population in Buka from 1915 and a rapid decline in New lreland from 1908.
War era, 1942-1946: Expectation of life 20 years
The war generated research into scrub typhus, malaria and other diseases that could affect the Australian troops. There was little prevention but other sulpha drugs and new anti-malarials became available. The Australian New Guinea Administrative Unit of the army (ANGAU) brought regular medical patrols to villages to balance the privation the people suffered. Education of primary school leavers as native medical assistants, and illiterates as orderlies, continued. Even though there was no fighting, deaths exceeded births in the Mekeo and significantly exceeded births where fighting occurred.
Curative era, 1947-1959: Expectation of life 40 years
1947 estimate: 1,300,000 persons
In 1947 the date of birth and cause of or age at death were rarely known. Total population was an estimate as large tribes were yet to be contacted. Malaria, pneumonia and dysentery were recognised as important causes of disease and death but the causes of the high infant and maternal mortality and of the declining population in some areas were unknown. However there was no high blood pressure, diabetes or obesity.
The 1947 New Guinea Nutrition Survey Expedition lead by Eben Hipsley assessed the impact of the war and the tropical environment on the health and nutrition of five villages. This basic research and later studies were made easier by the compliant sick people who accepted doctors studying them and taking samples.
On a Buka Island patrol in April 1948 I saw 7,000 people. This was of no value to them or to me as I only felt spleens, treated skin conditions and checked for anaemia. Seeking an understanding of individual health, I selected over 1,000 people from a coastal village and an inland group of villages to study in detail. The catechists had wrapped church journals dating from 1915 in banana leaves and hidden them in caves during the war. From these records, the Catholic Mission priests knew everything about everybody and they allowed me to use them to establish the vital records of these communities.
I went on leave in 1949, Joy Hann and I were married and I did the Tropical Medicine course in Sydney in 1950. Posting me to Kavieng, New Ireland, John Gunther suggested I look into the depopulation that Native Affairs and anthropologists considered to be caused by culture contact even though the population of the Tabar Islands had fallen from 8,000 in 1908 to 1437 by 1950.
I patrolled Tigak around Kavieng and the Tabar Islands and compared their population distribution with the Buka samples. The New Ireland populations were aged like Australia in 1941 with few children while those in Buka were young like Australia in 1901 with many children. The crude birth rate of 22 in New Ireland and 57 in Buka and infant mortality rate 71 and 319 respectively defined infertile unions as the cause of the declining population.
77 infertile married couples were selected and investigated as a fertility specialist would have done at that time. The cause of most of the infertility was fallopian tube obstruction due to gonorrhoea: Chlamydia, another cause today, had not been discovered. This study was accepted for the Degree of Doctor of Medicine at the University of Adelaide in 1954. In 1960 in Atlanta I detailed my study to DA Henderson of smallpox fame, he remarked that I was an epidemiologist, a title new to Australia.
From 1947 until 1957 Gunther was director and in his ‘lobectomy’ letter, written after his surgery in 1949, set out the four main divisions of the Public Health Department. In 1954 he detailed a medical training plan including content and projected numbers for education in every health discipline. Posted to Port Moresby as relieving assistant director I edited the first issue of the PNG Medical Journal in 1955. It included the seminal article by Gunther on how malaria was making those it did not kill sick and sabotaging every aspect of development of PNG. In Buka I had seen malaria kill many infants and, in New Ireland, cause enlarged spleens and poor school attendance.
On Christmas Day 1956, Vincent Zigas wrote to Gunther about a new Parkinson’s like disease called Kuru. On 15 February 1957, Gunther called me to his office and told me, “I’ve promised mad Zigas I will go next week and see four patients he has brought in. I am going to Canberra so would you go?” I went to Kainantu on my birthday, 19 February, and saw these patients and was fascinated by Kuru and its possible cause. On the next Monday I went to John’s office and said, “Can Ben take me to the hospital?” He said, “No, I’ll take you” and dropped what he was doing. Before we reached the corner of Spring Garden Road he said, “I’ve been appointed as Assistant Administrator and I’m leaving the Department next Monday (4 March 1957) and you’re to take over.” That was my introduction to my future years guiding the health service. On my third day as director, I had a visit from an American contemporary, Carleton Gajdusek, and infected him with my fascination with Kuru that led him to discover the prion in 1966 and to be awarded the Nobel Prize for Medicine in 1976.
As a 33-year-old with Gunther aged 47, I hoped to work with him for many years. Within the department, Terry Abbott about 43 and Harry White 53, each thought he should have succeeded to the position. I asked Ken Todd 63, the Medical Education Director, why was I selected. He responded, “Well, Roy you’re a strategist”. Robert Burns long ago wrote “Wad some Pow’r the giftie gie us to see oursels as others see us.” The structure John Gunther left gave me the opportunity to help define answers to the disease problems of PNG and develop a service to improve the health of the PNG people then and into the future.
One of the important things I learnt from Gunther was how to ensure that the Department was aggressively resourced. At the midyear review of finance, departments that were unlikely to spend their annual allocation would lose money to those who could. Through this process, the Department of Public Health, with access to Australian medical and nursing personnel and the ability to construct temporary buildings for new hospitals and clinics, received an annual percentage increase in staff and services greater than initially budgeted.
By 1957, appointments had been made of Stan Wigley – Tuberculosis; Douglas Russell – Leprosy; and Wallace Peters – Malaria. Clinical specialists in the essential categories were drawn from the European migrant doctors and by appointments from Australia. Frank Schofield was appointed Assistant Director Medical Research in 1959 and later defined the prevention of neonatal tetanus. Research into Kuru, endemic goitre and cretinism started as well as the continuation of my own studies of depopulation.
In 1947, four aid post orderly schools were established under the Commonwealth Reconstruction Training Scheme providing staff for many new aid posts. By 1960 sixty secondary school students had been sent to Fiji for training in medicine but eventually only 13 graduated. These worked alongside Australian and European doctors making 130 in all. Joan Refshauge initiated infant and maternal welfare and nursing training in 1948 and Eric Wright the first formal nurse training in 1958. Penicillin and improved anti-malarials became available at all health units. Pertussis vaccine prevented whooping cough and was followed by the widespread use of triple antigen. Church family records mentioned earlier and government records show that population in the coastal areas started to rise from 1950 but remained static in the highlands.
Preventative era, 1960-1975: Expectation of life 50 years
1966 Census: 2,150,313 persons
Research by individuals was always encouraged and, by 1975, 15 medical doctorates had been earned by PNG residents and five by Australians for significant contributions to human understanding of various diseases. Many others helped sort out significant health problems. Most of these studies were done by doctors in addition to their role in medical care as the sick always had priority.
Of note, Tim Murrell defined the aetiology, cure and prevention of pigbell, Frank Schofield proved that tetanus vaccine of mothers would prevent neonatal tetanus, Lawrence Malcolm and others elucidated growth and nutrition problems and Kuru studies continued in the research division which became the Institute of Human Biology in 1968. Studies initiated by Terry McCullagh into iodine deficiency diseases confronted Basil Hetzel as a clinical endocrinologist and the pneumonia problem confronted Bob Douglas as a clinical physician. Both doctors had an epiphany when they came to PNG and metamorphosed into epidemiologists to spread the knowledge they gained to the world.
An epidemiological culture had developed within all divisions of the health department where the fertile climate of unstudied diseases and enquiring minds given the opportunity to study and define causation, prevention and cure generated the understanding of many diseases. Young Australians who were infected by this culture and became epidemiologists of note include students Tony McMichael and Fiona Stanley and Stephen Leeder who spent two years as the doctor at the Bayer River Baptist Mission.
Whilst the Health Department was expanding, the mission health services were also expanding into new clinics and hospitals with better contact with the village people. Antibiotics became more available along with effective medication for tuberculosis, malaria, and leprosy. Between 1960 and 1975 the number of doctors working at all levels from specialists through to field doctors increased from 130 to 230.
The malaria eradication programme using teams of spraymen applying insecticides to huts and orderlies distributing anti-malarials was responsible for most of the improvement in national health. The immunisation of infants and children with triple antigen removed the risk of whooping cough epidemics and tetanus. PNG used the Sabin polio vaccine to control an epidemic in the Sepik and later for immunisation of children while the NHMRC of Australia questioned its value. All of the health measures provided meant that more children were surviving. The first national census in 1966 gave an expectation of life at birth of 43.5 years. The coastal populations doubled between 1950 and by 1975 was 2,800,000 increasing at 2.7% per year. Even though family planning advice was actively provided by clinics there was only a limited uptake.
The health programmes applying both the results of research on epidemic and endemic diseases added to the medical advances of the time ensured that students at all school levels attended their studies daily and that the massive national education investment achieved its objective. Disease no longer strangled the education process as it did for 50 years pre-war. In due course healthy people helped Papua New Guinea become an independent nation in 1975.
Secondary school graduates started training as medical officers, dentists, nurses and health extension officers providing national staff at all levels in the health system. In 1960 the first appointments were made to the Papuan Medical College and this intellectual resource expanded when the Australian government was persuaded in 1970 that there should be a degree in medicine. Students entered the UPNG Medical School in 1968 and five graduated in 1972 but only one was from PNG as many first year students could not cope with the course. In 1965, the medical profession organised itself into the Medical Society and took over the PNG Medical Journal.
Independence era, 1975 on: Expectation of life 55 years
1980 Census: 2,978,057 persons
2000 Census: 5,190,786 persons
The Institute of Human Biology became the PNG Institute of Medical Research and continued the research studies including kuru, pneumonia and malaria. The PNG Medical Journal helped maintain the epidemiological culture in the country.
Since independence there have been new medical problems that any government would find difficult to handle. Births still exceed deaths with no change in the high population growth. Population drug resistance, mainly an individual matter in Australia, affected the whole community when the malaria parasite became resistant to anti-malarials and the TB bacillus to all medications. New problems of obesity, diabetes and high blood pressure, rare in 1975, are now major problems affecting personal health. In 1987 the first cases of HIV-AIDS occurred and now thousands are infected and many more affected. The social environment indicates that HIV-AIDS could become as serious as it is in Africa. The Public Health Department and particularly the disease control programmes have problems of distribution of materials, management and finance. The net result today is a minimal fall in fertility, an increase in mortality and a reduction in the expectation of life could occur.
Since 1975, there have been increased numbers of medical graduates each year from the university. Today there are many in private practice but the projections that Gunther made have never been matched. The standard is set high enough to generate specialists in all areas to serve a country of over 6,000,000 inhabitants and to allow PNG graduates to practise in Australia. In PNG the doctor ratio is still about 1 for 10,000 people while the ratio in Australia approximates 1 in 500.
During my last visit to Tabar in 1987, I was completing my village visits at Tugitug on the east coast of Tatau and sent a message ahead that I was coming but only found a man and a dog. We exchanged greetings and I asked, ‘Ol e stop we?’ and he replied ‘O numba wun. Tok e cum long dokta tasol. E no tok long yupela.’ (We were told A doctor was coming. Not THE doctor). In record time the whole village assembled. During this visit the Tabar population was recorded at 2,500 and the people were cognisant of the population growth that followed my regular visits in the 1950s. However the reason for the reversal was not my counting heads but community wide use of penicillin in the Yaws campaign and the continued use of antibiotics for the treatment of episodes of venereal disease.
In my 27 years in PNG there was a massive Australian investment in the widespread provision of health services and the education of children through to matriculation. These were linked to provide a national health service that brought to the country the benefits of the great medical advances of the time. My contribution was matched by many of the multitude who worked with me to bring about this metamorphosis.