Saying Goodbye

It’s more than two years now, since this little man moved into my house as a foster placement.  I had been saying no to possible placements (except the odd brief overnight/weekend respite) for over two years, when I came home from a holiday in New York and was full of life and energy at the time the phone request came in.  They caught me at a weak moment, and I said yes to a one month placement.

On Friday night, 21 January 2011 the knock came at the door.  I opened it to a carer, a social worker, and a tiny little boy (not yet 6yo but the size of a 4yo), who  I recognised from the town pool days earlier.  He caught my eye because he was so fearless in the deep end and I initially thought he was about to drown, when his little head bobbed out of the water, before diving back down again, repeatedly, and I had watched him for a time before realising that despite being in the deep end of the big pool, he was actually fine.

Image

Before the adults and I had time to move inside, the small one took off into the house, through the house, and out of the back door.  We all followed in a hurry as though he might be about to trash the place or something, but he was just exploring.  He ran through the house checking at every doorway, then out into the garden and walked all around the garden attentively checking all the trees and plants.

I took a handover from the young carer who filled me in on what my new charge liked to do, his routine and diet etc.  I remember my heart sinking when he said “He likes to go to the skate park”.  Life was most certainly about to change.  Little did I know how insignificant the Skate Park sacrifice would be in the bigger scheme of things!

When the first month was over, things had settled somewhat.  I was enjoying seeing the positive changes to his behaviour and we were ever-so-slowly developing a connection, so I agreed to continue, and it became an ongoing placement with an unknown end date.

In what is now over two years, we have had one hell of a rollercoaster ride, but one I could never regret and will be with me forever.

From being called a Martha-Pharka regularly during extreme rages in the early months, to his speedy dashes through the house, hiding under the bed and in cupboards, the single tear that rolled down his face as he looked up at me from his pillow on one of our first nights together, screeching when I remotely looked like I might so much as pat him on the head.  We have moved to a settled, contented existence with a routine that doesn’t need to be spoken (but is sometimes negotiated, eg extra chapters of our bedtime book).  I now get hugs whenever I want them, and often when I am not expecting.

I know the family now and his siblings have had sleepovers here.

We had a year of 3x-weekly Jiu Jitsu class, many hours spent hanging out at the Skate Park watching him hone his skills (not such a bad place to hang out, as it turns out!), a trip together to Uluru, a trip together to Tennant Creek, and happy memories galore that we still share with each other regularly.

Recently plans have been set in motion for him to return to his family, and he has been spending most of his time with them, everyday during the holidays plus three nights a week, and one whole week where he didn’t come home to my place at all.

Now it seems that in just over a week he’ll be moving out permanently.

He wants to go, and I am ready to have my child-free life back.  But we’re both starting to be aware that our time is almost up, and so the conversations have started.  Tonight he wanted to know why children have to go into care?  I explained that sometimes families have problems that need the children to be removed to ensure their safety, but that these situations usually aren’t permanent, and most kids who go into foster care usually go back to their family eventually.  He asked why it takes so long, and I explained that some children can go home quickly, while others have to wait much longer, and that it all depends on the individual situation, but that everything is good for him now, and they’ve decided he can go home soon.  “But what if I have to go back into care?”.  I said well I doubt that is going to happen, but if it did, then the social workers will have to make sure you stay safe.  “Well if that happens I’m going to tell them that I want to come back here”.

These words really were the final demonstration to me, that our time together has been a positive experience for him (as it certainly has been for me).

He then settled into bed, but a few moments later appeared in the lounge and hugged me for the longest time.

What a great little man, and what an experience to have been able to connect to him in such a special way.

Foster care is a hard job, but I’ve seen far more reward than I ever imagined it would bring.

Advertisements

Cross Cultural Misperceptions

Writing about Linda earlier, reminded me of something else worth mentioning.

On her first night here, I explained some house rules, including to turn off electrical appliances (lights, air conditioning) when she wasn’t using them, because it costs money.  Later in the evening, she brought up the electricity issue with me, shyly saying “you gotta pay for electricity here?”. Yes. “But you got no power card?”. (The pay-as-you-go system used in most town camp / remote communities, whereby a little card that you buy at the shop slots into the meter and credits the house with so many $ worth of power).

I explained that I don’t have a power card, but every three months the man comes and looks at the box out there, and then they send me a bill. I got my last few bills out to show her. She was visibly surprised, and said “What about the other people along ‘ere , they gotta pay for power too?”. Yes, everyone does, noone gets free power. “Even the rich people?”. Yes, everyone! Did you think we got free power? “Yeah, coz you don’t have power cards, so we all think you got free power…… You pay rent too?”. No, I pay a mortgage, so that means this is my house, but the bank gave me a loan for it, and every pay day I have to pay the bank, and I’ll be paying them until I’m about 65 years old. If I stop paying them, then they might take my house away and sell it to someone else, so every pay day I have to pay them. Again, a big surprised look on her face, and again “What about along ‘ere?”. Well, some of them are paying the bank for loans, and some are paying rent. “And the rich people too?”. Yes, everyone is paying something, either rent or a bank loan, why, did you think we get free houses? “Yeah, we think these nice houses are for free for whitefellas”!

On her last night here, Grandad turned up from around the corner, having shuffled along with his walking frame.  When I answered the door I was greeted with “You never bring that baby to see me!”.  Yes I did, but you weren’t there! “Oh, yeah! Is ‘e ‘ere now?” Yes, come in and see him.

Kinship-wise, this little baby is the old man, and his wife’s, “uncle”. They call him “that little uncle baby”.

Later in the night grandma rang my landline from the community to ask me to call her daughter’s mobile, so I had grandma in one ear on the landline and aunty in the other ear on the mobile, conversing via me. Grandma wanted daughter to call her, so once I got it sorted out I said to grandma okay, she’s ringing you now. “Okay, I’m closing it off now”.

Grandad, Linda and I went out in my car that evening to visit Marcia, who was back in town and had called asking to see the baby before he went home the following day.  We piled into my car, and en route to Marcia’s accommodation, we stopped at the shop as Grandad wanted some cigarettes.

I got out to go in and buy them for him, and as I was paying, Linda appeared, to tell me that Grandad wanted me to buy him a lemon.  There was quite a queue and I’d already paid, so I said no, and we left the shop.

On our way out of the shop, a drunk woman approached Linda and was clearly harrassing her for money.  I interrupted and told her to leave Linda alone, which made her aggressive towards me.  I walked to my car and she followed me, apparently threatening me (in language).  I got into my car and reversed, then waved at Linda, who was being held back by this woman, to jump in the car quickly.  She did, and the woman reached through her open window and punched her!!

The security guard at the shop witnessed this, and we drove off before I rang the police.  They asked us to stay nearby, and within about forty minutes they turned up.  The drunk woman had hung around all this time, continuing to harrass the security guard, who took a photograph of her with his mobile phone, and as soon as the police arrived, she wandered off.  They made no effort to chase her, but seemed to think they’d find her – we were able to show them where she was walking.

Second Stab of Pathos

A couple of weeks ago, 20yo Mary rang from her remote community.  I have known her since she was 11yo and I looked after her now-18yo brother, Maxwell, for a year during a very tumultuous time in their (and consequently my) life.  They and their family consider me a mother.  Which makes me – a nulliparous woman – a grandmother now, to both of their babies!

 

The other grandmother to these babies is Alice, who I have talked about before.  Alice is the surviving sister to Mary and Maxwell’s deceased mother, so she has a strong connection to the children and their babies, but does not have the lifestyle to offer them much help.  When Maxwell’s baby was born, I heard a story that someone had said to Alice “Helen is a grandmother now”, and Alice replied jealously that “She’s not the grandmother – I’m the grandmother!”.  A similar story comes from their stepmother, who also allegedly responded in a smilar way when my name was mentioned.  Given that I have no desire to be anyone’s “grandmother”, I’m happy to relinquish the role to the more rightful owners!

 

Mary’s 4mo baby had to travel to town for a medical appointment that Mary couldn’t attend, so she was ringing me to say that he needed to stay with me.  He was travelling with her “little mother”, the 20yo daughter of her great-aunty.  Oneday I’ll try to explain these kinship systems, but suffice to say that there are many mothers, sisters, sons and grandparents that actually are not mothers/sisters/sons/grandparents in the western way of thinking.

 

Anyway, baby DJ was coming to town with his 20yo grandmother, Linda, and they needed somewhere to stay.  I was happy to have them in my back room.  They had to stay a week because the plane only travels once a week.

 

I had arranged on the Wednesday night, to have some work colleagues over for drinks, and decided that a young woman and a little baby could share that experience with us, without any hassle.

 

On Tuesday lunchtime their plane was due to land, and so I tracked Alice down.  She had been in hospital since the day I dropped her there, per my previous story.  But she was discharged this Tuesday, and so I rang Marcia who had Alice with her.  I said to Marcia I want to bring Alice to the airport with me, to meet DJ.  “Yeah, and me too Helen, I want to meet him too”.  Yes, but there’s not enough room in the car for everyone, so it’ll just be Alice and me, but we can come and see you with him”.  Okay.  She put Alice on the phone, who agreed to come with me.

 

We travelled out to the airport together, and arrived before the plane landed.  When the plane did land, and taxied in towards the fence, I “remembered” that the baby car seat wasn’t set up in the back seat, so I went to sort that out, and by the time I returned, Alice was holding DJ who was bouncing around happily in her arms.  She can always say now, that she was the first one to meet him, and I felt this would go some way to reducing any threat I might pose.  Not that I believe I should pose a threat in any way, but it had been implied!

 

He’s the most gorgeous little baby I think I ever laid eyes on, but of course the proud “grandmother” will think that!

 

We drove him into town and straight to Marcia, who wanted to meet him, then on to the hospital, where he was admitted overnight.  On Wednesday he was discharged and I picked them both up after work and we came home together for six nights.

 

On Wednesday night a knock came at the door at 8pm and it was Nana Alice, slightly intoxicated, wanting a cuddle.  I answered the door holding him, and handed him to her for some cuddles.  Linda came out and was humbugged to give Alice money, but had none and so after a brief conversation and cuddle, Alice left again.

 

On Thursday night my colleagues came over for drinks.  It was the middle of a heatwave, so we were sitting inside, sipping wine, snacking on nibbles, and chatting happily for a number of hours.  Linda and DJ were there with us, and DJ was quietly happy as he moved from one knee to the next sharing our company.

 

At 8pm another knock came at the door.  I answered it to Alice, who was very much worse for wear, her hair a tangled mess, her eyes glazed over.  So I said “Please don’t come around here when you are drunk”.  She replied with “Take me in your car”.  No Alice, I can’t, my friends are here and I can’t drive because I’ve had a glass of wine.  In a faux-angry voice she loudly stated “Helen!  You getting DRUNK!”.  No I’m not.  “You getting DRUNK!  You can’t get DRUNK!  You looking after that BABY!”.  I’m not getting drunk, go away.  And I shut the door and sat down again.

 

She didn’t stop though, standing at the door – a few metres from where we were all sitting, and shouting out that I was getting drunk!  So I got up and went out the door, shutting it behind me, and asked her to leave.  She stayed there, shouting at me.  So I walked to the gate and she followed behind me, shouting.  I asked her to leave and she continued shouting.

“Please leave now Alice”

“No!  You getting DRUNK!  You can’t get DRUNK, you gotta look after that baby!”

“Leave now Alice, or I’ll call the police”

“YOU not my SISTER!  I’m calling my LAWYER about you!”

“Okay, you do that, bye!”

My neighbour was over the road swimming, and heard the commotion, so she got out of the pool and came over to ask me was everything okay.  “Yes thanks, but can I borrow your phone?”.  She handed me the phone and I pretended to dial the police and have a conversation with them, saying “Could you please come over to , can you hear that lady shouting?  Yes, that’s Alice Green, can you come and pick her up?  You’ll be here in a couple of minutes?  Okay, thank you, see you soon!”.

She walked out then, and I shut the gate behind me after thanking the neighbour and returning her phone to her.

 

The next day Linda saw Alice near the shop, and told her what had happened.  Alice had little memory of it, and said that she would come to say sorry.  I haven’t seen her yet, but I know that all will be okay between us when we do see each other.

 

Meanwhile, we shut the gate every night after that, and there were no more evening encounters, and DJ went home with Linda last Tuesday, bouncing around in her arms all the way up the tarmac as I farewelled them onto the plane.  I wonder how big he’ll be next time I see him?

Paint Me Black

In recent years I’ve read a lot about being “painted black”, also known as “splitting”.  It means thinking in extremes, and has been described by such people as Anna Freud and Sigmund Freud.

Splitting occurs naturally in childhood, as part of the developmental process where children learn about good vs bad, and how to integrate the entities of positive and negative (eg love vs hate).  The final stage of this developmental process, is the ability to recognise that good and bad can co-exist, ie a person can have good as well as bad qualities, or a relationship can experience combined love as well as hate, conflict as well as friendship, etc.

When this developmental process doesn’t mature well, the person can have trouble in adulthood with integrating good and bad images, so that they will either idealise, or completely devalue a person, depending on whether the focus is on that person’s good qualities, or bad qualities.

This polarised thinking results in people being considered “all good”, or “all bad”, perhaps at different times, or perhaps permanently as they maintain the rage.  Relationships consequently become very unstable.

It’s much more complicated than this brief synopsis, and depending on certain other factors related to the “splitter”, can involve imagined offences which become real to the person, and can help to reinforce a negative split.  You can read more about it here http://www.toddlertime.com/dx/borderline/splitting-countertransference.htm

http://borderlinepersonality.ca/BorderlinePersonalityInsideOut/2009/06/splitting-devaluation-projection-and-lack-of-trust-in-borderline-personality-disorder/

I have been split in a number of different situations as an adult, and have struggled to understand it, hence my reading up about it.  It’s been a real challenge for me at times, as noone likes to be hated, or to find themselves in situations where they go from being considered oneday as “good”, “a friend”, etc, to being rejected, ignored, and treated as a pariah the next.  Being falsely accused of things which never happened also exacerbates the experience to levels that can be hard to come to terms with.

It’s not only hurtful, but can  be extremely confusing, leading to reactions of confusion that may reinforce the negative conclusions being made about you.

Reading about it though, the practice of painting others black when they are perceived to have done you wrong, is not an uncommon phenomenon, as seen in discussions at this forum

http://www.bpdfamily.com/message_board/ .

So if you find yourself painted black, make use of the resources available to you.  Your pain doesn’t need to be experienced alone, and understanding the reasons for someone’s behaviour definitely helps you to process your own reactions to what is happening to / around you.

A Stab of Pathos at the Front Door

I came home this afternoon after a swim and some grocery shopping, and was about to get in the shower when a loud knock came at the door.

 

I went to the door and Alice, Marcia’s “sister” (cousin), tried to come inside.  She is a big drinker, so I stood my ground in the doorway.  She had one foot inside, and the other outside, and I was holding the door as near to closed as I could push it while we debated who was going to win the battle.  She was almost crying and told me she was sick and I need to take her “to clinic”.  I said I can, but I need to get dressed first.  “Let me inside, it’s too hot out here!”.  I said no because I can smell grog, and I don’t let people in here who have been drinking, you’ll have to wait outside.

 

When she realised I wasn’t giving in she relented, and I locked the door behind me and went to have a quick shower.

 

When I was done, I went outside to find her, and she’d laid herself down on the footpath along the side of my house, with her arms under her head acting as a pillow, stretched lengthways up the path.  I walked to my car and said “Okay, let’s go”.

 

Alice looked up at me and said “I’m dying Helen!”.  What?!  “I’m dying!  I’m gonna die tonight, you gonna lose me tonight!”.  No you’re not, come on, jump in the car and I’ll take you to the hospital, you just need to listen to the doctors and do what they tell you and it’ll be okay.  “Nah!  You gonna lose your sister tonight!”.  But as she protested, she stood up and got in the car.

 

We made our way to the Emergency Department, and I helped her through Triage before heading off to sort the rest of my night out.  As I was leaving, I instructed her to follow what the doctors told her, and she said “Yeah, because last time I bin run away, but I don’t wanna die, you know, like my little sister”.  I know, I’ll see you tomorrow.  Okay, bye!

 

I picked up John, my little foster boy, from his Mum, and we came home in time for dinner.  Marcia rang to ask if she can stay here again tonight because “I wanna stay with you, not at Visitor Park, there’s too many people there, I wanna stay with my friend”.  Okay.  She’s no problem, stays out all day and asks for little, really just wants the bed, so it’s no loss to me if she stays.  She was out at one of the hostels visiting family when she rang me.

 

I then had a call from a friend, who was waiting for his partner at a restaurant and she had not turned up, and he believed she was asleep, two doors from here.  So I said I’d go around the corner and wake her.  Once John had his dinner, he jumped on his skateboard and we wandered around the corner to wake her.

 

Once that was done, we continued on down the street with some lamb I’d cooked, to give it to Kevin who is staying at a hostel around the corner from here, because he has to stay permanently in town now, to attend regular renal dialysis.  We stopped in and delivered the lamb and had a chat.  He was hanging out for cigarettes, and I deliberately took no money with me.  But when he heard that Marcia (his step daughter) was in town, he asked if we could call her, so we did.

 

She was sitting in town with some family, and agreed to give him some money.  So John and I walked home and picked up the car, then we drove around the corner to pick up Kevin (who is too weak to walk far), and drove him into town to Marcia.  She came to the car window with a $20 bill, then another family member came over and another $50 was passed across to him.

 

We then drove via Coles for cigarettes, back to the hostel, where our now-happy nicotine addict got out of the car and we came home.

Judging Disadvantage

There’s an excellent book I recently finished reading, called “Mountains Beyond Mountains” by Tracy Kidder.  It’s a biographical account of Dr Paul Farmer, an American doctor who became involved with a poor community in Haiti during his medical training at Harvard.  Since then he has become a Professor at Harvard, a consultant at a Harvard Medical training hospital in Boston, and the creator of Partners in Health, a charitable public health organisation involved in providing quality public health programs to disadvantaged communities.  Particularly, but not exclusively, in Tuberculosis programs.

 

I don’t often recommend books to read, but I would recommend this one to anyone interested in issues of global health and social inequality.

 

There are many things in this book that hit home for me, but one of the strongest was the following, quoted as Dr Paul Farmer talking to a group of prison doctors in Russia when one of them asked him if America is a democracy.  Farmer replied that the rich can always call themselves democratic, because when you have no shortage of resources and opportunities, democracy comes easy, but that this is not so much democracy, as privilege.

 

It hit home to me because I so regularly hear people judging the disadvantaged with the same criteria as they apply to themselves, in their state of privilege.

 

Today I arrived home from a delightful holiday with my lovely mother, on Norfolk Island in the Pacific Ocean, north-east of Auckland in New Zealand.  It’s a tiny island lush with rainforests, clifftop views of the Pacific, restaurants, interesting history and an economy almost entirely reliant on the tourist trade.  We had a lovely week there, and I followed up with New Years Eve celebrations overlooking Sydney Harbour Bridge with a small group of family/friends, sipping champagne and enjoying the very civilised festivities.

 

When I arrived home, I was immediately drawn back into Alice Springs life, with Marcia contacting me asking to help her.  Her 1yo child has been removed from her care after he became progressively ill during last week.  She was in a remote community with him, and took him to the clinic every day from Monday onwards, expressing concerns for him.  When Friday came around, the nurses decided he was sick enough to warrant being transported to hospital, 500km away, and Marcia became extremely irate and aggressive, arguing with her partner (the baby’s father) and destroying some property in the clinic (apparently by slamming a door and kicking a hole in it).

 

I’ve worked as a Paediatric nurse in city hospitals, and I am well aware of the aggression that parents of sick children can express when they feel they have lost control over their child’s situation.  As I am not a parent, I can only imagine the emotions that evoke such reactions, but I can completely appreciate where they come from, without excusing bad behaviour.

 

Due to her aggravation and refusal to cooperate with medical advice for her son, Marcia had him removed from her (and her partner, who was also terribly upset), and he was transported to hospital without a carer, and has gone into state care until they can work out the family situation.

 

So today, a few hours after I flew in on Qantas from Sydney, I picked up Marcia from the bus stop.  She was a forlorn figure sitting on the footpath looking more dejected than I’ve ever seen her, when I pulled up in my car.  She was hungry and alone, and asking to stay at my house.  I resisted at first, and she accepted my resistance, but wanted me to help her find somewhere to “be”, where she wouldn’t be alone.  The services were full though, and as she was hungry I took her to get some food.  While waiting for her order of fried rice to be cooked, I relented, and so she is sleeping here tonight.

 

She ate some food, had a shower, gave me her dirty clothes to put through the wash, and has quietly gone to bed, not before telling me how worried she is for the baby, who has never been away from her before.

 

I mentioned part of this story to someone tonight, and it was greeted with a critical comment, that had I not come home when I did, would she have stayed at my house anyway?  I didn’t argue.  But the reply is “no, she would have found a space under the bridge in the riverbed”.

 

No matter how wrong she has been in her reactions, the fact is that her child has been removed from her, which is not an experience any mother is going to take easily.  She was upset with the clinic staff, that they didn’t recognise the baby’s condition earlier than they did, and I have spoken to her about how difficult it can be to diagnose illness in small children, and the way children can simmer for a while before they become obviously sick.  She understands this now, and has apparently made amends with the clinic staff.

 

None of this even touches on the social circumstances of living in a community where poverty and alcohol fuelled chaos reign.  I know that if I was in Marcia’s position, I would be no different, so I try not to judge her because the closest I get to understanding, is imagining how her life must be.

 

Scabies Control in a Remote Aboriginal Community in the Northern Territory

I wrote this essay in 2001 as part of Master of Public Health & Tropical Medicine; subsequently published in online book: Rural and Remote Environmental Health.  Keeping it here for posterity.

Important factors in achieving and maintaining good health include adequate housing, access to clean water and the removal of refuse and human waste (ABS, 1999). These factors have a direct relationship with the prevalence of skin infections and infestations, including scabies. Conditions of poverty, poor hygiene, overcrowding and malnutrition
all contribute to scabies infestations (Braunstein, 1995). These conditions are identified as common experiences of people in Aboriginal communities throughout Australia (Reid and Trompf, 1991; GWA, 1994). It is not surprising then that scabies infestations are a
common public health concern in Aboriginal communities (Freeman and Rotem, 1999; Carapetis and Currie, 1999; Reid and Trompf, 1991; GWA, 1994).

Scabies is a disease of the skin caused by the Sarcoptes scabiei mite whose natural reservoir is human skin (Schaechter et al., 1993). Scabies infestation not only causes intense inflammation and itching, but by breaching the protective barrier of the skin it can predispose the host to bacterial skin infection and subsequent complications (Schaechter et al., 1993).

Group A streptococcal skin infection is of serious concern in the Aboriginal population. Transmission is closely related to overcrowded living conditions, poor hygiene and scabies infestations (Carapetis and Currie, 1999). The high rate of skin infections allows
Streptococcus to circulate in communities for prolonged periods, leading to the high rates of post streptococcal disease (Territory Health Services, 1997). Post streptococcal glomerulonephritis plays a significant role in the pathogenesis of serious renal disease (Reid and Trompf, 1991), which occurs at a disproportionately high rate in the indigenous population (ABS, 1999). The post streptococcal diseases of acute rheumatic fever and rheumatic heart disease also occur at disproportionately high rates. Aboriginal Australians living in the Top End of the Northern Territory experience the highest published incidence rates in the world of acute rheumatic fever and among the highest
prevalence rates of rheumatic heart disease (Carapetis and Currie, 1999).  It is argued that severe scabies contributes to malnutrition in children due to the increased energy requirements for sores to heal (Territory Health Services, 1997).  There is therefore, a strong need for effective measures to be taken as a matter of urgency in preventing the prevalence of scabies in Aboriginal communities.

Scabies programs have proven effective in improving the prevalence of scabies and related skin infections when appropriate treatment and follow up is implemented (Carapetis et al., 1997). It is also acknowledged that health programs and policies must enlist the active participation and involvement of community members in order to achieve improved health outcomes (Golds et al., 1997).

The community studied consists of 21 houses situated outside Katherine in the Northern Territory. Including the transient population, between 150 and over 200 people live in this community.  It was noticed in May 1999 at both the nearby community based Health Center and the local hospital that frequent presentations of people with scabies from this community were occurring. The Health Center assumed responsibility for addressing this problem as the primary health care provider.

After the scabies epidemic had been identified, the Health Center decided to conduct a scabies program to provide treatment and preventive measures. A small team of health professionals including medical officers, Aboriginal health workers and environmental health officers were coordinated to attend the community and speak with members of the community council about the problem. Council members voiced their concerns and the health team offered options for solutions. The council gave consent for a scabies program to be conducted in the community and a series of dates were agreed upon.

Three requirements for a successful community scabies program are identified by Territory Health Services (1997), being:
· Community support and education in the application of a single community scabies treatment of all residents at the same time.
· A maintenance program involving a simple screen of all children less than 15 years old, three times per year, to check skin for scabies and skin sores.
· An ongoing community education and evaluation of the program.

Community support was obtained by discussing the problem with community leaders who were able to appropriately inform the rest of the community and provide consent for the program to be conducted. The health team then attended the community on a prearranged date to conduct an environmental check, which involved assessment of:
· how many rooms per house
· how many people inhabiting each house
· numbers of pets
· availability of clean water
· availability of adequate waste disposal.

Findings from this assessment found that:
· the average house has two bedrooms, a living area and outdoor undercover area with open fire for cooking;
· between 10 and 15 people may live in each house at any one time;
· between three and five dogs or more per household;
· houses share ablution blocks where clean cold water is available with showers, tubs and pay-to-use washing machines, but hot water was unavailable anywhere in the
community;
· the local Community Development and Employment Program provides a weekly waste disposal service, including collection of waste from large rubbish drums situated around
the community and picking up litter from the grounds;
· a septic sewage system operates in the community, with sewage being pumped to a nearby field where it is treated.

Overcrowding was a clear concern in the community. The District Council was lobbied about this and two more houses were built in an attempt to address the issue. Given the degree of overcrowding, however, two extra houses have not relieved the experience of overcrowding in this community.

The lack of hot water available anywhere in the community was identified as an issue that needed to be addressed fairly urgently. The scabies program was conducted in late July, being the middle of the Dry Season when nights can become quite cool in this region. As such, it was found that community members were reluctant to shower due to the availability of only cold water. It has been impossible to find out exactly what was done to introduce hot water to this community, but apparently the Environmental Health Officers contacted the District Council who provided facilities for hot water to be installed as a matter of urgency.

Once the community survey had been conducted and issues highlighted, the health team prepared to conduct a week-long scabies treatment program in the community.  Aboriginal Health Workers attended in-house education sessions to ensure appropriate understanding of the issues and confidence in diagnosing scabies. The team gathered resources for community education, including posters depicting basic hygiene practices and pet care. As the community does not have a community center, these were displayed
in the back of the vehicles from which workers were based throughout the program.

Because of the genetic distinction between human and dog scabies, control programs for human scabies do not require resources directed against zoonotic infection from dogs (Walton et al., 1999). Human scabies is mainly transmitted by body contact and washing
of linen and clothes has been found to be of minimal benefit in a scabies control program (Lloyd, 1998). However, in order to improve dog health and promote personal hygiene practices, these two issues were both included in the control program. Health Workers reinforced to households that a restriction of two to three animals per house was required for optimum health standards. Dogs were desexed and dewormed, and where it was identified that there were too many dogs or dogs were too unwell, consent was obtained as possible to have them put down. Aboriginal Health Workers taught families about the importance of washing clothes and linen regularly and showering daily to reduce the risk of infection. This was at most minimally successful owing to the difficulty of ‘preaching’ to people in their own homes, particularly when some of the Aboriginal Health Workers were related to community members, and when facilities for hygiene are so basic.

During the screening week at least 15 Aboriginal Health Workers and two Medical Officers attended the community on a daily basis for four days. Reducing the rate of scabies requires treatment of all possible human hosts at the same time (Territory Health Services, 1997, Carapetis et al., 1997). It was intended to screen every person in the community and treat those diagnosed with scabies within the space of these four days. Any person diagnosed with scabies was given permethrin 5% cream (Lyclear) and taught (including demonstration where possible, eg on a young baby) how to apply and when to remove the cream.  Family members living with an infected person were also treated prophylactically.  Anyone diagnosed as having infected scabies sores was administered a single dose of intramuscular benzathine penicillin to treat potential streptococcus.  Other skin problems were documented and treated as appropriate (e.g. ringworm).

By way of addressing other health issues concurrently, the health team implemented other screening during the scabies control program. Children were measured and had their weight, height and head circumference plotted on a Road to Health Chart to assess their growth and development. Hemoglobin levels, blood sugar levels and blood pressures were assessed and deworming antibiotics were administered to everyone. This allowed the health team to assess the general health of the community and refer those requiring follow up to the medical officers who were present.

Problems experienced during this screening and treatment program included the health team’s inability to ensure all community members used the cream. One Health Worker reported that 10 tubes of Lyclear were found sitting in one household, unused, days after the program had finished.

Since the scabies control program conducted at this community, the Health Center have been restricted by resources to provide any follow up to the program, so the maintenance program recommended by Territory Health Services has not occurred. Data was not collated into a report, and the community did not receive any information about the success of the program. A medical officer involved in the control program stated that it was only minimally successful in the short term, and that it has not reduced the number of people from this community presenting with scabies infestations.

The scabies control program outlined in this report provides a short term strategy for treating scabies and preventing its serious consequences. Despite the effort and resources that were allocated to this program, a number of recommendations were omitted, leading to the relative failure of the program. These omissions were exacerbated by the inherent problems of conducting such a program in a small local community where the shame of having your lifestyle criticized can lead to resentment and refusal to actively participate in efforts to address the problem. The ongoing issue of
overcrowding has not been addressed adequately to ensure that once scabies is controlled in the community, it will remain so.

Whether or not this program had been successful in meeting it’s objectives, the fact remains that long term success will only be achieved when the underlying social, environmental and political factors which lead to these and other preventable
diseases in Aboriginal communities are alleviated (Carapetis and Currie, 1999).  Long-term achievement in proper environmental health conditions for Aboriginal communities is the subject of a number of obstacles and complications.  These include cultural issues; the number and range of agencies responsible for providing services that affect environmental health without an effective coordination between agencies; issues of funding between local, state and federal levels; and issues of social disadvantage which are too complex to discuss under the limits of this report (GWA, 1994).  Until a coordinated focus is provided for addressing these multi-faceted problems, ‘band aid’ measures such as this scabies control program will continue to be applied with limited success.

References

ABS – Australian Bureau of Statistics and Australian Institute of Health and Welfare
(1999) The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander
Peoples, Commonwealth of Australia, Canberra

Braunstein WB (1995) Scabies. In: Principles and Practice of Infectious Diseases, Fourth
Edition, (eds.) GL Mandell, JE Bennett, R Dolin. Churchill Livingstone, Melbourne.

Carapetis JR and Currie BJ (1999) Mortality due to acute rheumatic fever and rheumatic
heart disease in the Northern Territory: a preventable cause of death in Aboriginal
people. Australian and New Zealand Journal of Public Health 23:134-136.

Carapetis JR, Connors C, Yarmirr D, Krause V, Currie B (1997) Success of a scabies control program in an Australian Aboriginal community. Paediatric Infectious Diseases Journal 16:123-126

Freeman P and Rotem A (1999) Essential Primary Health Care Services for Health
Development in Remote Aboriginal Communities in the Northern Territory.  University of New South Wales, Sydney.

Golds M, King R, Meiklejohn B, Campion S, Wise M (1997) Healthy Aboriginal communities. Australian and New Zealand Journal of Public Health. 21:56-58.

GWA – Government of Western Australia (1994) Task Force on Aboriginal Social
Justice, Report of the Task Force. Government of Western Australia, Perth.

Hoy W, Matthews W, McCredie DA, Pugsley DJ, Hayhurst BG, Rees M, Kile E, Walker K, Wang Z (1998) The multidimensional nature of renal disease: rates and associations of
albuminuria in an Australian Aboriginal community. Kidney International 54:25-28.

Lloyd CR (1998) Washing machine usage in remote Aboriginal communities. Australian
and New Zealand Journal of Public Health 22:60-61.

Reid J and Trompf P (1991) The Health of Aboriginal Australia. Harcourt Brace Jovanovich, Sydney

Schaechter M, Medoff G, Eisenstein BI (1993) Mechanisms of Microbial Disease, Second Edition. Williams and Wilkins, Maryland.

Territory Health Services (1997) Guidelines for the control of acute post-streptococcal
glomerulonephritis. Center for Disease Control, Northern Territory Government, Darwin. http://www.nt.gov.au/nths.

Walton S, Choy J, Bonson A, Valle A, McBroom J, Taplin D, Arlian L, Mathews J, Currie B, Kemp D (1999) Genetically distinct dog-derived and human-derived Sarcoptes scabiei in scabies-endemic communities in northern Australia. American Journal of Tropical Medicine and Hygiene 61:145-148.