The Pineapple Prescription
By Gordon WeissMay 17, 2012
A rural doctor faced with a massive public health problem — kids going deaf from ear infections — finds the cure in a box of fruit.
Dave Ferguson has an eye for fine and shiny things. An Aboriginal painter and decorator by trade, 51-year-old Ferguson was raised in a two-bedroom cottage in Brewarrina, an edge-of-outback town, along with nine siblings. His father was a fencing contractor, working long days in the dust and sun, wrestling stubborn eucalypt posts that score and scratch the flesh, stretching blades of wire that tamed the scrub and kept the herds and mobs intact.
Rural missions were more common then, benign-sounding places where Aboriginal people — "Lords of infinite space" as the poets put it — who had once roamed the unfenced landscape now were suspended between their wandering existence and a difficult integration. Life was not easy in Brewarrina, same as any rural town, but when Dave accompanied his father on handy-work at the local mission, the young boy was struck by the squalor of the sickly children he saw there. "They used to have 'candlesticks' running from their noses, and ears stuffed with cotton wool," he says. "But nobody spoke about it. They were embarrassed and sat up the back of the classroom." Children would remain forever blighted by preventable illnesses that rendered them deaf. It was, according to Dave, "just the way".
Records from the late 19th century through to the mid-20th century offer scant evidence of the level of suppurating ears and "candlestick" noses common in Aboriginal rural communities today. From the early 1970s, however, studies were revealing very high rates of ear infections — various afflictions known collectively as otitis media (OM).
Most children throughout Australia contract middle-ear infections as infants, but they are quickly cured; as a result an average Australian child might muddle through two or three months of hearing difficulties before the age of five. But Aboriginal children now suffer the highest rate of these ear infections (chronic suppurative OM) in the world, with many enduring close to three years of hearing loss during their most vital developmental years — that's 10 times the level considered a "massive public health problem requiring urgent attention," according to the World Health Organisation. Newborn Aboriginal children in risk-prone environments will typically acquire potential OM pathogens within days of birth.
"Just the way" was the way it was when Dr Ray Jones came to Grafton from Sydney in 1981 to work as a general practitioner and for the Bulgarr Ngaru Aboriginal Medical Corporation. At that time, the notion of asbestos as a boon to the Australian economy was beginning to breathe its final, rasping breaths. In Baryulgil, about 70 kilometres north of Grafton, the heart of the Northern Tablelands, James Hardie Industries extracted the deadly mineral between 1944 and 1979, knowing its dangers. The local Bundjalung Aboriginal settlement provided raw manpower for the mines, while JHI provided asbestos dust for school playgrounds, park paths, and driveways, and contaminated materials were even used to manufacture shopping bags. Black men rose from the mines covered in white man's dust. 'Candlesticks' and problem ears were the least of problems in a community now faced with a health apocalypse called mesothelioma. Today there are only around 45 inhabitants of Baryulgil and the tiny village of Malabugilmah, down from the 350 who lived there during mining days. Despite expensive efforts to rehabilitate mining-affected land, colonies of ants still bring mineral crumbs of asbestos to the surface around Baryulgil Primary School.
In 2003, when Dr Jones began to drive out from Grafton, the children were evidently sickly. So many kids had their ears stuffed with cotton wool in a vain effort to stop infection, the classroom was wired with speakers, and teachers taught the 20 students with a microphone in hand. That's just the way it was.
The antibiotics prescribed by Dr Jones were ineffective against the ear, nose, and throat infections that exhausted the community's school children, for reasons similar to those of other Australians: antibiotic overuse, and mismanagement of the 22 million antibiotic courses prescribed each year, results in evolution of bacteria that are immune to existing antibiotics.
THE HUMAN EAR DRUM is like the skin of an orchestral tympani. It's a taut membrane stretched across a cup of gleaming cartilage, receiving soft blows of sound that signal the movement of life all around; it protects the middle ear. The membrane flutters rapidly with high-pitched sounds, and deeper blows stretch it inwards. Unlike a tympani, when struck by a too-violent blow the eardrum (or tympanic membrane) expands with surrounding bones to reduce the impact of the blow on the inner ear.
Like all things human, the eardrum is durable, but fragile when neglected. When healthy, says Dave Ferguson, it is "nice and shiny". After moving to Grafton, Ferguson had given up painting and decorating to become an OM health worker alongside Dr Jones, screening Aboriginal children in the Grafton area for signs of the infections that he first noticed as a child in Brewarrina four decades ago.
Chronic OM is essentially a disease of poverty. The greater the over-crowded living conditions, exposure to smoke, poor hygiene and nutrition, and the fewer available health services, the more likely the ears of a child will be constantly 're-colonised' by the bacteria that cause OM. When infected, the eardrum is red, swollen, clouded by pus, and can emit a constant, unpleasant odour. Children will suffer from pain, fever, and general discomfort. In the worst cases, the pustular infections can rupture an eardrum, cause excruciating pain, and even lead to facial paralysis or meningitis. The effects often last a lifetime, and in some Aboriginal communities a majority of people have poor hearing. Once chronically or repeatedly ill with OM, a child begins to lose ground in language comprehension, learning capacity, memory skills, and the development of attentiveness — quite apart from their intellectual, social and emotional development. Many children, barely able to function in their own first language, enter school for the first time to encounter English as a second language.
"You'd have to yell at them," says 62-year-old Carol Wilson, now retired but then a teacher's aide at Baryulgil who saw how antibiotics could not cure the children's ear ailments. According to Wilson, stricken children avoid answering questions, daydream, fidget, disrupt classrooms, or avoid attending. They are 'problem' children, confined to a world not of their own making. If they graduate at all, it is to a probable life of semi-literacy, unemployment, social welfare, and the associated drug and alcohol abuse that accompanies disaffection. Violence, criminality, and the repetition of the downward spiral from generation to generation, are the ensuing logic.
IN DR JONES'S Grafton office, an old patient slaps down a gift of a plastic bag filled with a gelatinous and bloodied matter that looks suspiciously like road-kill. "Echidna," says Jones, with an almost convincing enthusiasm. "It's considered a great delicacy, very fatty." His office wall is decorated with Aboriginal art work depicting the echidna, goanna, and kangaroo that once formed the highly nutritious 'bush-tucker' Aboriginal diet, one largely extinguished by access to cheap, processed foods. The contrast between those two diets is illustrated by the results of a remarkable and simple experiment that has profoundly changed Baryulgil.
"The Royal Deaf and Blind Society had been doing audiometry on the community at Baryulgil for years," says Jones. "The results were the same each year — atrocious. Only 40 per cent of the kids had normal hearing at school." In 2003, Jones began a concerted effort to tackle the failure of antibiotic regimens that were leaving Aboriginal children deaf. From a series of blood tests, he found that the children were uniformly suffering deficiencies in vitamin C, folic acid, and iron.
Photos courtesy of Bulgarr Ngaru Aboriginal Medical Corporation
Photo by Mike Bowers
Photo by Mike Bowers
"We used to have yarns trying to work out what to do," says Carol Wilson. "First we tried vitamin pills, but the kids just refused to take them. So then Doc just started bringing boxes of fruit. Never underestimate the power of fruit and veg — especially pineapple."
A new regimen was instilled. At first, the 20 school children of Baryulgil resisted. But gradually they dutifully began to chomp their way through the boxes of fruit purchased at Farmer Lou's in Grafton. "We stuffed it in them until it was coming out their ears," says Wilson. One box a week became one a day. "They didn't like it at first, but then they got a taste for it. After about a month, you could see the changes." Within a few more months, skin infections had reduced or disappeared altogether, and children's hearing began to improve as infections cleared. Within a few years, the rate of children with hearing problems had been halved, and the sound system had been removed from the classroom. Hospital visits, sickness, and the use of prescription medicines declined steeply, while school attendance, attention in class, and general health rose.
"THE BARYULGIL STORY is how it can work well," says Andrew Black, a physician working alongside Ray Jones and Dave Ferguson, and who is now writing a PhD on the nutrition program. "There was great support in the school, with driving personalities, and support from the local big landowners, the Myer family." Black is studying the effects of similar nutrition initiatives, now extended to socially disadvantaged Aboriginal communities in towns around Grafton — target populations that are inherently more complex to identify, reach, and monitor. The programs also include some Caucasian children.
"We're seeing a 30 to 50 per cent decrease in visits to hospitals, and a similar decrease in skin infections," says Black. "This is not just statistically significant, but also reveals clinically relevant improvements in the children's health." Blood tests similarly show a marked increase in Vitamin C, folic acid, and antioxidants called carotenoids.
The feeding program at Baryulgil now includes meals prepared at school, and cooked by the children themselves. They learn how to use a variety of vegetables and fruit, how to prepare and cook the food, and then they consume the meals with their classmates. Children carry the knowledge home, with mothers responding to acquired tastes by shopping for fruit and vegetables, and cooking the same meals.
"Baryulgil was the low-hanging fruit," says Dr Jones. "The situation was so bad, and it was an isolated community, so the results were particularly striking. But a box of fruit? Cheaper than antibiotics, and it boosts the immune system so kids don't get sick in the first place. It's the best thing I've done as a doctor, no question."