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In Deep
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Belinda Olding, left, and sister Dr Melanie Olding.

IT’S Sunday morning and Dr Melanie Olding, relaxing on the front step at home, is about to hear a story, PNG style.
It’s a story about something unexpected, gory and very smelly, but she has no sense of that yet, as Pius, the emergency nurse, strolls past the high mesh security fence and down the boggy driveway towards her.
Having spent five months in Namatanai, the second largest settlement on the remote island province of New Ireland, Melanie knows she’s probably in for a long-winded account of something that may, or may not, be urgent. The volunteer with Australian Doctors International, a not-for-profit medical aid organisation that focuses entirely on PNG, drops any Australian-based expectations of how things should be, and nods, encourages and listens respectfully to the end.
Pius tells her about someone with a bedsore he’s seen that morning and spends 10 minutes detailing his treatment. In a seemingly random offering, he adds that people have been fishing off Number Two Bridge. He does a bit of scene setting,
explaining who was there and why, and says a fisherman hooked something and dragged it in. With no increase in animation, his story suddenly gets interesting. The catch is human remains. Melanie is required at Namatanai Hospital,
where a crowd thinks someone has been killed, and at least partly consumed, by a crocodile. They are waiting for her to identify the deceased.
“I’ll identify it as bits of stuff,” Melanie confides as we walk to the hospital, just minutes up the road. The 32-year-old emergency registrar from Darwin has passed her primary emergency exams and hopes to start studying for the ACCRM fellowship next year.
She’s no expert in forensic pathology. But that’s no bother to the 30-odd people standing expectantly near a rice bag of entrails, tied with string. The fisherman asks for DNA testing. Others ask whether it was a man or a woman. Can she tell them who it was?
Melanie is hosing down expectations — “I’m happy to look but I won’t be able to tell you much today” — and trying to call the coroner when her sister, Belinda Olding, comes tearing around the corner.
Belinda is wearing a pair of latex gloves and has come from the delivery suite, but she is no doctor.
The 30-year-old from Newcastle has a construction background and is saving lives in other ways.
Her main aim at the moment is to install four water tanks to get running water to hospital wards, which should significantly reduce infection and prevent deaths.
The 56-bed hospital in Namatanai, which sees about 77,000 patients a year, has four small rainwater tanks — each with a tap.
It’s not enough to provide drinking water for patients during the dry season, let alone wash, clean, or flush toilets. Earlier this
year, a patient walked down the hill behind the hospital to a creek so she could wash after giving birth. She slipped on the way back up, haemorrhaged and died.
Installing extra tanks would be a no-brainer for Belinda in any Australian context, but here it is a slow and tedious process that will take far longer than the Olding sisters’ six-month stay, which ends in August.
Between battles with dysfunctional bureaucracy and noble attempts to vanquish corruption, Belinda is putting her project management skills to use across a range of other projects. She’s trying to introduce a triage system at the hospital (patients
are currently given a number according to when they arrive and are seen in that order, even if their child is dying) and a system for unpacking AusAID boxes (when the sisters arrived, the hospital had run out of supplies, but 500 boxes were
sitting — unpacked — in a storeroom).
Her fundraising efforts have paid for the construction of seven pit toilets (patients previously defecated on hospital lawns and in the backyards of staff homes) and solar lighting (many night-time emergencies and births occurred in the dark).
The situation in Namatanai is far from unusual in PNG. The country has fewer than 400 doctors, only 51 of whom practise outside the capital of Port Moresby. In New Ireland Province, there are just seven doctors serving a population of 160,000
— all of them based in the provincial capital, Kavieng, despite 91% of the population living in rural areas.
On this not-so-lazy Sunday, while Melanie has been dealing with the fisherman’s catch, Belinda has been touring
the maternity ward. She’s under no illusions about her (lack of) medical qualifications.
But she knows that feverish children are automatically treated for malaria, sometimes repeatedly; it has become instinctive for her to feel little heads for bulging fontanelles.
Belinda also knows many viable newborn babies die at the hospital, having been put aside, unattended, while medical staff focus entirely on the new mother. So she’s also a regular at the maternity ward where, today, she’s found an unattended newborn in trouble. That is why she has made haste to get her sister.
Melanie follows Belinda to the flat, cyanotic baby with excessive secretions and obstructed breathing.
Within 20 minutes, Melanie has stimulated, suctioned, bagged and masked the baby, and it has brightened and settled. Melanie has no obstetrics training or experience. This is her least favourite part of the hospital.
There’s no fetal monitoring and no chance of a caesarean or blood transfusion.
Humidicribs are made with glad wrap. There’s no ventilator, autoclave or phototherapy lamp, or regular electricity to run them. Even taking a woman’s blood pressure can swallow half an hour; it’s a struggle to find a sphygmomanometer that achieves pressure and isn’t spilling balls of mercury.
It’s a depressing place, where patients lie on putrid, torn mattresses that have absorbed decades of bodily fluids.
“The wards are filthy so we have enormous amounts of maternal and neonatal infection and mortality,” Melanie says. “In a lot of cases, women would be better off taking their chances in their village.”
Melanie is making her final assessments on the revived newborn when a woman bursts forcefully through the door, rips off her sarong and makes a beeline for a delivery bed.
Wisely, she avoids the bed with exposed foam poking through cracked vinyl and a mysterious big hole, placed, it seems, for newborn babies to fall through.
This woman has had contractions for days. They stopped after she was treated for malaria (which she’d caught while in hospital) and an STI, but it’s clear her baby is finally on its way.
Melanie and the nurse do their best, but don’t manage to save the woman’s perineum as the baby is born, dark blue, without a heartbeat, in a flood of meconium.
Without the luxury of a laryngoscope, Melanie resorts to deep, blind suctioning and wishes she had the support of someone who could put in an umbilical line.
Intramuscular adrenaline doesn’t achieve a heartbeat.
For the second time in her life she tries a single shot of intra-cardiac adrenaline.
Within 30 seconds the baby’s heart rate is perfect and there’s a short-lived burst of euphoria.
It’s ridiculously humid. Sweat runs down the Olding sisters’ arms for the 90 minutes they try to resuscitate the baby. But the baby’s lungs have stiffened. This baby will never draw her own breath.
Belinda walks the hospital in search of staff and brings five to stand around the baby to learn an essential new skill. The mother watches on as Melanie teaches each of them how to use the bag and mask, encouraging them to reposition the mask each time its seal breaks. Calmly and gently, she cycles each of them through the process twice, mindful that in Australia no mother would watch on so patiently, waiting to hear their first child’s fate.
“I feel horrible for that mother,” Melanie says later.
“But I think it’s a price worth paying because there are now potentially five staff members who could save a baby, when yesterday I can assure you they couldn’t.
“You have to find silver linings or it’s just too sad.”
She says the hospital has three rotating on-call midwives, but they rarely attend deliveries because there is a culture of not calling for help. Compounding that, hospital staff are paid when they don’t turn up for work, and are unwilling to engage
with a rostering system or find someone to fill their shifts.
“If you’re lucky, babies are delivered by a nurse with some obstetrics experience, more likely by a community health worker, which is similar to a nursing assistant. In many cases, because of the rostering system, they birth without anyone present.”
Melanie leaves the last staff member to continue with the bag and mask and walks over to the woman still lying on the delivery bed. Gently, Melanie explains that her baby is very unwell, was not breathing when it was born and had no heartbeat.
“We managed to get the heart working again, but the baby’s brain has gone to heaven and because of that, the baby can’t breathe anymore,” she says.
“So we will stop breathing for the baby now and we will bring the baby to you for cuddles. Would you like to cuddle your baby?”
The woman smiles, reaches out to hold Melanie’s hand and says thank you.
Melanie has been so composed and so sensitive it’s a surprise when her voice gains a terse edge. “She holds the baby for as long as she wants,” she instructs the nurse, before leaving the room.
Melanie does ward rounds before facing the morgue, where the rice bag and its followers await her.
She opens the bag, which challenges even her clinically hardened stomach, assesses the decaying contents and scratches out a note for the police.
“Intestinal remains bought to me. Indeterminate — possibly human, unable to tell if male or female. Possibly large animal. Recommend coroner’s involvement. Please call me for clarification. Dr Melanie.”
Melanie then wanders home, where she debriefs with Belinda about the death of a baby who likely would have lived had it been born in Australia. She provides an entertaining account of the vile smelling entrails — “Holy mother of God” — while downing a quick 3pm lunch of twominute noodles.
When Melanie first arrived at Namatanai, she wanted to tackle and change everything that was wrong, but she soon learned that was futile, a one-way ticket to burnout.
“I see so much that is wrong, every day,” she says.
“What I have to do is pick the problems that I can make meaningful change to, otherwise I’d go crazy.”
In a culture heavily focused on personal relationships, she spent the first three months listening, building the respect of hospital staff and trying to understand why strange things happen.
“It’s easy to walk in and say ‘That’s not right’, but you have to sit back and learn. Sitting back is the hardest thing you can do.”
The sisters say they wouldn’t have coped in this place, where nothing makes sense or goes to plan, without having one another for support.
“You can’t keep an emotion for an hour,” says Melanie.
“Just when you hit rock bottom, something wonderful happens and just when you have a win, everything comes crashing down.
“Any win is always shortlived and any loss is just surpassed by something else. You need a familiar face to bounce things off and say,‘Did that really just happen?’”

IMG_6603

When Belinda and Dr Melanie Olding arrived at Namatanai the hospital had run out of supplies, but 500 AusAID boxes were sitting – unpacked – in a hospital storeroom.

Triage, PNG style. Take a number and wait your turn.

Triage, PNG style. Take a number and wait your turn.

One of the dogs that roam around Namatanai Hospital, biting children waiting to be seen.

One of the dogs that roam around Namatanai Hospital, biting children waiting to be seen.

A mattress in the maternity ward.

A mattress in the maternity ward at Namatanai Hospital.

IMG_6656

Rather than use the toilets at Namatanai Hospital, patients defecated on hospital lawns and in the backyards of staff homes.

 

Patient transport, PNG style.

Patient transport, PNG style.

 

Belinda and Dr Melanie Olding with a hospital delivery bed, complete with mysterious big hole and exposed foam poking through cracked vinyl.

Belinda and Dr Melanie Olding with a hospital delivery bed, complete with mysterious big hole and exposed foam poking through cracked vinyl.

 

 

Working in the dark
DR Melanie Olding will never forget the night she sewed up a seven-year-old child with 13 puncture wounds from a crocodile bite, by the light of a head torch and a kerosene lantern.
Called to the hospital at 1.30am, Melanie tracked the chest wounds and found that some were the depth of her index finger.
One tooth had punctured the child’s skull.
Melanie supervised a hospital colleague as he flushed the wounds, administered antibiotics and stitched in makeshift drains made from urinary catheters, sterile gloves and tape.
Knowing that no surgeon was available at Kavieng, a bumpy five-hour drive away,
Melanie bent the rules and evacuated the patient by boat to another province, where there were three surgeons.
The child made a full recovery.

 

IMG_4133 - Mel treating croc bite child

A camera flash creates a deceptive image of Dr Melanie Olding, working in the dark. Photo: Belinda Olding.

IMG_4121 - Mel in dark stitching croc bite

Dr Melanie Olding stitching crocodile bites by the light of a head torch and a kerosene lantern. Photo: Belinda Olding.

The seven-year-old child had 13 puncture wounds from a crocodile bite - some the depth of Dr Melanie Olding's index finger.

The seven-year-old child had 13 puncture wounds from a crocodile bite – some the depth of Dr Melanie Olding’s index finger. Photo: Belinda Olding

 

Dr Melanie Olding supervised a hospital colleague as he stitched in makeshift drains made from urinary catheters, sterile gloves and tape. Photo: Belinda Olding.

Dr Melanie Olding supervised a hospital colleague as he stitched in makeshift drains made from urinary catheters, sterile gloves and tape. Photo: Belinda Olding.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

‘That was heartbreaking’
Soon after arriving at Namatanai Hospital, Dr Melanie Olding realised children were dying of cerebral malaria and meningitis, and so made this the focus of her regular staff teaching sessions.
She was thrilled when staff could parrot the sessions back to her. The quality of admissions was improving, the
correct drugs were being used more often and fewer children were dying.
“I was feeling really great that people were starting to take it in,” she says.
“And the next day I stumbled onto the ward to find this child who had presented and been turned away.”
The 18-month-old had been brought in twice by well-educated and concerned parents. But he had been given IM penicillin and sent home both times.
By the time the baby was admitted to hospital, where Melanie discovered him a day later, it was too late.
“I worked on the baby for ages. It was severely dehydrated, end-of-the-bed septic and nonresponsive,” she says.
She gave him the correct antibiotics and fluids, but the baby arrested two hours later.
“That was heartbreaking, because it was the one thing I had been trying to focus on with the staff and it was such a textbook example.
“You could see when you walked into the room he was septic. He had a bulging fontanelle.”
Melanie, who delivered 70 interactive teaching sessions during her stay, says she sobbed and had a moment of wondering, ‘What’s the point?’
“It was heartbreaking. You understand people don’t have the education, knowledge or skills.
People here genuinely want to do the right thing, but the frustration of everything going wrong despite everything you’ve tried to do — that’s the worst.”
Emotionally exhausted, Melanie headed back to the hospital later that afternoon. She found a healthy baby to model the case on, pulled out the whiteboard and ran the education session again.

In Deep pdf - Australian Doctor

 

Failed by the system
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IT was a simple question, bluntly put, that rattled an experienced inner-city GP to the core. “What evidence have you got?”

The GP had called the NSW Department of Community Services (DoCS) to report a case of suspected child abuse, thus meeting her legal and ethical obligations. But having outlined the mother’s concerns and the three-year-old girl’s inappropriate behaviour, the GP suddenly felt she was the one coming under scrutiny.

“I felt like everything I was saying was being disbelieved,” says the GP, who does not wish to be named. “I was devastated. I felt I’d been put in a court and stood in the dock and found guilty.

It’s a scenario that highlights the disconnect between laws that require GPs to report child abuse on the basis of ‘reasonable suspicion’ and the far greater threshold of evidence required by state government child protection departments to trigger an investigation – a threshold that is increasing as overloaded state departments struggle to cope with dramatic increases in the number of reports.

While GPs are among the professional groups least likely to report child abuse, those who do report it told Australian Doctor of their rueful acceptance that action was unlikely. Having to meet their legal obligations while knowing their notification may not lead anywhere leaves GPs wondering whether such a seemingly futile process justifies the threat it poses to their relationships with some of their most vulnerable patients.

Professor Dorothy Scott, director of the Australian Centre for Child Protection at the University of SA, says the statutory child protection system’s emphasis on reporting has left authorities so overwhelmed that notifications often just go “into a vacuum”.

“In most cases they don’t reach the threshold for investigation, let alone statutory intervention of a court process,” she says. “The lack of effective response deters GPs and other mandated notifiers from making subsequent notifications.

“We need a mandatory response to at-risk children, which is not the same as a mandatory report.”

Associate Professor Leanne Rowe, a Victorian GP and former director of a health service for disadvantaged youth, says: “There are many anecdotal cases of GPs reporting child abuse to the appropriate authorities and then being frustrated by the lack of support or to find they then lose touch with a vulnerable family.”

It’s a view shared by Sydney GP Dr Liz Marles, who had one vulnerable woman race from the surgery, never to return, after seeing another doctor’s note in her file about a DoCS notification. In another instance, Dr Marles reported concerns that children were at risk in a family with a suicidal, alcoholic father who was regularly violent. It emerged that four other agencies had also made notifications about the family.

“Nothing happened,” she says. “It does make you wonder what the whole thing is about really. It is about building up a file and when you get to a certain point, they’ll come out [and investigate]? Or is it only if a child turns up with broken limbs that they intervene. You have to report on suspicions, but what does that actually lead to?”

It’s a pertinent question given the pressure on governments to address a mounting crisis around the nation. In WA, a bill before Parliament is set to introduce mandatory reporting for GPs in the state for the first time, while in NSW the State Government’s special commission of inquiry started its focus on DoCS last week.

The NSW inquiry follows an onslaught of adverse publicity surrounding several tragic cases, including that of a seven-year-old girl, known to DoCS, who starved to death in her bedroom. A December report by the NSW Ombudsman revealed that 114 children who died in 2006 were known to DoCS. Of these, 81 were the subject of one or more ‘risk of harm’ reports.

The issue of mandatory reporting is included in the commission of inquiry’s terms of reference. It will investigate “the system for reporting of child abuse and neglect, including mandatory reporting, reporting thresholds and feedback to reporters” and “the adequacy of the current statutory framework for child protection including roles and responsibilities of mandatory reporters, DoCS, the courts and oversight agencies.”

A DoCS spokeswoman told Australian Doctor that a five-year, $1.2 billion reform of the NSW child protection system, which finishes in June, did not allow for the ”dramatic and unsustainable rise” of an 80% increase in reports through its helpline in the past five years. DoCS has asked the inquiry “to examine the issue and recommend an appropriate mandatory reporting scheme”, but will not elaborate further on what that might mean.

Rare insight into how the department has managed its demanding workload in the past is offered by a NSW Ombudsman’s report after the 2003 death of a three-year-old boy, whose mother had left him and his sister in the care of two sex offenders she met at a railway station.

The Ombudsman’s report, which details DoCS’ extensive involvement with the children’s family over more than three years, says this case was closed in accordance with a ‘priority one’ policy: the case had not been allocated to a staff member for four weeks and the department had not been notified of additional or further concerns within that time. The case was closed the day before the child’s death “despite the absence of any action by DoCS to determine whether the reported risks had abated”, the Ombudsman found.

The DoCS spokeswoman told Australian Doctor that a new policy, called ‘intake assessment guidelines’, is being phased in to replace the priority one policy and “make sure that the children who genuinely need the greatest protection and support are given priority”. She said the guidelines “also help identify reports which can be closed”, but did not explain how this differs from priority one.

A report by the Australian Institute of Family Studies in August last year says that when child protection services are underfunded and over-whelmed with cases, this impacts on which cases are deemed worthy of investigation.

“In order to cope with this influx of reports, some child protection departments have ‘raised the bar’ or level of seriousness of reports that they will investigate, while those cases considered to be less serious may not be investigated at all,” the report says.

“When mandated people report suspected child abuse or neglect, they expect the child protection department to investigate and take action regarding their report. When this does not occur due to a lack of resources in the department, those who have made reports may become disillusioned and therefore cease to make reports to the department.”

However, the report says lack of common ground between mandatory reporting requirements and legislative grounds for intervention “does not mean that the system is failing to work as policymakers had intended”. Mandatory reporting raises awareness of child abuse, represents a “symbolic acknowledgement of the seriousness of child abuse in a community” and “aims to overcome the reluctance of some professionals to become involved in suspected cases of child abuse by imposing a public duty to do so”, it says.

Dr Terence Donald, director of child protection services at Adelaide’s Women’s and Children’s Hospital, says reporting on the basis of suspicion can represent little more than wasted time and resources.

“It’s really disastrous when someone has to make a notification and they have to hold on to the phone for 40 minutes [and] … there’s almost a 50% chance nothing can come of it,” he says. “There’s a substantiation rate of 30-40% across the country, which means there is potential for the notification rate to be very significantly reduced.”

Dr Donald says it’s not realistic to expect child protection authorities to do a meaningful assessment on the basis of a doctor’s suspicion. “The reality is that they can’t,” he says.

Instead, more emphasis needs to be placed on doctors being able to conduct more in-depth assessments, in order to evaluate and potentially manage the case themselves.

“It comes back to having some system of being able to assist health and education professionals to look more into situations of concern and decide whether they should be able to manage situations more, because the child protection system will never be able to meet the need,” Dr Donald says.

Given the overload within the current system, if GPs are not able to sift through the case closely to determine whether their suspicion has weight then a government department won’t stand a chance, he says.

“So the question is: ‘Does that sifting get done anywhere?’”

Dr Geoff Steward, a GP working in a remote NT Aboriginal community where it is often difficult for authorities to investigate suspected abuse cases because of cultural differences (see box * below), wants to be able to investigate cases more thoroughly with the assistance of local Aboriginal people, so he can give the NT Department of Family and Community Services (FACS) more information to work from. But this offer has been flatly refused – he says members of the department’s staff simply recite the number he should report abuse to and say: “Please just ring.”

“My response is we could do that, but you couldn’t cope with the increased number of referrals that would generate and you have no way of making the investigations yourself.

“I have to make sure I cover my professional responsibilities under the Act, but this is an ongoing argument. In the end, I have to divorce myself from the response. But part of this is keeping the pressure on FACS so they have to respond.

DEPARTMENT STANDS IN WAY OF LOCAL INVOLVEMENT

When a 13-year-old girl; comes to Dr Geoff Stewart asking for Implanon, he knows he stands no chance of establishing whether the girl’s sexual relationship is consensual and with another teenager, or abusive and with an older man. It’s clear that he’s legally obliged to report suspected abuse. But he knows that the NT Department of Family and Community Services is even less likely to be able to determine the status of the relationship than he is, as a white male working in a remote Aboriginal community.

The GP, who works for a community-controlled Aboriginal health service at Maningrida in the NT, says he most commonly makes reports to the department about failure to thrive and neglect, but it is rare to get a prompt and adequate response.

“There’s an obligation for government to fill their requirements under the Community Welfare Act by appropriately investigating all notifications. They haven’t been doing that and that hasn’t really changed,” he says.

Even if they did respond, staff based in Alice Springs or Darwin have no hope of developing the relationships with local people that are key to establishing whether abuse is occurring and how best to deal with it, Dr Stewart says. There’s been a glimmer of hope – a fledgling child protection service has been established and is staffed by local women, who know and understand local families, languages and culturally based care arrangements. The women are working to increase understanding of the law and what constitutes abuse, but the department has rejected Dr Stewart’s proposal that they also support him in trying to establish whether children are in danger of not.

Dr Stewart says that, before making a notification about the 13-year-old girl, he wants the women to be able to help him with information about her relationship. He also wants to be able to contact the local school to check her attendance and see whether local police have any concerns.

“All of this would help me contextualise the situation and determine if a notification is required,” he says.

“Family and Community Services doesn’t want me to do that at all. They’re very resistant to the idea of involving the women, even though it’s the women’s stated aim to be involved.”

WHAT GPS SAY

Dr Elizabeth Hindmarsh, a GP who worked in an inner-Sydney practice for almost 30 years, remembers mandatory reporting being introduced in NSW and has changed her views on its value.

“I was really pleased it was happening at the beginning. It was the community saying this is not okay. But at the moment I don’t think the system is working.

“Somehow we left DoCS with the whole responsibility of doing something about it.”

Sydney GP Dr Bronwyn Gould has trained DoCS staff to recognise injuries that are consistent with abuse.

“People have said why bother reporting to DoCS, but legislation in NSW doesn’t allow you to make that decision. It’s a GP’s job to do their best to help DoCS get it right.

“The information we give may add to a picture they’ve been slowly building and might just tip the balance. You have to remember you’re not the sole source of information about that family.”

DoCS is staffed by hundreds of good people with too much work to do, Dr Gould says,

“I have a huge respect for people in the front line at DoCS and other statutory agencies, and no one ever thanks them. They live with a workload they can never get through.”

First line of defence
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Editor,
I was recently interviewed by your writer, Heather Wiseman, for the article regarding a GP’s role in reporting child abuse to the government (‘First line of defence’, News Reviews, 15 February).
I have previously experienced disappointment and alarm at the failure of the Queensland Department of Child Safety to heed and respond to my reports.
After your article I was contacted by the Queensland Minister for Child Safety and Women, Ms Margaret Keech, who requested a meeting with me at my practice.  She attended and we spoke for an hour.  Also in attendance was a family court lawyer who has had parallel difficulties.  We had a very frank and constructive discussion regarding problems that GPs and lawyers have in communicating with the department.
Other issues were also raised, such as problems accessing medical histories of children in foster care because of strict interpretation of the privacy laws.
Your article has already had a measurable and beneficial impact.  Within a few days of the meeting, a ministerial briefing was despatched and all the cases we discussed have been re-opened.
Dr Thomas Lyons, Eagleby, Qld.

HE was seven years old when he started playing a disturbing new game with his younger sister:  pretending to have sexual intercourse.  Deeply distressed, his mother turned to her GP for support.

Dr Thomas Lyons, who works in a marginalised suburb outside Brisbane, reported the case to Queensland’s Department of Child Safety, detailing why the mother was convinced the boy was being abused.  But late last year, two years after the GPs report, the now “grief- stricken” woman returned.

The alleged abuser still had access to the child and the child’s sexual behaviour has become so frequent that his once-supportive school has transferred him in order to protect other children.

Dr Lyons’ calls to the Department of Child Safety revealed that caseworkers believed the mother was anxious, strung out and could not be taken seriously.  It’s a judgment Dr Lyons isn’t convinced the department’s “young, inexperienced and incredibly arrogant” staff are well equipped to make, but he’s been told the case is closed and won’t be revisited.  He’s now turned to the Minister for Child Safety’s office for support, lobbying for access to the child’s file.

Dr Lyons, who finds himself making about four reports of child abuse each year, says the department is usually dismissive and tends to steer clear of difficult cases.

“Most of the time they’ve found reasons not to investigate, or the allegations difficult to substantiate, and so months later nothing has happened,” he says.  “They have no rigor at all.  They’re completely lethargic to the point of being indifferent.”

The department told Australian Doctor it could not comment on the specifics of the case.  But whether its decision in this case was well-founded or not, potentially devastating shortcomings within the child protection system extend well beyond Queensland.  There’s broad agreement among leading authorities on child abuse that the crisis is national.

“We are failing the most vulnerable children in Australia by our reactive, bureaucratic and legalistic child protection system,” says Professor Dorothy Scott, director of the Australian Centre for Child Protection at the University of SA.

“State child protection services are completely overwhelmed.  They’re like overloaded casualty departments in a health system without GPs.  Looking for the child who is seriously at risk is like looking for the needle in the haystack.”

In January, the Australian Institute of Health and Welfare revealed that abuse and neglect notifications have increased by more than 50% in the last five years, to 309,517 last financial year.

A spokesperson for the NSW Department of Community Services, which receives about 60% of all reports made in Australia, told Australian Doctor it had experienced an 80% increase in reports through its helpline, compared with five years ago.

A series of child deaths in the lead-up to Christmas have added heat to the issue.  In NSW and Queensland alone, a 19-day-old baby died with fractures to his ribs and skull, a two-year-old boy died after being released from foster care, a 10-year-old girl was raped and murdered, a seven-year-old girl starved to death in her bedroom and a two-year-old boy’s body was found in a suitcase floating in a pond.

Professor Scott says such tragedies can galvanise change.  With the recent change in Federal Government, she believes the climate is right for national reform.

So far, federal intervention has been limited to remote Aboriginal communities in the NT under the previous government’s controversial response to the Little Children are Sacred report.

Details of the new Labor Government’s policies for children in remote communities are still being finalised, but there are some signs of a broader federal interest in the issue of child abuse.  Federal Minister for Families, Housing, Community Services and Indigenous Affairs Ms Jenny Macklin is working on plans to give state and territory child protection authorities powers to recommend that Centrelink quarantine income support and family payments.

“Parents have an obligation to ensure children attend school and have adequate food and shelter,” Ms Macklin’s spokesperson says.

But Professor Scott is hoping for a deeper change in philosophy – to one with less emphasis on reporting and a greater investment in prevention, which would include a much greater role for GPs.

“We really need national leadership – a summit led by the prime minister calling all states and territories and relevant professionals together to tackle this as a national priority,” she says.  “We need to remove the risk from children rather than thinking about removing children from risk.”

GPs are “vital” in making children safer, by detecting marginalised and vulnerable families and mobilising the support these parents may need to better nurture their children and prevent abuse occurring.  Yet “GP’s have been completely neglected in child protection policy”, Professor Scott says.

“We need to be able to provide the resources for GPs to do comprehensive assessments and referrals for vulnerable children and families before it gets to the stage of mandatory reporting to a child protection agency.”

Just as general practice has adopted a more significant role in mental health, Professor Scott expects bolstered funding, training and community-based resources will enable GPs to play a crucial role for vulnerable children.  She does acknowledge though that while GPs are likely to be seeing marginalised parents, it’s not clear whether they are seeing the most vulnerable of abused children.

This may partly explain why doctors are one of the least likely professional groups to make notifications.  Last financial year in NSW for instanced, 0.6% of finalised cased were referred by GPs compared with 28.5% reported by police, who refer the most (see box *).

Dr Elizabeth Hindmarsh, a GP who worked in an inner-Sydney practice for almost 30 years, says she reported cases of suspected abuse but didn’t come across many.  Someone who has abused a child is unlikely to bring them to a doctor still covered in bruises.

“GPs only see children for very short periods of time, so it’s not always easy to know when abuse is occurring,’ she says.  “It has always concerned me that we knew there was child abuse out there but we were not necessarily picking that up.”

Dr Ian Cameron, a GP on the NSW Ombudsman’s reviewable child deaths team, says GPs are better placed than the bureaucracy to identify families at risk and offer support.  Simply asking, “Are you worried about the children?” can create an important opportunity for parents to voice concerns.

“The GP can start an intervention that’s about health and wellbeing, rather than a departmental or police response.”

While some GPs may be reluctant to accept increased involvement, Dr Cameron agrees a new focus on prevention is necessary.

“Kids who are at most risk are vulnerable about a whole lot of areas – education, risk-taking, anti-social behaviour – and GPs may not see it as a health-related issue,” he says.  “Ultimately, I think GPs are well placed to make a difference, and ultimately I do believe it is a health issue.”

AMA president Dr Rosanna Capolingua says the current system leaves GPs frustrated by the ‘then what’ question that follows detection and reporting of child abuse.  If a new approach required more of GPs, “we would need to know that there are very solid support and intervention services there that we could trust and refer to”, she says.

“If a GP feels helpless, it would be about knowing they could refer a family to an intervention or support group that would make a difference.  That’s the great space that needs funding.  GPs can’t go into the home and that’s where a lot of work needs to be done.”

Some GPs are not aware of the range of resources that do exist, according to director of child protection services at Adelaide’s Women’s and Children’s Hospital Dr Terence Donald.  When he has gone to speak at large group practices in Adelaide, the GPs were not aware of local community supports, such as an Anglicare office just down the road.

“They hadn’t considered it would be useful to meet with staff there,” he says.  “That’s not a criticism.  It’s a statement of how far training needs to redirect itself.  Registrars are starting to appreciate they have to take the initiative to find out what services are available and develop some kind of relationship with these service providers.”

Dr Donald, who is a medical education consultant for the Australian Centre for Child Protection at the University of SA, says the training GPs receive is largely ad hoc and the content largely influenced by the doctors they encounter during their hospital and practice-based training.  He believes an additional clear, prescriptive curriculum is needed.

“In the absence of a set curriculum, their training will be hit and miss.  It’s not clear who gives the training at the moment.  They might get someone like me with a broad perspective, or might get someone who talks about suspicious bruises.”

As a paediatric forensic physician, Dr Donald says he has “zero chance” of engaging a family when a child is referred to him by community services, because the parents assume he is taking the department’s side.

“One of the first things I say is, ‘You really need someone who will listen to you and advise you’ – and a GP is in the perfect situation to do that.”

Where abuse has occurred, support services for traumatised children are “virtually non-existent in most states”, Dr Donald says.  He sees this as the key measure of just how badly the system is letting down vulnerable children.

“No system we can ever develop can prevent children being harmed, but therefore the least we can do is treat children who have been harmed,” he says.  “If you’re treated for the trauma you’ll be able to live your life in an optimal way.  If you haven’t been treated, you go into relationships where things are not good for you, you’ll have a child and get stressed and hurt the child.

“It’s a really important form of primary prevention that’s hardly given any notice.”

 CHILD ABUSE LOOKS TO BE ON RISE

The Australian Institute of Health and Welfare’s latest report says there is strong evidence that the number of substantiated cases of child abuse and neglect is on the rise across Australia.  The report reveals that:

  •  Medical practitioners were one of the least common sources of finalised child abuse notifications last financial year.  However, reporting rates varied greatly across states:  in SA doctors made 10.2% of notifications compared with 3.4% in Victoria, 1.4% in WA, 0.6% in NSW and 0.2% in Tasmania.
  • A relatively high proportion of substantiated cases involved children living in lone mother families and in two-parent step-families or blended families.
  • The most common type of substantiated abuse in NSW, Victoria, Queensland, SA and ACT was emotional abuse.  In the NT it was physical abuse and in WA and Tasmania it was neglect.
  • The number of children living in out-of-home care rose by 102% in the past decade.
  • The rate of Aboriginal and Torres Strait Islander children in out-of-home care is more than eight times the rate for other children.
  • Nationally the number of substantiated reports of abuse or neglect increased by 45% in the past four years.

Reference:
Child Protection Australia 2006-2007, Australian Institute of Hewalth and Welfare, Canberra, January, 2008.

 GPS IN PLACE FOR EARLY INTERVENTION

Sydney GP Dr Bronwyn Gould says GPs are well placed to identify families where children are vulnerable and support them before abuse becomes an issue.

“You can see mums or dads in the waiting room who are losing it, who have inappropriate expectations of the child, and so get cross when a baby soils their nappy in the surgery,” says Dr Gould, a former chairwoman of the Australian Council for Children and Parenting.  “As a GP you can work with those families, helping them to understand what you expect the kids to do, and to be adaptable.

“You can do a lot of work helping them problem solve, anger management [and] plug them into support agencies before the wheels fall off for the kids.”

If GPs do make a report, there is great benefit in their continuing to support the family, when possible, Dr Gould says.  “Even if you’re looking at an extreme case where a child is removed, both of those parents [may] go on to parent again.”

Dr Gould, who has carried out forensic investigations on abused children in a hospital setting, says it can be difficult for GPs when a parent is concerned their daughter has been abused and asks them to check the child’s vagina because it is red.

“I used to be one of the people who did it, but even now I would hesitate.  The knowledge and expertise around what is indicative of abuse is constantly being refined.”

GPs are often pressured to examine a child, but while it’s appropriate to check for STIs – using urine tests, not swabs – the child should be referred to a tertiary hospital with a specialised child protection unit.

“A normal genital examination does not exclude sexual abuse,” Dr Gould says.

Dealing with cases of suspected child abuse is difficult and can leave GPs feeling they’re in a no-win situation.

“Remember, the real person in the no-win situation is the child,” Dr Gould says.

Coming full circle
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Photo by: Warren Clarke. Dr John D'Arcy

WHEN Dr John D’Arcy says that he has a story to tell about the Pope, it feels like he’s about to embark on some kind of well-rehearsed bad joke. As it turns out, the tale is exceptionally well rehearsed, but it is not so much about the Pope as the accidental launch of D’Arcy’s media career.

It was 1981 and D’Arcy’s practice was not far from Channel 7’s offices in the Sydney suburb of Epping.

As a result, many of his patients worked in TV and called on him for advice when medical issues cropped up in stories. One patient, a producer, called him in excited tones to announce that Pope John Paul II had been shot. Did D’Arcy know a surgeon she could speak to for the story?

D’Arcy put forward a name, but shortly afterwards received another call. The surgeon wasn’t available. There was a car waiting out the front. D’Arcy was required at the studio. At once.

Steve Liebman said to me, “Tell me, what do you make of the Pope being shot? Could he die?” D’Arcy recalls.

In the absence of detail or specialist knowledge, D’Arcy responded in the only way he could

“Yes.”

Could he survive?

”Yes.”

D’Arcy chuckles happily, 26 years of telling the story not detracting from his enjoyment.

Then he sobers. It’s a true story,” he says, enhancing any suspicion it’s improved in the telling over time.

I’ve read his agent’s promotional blurb, which heralds D’Arcy as Australia’s best-known media doctor and the first medical practitioner appointed to an Australian newsroom. He’s worked on some of the country’s highest rating TV shows and these days he stars on breakfast TV, regional radio and has a regular column in a high-profile women’s magazine.

I’m half expecting to meet an intimidating, arrogant smooth talker. Within minutes of meeting him, it’s clear he’s anything but.

D’Arcy, 60, collects me on his way past Australian Doctor’s office, en route to the studio where he records his radio show.

A flustered pink face stark against white hair, he introduces himself and launches straight into telling me about this morning’s horrible discovery; a dead possum rotting in his roof in a tight spot where it can’t be removed. From there, his conversation flits from one subject to another. He tells me his radio show, Health Matters, is beamed to 63 regional radio stations and that he also writes a weekly column for New Idea. He misses talkback radio, having worked for 2GB and 2UE years ago. He’s concerned because he has only four minutes today in which to interview the father of a young girl with Rhett’s syndrome. He won’t have time to speak properly with the father, which makes him uncomfortable. That’s one of the reasons he’s keen to work as a GP again, sometime this year.

“Getting to know the person you’re dealing with, what their pressures and enjoyments are, I miss that enormously and that’s why I do plan to go back to general practice,” he says.

“There’s a great privilege in that.”

We arrive at the studio with time to spare. D’Arcy orders coffees and one macadamia biscuit, which he divides neatly into four and sits on top of a paper bag to share. He offers a quick family history. Both of his parents were actors. His father, Francis Theodore O’Donnell, died aged 49, when D’Arcy was nine.

D’Arcy is his mother Marie’s maiden name.

“When I started in the media in 1981, the AMA and doctors in general were severely opposed to people using their own name, because it gave you an unfair advantage in practice,” he says.

Marie is 91 years old, living independently in the Blue Mountains and 100% with it; “a wonderful

woman”

He remembers his mother bursting in on him in the bathroom when his father passed away.

“I couldn’t understand why she had come in. I was on the loo.”

The image of soiled bed sheets, piled up in the laundry has stayed with him. An overweight smoker, Francis had a stroke in his sleep, leaving Marie to raise their three children, and later a nephew, alone.

“My early life was very troubled,” D’Arcy says.

“But my mother never allowed us to be anxious. I never for one moment felt we were any different to anybody else, yet we were absolutely impoverished.”

His father, once a carpenter, built the house he grew up in, in Gillies St, Wollstonecraft, on Sydney’s leafy North Shore. The house has long gone but D’Arcy enjoys driving past to admire an old eucalypt that still has two hooks from his childhood swing.

The family’s GP lived across the road. As a child D’Arcy watched him come and go in his Rover, doing house calls at night. He was touched by the way he looked after his family, both when his father was alive, and afterwards. That, combined with the impact of his father’s death, inspired him to enter general practice.

Up in the recording studio, D’Arcy looks so at home it’s difficult to picture him at a surgery. That’s not to say that he is cool and in control, or that he has the technology mastered. He pokes at the buttons on the audio mixer muttering, I’m hopeless at this” before appealing, with a laugh, for help from a staff member who clearly adores him.

D’Arcy’s reading through a script someone else has written, scratching things out and “D’Arcy-ising it”

Mid-way through the session he rocks back in his chair, takes a breath and says: “I’m a bit exhausted now.”

He strums his fingers on his desk and gets straight back into it. On air, his voice springs into animated enthusiasm. He’s personable and warm, bubbling with good nature and gentle humour. Off air, his voice becomes that of a man quietly frustrated by a distracting buzz through his headset, bad phone lines, interviewees not answering his calls and time running out.

He’s at the end of his show and his interviewing style suddenly reflects that he really needs to wind up and go. Off air he directs the expert he’s interviewing, “Just close off and tell me something nice and then we’ll go off, mate.”

He leaves in a fluster, confident he’s late for his next meeting and has copped a parking fine.

“I’ll have been booked for sure,” he says. Yet he makes time to give my arm a gentle, grandfatherly pat and offer advice on where to find a cab.

AS much as I’ve come to quite like D’Arcy, I’m fighting a very real urge to throttle him.

I’m trying to work out exactly what relationship he has with Yakult, the Pharmacy Guild and various other companies and organisations that pay to have him spread their message.

It’s reasonable territory to explore, given the obvious ethical issues surrounding cash for comment, but the more I try to clarify the arrangements the more confused I become.

There’s no sense that D’Arcy has anything to hide — he spells out that he’s careful not to take on sponsorship deals that would compromise him and that all financial relationships are announced. And, to be fair, part of the reason it’s confusing is that it’s a complex set-up — some sponsor his weekly radio show, one sponsors his daily one-minute Health Check flash, others have a direct financial relationship with D’Arcy outside both these radio commitments and sometimes these relationships overlap. But exacerbating all of this is that when asked a simple and direct question, D’Arcy offers anything but a simple, direct answer.

Asked what he does for Australian Hearing, he starts a long-winded story about how his son-in-law asked him that very question while they were playing golf the other day. He does a little impersonation of his son-in-law’s American accent. He explains how he then happened to bump into a woman he’d met though Australian Hearing and how she had a child who was hearing impaired and ended up with a Cochlear implant.

I ask the question again.

He says he acts as Hearing Australia’s ambassador. I ask what being an ambassador entails. “I put a face on their scientific efforts.”

I start to question my interview technique. Then he volunteers that today he’s going to meet with an audiologist and “it’s her point of view we’ll be pushing” on Health Matters.

I’ll speak with her today and their [Hearing Australias] communications guru about what they want to achieve.”

He sometimes does the same for the Meat and Livestock Corporation, or Dairy Australia, or a pharmaceutical company “wanting to emphasise the appropriate use of their medication”.

Finally, D’Arcy explains that Australian Hearing is one of the organisations that sponsors Health Matters and so pays the Macquarie Regional Radio Works Network. I’m still not entirely clear, and this is a dreadful confession from a journalist whether the organisation has a separate direct financial relationship with him as well.

Sensing my exasperation, D’Arcy offers cheerily, “The interesting thing about me is that I’ve got a short attention span.”

Rather oddly, he adds: “It’s the sort of thing that attracts you to general practice.”

In the end, it’s one of D’Arcy’s former general practice colleagues who helps to make sense of D’Arcy’s scattered style. Dr Peter Skelton, who bought D’Arcy’s general practice partnership when he left to focus on media, says D’Arcy is a natural story teller and a big-picture person whose natural instinct is to tell a story rather than formulate disciplined answers.

He says that D’Arcy’s media roles mean he does have to observe some rules and he can rise to the occasion when he has to, “but generally details are someone else’s problem”.

Dr Skelton admires the courage it took D’Arcy to change career, but wasn’t surprised and says the role suits him.

“He’s a frustrated actor, I would think.”

As a GP, Dr Skelton says D’Arcy was widely loved, and there was a positive aura when he was around and loud laughing heard from his room

”D’Arcy’s style didn’t appeal to everyone, however, with one patient complaining that the consultation was like a three-ringed circus.”

While circus is probably unfair, D’Arcy does have a reputation for juggling more balls than he can calmly manage at once and, as a result, regularly being late.

Dr Skelton recalls D’Arcy getting booked for having parked too long in the street outside the surgery and deciding that he wasn’t going to cop it sweet.

He waited keenly for his time in court, but then got caught up with media commitments.

“He sent his mother to represent him,” Dr Skelton says.

“She is this warm, delightful raconteur. I’m sure she got him off.”

It seems D’Arcy has inherited some of these traits. Dr Skelton says when D’Arcy announced he was leaving the practice, he wanted to have the option to come back if his media aspirations failed.

“Some other partners were not at all keen and they got a bit heated about it,” he says.

I remember him smiling and saying, “This is what I’d like to do. He appealed to our better nature and sense of fair play to accommodate his desires. He didn’t get angry and shout.”

D’Arcy won and a contract was drafted. But he never did need to go back.

DEDICATED TO GETTING THE MESSAGE OUT

Having worked on Today Tonight, Terry Willesee Tonight and with Derryn Hinch, Dr John D’Arcy makes no apology for having starred at the sensational end of journalism.

“It’s all very well to be on the Australian Government’s broadcaster and talk cleverly with other people of intelligence about what they consider the point of the day,” he says.

“But it’s very difficult to talk to people in the malls and football grounds about similar topics. They are my most important target. They reflect the people you see in general practice.”

D’Arcy says sometimes you have to put information in the oddest places to ensure people see it.

“It doesn’t matter what your education level is, it’s amazing the people who read, or are stimulated by, gossipy encouragements to read, listen or watch”

It is important to him, however, that some kind of reasonable perspective is achieved by the story’s end. If I thought an issue was going to increase anxiety, not lower it throughout the program, I would have to bite leather and argue my point forcibly.

”D’Arcy can remember only one time when he felt seriously compromised. He covered a story on statins, sparked by one high-profile patient from the US who claimed they caused memory loss. D’Arcy covered the story, but argued with his producer about one grab. D’Arcy felt it would cause people to stop taking the medication. The producer didn’t. D’Arcy lost.

“I questioned my role and came to think if suddenly someone did stop taking their statins and die, what would I say to the jury,” he says.

“I felt bad about that.”

While D’Arcy has worked for a significant number of TV and radio shows, he probably achieved his greatest media exposure after falling out of a tree. He’d just finished an eight-week trip with the science show Beyond 2000 and arrived home to find he had been robbed. D’Arcy was concerned the thief had climbed up a tree, which had branches dangling over the roof, so he set about hacking it back.

“Like all good men, I think I can do anything,” he says.

A green branch flicked back, knocking him in the head. The father of four split his cochlear in two and sustained severe frontal lobe damage.

“I shouldn’t have survived,” he says.

The accident made newspaper headlines and his progress was followed on talkback radio by John Laws and Alan Jones. Friends rallied round and collected money for him, which was wonderful but bad

Friends rallied round and collected money for him, which was “wonderful but bad” (touched, but embarrassed, he gave the money back) and the first girl he ever kissed left a roast dinner on his front step.

It was a traumatic time for D’Arcy, who had to learn to walk and talk again, but he says it was much harder on his wife, Wendy O’Donnell, a nurse who has worked as a medical adviser for All Saints, A Country Practice and now for Home and Away. Their youngest child was two.

“I felt vulnerable, but not as vulnerable as my wife did,” he says.

After the accident, he returned to Beyond 2000. His producer at the time, Brad Lyons, says Darky, as he was affectionately known, was still recovering during the eight-week trip they did through New Zealand, the US and UK. Despite being unsteady on his feet, D’Arcy finished 20 stories on topics as varied as hydro-electricity, heated prawn farming and depression.

“He worked bloody hard to get back to full speed,” he says.

“Beneath the good-natured, humorous bloke, he’s very dedicated to his cause. He’s very passionate about getting medicine’s messages out and demystifying it – getting messages out in a very simple way.”

While he says D’Arcy communicates complex messages simply, he also has a natural charisma that helps to ensure he is heard.

“If you want to talk bedside manner, I reckon he has one of the best. He’s a great people person.”

He remembers people constantly being drawn to D’Arcy while they were away. He laughs: “And it’s not because of his devilish good looks, I can tell you that.”

 

 

Enemy of psychiatry
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When a Sydney court was told last month that a 25–year-old woman stabbed three family members, killing her father and sister, the Church of Scientology was thrust into the media spotlight.

A medical report filed in court alleged the woman was mentally ill, but stopped taking prescription medicine and receiving treatment, apparently because of her family’s Scientology beliefs.  The court also heard that she resumed taking the medication prior to the attacks.

What ultimately led to the tragedy is for the courts to decide.  But the case has renewed debate about Scientology’s objection to psychiatric care.

Professor Ian Hickie, executive director of the Brain and Mind Research Institute at the University of Sydney, is concerned that Scientology may influence vulnerable individuals and says the negative health implications of this have never been adequately addressed.

“That, from a medical point of view, needs to be confronted,” he says.

“Individuals, particularly vulnerable individuals, may be taken in and a avoid treatment.”

It’s a concern that is not new.  The religion was banned for some years in Victoria after a 1965 State Government-commissioned inquiry that said Scientologists were conditioned to avoid psychiatrists and this “may have tragic results”.

Today, the Church of Scientology says there are constant “horror stories” of people who are adversely affected by psychiatric medication “who repeatedly report their inability to get anybody to listen or take notice”.

Professor David Copolov, professor of psychiatry at Monash University in Melbourne, rejects Scientology’s view that psychiatric drugs are dangerous and ineffective.

“For Scientology to say there are no data to support [psychiatric medication’s] usefulness is clearly incorrect,” says Professor Copolo , who was the Australian Drug  Evaluation Committee’s psychiatric expert from 1992 to 2000.

“All medications have side effects, but the balance between efficacy and side effects [with psychiatric medications] is hugely in favour of efficacy.

“We have to counter this anti-psychiatric rhetoric.  To the extent that it discourages seriously ill people from seeking and receiving treatment it could be very dangerous.”

Public affairs director for the Church of Scientology in Australia Ms Virginia Stewart told Australian Doctor that the church does “not agree with psychiatric drugs for a myriad of scientifically proven reasons”.

“It is not based on belief, but on fact, that drugs do not resolve mental problems,” she says.

“They cover them up and in doing so often cause great harm, including a worsening of the original feelings of depression, resulting in violence or suicide.”

She says this is why the church, which has 250,000 members in Australia and 10 million internationally, founded a separate organisation called the Citizens Commission on Human Rights (CCHR) in 1969.  The Australian Scientology web site explains that the CCHR’s role is “to expose and bring to an end the brutalizing of individuals in the name of ‘mental health’”.

The CCHR claims to operate in more than 100 countries and is an active force in Australia, making submissions to government inquiries, forming relationships with other interest groups, issuing press releases and lobbying politicians.  It claims to have exposed the Chelmsford Private Hospital’s notorious deep sleep therapy and is now lobbying strongly against pregnant women and children receiving ECT, against involuntary psychiatric treatment and the “drugging of children” for ADHD.

The Australia CCHR web site says:  “Recent studies show that children who take psychiatric stimulants for ‘ADHD’ are 46% more likely to commit one felony and 36% more likely to commit two or more felonies.  Instead of overcoming supposed learning difficulties, these children are at risk of moving toward a life of crime.

A string of sensational messages flash across the web site, borrowing spelling and facts from the international site:  “There are 374 ways for psychiatrists to label you mentally ill; every 75 seconds another innocent citizen is encarcerated [sic] by psychiatry; two million children and adolescents are on antidepressants that can induced violent or suicidal behaviour.”

The Australian site describes ECT as one of the “two main treatments used by psychiatrists today” and says its effectiveness relies on “overwhelming and damaging the individual”.

Professor Patrick McGorry, professor of youth mental health at the University of Melbourne, says the CCHR presents a very distorted picture of modern psychiatry.

“They’re projecting … that psychiatry as a profession would endorse widespread use of Ritalin, involuntary treatment of ECT,” he says.

“All of these things we have cautious views about.  They’re misrepresenting psychiatry’s position and modern psychiatry’s perspective.

He says the CCHR uses evocative issues such as ECT to more deeply entrench a One Flew Over the Cuckoo’s Nest version of psychiatry, which is “not what most people’s experience of psychiatry is”.

Professor McGorry says there is a great potential for CCHR fear-mongering to cause harm if it leads to a delay in people receiving treatment.

He says both the CCHR and Scientology “haven’t been tackled adequately” despite their beliefs having potential to interfere with vulnerable people’s health care.

“It is very damaging and yet they’ve not been brought to account for that behaviour,” he says.

“Great harm … can flow from the stance they have taken.”

Executive director of the CCHR’s National Office for Australia Ms Shelley Wilkins rejects that psychiatrists are cautious.

“It cannot be proven that anyone has any of psychiatry’s disorders and their DSM actually says, for example, that there are no laboratory tests for ADHD or schizophrenia, so caution does not come into it.  Any use of Ritalin, involuntary commitment or ECT is therefore based on a fraudulent diagnosis and abuse,” Ms Wilkins says.

In response to the suggestion of CCHR fear-mongering, she says psychiatry “causes fear with its brutal treatments and dangerous drugs”.

“People do not want to seek help from psychiatry because their treatments can cause great harm and even death and they fear being involuntarily detained and treated,” she says.

“CCHR is dedicated to informing the public about the dangers of psychiatric treatments, and as a result lives are saved.”

Chief psychiatrist for NSW Associate Professor John Basson acknowledges widespread concerns in Australia about Ritalin being over prescribed.

He also says some US courts have deemed that Prozac can make some people violent.  “These circumstances seem to be rare, but they are to be concerned about,” he says.

But Professor Basson says the CCHR uses extreme, negative examples from the world literature to evidence its stance against psychiatric medication.

“It uses extreme examples to make an argument about the general use of the drug,” he says.

“A lot of adults take these drugs and get relief from serious and debilitating circumstances.”

He says those who are influenced by the CCHR “might choose not to go and get help.  They may try and do without and become very sick indeed”.

Professor Basson says there is a danger in not treating mental illnesses that recur.

“Those that recur would recur much more seriously.  The [risks] in not doing anything are very bad indeed.”

He says psychotic episodes can cause people with schizophrenia to lose key non-verbal communication skills and experienced a degree of emotional blunting.

“It damages people’s capacity to have good intimate relationships,” he says.

“It could lead to long-term disability for people, which we feel [with treatment] we could avoid.”

Professor Basson says poor compliance is already a problem, with about 50% of mentally ill patients not taking prescribed medication.”

There is a danger [the CCHR] encourages that percentage to stay high when we are trying to reduced it.”

 

Scientology at centre of GP’s beliefs

Dr Helen Smith is a Scientologist. Photo by Warren Clarke.

It was while studying medicine in Perth about 20 years ago that Dr Helen Smith became a Scientologist.

The New Zealand GP says her interest was sparked after reading Dianetics: the Modern Science of Mental Health, written by Scientology’s founder L Ron Hubbard.

“I tried it out on family and friends and saw it had something in it – it actually helped people,” Dr Smith says.

“It’s basically a study of the mind. There is a part of your mind that contains all of the painful experiences … Dianetics allows the person to go back to those moments, uncover what happened at the time and get relief from it.”

Dr Smith, who is also a commissioner for the church-founded Citizens Commission for Human Rights (CCHR), gives the example of an acquaintance who experienced bad headaches after a car accident.

“He … had a memory of the accident, and as we went through it, he got memory back of smacking his head through the windscreen and as he spoke about it he got relief,” Dr Smith says.

Such is her faith in the process that she recommends it to patients with psychosomatic symptoms.

“In my current practice, if I have anybody who is having trouble with grief and loss, who is psychosomatic, I’ll get a dianetics counsellor in the community to help them out with it,” she says.

She says these patients also benefit after a couple of sessions. She says it is not used as a way to recruit people to Scientology.

Dr Smith says about 20% of her week is spent working with CCHR to educate youth about human rights issues and will attend a forum this month for 13-18-year-olds. She also has a role liaising with New Zealand MPs and helps the CCHR document incidents of psychiatric abuse, working through medical records obtained using freedom of information laws.

The rest of her time is spent at the Holistic Medical Centre in Auckland – a practice she established four years ago, which is staffed by 4-5 GPs, a Naturopath and a nurse.

She says the clinic is upfront with patients about its policy that doctors do not prescribe antipsychotics, antidepressants or Valium.

Patients already taking these medications are told they need to keep seeing the doctor who prescribed them.

“If someone is already a psychiatric patient and in that whole world, I say if you’re on those drugs and on that road, you carry on with that. I don’t interrupt that in any way,” Dr Smith says.

However, she runs these patients through a full physical check and reviews their biochemistry and haematology indices.

She says patients often have low vitamin D, which makes them feel depressed, unable to sleep and low in energy, and psychotic patients with low vitamin D become more stable if the level is raised.

Dr Smith has three times in her career managed people experiencing a psychotic episode. She says these patients need to be given a light sedative and watched over until the episode has ended. Then they should be given a thorough physical check and provided with good nutrition.

Dr Smith says she prefers not to use diagnostic terms such a depression used within the DSM because it is “a bit arbitrary”. She says these labels tend to put people on a path to medication.

“Sometimes if you get protein in their diet, they feel better.”

In terms of non-drug therapies, Dr Smith says she doesn’t oppose cognitive behavioural therapy if it creates an improvement.

I’m into Hippocratic oath – do no harm,” she says.

 

Ice baths, broken bones and lobotomies

How Scientology sees psychiatry

The Church of Scientology is open about its views on psychiatry. Put simply, it rejects the notion that mental illness is caused by a chemical imbalance in the brain and it rejects psychiatric diagnosis and medication.

“We do not believe people should be stigmatized with labels and ‘treated’ with ‘cures’ that have no basis in fact or science and are brutal in the extreme,” its Australian web site says.

The site says psychiatry has a history of abuse, listing past treatments such as ice baths, insulin shock and ECT that breaks teeth and bones, causes memory loss and “regression into a vegetable [sic] state.”

“Next it was pre-frontal lobotomies with an ice pick driven through the eye socket. Today it is drugs. The reason is obvious. Drugs are more palatable to the public than [sic] 220 volts of electricity or an ‘apple-cored’ brain and a lot more profitable – by billions of dollars a year,” it continues.

The site says it is frightening that psychiatry is pushing “to label and stigmatize an entire nation and its youth with labels of mental disorders” and despite there being no evidence that mental illness is caused by a chemical imbalance of the brain, “antidepressants are prescribed like candy”.

It says drugs for ADHD and depression do not offer a cure, but once people start taking them “it’s an unending series of pills that one cannot even quit taking because of the withdrawal effects”.

When it comes to the issue of mentally ill people posing a risk to themselves or others, public affairs director for the Church of Scientology in Australia Ms Virginia Stewart says they should be placed in a safe, quiet facility, sedated if this is required, and given good nutrition, the opportunity to rest and time to recover.

“Such people must be treated with decency, not placed in open wards full of drugged-out psychotic people who have been chemically restrained. They must undergo full, searching medical tests by a non-psychiatric doctor, conducted too find any physical condition, underlying the person’s behaviour,” she told Australian Doctor.

“They should not be given drugs which have been proven to worsen their condition and they should be healed.”

The WA charter of the church-founded Citizens Commission on Human Rights (CCHR) says criminal statutes should be relied on to address instances where a “dangerous offence” is committed.

“Studies demonstrate that psychiatric predictions of dangerousness are no better than flipping a coin. Psychiatrists cannot ‘cure’ what is essentially criminal or anti-social conduct,” it states.

It quotes US professor emeritus of psychiatry Dr Thomas Szasz who co-founded the CCHR with Scientology, as saying: “All criminal behaviour should be controlled by means of criminal law, from the administration of which psychiatrists, ought to be excluded.”

When asked if Scientology opposes cognitive behavioural therapy, Ms Stewart responded: “I personally do not know what cognitive behavioural therapy entails and thus don’t have any comment. We do not agree with treatments such as electric shock treatment or lobotomies or aversion therapy – or other practices still bent on imposing physical treatments for mental ills.”

Given time to research CBT further, she still declined to comment, but said” “There should be far more talking therapies. If you can address the underlying cause and you resolve it, then it’s a whole different game.

“If someone has a relationship problem and you address the relationship problem if they were depressed because of [it] there would be some likelihood of diminishing the depression. When someone can go to a GP and get a psychiatric medication, I think that sucks.”

Ms Stewart says that while Scientology rejects psychiatry, many members see chiropractors and naturopaths, and they rely on GP to diagnose the physical issues that may cause mental symptoms.

“If someone was acting extremely depressed, they would immediately be sent to a very good doctor and tested inside and out, and every single time something is found with their physical health. If you fix that you might get an improvement in their depression symptoms.”

But she says the counselling offered by Scientology works to enhance mental health.

“Someone who was a Scientologist and had dianetics counselling would definitely have, statistically, less chance of experiencing mental health issues,” she says.

The principle underlying dianetics, which for Scientologists is “the modern science of mental health”, is that when people are unconscious or have lowered awareness, due to being sick or exhausted, their unconscious mind takes a detailed recording of everything that takes place. This recording, called an ‘engram’, is stored in the mind and can take control – like a form of hypnosis. This is evident when people are anxious or have panic attacks.

“They [engrams] can make you think or behave irrationally,” Ms Stewart says.

Dianetics counselling enables people to remember the recorded event and pull it into their “analytical mind” where they have control over it, she says.

“When they can see it [the recorded incident] and remember it, it loses that hypnotic power.”

Ms Stewart says Scientology also offers “assists”, which are used for a range of conditions, ranging from toothache to trauma and are “very effective” at making drunk people sober.

“An assist is not a substitute for medical treatment and does not attempt to cure injuries requiring medical aid, but is complementary … It is even doubtful if full healing can be accomplished by medical treatment alone and it is certain that an assist greatly speeds recovery.

“Often people have emotional upsets and stress prior to getting sick or injured, and unless this is addressed and the problem removed, then the conditions can persist, despite the best intentions of the medical practitioners.”

Some assists involve touch, while others are spoken. Ms Stewart says the assist for a cold involves asking specifically worded questions that the person answers until they “come to their own realisation” about the loss that has caused them to get a cold.

“They could have had a large fight with someone or a threatened loss,” she says.

“You ask the person and they have to answer you until the person has their own realisation [about the cause].”

 

No attack dog
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Photo by: Patrick Cummins

ONE suspects Bill Madden’s nondescript tie, with its diagonal stripes in various greys and blues, was a practical choice, made on the basis that it would team nicely with most other outfits in his wardrobe.

His grey pants, pleated at the front, have ample room in the back. His blue shirt pulls slightly over his middle and his rumpled sleeves have had a busy morning of being rolled up and down.

There is nothing slick, showy or self-important about Madden, 49. If you bumped into him on the street, you’d never pick him as one of the country’s leading plaintiff lawyers.

Slater & Gordon is the largest plaintiff law firm in the country and he’s responsible for the firm’s professional negligence work. His opinions of doctors and the health system have been coloured by more than 20 years of hearing angry stories about patient suffering and injustice, yet his views on health care are almost as straight and sensible as his tie.

Working as a plaintiff lawyer has made him realise that, as a patient, “it’s often wise to pay attention”.

“I don’t think you can abdicate responsibility when you go into the health system,” he says.

He doesn’t dislike doctors. And if that’s a little difficult to digest, consider that he sometimes helps angry clients see doctors in a different light.

“There are some cases where the activity of the doctor has been appalling,” he says. “But what you usually find is that there’s been a mistake and there’s probably no great medical culpability. Sometimes it helps people to know that it’s human frailty involved, not that they’ve been singled out for some kind of arrogant behaviour.

“Just because something goes wrong, it’s not necessarily the result of negligence or failure of the hospital system.”

Inner-Sydney GP Dr Brian Churnin has clearly enjoyed being Madden’s doctor for more than 20 years.

“He’s not a doctor-basher,” Dr Churnin says. “He’s a very normal person doing a job, just as I’m doing a job. I find him a very-easy-to-get-along-with gentleman, who listens to advice and has the utmost respect for the medical profession.”

The former Chief Justice of NSW, Sir Laurence Street, agrees. As a mediator, he has worked closely with Madden for about a decade and says he lawyer’s calm and reasoned style serves him well.

“The flamboyant lawyer may be good on television, but in the real world of lawyers, they don’t cut much ice,” he says. “He’s trusted and respected by his colleagues – including those on the other side.”

***

Clutching tissues and shaking with grief, two traumatised parents sit in Madden’s Parramatta office, reliving the death of their baby at a major Sydney hospital. There is plenty of opportunity for Madden to reinforce the evils of the hospital system or the shortcomings of young doctors. He doesn’t.

The mother is disturbed the staff seemed so casual when their baby was so ill. Madden gently suggests this approach could be preferable to panic. She’s had letters of explanation and apology from the hospital, but still doesn’t understand how things could have gone so wrong. Madden reassures her the hospital is one of Sydney’s best and has a reputation for openness.

Along the way, he’s encouraged the couple to work out what they would like to achieve if they opt for legal action. The case would be likely to offer some money and maybe more answers, but gently woven through his explanation is a reminder that it won’t wind the clock back.

The parents leave the meeting upset by the memories they’ve relived but, it seems, no more disillusioned with the hospital system than when they went in.

Madden is the kind of legal big wig who makes his own cup of tea. As he strolls towards the tearoom, he reflects on the meeting.

“Every now and then you find cases that are more upsetting than others, especially when other children were involved and if the children are the same age as your own,” he says. “It’s always very distressing, but it’s unhelpful for me to get emotional in these situations. My role is to find a way to navigate the legal system for them.”

Madden spends most of his time talking to distressed people and medical experts, usually with the aim of trying to answer one basic question. If the problem had been recognised and treated earlier, or if the treatment had been different, what difference would that have made to the patient’s health outcome>

“I try and find [a medical expert] who is competent and skilled in the area. There has always been this debate as to whether court experts are a hired gun,” he says. “That’s very unhelpful for me. It doesn’t help me predict the outcome of a case. I want someone who is going to give me a nice, conservative, well-balanced opinion.”

The firm receives about 250 inquiries each month and Madden reviews a two-page summary of each to determine which cases warrant further investigation.

“At any one time there are 80-100 matters under investigation here,” he says.

He needs to do a quick calculation of some pretty large figures when deciding whether or not to pursue a case.

“Some doctors have a sense that lawyers will take on any case, regardless of whether they will win or lose. I can assure you that is not the case,” he says.

“I have a budget in terms of how much I have to produce for the firm, a budget for medical reports and staff I can employ. At the end of the day all of those numbers have to add up to make sure its financially viable.”

If Slater & Gordon loses a case the firm doesn’t get paid; not for lawyers’ time or money invested in medical reports. But Madden also has a responsibility to protect his clients from unwise decisions, since losing could mean having to pay the other side’s legal costs.

“It’s the risk to them [the client] that’s the problem, not to us,” he says.

“[Sometimes] people are forced to compromise because they can’t run that risk.”

These days, most cases settle before they get to court, which is why Madden doesn’t have a list of high-profile medical cases that he’s lost or won.

“It’s rare to run a case to trial these days,” he says. “That’s not to say they don’t get close.”

He strolls back to his office, which has views through sheer black blinds to the barred windows of a carpark across the lane, and reaches into a tiny bar fridge beside his desk. As he grabs a can of coke, he sheepishly confesses the fridge is dedicated to that particular beverage.

“You’ll see that it is Coke Zero,” he smiles. “Otherwise I’d get into all sorts of trouble.”

His voice is matter-of-fact and without colour when he speaks to clients over the phone. It’s a style that seems to enhance his ability to sensitively glean the facts from people who are emotional and have long stories about how they’ve been wronged.

“Obviously all that would have been devastating for you, and no doubt still is, but I need to be able to demonstrate that there would have been a different outcome if something had been done sooner,” he says to one.

He gently steers another back on track. “So, before we get into that level of detail, I’m just trying to get my head around…”

He started work at 7am and his voice is starting to crackle as he calls another client. Hand clenched around his Coke, he takes a sip through the straw.

Discussing he potential outcomes of the case, the client says: “It’s never been about the money.”

“Unfortunately that is the only thing I can do, and in the process get some questions answered,” Madden says.

He takes a break from the phone to explain the importance of clients having realistic expectations.

“The term that gets used in the profession is ‘expectation management’,” he says. “Similarly to the medical profession, I need to ensure people understand what the broad range of outcomes might be. If I’ve done my job well enough, by the concluding phase they’ve been able to understand what is and is not realistic.”

Listening in on Madden’s conversations it’s clear he has extensive clinical knowledge – a point not lost on his GP. D Churnin says he doesn’t treat the plaintiff lawyer any differently from his other patients, except that at times it’s like treating a medical specialist.

“It’s almost like talking to a doctor and probably on some topics he knows more than me,” Dr Churnin says. “I think he knows a lot about the topics because he researches very thoroughly and has a very retentive mind. I certainly wouldn’t like to have him on my tail.”

It’s probably small consolation for those who do find Madden in pursuit, but Dr Churnin thinks the plaintiff lawyer’s expectations are reasonable.

“He has a very good understanding of what a normal doctor should do, not what God should do,” he says.

 

A MAN FOR JAPAN

We settle on a quick bite of sushi for lunch and Madden looks amused as he ponders how this trivial decision might look in print.

It’s the second day in a row we’ve had Japanese and it’s been noted several times that Madden’s interests outside work seem very consistent; anything to do with Japan.

“It will give you scope to portray me as entirely one-dimensional,” he chuckles as we head for a table.

Madden has been to Japan three times, but no other country, to date.

“Japan is a terrific place to go with kids and it’s like visiting the past and the future at the same time,” he says.

He has created a Japanese garden in his backyard at home and there are three photos on his office wall, each taken in Japan. One small shelf in his wall of textbooks and folders holds a collection of Japanese trinkets.

“Once you have these up,” says Madden, gesturing at the photos, “people give you Japanese things.”

Madden says Japan and photography are the two obsessions in his life, aside from his 14-year-old son, Ben.

“Everyone is obsessed with their children, of course.”

But there is one other dust collector in the bookshelf that varies from the theme. It’s a silver model of a VW Beetle, complete with sun roof – a miniature version of Madden’s first car. He spent many hours restoring the grey 1962 Beetle, hand stitching old seats, rubbing back paintwork and searching for a radio that operated on six volts (his father found one in Papua New Guinea in the end).

He remembers the car fondly, even with its limitations.

“If you opened the sun roof, it slowed the vehicle to half its speed,” he says.

 

Turning the tide
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Photo by: Warren Clarke. Dr Jamal Rifi (left) with surf lifesaver Mr Lee Howell.

IT’S a scorching Saturday in Sydney’s south-west but no one seems to begrudge having sweltered all morning in this airless brick box. The instant a lunch break is announced about 20 teenagers fill the sterile clubhouse with talk. All eyes turn to Dr Jamal Rifi – or at least the tower of pizza boxes he’s navigating through the door.

The Muslim GP has spent the past week bombarded by extreme messages of hate, gratitude, admiration and contempt, after he called for Sheik Taj El-Deen El-Hilali to stand down as Mufti of Australia for likening immodestly dressed women to uncovered meat.

But today Dr Rifi is distracted from this emotion-charged drama by the grand plan taking shape in this horrible hot room.

Pizza distributed, Rifi heads over to chat with a friend, an animated Lebanese taxi driver – Sheik Hilali’s taxi driver, no less – who’s smiling broadly and helping himself to a slab of watermelon. A cameraman steps around to get a better view as the two discuss the logistics of getting everyone to the pool.

Rifi, in a crisp, lemon shirt and dark-blue jeans, leaps on to a chair and issues a short, sharp whistle. In an instant, the room is silenced and every teenager looks to him for direction. He is warm but formal as he sets about housekeeping. The room will be left tidy. Raise your hand if you need a lift.

It’s only the documentary makers, filming unobtrusively in the background, who give a sense of the significance of today’s events. These Muslim teenagers have just had their first theory lesson in surf lifesaving. By December, they’ll be patrolling the beach in red-and-yellow caps. Cronulla beach.

Some of the girls will team the caps with a traditional, modest full-length ‘burqini’, as they work alongside blond-haired, blue-eyed Aussie blokes.

It’s a profound image of reconciliation and healing that isn’t lost on the BBC and SBS, who’ve teamed up to film Race for the Beach. Set to screen in the middle of next year, it will track one of the teenagers working to become one of Australia’s first Muslim lifesavers. Rifi, a former Community Relations Commissioner, has recruited 22 teenagers from the Lakemba area and inspired them to become cultural ambassadors. It’s a bold plan he conceived when he took time off from his practice to work with youth and bring about peace at the time of last year’s Cronulla riots.

“What happened at Cronulla was a shame on some of us,” Rifi tells Australian Doctor. “If it happens again, it will be a shame on all of us.”

Surf Life Saving Australia’s national diversity manager Mr Lee Howell says Rifi has an extraordinary capacity to rally people and get things done.

“He’s a very focused man,” he says. “If the doc says we’re going to do something, it happens.”

Mr Howell acknowledges there has been “quite strong” scepticism about the project.

“There are knockers from within south-western Sydney and surf lifesaving,” he says.

“Dr Rifi says we must deal with people through showing the positives and showing we can achieve harmony.”

It’s the desire to achieve harmony that inspired the recent upheaval in Rifi’s life.

Back at his Belmore home and surgery – a heritage listed Tudor-style building set on large grounds – Rifi closes the padded sound-proof doors between his waiting and consulting rooms. Sipping a strong espresso, he says many Muslim people have strongly supported his stance against the Mufti.

But not everyone approves. He pulls out a threatening letter penned in Arabic that he has forwarded to police and swings his computer screen to show e-mails ripe with contempt. A drawer holds four mobile phones he leaves switched off because the harassing calls were so constant. He has increased security, is in close contact with the police, and has tried to explain the situation to his wife and five children, aged between eight and 20, so they will be “alert but not alarmed”.

“All it would take is one person to hate me strong enough, for long enough,” he says. “I don’t pretend in any way what I have done is of a small scale. I knew what I was doing. I knew if I didn’t do it, I would have a tormented conscience for the rest of my life.”

Rifi and the sheik had been good friends for more than 20 years.

“We became friends through my good work in the community and his good work in the community,” Rifi says. “He assisted me a lot. But our spokesman has done so much damage to our community’s reputation. When I go to my community, I go to build the bridges.

“You shouldn’t be defiant. You shouldn’t be insular. What he said was totally wrong. When he was talking he was dangerously wrong, because he was taking us on a collision path with the rest of society.

“To be a good Muslim in Australia is different than being a good Muslim in the Muslim world. You need to adapt your religious values to comply with the cultural aspect of life in Australia,” he says.

***

It was a sweet young Lebanese girl who led Rifi to Australia in 1984. He had been studying medicine for four years in Romania when he learned that someone was planning to marry his beloved Lana.

“Her cousin had asked for her hand and her father approved,” Rifi says. “So if I didn’t act I would have lost her.”

Lana, who had lived in Australia from the age of three, was in Lebanon on holiday after her HSC when Rifi secured her hand. His family approved of Lana but wanted him to finish his degree. For Rifi, the stakes were too high.

“We met when we were little – when I was 14,” he says.

“I knew from then that I wanted to marry her. Not just me. She knew too.”

The couple moved to Australia, penniless, and had their first child when Rifi was in his third year of medicine at the University of Sydney.

Rifi decided he was going to be a doctor as a young child when grieving the death of his two-year-old brother – “the darling of the house”. The boy died after a doctor gave him an injection, from what Rifi knows now was an anaphylactic reaction.

“I still remember my mother crying over the body of my brother,” he says.

“Then I decided I wanted to be a doctor who saves life. I wanted to become not just a doctor. A good doctor.”

It was a goal encouraged by his father, Ahmad, who taught Rifi from a young age that poverty, illiteracy and sickness were the enemies of a functioning community. The owner of a wheat mill, Rifi’s father formed a health co-operative in Lebanon in the 1960s, pooling funding to give Tripoli’s destitute access to GPs, dentists and pharmacists.

“He ended up in prison… because he was so successful and he had a lot of followers. Because poor people were being treated properly for the first time,” Rifi says. “He went a couple of times to jail. I remember the poverty we went under because we had no income and my mother struggled to feed us. But I also remember us walking with our heads high. He did the right thing and was very much respected.”

Rifi, 47, has his own reputation as a peacemaker and he too holds his head high. Although he is not keen to big-note himself, the photographs by his desk do the talking. There he is with NSW Premier Morris Iemma, a good friend and patient. Or, again, standing proudly beside former premier Bob Carr.

Another photo shows Rifi sitting with his two brothers in majestic gilt-edged chairs. Both brothers still live in Lebanon, where one heads the country’s police force. In another shot, Rifi is posing with an Aboriginal dance group who caused a sensation when he took them to perform in Lebanon.

Despite his recent time in the media spotlight, Rifi is most comfortable behind the scenes, working on small community projects that bring about significant change. The stigma attached to being a Muslim appals him and he’s doing his best to help his community chip it away. The photo with Bob Carr was taken at the recent launch of a parenting magazine written in both Arabic and English, a project Rifi instigated because he could see the damage disrespectful Lebanese teenagers were causing.

“Arabic boys, they respect their parents and behave positively at home but they don’t show that respect to their teacher, or coach on the soccer field, or even the police officer,” says Rifi, who believes this stems from a lack of discipline at home.

The boys, who are fluent in English, take advantage of their Arabic-speaking parents who rely on them to translate, he says. Any attempts to discipline the teenagers are met with a defiant explanation that here that is against the law.

“Parents did not know their role in terms of disciplining their children in an Australian cultural context,” Rifi says.

The teenagers can be bold and crafty in their deceptions. When one school principal called for a meeting to discuss errant behaviour, the parents were told they’d been summoned to be congratulated on their son being top of the class.

The parenting magazine is just one of the many projects developed by the Arabic Youth Partnership Rifi instigated with the NSW Government five years ago. And he’s also active on the ground, speaking with parents on Arabic radio and giving talks at local schools, often with one of his own children speaking alongside him.

But it’s not only people from the Muslim community who have benefited from Rifi’s willingness to fight for a worthy cause. When he was asked to become involved in the Lakemba Sports Club, he happily took on the role of president.

“That club was run down. I saw we can ill afford not to have a sporting organisation in this area,” he says, appreciating sport’s role in building self-esteem and intercultural friendships. On weekends, he supervises 20 people on parole, who he has organised to do community service at the club.

Local war veterans are also grateful for the efforts Rifi has made on their behalf. Rifi pops in once a week to the block of units where some of them have lived for more than 25 years.

As they wait to see him, a small group of veterans struggle to convey the depth of admiration they have for their doctor who successfully lobbied state and local governments to prevent the flats from being sold and the vets being shipped off to live in country towns. Not that the flats were a great place to live when Rifi started his weekly visits in the early 1990s.

“It was a place for people to die. It was a very depressing place,” Rifi says.

But he established a common room, to encourage the residents to socialise, and secured a dedicated treatment room. He has also organised for a pharmacist to collect his scripts and deliver medication.

“I never knew a Muslim before him,” a patient in the waiting room explains, laughing so hard at his own story there’s a risk it may not be old.

“I said, ‘How do I become a Muslim?’ And he said, ‘Peter, you’re not allowed to – we’ve got enough ratbags already’.”

There are plenty of others with good reason to feel gratitude to Rifi. Like the Lebanese woman with kidney failure he brought to Sydney to receive a donated organ from her brother. He arranged visas and helped raise $55,000 to cover the woman’s costs.

But the achievement he is proudest of was bringing a five-year-old child with oesophageal stricture from Iraq to Australia for a life-changing operation. The boy, who had only ever been able to swallow fluids, weighed just 15kg when he arrived. Rifi organised his visa, not an easy task in the days when Suddam Hussein ruled Iraq, guaranteed to meet expenses and found a surgeon who would operate without charge. Rifi watched in delight as the child took his first bite of a hamburger.

“There was a job to be done. I was able to do it. I did it,” he says. “Did I have pride in doing it? Yes.”

It’s not surprising that Rifi doesn’t waste much time on sleeping.

“I only live once. I don’t have much time to waste,” he says. “A lot of my networking and my communications will happen while I’m driving in the car or late at night. I send e-mails at 4am.

“During the day, I have to earn my living. I have five kids. I’m not a rich person. I don’t have the time to [focus on earning] money.”

The time for reflection on everything he’s achieved may come later.

“I’m hiding it for when I get old,” he laughs. “So when I lay down and look at what I’ve achieved in my life, I know it won’t be in vain.”

Abortion: Part 2 – Law and disorder
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Photo by: Warren Clarke. Dr David Grundmann...

It sounds like such a simple and sensible fix:  make Australia’s abortion laws clear and consistent, so doctors and their patients know what is legal and what is not, and women across the country have equal access to the procedure.

But it’s not simple and it may not even be sensible.

The AMA’s calls for clarity and consistency in abortion laws have acquired new urgency after recent controversial cases in NSW and Victoria.

But one expert in health law and ethics believes there are serious risks in asking for abortion laws to be spelled out, describing such a move as “unwise”.

Associate Professor Cameron Stewart, from the law department of Sydney’s Macquarie University, says the vagaries of the law enable doctors to make their own informed judgments in a complex area with many variables.

“The cost of having certainty is that you may need to have more regulatory control,” he says.  “[New laws] might be more prescriptive and more difficult to comply with.”

Although he understands doctors feel vulnerable, particularly in states where abortion comes under criminal law, he says their fear is ill-founded.

“The wobbliness is in favour of doctors,” he says.

“Doctors have a tendency to feel victimised, but it’s crap – the system is set up to protect them.  Criminal law presumes you’re innocent.  This is not an area of law where abortion practitioners should feel threatened.”

AMA president Dr Mukesh Haikerwal disagrees.  While he acknowledges any effort to address problems with abortion legislation is risky, he says it would be an improvement if doctors knew where they stood – even if the law became more prescriptive.

“If you’re working in a fog, and a practitioner is caring for a woman in this way and is at risk, I don’t think that is a tenable situation either,” he says.

Although it would  be “problematic” if clarifying the laws resulted in more restricted access to abortion, Dr Haikerwal says the current lack of clarity brings its own difficulties.  “I don’t think the position would be worse than now if it clarified doctors’ rights and responsibilities in this area.”

The AMA has stopped short of calling for abortions to be removed from criminal legislation, but Dr Haikerwal says if this brought clarity and consistency the AMA would support it.

“The issue is that, where abortion is deemed legal and is being carried out, that practitioners should not be at risk of being prosecuted,” he says.

“Because of the nature of the current laws, in some states that is a possibility.”

Decriminalisation is exactly where the AMA should focus its lobbying, according to Dr Leslie Cannold (PhD), senior lecturer at the centre for gender and medicine at Melbourne’s Monash University.  The AMA should stop pushing for nationally uniform legislation and aim for state based change, one jurisdiction at a time, starting with Victoria.

“It is exactly the right time to push for a repeal bill [to remove abortion from criminal law] in Victoria, because the Bracks Government is about to be re-elected and it is only at the beginning of the term of a new government that they will take this issue on,” says Dr Cannold, who is also a board member of Family Planning Victoria and a principal of Reproductive Choice Australia.

“If Victoria goes, there is a very good chance of repeals in NSW and Queensland, and then you’ve covered most of the doctors and most of the women in the country.”

Last month the NT became the second Australian jurisdiction, after the ACT, to remove abortion from criminal legislation, including it in the Medical Services Act with all other health-related legislation (see box * below).

Private obstetrician and NT AMA treasurer Dr Jenny Mitchell says moving the legislation out of the Criminal Code of NT has brought some peace of mind, but the new laws still lack adequate clarity.

“They only changed about five words in the whole Act when they moved it,” she says.  “[But] it’s good not having that big knife hanging over your head – that if someone gets their knickers in a knot, the police will come knocking on your door and charge you.”

The call for decriminalisation has also come from leading Melbourne obstetrician and ultrasonologist Associate Professor Lachlan de Crespigny, who write in the Medical Journal of Australia highlighting the inequity of Australia’s inconsistent laws and calling for “a single clear national law on abortion, both in early and late pregnancy”.  While acknowledging there would be “objections and difficulties in clarifying and unifying Australian abortion laws”, Professor de Crespigny said previous legislative reform on other state based issues showed it was possible. (1)

“Unifying laws would require states and territories to work together, presumably with Federal Government input,“ he wrote.  “The process would not be easy but could be achieved with sufficient co-operation and determination, as shown by the successful introduction of new laws on gun ownership and embryo experimentation.”

A spokeswoman for the Attorney-General’s Department says the Federal Government does not have power under the constitution to enact uniform national abortion laws.  Uniform gun laws were only passed after state and territory agreement at a meeting of the Australasian Police Ministers’ Council, while consistent laws on embryo experiments arose out of agreement in the Coalition of Australian Governments.

Either of these bodies could, in theory, bring about national conformity on abortion laws, as could members of the Standing Committee of Attorneys-General.  The standing committee could have done this through the subcommittee it set up to draft a national model criminal code.  However, in 1998 the subcommittee formally backed off on abortion, saying it was “not in a position to make a final report to ministers on … a recommended legislative position” and that “consultation proved that the issue is ultimately one for political decision”.

A former adviser to Federal Parliament, specialising in health and bioethics issues, Dr Natasha Cica (PhD), says chances of national legislative reform are “pretty much zero”.

“It would be possible for the states and territories to get together to achieve national reform, but that demands politicians’ will and, in the case of abortion that is most unlikely,” says Dr Cica, who prepared a comprehensive report on abortion law designed to be used as a resource for MPs debating the issue.

Member of the ACT Legislative Assembly Mr Wayne Berry proved he had the will when he lobbied successfully for abortion to be decriminalised in the ACT in 2002, but he too holds out little hope for consistent national reform.  “It could occur – at COAG there could be a broad agreement – but I doubt it would happen,” he says, suggesting a state based attempt at decriminalisation is the only way ahead.

But even that would take great time and patience, largely because politicians believe taking a stand on abortion issues can end their careers.  Mr Berry, though, found the opposite to be true in the 10 years he pushed for reform in the ACT, despite heavy lobbying from the Right to Life Association.

“The important thing that I learned from my experience as a campaigner for abortion law reform was that most in the community supported the actions I took and my stance earned their respect,” he told a recent Reproductive Choice Australia meeting.  “While anti-abortion campaigners are loud and well organised, they are out of step with the rest of the community.

“It is a mistake to view their loudness and organisational ability as a reflection of how the rest of the community will vote on the issue of abortion.”

Abortion provider Marie Stopes International works across four different legal jurisdictions in Australia – NSW, Queensland, WA and the ACT – and sees the problems caused by complex and unclear laws.  But Australian CEO Ms Suzanne Dvorak cautions against hasty moves for change.

“While it is important that the community discusses this issue, we need to be careful about jumping to what we think is the solution too quickly,” she says.

“National legislation, particularly the decriminalisation of abortion, could be the answer, but there may be other possible solutions that need to be explored before making that decision.

“It is important that the debate remains focused on upholding a woman’s reproductive rights.”

 Reference
(1)  MJA 2004; 181:201-03

 ENDING AN ANOMALY

There has been a bizarre anomaly in the NT’s abortion laws for the past 30 years.

The laws stated that only a gynaecologist or obstetrician could terminate pregnancies of 14 weeks’ gestation or less, while any “suitably qualified medical practitioner” could perform terminations up to 23 weeks.

Private obstetrician and NT AMA treasurer Dr Jenny Mitchell says this had prevented private clinics from operating in the territory, where the workload was being carried almost entirely by one obstetrician in Darwin.

But legal reform last month, which saw abortion laws moved from the NT’s Criminal Code to the Medical Services Act, have overcome the long-standing inconsistency.

The new law still requires an obstetrician or gynaecologist to be involved “where reasonably practicable” in any termination before 14 weeks, but Dr Mitchell says it now allows qualified GPs to perform these terminations and does not preclude the use of RU486.

 WHAT THEY SAID…

Queensland

Dr David van Gend is a Toowoomba GP who will not prescribe the morning-after pill or refer patients seeking an abortion.  He is Queensland secretary of the World Federation of Doctors Who Respect Human Life.

“The laws are inadequate, but in the current brutalised cultural climate, any change would be for the worse.  The laws should not be removed [from the criminal code], because they keep a social ‘truce’ between those who [believe] that it is wrong for adults to kill their young, and those who want … the unrestricted freedom to kill their young.

“The current [criminal code] arrangements … achieve that pragmatic truce, and to upset that balance would only heighten the social discord over abortion.  Prudent politicians know the laws are best left well alone.”

Victoria

Dr David Grundmann performs late-term abortions at a Melbourne surgery and earlier abortions in the four clinics he owns in Queensland and one in NSW.

“We treat our patients as normal medical patients, but the law doesn’t.  There’s no reason why abortion should still be in the criminal code.  I don’t think there should be any laws regarding abortion.”

Associate Professor Lachlan de Crespigny is a leading Melbourne obstetrician and ultrasonologist.  In 2004, he co-authored a Medical Journal of Australia article calling for clarification of Australia’s abortion laws, which included the following comments:

“Why should an ACT woman carrying a foetus with major abnormality at 20 weeks be entitled to a legal abortion yet if she lived in WA she would need to win approval from a government committee, while in NSW her access to abortion would be uncertain?”

 NSW

Dr Geoff Brodie is a medical director of Australian Birth Control Services and has two clinics in Sydney.

“[In NSW] the doctor must have an honest belief on reasonable grounds that … [it] would be detrimental to the woman’s health [to continue the pregnancy].

“Only one doctor’s opinion is necessary and the onus of proof is on the crown, which makes it even harder for someone to prosecute the doctor.  No jury is going to convict a doctor under normal circumstances.”

NT

Dr Jenny Mitchell is a private obstetrician and NT AMA treasurer.

“I think the law as it stands gives us a lot of scope because it’s not restrictive at all.  A lot of people would call for more clarity, particularly for termination where, in a life plan, a pregnancy isn’t what the woman wants, which is what the majority of terminations are for.  Technically it’s still not clear whether these terminations are legal or not.”

 

Abortion: Part 1 — The fear factor
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The AMA’s Dr Andrew Pesce looked on nervously as Sydney GP Dr Suman Sood was prosecuted under NSW abortion laws, and he fears the fall-put still.  It’s not that the association’s national spokesman on obstetrics considers Dr Sood to be an innocent doctor who didn’t receive a fair trial.  Rather, he’s concerned about the mind-set of others who also watched her trial with interest.

Dr Pesce says anti-abortion campaigners will ultimately determine the long-term significance of the Sood case.  He’s troubled by comments in the lay press suggesting her conviction was a victory, and that it’s just the start – there are many more abortion doctors to go.

“If anti-abortionists see this as a call to arms and start reporting other doctors as well, what will happen is that doctors will be genuinely fearful that they will be prosecuted, which is what the anti-abortion lobby wants,” Dr Pesce says.

If they create a climate of fear, more doctors will wonder whether providing the service is worth the risk.

“I think it would result in a lot of doctors withdrawing those services,” he says.

Dr Persce says doctors already feel vulnerable under the state’s abortion laws, which have been widely criticised as being too open to interpretation.  The Sood case offers no clarification because it was tried by a jury and, with jurors not required to document reasons for their decisions, the specific reason the termination was found to be illegal will never be known.

With Victoria also feeling the fall-out from a high-profile abortion case, there is a perception within that state’s medical community that its abortion laws are unclear.  Obstetricians are still coming to terms with a protracted medical board investigation of five hospital doctors that was instigated by a politician with a strong anti-abortion stance.

The Medical Practitioners Board of Victoria took five years to investigate the complaint about doctors from the Royal Women’s Hospital, who had terminated a 32-week foetus with dwarfism after judging the mother to be suicidal.  In September, the board announced it had found no evidence of unprofessional conduct.

Given the duration and profile of the case, one of the doctors cleared of any wrongdoing is concerned about its impact on obstetricians who provide later terminations when the foetus has an abnormality. The doctor, who cannot be named for legal reasons, surveyed 17 private obstetricians in Melbourne who perform such terminations and found seven of them no longer provide terminations as late in pregnancy as they did before the medical board investigation was announced.  All but one said Victoria’s abortion laws were not clear or appropriate, 12 were worried about the law being unclear and 10 acknowledged the lack of clarity affected their patient management.”

“It has become much harder for Victorian women to access abortion, after the diagnosis of a foetal abnormality, over the last five years,” the doctor says.  “It’s because obstetricians are feeling very vulnerable.”

“Doctors are compelled to think of their own risk in offering an abortion because of the uncertain laws.”

Melbourne epidemiologist Dr Julia Shelley (PhD) says the medical board investigation has not affected doctors’ willingness to provide early terminations.

“In terms of late terminations I’m sure there’s more caution,” says Dr Shelley, principal research fellow at the Australian Research Centre in Sex Health and Society at La Trobe University.

“I think there is some ‘twitchiness’ in Victoria, mostly because of the general climate federally,” she says, referring to Health Minister Mr Tony Abbott’s strong anti-abortion stance, the presence of the Family First party in the Senate and strong anti-abortion sentiment evident during the Senate inquiry into RU486.

This nervousness among doctors is typical of the fall-out where there is a legal or political controversy about abortion, Dr Shelley says.  In 2002, the Australian and New Zealand Journal of Public Health published her research documenting the extent Australian women travelled interstate for abortions and how closely this related to each state’s legal and political climate.  From 1984 to 2000 more than 2000 Queensland women travelled to NSW each year for terminations, her paper suggested.  There was a spike in the numbers in 1985, the year police raided abortion clinics in Brisbane and Townsville.

“The raids, during which medical records were removed from the clinics, were followed by the prosecution of two doctors for procuring an illegal abortion,” the paper says.  “The perception of termination of pregnancy as illegal and the level of media coverage of termination of pregnancy issues continued for many years following this event.”

Dr Shelley says the last time doctors became “twitchy” about abortion laws was in WA when two Perth doctors were charged under the state’s abortion laws.

“WA [doctors] had been operating in the same way as Victoria and NSW and felt things were stable and then several doctors were charged after the ‘baby in the fridge’,” she says.

A patient had been given her aborted foetus so she could conduct a culturally sensitive burial but, when one of her children told a teacher there was a baby at home in the fridge, it led to a police investigation and arrests.  The case sparked significant legislative change, with doctors refusing to perform terminations until the law was clarified, Dr Shelley says.

“Terminations became completely unavailable in WA for a period of some weeks while they got the new legislation through,” she says.  “In that time, several women were hospitalised after trying to perform their own abortions.

 ON THE ABORTION FRONTLINE

“If you want to have an abortion beyond 20 weeks, you’re probably going to have to come to Victoria to us,” says Dr David Grundmann, one of two GPs who perform late-term abortions at Croydon Day Surgery in Melbourne.

The number of women coming to the clinic for “late second trimester” terminations increases each year, reflecting greater unwillingness among doctors in other states to perform them, Dr Grundmann says.

“I don’t know for a fact, but it makes sense that any fear of prosecution doctors may have is going to decrease their willingness to help women achieve an abortion,” he says.

Dr Grundmann also owns four clinics in Queensland and one in NSW but only performs late terminations in Melbourne.  He says this is not due to Victoria providing any greater legal safety, but because such terminations take three consecutive days to perform and he does not spend enough time in other states.

He is confident the late-term abortions he provides for psychosocial reasons are safely within the law and has not been concerned by the Sood case in NSW or medical board investigation in Victoria.

Medical director of Australian Birth Control Services Dr Geoff Brodie says Dr Grundmann is filling an important role.

“It’s great that you’ve got a really good, competent operator that is able to act as a safety valve for the nation,” says Dr Brodie, who has two clinics in Sydney.  “You don’t want these women going to backyarders or doing self-harm, trying to do the procedure themselves.”

NSW clinics draw an “invisible line in the sand” in regard to doing terminations over 20 weeks, Dr Brodie says.

“There’s the law of diminishing returns after 20 weeks,” he says.  “If you stuff up, people start to say why in the hell are you doing the procedure.  The system starts to turn on you.”

Dr Brodie does not have the skills required to perform late-term abortions and chooses not to acquire them, for personal reasons as well as wanting to avoid controversy.

“I don’t want to be involved and be a target for these late, late stage terminations,” he says.

During the NSW Supreme Court trial of Sydney GP Dr Suman Sood – who was recently convicted under the state’s abortion laws – a patient gave evidence suggesting NSW clinics may be referring women to Queensland.  The woman said her cousin called eight or nine clinics in the state on her behalf, to see whether they could help her.

“She asked if it was possible to have an abortion over 20 weeks,” the patent told the court.  “She told me that they all said it was illegal to get it done here and, if I want it done, to go to Queensland.”

Dr Grundmann says it “simply isn’t true” that abortions for psychosocial reasons at this stage are illegal.

“From time to time we get people who come to us who are given this information, erroneously or out of ignorance, or may be maliciously so they [other doctors] don’t have to deal with them,” he says.

Some doctors’ religious beliefs also impact on patients, he says, citing the example of a country doctor in Queensland who told a woman it was not legal to have an abortion at 16 weeks’ gestation.  By the time the woman arrived at his clinic, she was 22 weeks’ pregnant.

“This is not an isolated situation,” he says.  “I’ve seen this a number of times.”

Marie Stopes International research from 2004 found Australian GPs were not always well informed about the legal framework surrounding abortion.

“More than half of the GPs who practise in states where an abortion may be legally performed to prevent serious social and/or economic consequences to the woman are unaware of this fact,” the research paper says.

“More than one-third of GPs readily admit that they do not fully understand the abortion laws in their state or territory and, in many instances, GPs’ stated understanding of specific legal requirements [does] not necessarily match reality.”

 LATE-TERM DISCRIMINATION

Doctors’ reluctance to terminate pregnancies after 20 weeks discriminates against some women because various foetal abnormalities may not be diagnosed until after this time, according to a leading Melbourne obstetrician and ultrasonologist.

Associate Professor Lachlan de Crespigny says it is also unfair to apply the 20-week cut-off to overweight or obese women, because there are often delays in diagnosing foetal abnormalities in these patients.

It is difficult to get clear ultrasound images, particularly of intricate areas such as the heart, when women are overweight, he says.  If a foetal heart abnormality is suspected at 20 weeks, the patient may not be able to see a cardiologist for a week and the cardiologist may then suggest an amniocentesis.

“It could easily take two weeks to have the full assessment,” he says.

Other abnormalities – such as hydrocephalus, dwarfism and microcephaly – may not be diagnosed before 22 weeks, even in women of normal weight.  The patient would then need time to digest the information and make a decision.

Women are generally devastated when an abnormality is diagnosed and will be further traumatised if they have trouble finding someone who will perform a termination, Professor de Crespigny says.

“These women who have the diagnoses of an abnormality make a difficult decision and then to get pushed from pillar to post [to achieve a termination] is just awful.  It’s grossly unfair.”

There is no clinical basis for a 20-week cut-off point for terminations, he says.

“Twenty weeks is used in the public debate a lot, but there there’s no foetal milestone [at this time].  It is arbitrary cut-off that discriminates against women who need a scan after that time to get optimal care.”

Warrior’s last stand
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Photo by: Warren Clarke. Dr Geoff Hittmann at his favourite watering hole.

Dr Geoff Hittmann opens the door of his Wollongong apartment and scares the hell out of me. It’s not just that he’s barefoot and in his pyjama pants, it’s that he looks like a big, hairy mountain man.

I’m early. He’s gracious and welcoming. One warm smile and the wild man is tamed.

Hittmann and his long, greying beard settle back into the lounge and he continues his morning routine. Three pieces of tape are stuck to the side of his TV cabinet and there’s a birds’ nest of bandages at his feet. He rests his grossly swollen left leg on top of a green Tupperware container and continues his strapping.

On 2 June, the 58-year-old GP was diagnosed with a brain tumour and given three months to live without treatment or a year if he opted for surgery, radiotherapy and chemotherapy. He chose treatment and has endured two and a half months of hell. But this morning, as he struggles into one shoe and one Velcro-strapped sandal, it is cellulitis, not the brain tumour, that’s giving him grief.

If you’re a regular reader of this newspaper’s letters page, Hittmann’s name is likely to ring a bell. He’s the proudly non-VR GP from Mt Kembla, NSW, who told the RACGP to “stick your VR where the sun don’t shine”, refused two chances to be grandfathered and thereby sacrificed an estimated $500,000 in potential earnings.

Whether you can make sense of his stance or not, it says something of his passion that he has raged against the RACGP since 1977 – when he says his concerns about hospital registrars being exploited and poorly trained were ignored by his college representatives.

Hittmann’s conscience won’t let him join the vocational register because he would see it as condoning the college. But, having shunned the register, he’s indignant non-VR rebates have remained stagnant, not even keeping up with inflation when even “pensions are indexed”. His letters to the editor rage about this “kick in the guts” and being terminally ill hasn’t distracted him from his theme.

“Before I fall off the perch, I want to bring some kind of justice and fairness to how general practice is run,” he says. “I’m not going to turn my back on it now and say stiff shit.”

In a shocking piece of timing, just before he discovered he was going to die, Hittmann had turned his life upside down so he could finally access the higher rebates. In May this year, Australian Doctor reported he was leaving the Wollongong suburb of Mt Kembla, where he’d lived for 29 years, and heading for Bourke, an area in need in outback NSW. He’d been there two weeks when he experienced a blank spot in his vision and ended up in hospital.

“Next thing I heard the ambos talking to the air ambulance,” he says. “They said I’d had a convulsion and they flew me to St Vincent’s [in Sydney]. Did an MRI and showed a brain tumour.”

Hittmann lights a cigarette and heads out to the balcony of the modern apartment where he lives with his partner of two years, Margaret Flynn. The son of a pharmacist from Sydney’s North Shore starting smoking “roll-your-owns” as a medical student, but swapped to “ready-rolls” when he got a job driving cabs.

He and Margaret have only been here a week and are still soaking up the mountain and ocean views. Margaret confides that it’s something of a miracle they have the place at all. She left her new teaching job in Bourke when Hittmann got sick and feared an unemployed school teacher and a dying doctor would not be considered desirable tenants.

But Hittmann has long been a legend in Wollongong. He called Lord Mayor Alex Darling and, within a week, a real estate agent was giving them a tour of the place. Mr Darling, who met Hittmann 15 years ago, says the doctor is widely loved and respected, particularly in Mt Kembla, where he’s known simply as “the Doc”.

“He’s a very natural person. There’s no airs and graces with the Doc. He’s a very good man. If you went to visit the Doc and you couldn’t pay, it wouldn’t worry him one bit. He’s a person you couldn’t help but like.”

Hittmann practised from his home, Bedside Manor, located directly opposite the Mt Kembla Hotel, and kept a prescription pad in both places. “If it was someone who had something they needed urgently and it was someone I knew, [having the pad at the pub] would save me a walk home,” he says.

 

It was camaraderie that pulled Dr Hittmann to the pub. Photo by Warren Clarke.

Dr Greg Mason, a general surgeon who used to work in Wollongong, says it is camaraderie, not drinking, that pulls Hittmann there. The GP regularly referred patients to him and would always start his introduction with “this patient’s a good mate of mine”. Dr Mason admires his clinical acuity and thorough approach to the job.

“If you get a letter that says, ‘Dear Dr Mason, please treat so and so for bleeding piles’ and I stick my finger in his backside and feel a big cancer, I know the GP hasn’t even looked,” he says. “That’s never happened with Geoff.”

Another of Hittmann’s closest friends is 40-year-old local radio announcer Phebe Irwin. They met – at the Mt Kembla pub, of course – after she moved to Wollongong 10 years ago.

She and other locals timed their visits to the pub around his routine. “The very first thing I do when I walk into the pub is look for Doc’s spot at the bar to see if he’s there,” she says. “It’s like when you wake up in the morning and look to see if the sun’s in the sky.”

She’s never succeeded in buying him a drink, though. He always shouts and, although he always has a beer in his hand, she’s never seen him drunk. Laughing, she recalls the time Hittmann hid near the finish line of the annual Mt Kembla foot race. When the first runners came into view, he burst out of nowhere and beat them all to the line.

When Ms Irwin’s boyfriend, Fish, died two years ago, Hittmann was the first person she called.

“I drove to the pub and he had a drink waiting for me,” she says.

“He said let Fish’s memory live on with you, so you can take the best things about him and make them part of your life.

“You can be feeling you want to kill yourself because your boyfriend is not around and he shows you reasons to keep on keeping on.”

Hittmann understands the pain of losing somebody you love. He remembers the exact time, 12 years ago, when police knocked at his door to tell him his son, Garth, was dead. Garth had been celebrating his 23rd birthday and gone for a spin on a motorbike with a mate. They’d been drinking and Hittmann suspects the bike had no headlight. They drove through a park, straight into a slippery dip.

“When my son was killed in that bike accident, I thought, nothing worse is ever going to happen to me now,” he says. “The coppers knocked on the door at 4.22am.”

In some ways, Garth’s death has helped Hittmann deal with his own grim prognosis.

“When my son was killed, I thought, I can’t do anything about it,” he says. “It’s happened. You’ve just got to get on with it.”

Although he has bawled as he thinks about dying, he’s found some solace in knowing there’s not much he can do about that either.

“I’ve always been a believer in, if it happens, it happens. If it’s good, it’s good. If it’s bad, it’s bad. You’ve just got to cop it.”

Being a doctor hasn’t eased the challenges posed by his treatment. He woke after his surgery at St Vincent’s Hospital with a 30cm scar across his head, when he’d expected something the width of his fist, and he was shocked by the memory loss that followed. Later, when his head was strapped tightly to the table for one of his first radiotherapy treatments, he had a panic attack.

His 29-year-old daughter, Bonnie Hittmann, took time off work to care for him and saw him at his lowest.

“Straight after the surgery he got easily agitated and upset and frustrated. He didn’t expect to have such memory loss and confusion, particularly with short-term memory and finding appropriate words,” she says.

He’d get one word stuck in his head for a day – usually something to do with his treatment – and he’d use it over and over. One day it was “X-ray”, Bonnie says.

“He might say, ‘What’s for X-ray tonight?’ instead of, ‘What’s for dinner?’.”

More recently he has had difficulty remembering names, so he can lack confidence about personal interactions, such as taking phone calls.

“With being such an independent and intelligent person, to becoming someone at the other end of the spectrum, needing help with his communication – that was very difficult for him,” Bonnie says.

Any problems with memory and speech are not obvious the day I meet Hittmann, apart from his constant apologies for his short-term memory loss. He certainly has vivid memories of the worst parts of his hospital treatment.

“They put a lumbar puncture in me. They gave me three goes in the ward and couldn’t get it through, so we went down to the X-ray department and they got it the fourth time,” he says.

He felt so miserable in intensive care after his surgery that he threatened to sign himself out.

“It was a waste of time,” he says. “No one was doing anything. They sent me in there with a nightie tied up at the back, a tube of toothpaste and toothbrush and that was it. There were no windows. You’re not allowed out of bed. It was two days of absolute hell. The lights were on all the time. I had a drip on both sides so couldn’t roll over to sleep.”

Strangely, after this tirade, he adds: “It’s the first time I’ve ever been a patient and most of the time it was good.”

Hittmann says he’ll never practise medicine again and there’s no point planning what he wants to do with his remaining days because he wouldn’t remember anyway. For now, he is more concerned with the recent past, questioning whether he made the right decision in opting for medical treatment and a prognosis of 12 months, rather than no treatment and three months of peace.

“It’s been over two months now and that’s been spent seeing doctors – two and a half months of hell,” he says.

“That’s not a life, mate. That’s not a life.”

He shows me the kitchen cupboard devoted to his medication.

“I woke up feeling good,” he says. “The sun was shining. I took 12 tablets and half an hour later felt like throwing up. Welcome  to good health.”

Bonnie says her father has always been matter of fact about where medical intervention should start and stop.

“His belief has always been it’s better to live a quality life for a short time, rather than live a longer life at the mercy of doctors’ treatment.”

On top of weighing the balance between quality of life and quantity, a sense of injustice haunts him.

“There are so many layers to his disappointment,” Bonnie says. “He thinks, ‘I’ve spent my whole life looking after other people, and now this happens’. And it happened after he made all of these really drastic lifestyle changes.”

The old injustice of non-VR rebates being so low continues to eat away at him.

“He’s always thought, if he keeps fighting it, some changes will occur and it will be worth it,” Bonnie says.

“Now, since he’s been diagnosed with the brain tumour, he feels as though he doesn’t have the time left to keep fighting.

“He’ll fight it to his death bed. But he’s extremely disappointed. He’s disadvantaged himself by fighting this, his whole life, and nothing’s come of it.

“He’s upset by that.”