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22 06 09 DR Susan Hemer Fellowship
*Speakers: Kathryn Favell (K), Susan Hemer (S)
K: - of Australia. I’m Kathryn Favell, Director of Reader Services. Thank you for attending this event here in the theatre and online. We’re coming to you from Ngunnawal and Ngambri country. I’d like to begin today by acknowledging Australia’s first nations peoples as the traditional owners and custodians of this land and give my respect to elders past and present and through them to all Australian Aboriginal and Torres Strait Islander peoples.
This afternoon’s presentation, Women and Children Last, the establishment of Maternal Child Health Services in Papua New Guinea, is by Dr Susan Hemer, a National Library Fellow. Our distinguished fellowships program supports researchers to make intensive use of the National Library’s rich and varied collections through residencies of up to three months. National Library fellowships are made possible by generous philanthropic support and today I’d like to thank the Stokes family for supporting Susan’s fellowship.
Susan is a social anthropologist based at the University of Adelaide. Her work focuses on medical and psychological wellbeing as well as issues of colonialism and development, particularly in the context of Papua New Guinea. Susan received the Fred Johns Scholarship for Biography and undertook significant archival and biographical work on Elizabeth Crouch, a Baptist missionary nurse focusing on maternal health in the New Guinea highlands for 25 years.
Today Susan is going to give us an insight into her research on the establishment and practices of maternal child health services in Papua New Guinea after world war two. The aim of Susan’s project is to understand the historical underpinnings of the contemporary health status of women in Papua New Guinea and I’m looking forward to hearing what she’s discovered in the Library’s collections. Please join me in welcoming Dr Susan Hemer.
S: Thank you, Kathryn. I want to also begin by acknowledging that this research has been carried out on the lands of the Ngunnawal and Ngambri people. At home my work is carried out on the lands of the [Kaurna] 2:16 people. I wish to acknowledge elders past and present and note that sovereignty was never ceded. I also wish to acknowledge that this topic relates to the lands of the people of Papua New Guinea who were also subjected to Australian colonisation. I particularly want to mention the Lihir people with whom I have worked and the [Kiaka] 2:37, Enga and Telefol people of the highlands.
The title for this research project comes from the chapter of a book on public health in Papua New Guinea by Donald Denoon. In that chapter he argues that despite the work done on public health in Papua New Guinea by Australians, women’s and children’s health was an afterthought and was given little focus. Instead, his argument goes, the Australian administration was firmly focused on their own health and then the health of their workforce. Denoon argues that, the Department of Public Health was highly mobile, technical and masculine, catering predominantly to urban and mobile patients.
Having worked in PNG myself for years as a medical anthropologist I knew that women and children’s health was poor. In fact PNG has one of the highest maternal mortality ratios and infant mortality rates in the Asia-Pacific region. Yet I was also aware that maternal child health had been the focus of both administration and mission efforts.
While researching a history of the Australian Baptist mission health work in the National Library in 2017 just for two days I’d come across the name of Dr Joan Refshauge. The Library holds 15 manuscript boxes of material that – which relate to her work establishing a maternal child health service in Papua New Guinea post world war two. This intrigued me and it led to my application for a fellowship to start a new research project.
In this presentation I’ll provide an overview of the work I’ve done here in the National Library and the light it sheds on the establishment of maternal child health services in Papua New Guinea after world war two. There is some truth to the idea that woman and children’s health comes last yet it is not a simple story. To tell it properly it’s necessary to touch on the situation before the war and also to understand the apparent anxiety about falling population numbers in parts of Papua New Guinea in the 20th century. To begin I provide a mini history of PNG just for some context.
So Papua New Guinea’s the most populous country in the Pacific with approximately nine million people who speak about 830 languages, making it one of the most linguistically diverse places in the world. This map on the slide is a picture of the state of affairs in 1887. The southern part of the territory became a protectorate in 1884 and was annexed by Britain as British New Guinea in 1888. Responsibility was transferred to Australia in 1906 after our federation and it was renamed Papua.
The northern part of the territory became a German protectorate in 1884 and was named Kaiser-Wilhelmsland with other island groups added later and together these were known as German New Guinea. These territories were taken by Australian forces during world war one in 1914 and were granted to Australia as a League of Nations mandate after that war.
Papua and New Guinea came under attack and occupation by the Japanese during world war two. After the war the administration of the two territories were merged meaning that for the first time there was a central public health department and co-ordination of health efforts in the two territories. Papua New Guinea became self-governing in 1973 and independent in 1975. So my fellowship is largely focused on the post-world war two era with some excursions into earlier material for context.
My experience with Papua New Guinea began when I met Papua New Guineans at my grandmother’s house. They were visiting because my great-aunt had been a missionary nurse who lived in the highlands region from 1949 to 1974 and she was on that last slide. I became fascinated with Papua New Guinea as an undergraduate, taking anthropology and I conducted my doctoral field work in the Lihir Islands in New Ireland Province and on this map the Lihir Islands are right up here. Just for context the capital is down here, Port Moresby, which comes up in this presentation a bit.
I have returned many times for research on matters of health to Papua New Guinea. Normally my research process looks a little bit like this and so the top one is in the Lihir Islands in New Ireland Province in 2000 and the bottom one was one of my recent trips to the Western Highlands Province.
However in this research project my research looks a lot more like this and I had to learn a whole series of new skills because as an anthropologist I'm normally talking to people and eating food, living in tropical climates, working in multiple languages but this of course was a lot more documents and a lot less talking.
So the beginnings of the MCH work, Dr Joan Refshauge. My first work in the National Library was to trawl through the 15 boxes of material accumulated by Dr Joan. She was the eldest of five children born in 1906 in Victoria. Her father was a school headmaster and education was highly valued in their family. She gained a masters degree in science, a Diploma of Education, taught mathematics at university and went on to study medicine. She worked in the Australian Army Medical Corps. Her husband served in the Australian New Guinea Administrative Unit, ANGAU, in world war two and Joan followed him to Port Moresby in 1947.
Given the attitudes of the day she was not allowed to treat male patients, either Australian or Papua New Guinean so she was to restrict herself solely to maternal child health. She was also not allowed to be given a permanent job until she proved that she was divorced from her husband in 1948. Throughout their time in PNG her salary was also less because she was female. That’s a bit of an aside.
But anyway in her own words Refshauge describes the precursors to this work. This health service was formed by the Health Department in the post-war era but pre-war in the territory of New Guinea an infant welfare centre was opened at [Malabunga] 9:11 in August 1931. This was built and subsidised by the administration and staffed by the Methodist Mission. Generally the missions were given subsidies pre-war for health work including infant and maternal welfare but the extent and type of the work done is not clearly known and there appears to have been no extension of the type of work done in [Malabunga] except that in 1939 a European infant welfare clinic was started in Rabaul. There was no infant welfare organisation as such in Papua pre-war. So that’s her statement on the beginnings of it all.
In her histories, and I say histories because I found multiple drafts of undated histories handwritten in her scrawly cursive in her papers, Refshauge states that the first clinic work for infant health after the war was 1947 at Hanuabada, a village close to Port Moresby. This was in the London Missionary Society building. She describes it as an experiment where advice was given to women but sometimes it was not well accepted. Here she learned that there was a need to compromise to suit people and their customs. She says, the experience gained at Hanuabada was applied and is the basis of all infant welfare work in the territory today.
Refshauge notes elsewhere that the staff of Hanuabada were untrained and so the Public Health Department did the majority of clinic work and supervision. When the team of the infant and maternal welfare section was formally established it consisted just of herself, a nurse and an assistant who also interpreted for them.
There are alternate versions of this early history of infant and maternal health work. I do like this photo, it’s the earliest photo I’ve been able to find so far of any kind of clinic work going on and it’s 1913 but I couldn’t actually find reference to it in many places.
So here I want to make a brief examination of the years before the war. From various missions’ reports it’s clear that the welfare of infants was of concern from the earliest days in the territories. Mostly this work was ad hoc in terms of taking and raising babies when their mothers died at birth. In some areas such as Catholics in New Britain this evolved into orphanages in the 1890s. By 1904 as I mentioned baby welfare clinics being held by the Catholic sisters in New Britain and New Ireland. In Papua there was work done by the Methodists, by the London Missionary Society, the Catholics and the Anglicans since at least 1926 so well before the war, none of which was referred to by Refshauge.
By the 1930/31 annual report of the Territory this work is significant enough to warrant a full page report titled Infant Welfare that says, this work is being extensively carried out. The work did not only focus on infants as the London Missionary Society reported 15 confinements as they were called, births, 17 examinations for sterility and mothers’ class with 32 attendees in the mid-1930s.
By 1938 there was an infant welfare nurse posted to Milne Bay subsidised by the administration so clearly this work was expanding pre-war yet this work was not without its critics. The clinic mentioned by Refshauge set up at [Malabunga] by the administration around this time was met with derision by an anonymous male plantation author in the Pacific Islands Monthly magazine so this is the title that he gave his piece and I quote.
The planter in question, referring to himself, takes a bitter pleasure in calculating how many miles of road could have been built with the money that is wasted in sending highly skilled Australian nurses out into the bush to urge naked black mothers to give their offsprings 10 drops of orange juice four times a day. In his view this work should only be done by missions.
So the key difference between pre and post-war efforts then seems to be the greater involvement of their administration and their role as co-ordinator of the work. This has become an accepted part of the work of the Health Department.
So coming back to the early post-war period Sister Annette Herbert of the Catholic Mission at Koki also in the Port Moresby area describes the beginnings of their work in a letter found in the papers of Ellen Kettle housed in the National Library. So Kettle wrote a history of nursing in Papua New Guinea from 1874 to 1974 and her papers contained hundreds if not thousands of letters from nurses including one from my great-aunt which was a nice find.
So for Sister Annette, after seeing a woman die before the war of sepsis after giving birth and not being able to help in any way, during the war she went to Australia and trained in obstetrics and nursing training. On return to Papua post-war malnutrition was rife and the child mortality rate was high. She referred pregnant women to Refshauge and met her at this time.
She says, after giving me her opinion and diagnoses of this women, Doctor asked me where I worked and was most interested to hear we were seeing so many children, especially infants, suffering from malnutrition, worm infestation etc, etc. She stated that she was most anxious to commence a child welfare clinic somewhere in the Moresby District and asked if we would care to join with her and give her some assistance. Sister Annette states that the London Missionary Society clinic, operated by Mrs Ewer, was started soon afterwards. In her understanding Refshauge had to get permission from the Director of Public Health, John Gunther, to start the clinic.
By 1949 when Sister Betty Crouch of the Australian Baptist Mission was visiting Port Moresby to learn about infant and maternal welfare work she was taken to Koki by Refshauge. She noted that this was Refshauge’s show clinic with everything clean and in order. She also went with them to do infant clinics in three villages. It seems strange then that Refshauge neglects to mention Koki in her histories of maternal health work.
Gunther in an interview about his role as Director of Public Health states that, infant welfare was one of the things I was proud of. He takes credit for the service and for Refshauge’s role in it, noting that, she came to this country with experience in children and maternal welfare. She came with her husband who’s a surveyor and we grabbed her and told her to set up an infant welfare service which started in the town of Moresby. Then she employed people and trained girls and it spread out.
In an early paper on health Gunther argued that the appalling death rate amongst infants and mothers throughout the territory must receive urgent and immediate attention. Following this the administrator of the territories, Colonel Murray, in a letter to the Minister in 1949 argued that the maternal and welfare sides needs to be given increased attention, not only because of the usual humanitarian considerations but because the increase in native population in the territory is almost certainly a condition of survival. He went on to argue that the reduction in child mortality would mean an increase in the availability of native labour within a generation. His terms, not mine.
At this time in the territories of Papua and New Guinea just after world war two health was an acute problem yet there were few staff and little functioning infrastructure. When Gunther arrived there were five doctors, five nurses and 22 European medical assistants known as EMAs. EMAs were mostly men with minimal training, sometimes partial nursing training, sometimes a St John’s certificate, sometimes almost nothing and then a bit of training in the territories. They were often posted to outstations and accompanied patrols, examining villagers and providing minor medical treatments and referrals. Some stayed for decades in the territory and were central to the health service. However their role in the health of women and infants was generally very limited.
The late 1940s also saw missionaries who provided a great deal of medical care return to Papua and New Guinea post-war. So these are pictures from my great-aunt’s work up in the highlands and these are some of the really early clinics that were going on where - it’s a little bit difficult to see but here, she’s standing here and this apparatus was called a flannelgraph where they gave education. The other photo is of her doing infant clinics. Refshauge commented that mission staff was in no case sufficient just after the war to cope with general medical work with the result that in most cases maternal and child welfare was at a standstill. All missions were in accord with the need for this work.
The expansion of the infant and maternal welfare service throughout the territories occurred gradually throughout Refshauge’s time. Annual reports were written by her each year and they reflect the growing number of centres and clinics that are occurring. So this is a picture of a baby clinic in the Markham Valley taken by Margaret Budd.
They also – her reports also reflect constant shortages of staff, accommodation and transport. In a speech written in the lingua franca Tok Pisin, Refshauge states that, an infant welfare clinic opened in Lae in 1949 and clinics at [Caving] 19:46 and Rabaul opened in 1950. In 1949 she also notes that mission staff were increasing with two doctors and four trained nurses arriving. By 1955 Refshauge reported there were 86 villages seen by mobile clinics in Papua and 321 in New Guinea by Public Health Department staff. By this time there were some 110 mission centres also working in infant and maternal welfare.
It was also during this time in the early 50s that donations were received in response to the coronation of Queen Elizabeth and the service was renamed Queen Elizabeth II Infant Child and Maternal Health Service with Queen Elizabeth’s permission. It’s a real mouthful. It’s a little bit hard to see but you can see that’s the Queen Elizabeth coronation ambulance at one of the clinics.
In this early period the infant and maternal welfare section was one of the first in the Department of Public Health to be in – training local people in a substantive way. Three young women were brought from Daru to Port Moresby where they were trained at the Koki Clinic. By 1952 there were four graduates of a three-year course in maternal and infant welfare. They keep changing the names across the years, the order of them and which words were used.
A training school was also set up at Sihe in Oro Province at about this time and gradually many of the places in the country began nurse training. The syllabus for this training is held here in Refshauge’s papers.
Throughout Refshauge’s time in Papua New Guinea the narrative is one of expansion territorially to cover a greater proportion of the area through increasing numbers of nursing graduates and expansion in spheres of influence yet she was also highly concerned to ensure that any clinic started could be maintained. Clinics which had gaps in staffing or staff turnover eroded the confidence of women. That said, documents and letters showed that the nurses employed by the Public Health Department were frequently transferred between stations whereas mission staff were not.
The service began mostly with a focus on infants, extended to antenatal care to hospital deliveries for women with complications then extended to school health and in later years there was a focus on delinquency as an aspect of disrupted home relations so it kept kind of changing and growing.
So the focus on infants. In address to the conference between the Public Health Department and representatives of the missions Refshauge stated that the aim of the maternal – the aim of the infant and maternal welfare section of the Public Health Department is to work in cooperation with the Christian missions for the benefit of the people. The endeavour is to lower both the infant and maternal mortality, to encourage widespread personal, domestic and village hygiene and to build healthy children for healthy adulthood.
She impressed upon mission staff that in this work they were continuing what was discovered in Europe when it was realised that infant mortality related to epidemic diarrhoea where home was the source of disease. So she says, attempts were made to secure a domestic hygiene of high order and other essentials of baby nurture and these were the beginnings of the infant welfare movement. The establishment of infant welfare clinics reduced infant mortality rapidly and considerably and became part of the normal community life. She asked, can we not hope that the same will apply here?
From the beginning there is clear evidence that it was infants that were the core focus of the work as can be seen in her words just before but also in the records maintained by people doing the work. From the 1950s monthly report forms were developed and missions receiving subsidies were expected to submit reports. Apparently this section of the Public Health Department developed and maintained the most reliable statistics in the Department.
From the manuscript collection of Ed Tscharke, a European Medical Assistant based at Karkar Island whose papers are held here, it can be seen that these forms, and here they are, were called Infant Welfare Report: Native Clinics. So at the top of this one over here you can see that that is the title because native people as they were called were separated from Europeans and also disturbingly what were called Asiatics so they had three clinics in the territories. But it’s called an Infant Welfare Report.
This highlights both the emphasis on infants and the separation of medical services for Europeans and local people. These forms required statistics on the clinics conducted, the number of children of various ages, their health and how many infants were missing from any particular clinic who were enrolled and should be there. It also collected data on antenatal clinics, birth and any maternal or child deaths hence the focus wasn’t entirely on infants. This form was later changed to Maternal and Child Health Monthly Report in the mid-1960s as you can see – where is it? There so you can see that the title has changed some years later.
There was heavy emphasis in these clinics on the weight and nutrition of children. Most clinics had what was called a test feeding room. In this room an infant would have its nappy changed, they would weigh it, the mother would feed for 10 minutes, they would weigh it again. The mother would finish feeding it and they would weigh it again and then they would subtract all these things and they would come up with the amount of breast milk that the child had consumed. This was compared to what a baby should be receiving and here is the instructions for how to do it and how to calculate how much milk a child should have over a 24-hour period.
Occasionally this process was repeated for a full 24 hours to provide details on how much milk an infant was given daily. There were clear guidelines on when to feed babies and for how long. They should be fed at four-hourly intervals for 15 minutes on each breast.
As can be seen from the posters infant feeding was seen to be a problem. Throughout the late ‘40s and the ‘50s Papua New Guinean mothers were being instructed on infant feeding practices either through these clinics through posters and cartoons, through a guideline written in Tok Pisin and through their local nurses who also taught in quite rigid detail about how babies should be fed. This was termed the educational diet.
Now the posters were not dated but looking at them personally I would say that this one here is possibly older and might have been more used for women in rural areas because this one here, it’s just unusual that she’s wearing a dress and there’s clocks and so forth. But they did like to put these things on posters.
So I want to go into this poster. I want to point out a couple of things from the posters that were specifically made for the Infant and Maternal Welfare Department of Public Health. First of all you might notice and wonder what that is there and that is a jar of Marmite. Throughout their clinics staff emphasised that babies should be given Marmite mixed with boiled water from as early as 10 days old. Soon after this an infant could be given pawpaw mashed mixed with water and strained. Broth from cooked vegetables was also to be given. Gradually these were to be increased and there’s actually a table in the papers of each month and what they should give and all this.
By the age of two months they should be given as much Marmite as he can take before they were given the breast milk. Partially the emphasis on nutrition reflected newly understood linkages between nutritional deficiencies and illnesses. Beriberi was a common illness among contract labourers in New Guinea in the earliest 20th century and frequently was cited in annual reports of the territories. While rations for labourers suggested that brown rice or vegetables be given generally white rice was given and vegies very rarely were given.
So diets were deficient in B vitamins. Likewise rickets were occasionally seen and understood to be linked with diet deficient in vitamin D hence frequent supplementation with cod liver oil which you can also see on that poster.
The difficulties of these requirements for women living in villages does not seem to have been considered. In a book titled Hints to Native Mothers written in Tok Pisin there is a list of equipment including a teaspoon, a tablespoon, a china cup, a strainer and a bottle with a lid. It is also recommended that women give infants eggs, meat, fish and chicken despite the fact that these were very difficult to source in many places in Papua New Guinea. That these difficulties were not always understood is illustrated through Ed Tscharke’s reflections on the maternal child health clinic in Madang in the 1950s.
He comments that the Sister sat on a nice chair and table and talked about sweet potatoes, eggs, clocks and spoons and took 10 minutes to do one child. When the nurse asked the women to return the next day none of the women did, they only had taro, no sweet potatoes, no eggs, no clocks and no small spoons to eat enough egg to put on a sixpence.
Nutrition and infant feeding practices were the subject of considerable research. In 1947 a nutrition survey was carried out in five villages, each chosen to emphasise a different staple crop, taro, yams, bananas, sweet potato and sago. Interestingly this survey showed very little evidence of rickets, none of beriberi or scurvy and adequate levels of serum vitamin C and calcium intake. What it did show was the overall calorie intake was about 80% of what it should be for adults and intake of fats and proteins was very low.
By 1950 so only a few years after the Infant Maternal Welfare Service started there was a nutritionist appointed to the Department of Public Health. In 1956 she researched the nutrition of infants in the [CPIC] 31:08. She followed three babies and their mothers very closely like obsessively so she sat there with a stopwatch and timed breastfeeds and stuff. She reported on these habits. It is possible to almost hear the incredulity in her writing as the infants were fed entirely on demand.
So she says, even when the mother is tending a fire or preparing a meal she frequently holds the baby on her lap and it may be sucking. No care is taken to see that the child is undisturbed while feeding, no attempt is made after feeding to hold the baby in such a way that the wind will be brought up. The babies very often suckle with their eyes closed and they also very frequently fall asleep while feeding. It is not known whether the baby gets any milk when it suckles the breast like this during sleep.
Research such as this and that occurring overseas was acknowledged by the Infant and Maternal Welfare staff and a weeklong conference on infant maternal welfare in 1954, it was noting that, feeding is no longer by the clock but by demand. In modern life there is compromise between the two and the demand feeding gradually adjusted to fit in with the maternal domestic program. Members of staff working with natives who primarily demand-feed their infants find that the strictness of their former teaching has been modified. So there was some sort of feedback happening, they were gradually changing things. That being said, the length of time sucking was still seen to be important with a minimum of 15 to 20 minutes advised and the syllabus for nursing training still emphasised the timing of feeds.
So my next section is hygiene and health education. Refshauge argued strongly that the focus of the service was on prevention. In her address to the third South Pacific conference on the history of the service, prevention of disease and hygiene are listed as the second and third priorities. In another history of the service she states that, preventative medicine is the basis of the work. What this meant in practice was that Sisters and the nurses insist that babies are washed and cleaned before they are examined and weighed. Advice about village sanitation is given, talks on diarrhoea and dysentery are given.
This in-person advice was supported by a range of materials in posters and cartoons about health and hygiene like the ones seen here about flies, mosquitoes and rats. There are a range of books telling women what to do such as one called Health Badge. I think they could kind of like earn a badge of health. And another called The Story of Two Women, comparing the outcomes of two families, one of whom had a woman who kept her family and house clean and the other one who didn’t.
The picture on the left is a slide from this and it actually has questions in it where people are meant to present it publicly and they’re meant to discuss about why this one is a good woman and this one is a bad woman.
It is to be noted that many of these materials reproduced what was seen to be appropriate gender roles and the domestic division of labour at the time. So there’s also this one about milk for Rauna which was produced by the South Pacific Commission so all these kind of educational materials.
This focus on hygiene was also central to the training of nurses. In the first year syllabus for training, hygiene was the first thing that was taught. The manual for the course provided details on how often to wash – it’s a bit difficult to see but how often to shower, to brush your teeth, to clean under your toenails, to cut your fingernails but also be on time, be quiet and have good manners. Hence this teaching was as much about appropriate comportment as a nurse as it was about hygiene.
So mothers and maternal health. While maternal is listed in the name of the Department and expectant and nursing mothers were listed as a core priority of the service antenatal care and maternal health were seen to be difficult. Refshauge states that antenatal care takes much longer to become popular than infant care. It is hard to really know why.
In another report she stated that, the infant work gradually became accepted while maternal work lagged behind amongst the native people. In an undated report she comments further, it is going to take a long time before any true antenatal work is done in the villages. Custom, modesty and general acceptance of the inevitable are factors that will take patience and perseverance to overcome. Only those in close contact with Europeans and those in highly missionised areas will even ask for advice. There is a general increase in the number of women who enter hospital for confinement but these are mainly women whose husbands hold responsible positions in the administration. Despite this increase numbers are still negligible. Postnatal work is as yet almost unknown. Hence in these very early years there was a sense of discouragement about the uptake and popularity of the service.
In 1950 Refshauge was asked by the administration to travel to New Ireland Province, as it is now known, and there were grave concerns about depopulation in the area dating back to at least 1913. The aim was to discover whether depopulation was continuing and if so what the cause was. There had been studies by a medical officer and anthropologist in the 1920s and the ‘30s and the anthropologist had been asked to repeat this study in 1950. Refshauge was to go and medically examine the population.
So this is some of the material from that. She went with a nurse and driver and spent March to June in the area visiting each village down about half the east coast of New Ireland. She examined all the people she could find in each village to provide a general picture of health. In addition with each woman she recorded – and this picture on the slide is out of her notebook so these are actually husbands, wives and then all the health information across there. So this book recorded everything from her relationship status, her number of pregnancies, stillbirths, miscarriages, the state of her current menstruation, all kinds of stuff. Also whether they had any symptoms of sexually transmitted diseases.
For those who appeared to be having trouble conceiving either their first or subsequent children she physically examined them, noting the state of their internal and external organs. And all of that is also listed. Then for each village she went through and recorded the rates of stillbirth, the rates of sterility and so forth.
On the right-hand side are actually the notes from the anthropologist, [research Tinnery] 38:53 so he – that’s villages with all the details, huge amount of information. From this research he produced a lengthy report. I’ve only been able to find a handwritten copy in her papers here, I can’t find a typed copy anywhere. It was – so we’re looking for it in the 1970s and they said it’s not held in Papua New Guinea or in the Australian archives or anything, it’s nowhere.
So the handwritten report comes to about 10,000 words because I transcribed it and there is an additional 60 handwritten pages on a description of the working characteristics of each village. Amongst her many findings was that death in childbirth was too common and is the cause of 11% of adult female deaths. Many women faced sterility through gonorrhoea as well as a range of gynaecological issues such as prolapse, infections and cervical lacerations. Women tended to develop later with menarche starting at about 15 and menopause appeared to happen younger with many people – many women, menopause starting in their 30s.
In addition she found that birth injuries were the third highest cause of infant death. This research prompted Refshauge to call for better health services for women and so [Caving] on New Ireland was the first place outside of Port Moresby that welfare clinics were established. She also hoped to repeat the research in the following year with a female pathologist but this never eventuated.
The high maternal mortality rates and poor health of women was also indicated through other reports from parts of the territories. In their undated annual report for the late 1950s she notes that, from 6,329 births there were 100 maternal deaths. Statistics from a rural area in mainland New Guinea suggested 30 deaths per 1,000 births and Gunther cited a rate of 60 per thousand. Now at the time in New South Wales the rate was about one per thousand. However for most places in the territory and most annual reports there are no indicators of rates of maternal mortality. Statistical data and analyses were and remain extremely difficult to ascertain.
By the 1954-55 annual report Refshauge was able to say that maternal care is extremely popular among the indigenous population, it consists of antenatal and postnatal care and care during confinement. The demand for antenatal clinics has increased and attendances are regular. The women are encouraged to go to hospital for their confinements. The improved health of women attending the clinics and the lowering of the complication rate as well as the lowered mortality rate have played their part in making this section popular. In addition it is reflected in the growing desire for maternity hospitals which is evidenced through the whole territory. This is particularly so in New Ireland and Wewak.
Refshauge was to stay on in the infant child and maternal health section until 1963 so about 16 years, two years post official retirement age for women working in the territories. She was replaced by Dr Bowler, a male. Not long afterwards the Department of Public Health was restructured. The position of Assistant Director, Infant Child and Maternal Health was abolished and the section was subordinated beneath Community Health. This lowered the visibility of the service, reduced its autonomy and shifted reporting lines. These are changes which Refshauge had been fighting against during her time in the territories.
So some conclusions. While it is in some ways – is relatively easy to trace the formation, structure and content of a particular program it is more difficult to ascertain the importance or valuation of it. What was the status of maternal child health work in PNG in that post-war period? John Gunther, as Director of Public Health, 1946 to ’57 certainly was integral to establishing the service yet in an interview about his work he almost forgot to mention it. It came after a long list of tropical diseases and medical training efforts, epidemiology and so on.
In an address to a meeting in 1946, very early on, he labelled maternal child health as allied health, effectively labelling it as not central to overall health of people.
Dr Royce Grad was the Director of Public Health following Gunther from 1957 to 1970. It was under his leadership that infant child maternal health was restructured and downgraded to a folio in Community Health. In an oral history interview held here at the National Library he states categorically, we didn’t have anything really happening other than expanding the curative services through to 1960. He does mention penicillin and malaria campaigns and mentions child health without any details or further comment. This ignores Refshauge’s stringent attempts at preventative work and health education through this service.
In a review of medical training and maternal child work in Papua New Guinea conducted in 1968 Lawson was able to state that there isn’t much maternal in the infant maternal child health program. The lecturer in obstetrics did not teach on maternal and perinatal mortality because, in their words, I myself know little or nothing of these subjects. The lecturer called for much greater research on maternal and perinatal mortality and morbidity particularly at village level. This was echoed by Johnson five years later in his review of obstetric services in Papua New Guinea, noting once again, there is very little M in the MCH in many areas. Even as late as 1971, just a few years before independence, missions were still predominant in this work with 101 clinics and 443 nurses as compared to 65 clinics and 223 nurses in the Public Health Department staff.
It appears that the efforts of Refshauge and her team to expand the service and to gain the confidence of women in ante and postnatal care stalled at some point in the 1960s. After her departure there is no clear leadership that I’ve been able to find in the records. The Principal Matron of the Department left in 1973. Paediatrics was picked up by Dr John Biddulph in the 1970s who led in the area of child health in the country and did great work but maternal health was left to falter. Thank you and that is my references.
K: Thank you so much, Susan. I’m always – well actually I’m still a bit gobsmacked by the reliance on Marmite for small babies. Take me a little while to get over that one. We have time for some questions and Kelly and Ben will have the microphones to bring to you so we can pick you up on the livestream and on the hearing loop so if you have a question pop your hand up but I am going to sneak a first one in. You mentioned the extraordinary number of languages that are spoken in Papua New Guinea, 830 but all of the posters that you were showing us were in English. I was wondering if you found posters in language or perhaps you could tell us something about how much English was spoken by Papua New Guineans.
S: Thank you. I did not find posters in – no, I didn’t find any in Tok Pisin so there were a couple of little handwritten manuals so Tok Pisin is the lingua franca and so is Motu so there were these little handwritten manuals in both of those but the posters were in English and some of the posters – so they make an effort for them to be very visually grabbing and you can see what the vegetables are and what the things are and so forth. But English was not widely spoken at all. It’s still not in Papua New Guinea and even Tok Pisin was only used in certain areas, particularly for women and particularly in the ’50s and ‘60s so it is interesting that there was that kind of barrier.
Certainly mission staff who went out to outer areas learnt the local languages ‘cause they lived there for years and years and they did a lot of their education in the local language whereas the Public Health Department staff, ‘cause they kept getting moved and the longest postings may be two or three years but a lot of them were shorter, they were not able to ever get that kind of linguistic competence. Some of them didn’t even learn Tok Pisin so I don’t know how they managed.
K: Thank you. Any questions from our live audience? I think that’s Marie-Louise hiding behind a mask there, just get a mic to you.
A: Thanks so much, that was fascinating, Susan. I’m just thinking – I mean this is something that you might have gained an impression of because you’ve looked at so many papers – I was struck by of course the descriptions of shock, horror, you actually breastfed your baby when it asks to be fed but from the other evidence it doesn’t sound as if these health workers, who had a mission of course to try and save mothers and babies, it doesn’t sounds as if they had any ability to step back and say how were – how did the raising of babies, how did pregnancy and childbirth, how did they kind of work in the local context? It sounds very much as if they came in and were kind of imposing views that of course were common in the western world.
Is that an overstatement or is it – it sounds as if they couldn’t necessarily observe beyond their own kind of norms of what they thought should happen. ‘Cause so many of these things, of course, the Marmite, you think that’s a recipe for breastfeeding failure but they probably couldn’t see that. So I’m just wondering if you had any impressions about whether people could look at a culture holistically or only bring their own to it.
S: I mean it’s hard to generalise because I mean what was interesting about the Ellen Kettle papers was the hundreds and hundreds of letters from nurses who - I think the ones who came in and stayed for a long time and got to know people and got to understand what was working culturally were then much less likely to impose things. So what’s interesting is my great-aunt’s work that put up there, they never – so she was there from 1949 to 1974, they never did Marmite at that mission station. They developed - where they felt that people were struggling with nutrition they developed a peanut mixture that was roasted and ground and mixed with banana so it was all local stuff and if there was breastfeeding failure for whatever reason the kids would munch on these peanut banana balls or just use it as a supplement when they were sort of – as a weaning food.
So some people certainly seemed to get it but other people who came in, particularly if they came from down south here in Australia and they’d had their training and they were full of gung-ho and they went up there and they were like right, we’re going to fix these poor women with their lack of understanding with their infants. We’re going to – it was very, very you’re doing it wrong, you need to do it in this particular way and just the kind of insanity of these people did not have clocks like – and at one stage there’s this funny line – so they were really rigid because they said I suppose it’s okay – if it works better for the mother to do the first feed at 9:00 in the morning rather than 10:00 well that’s okay. Or to do it at 7 rather than 6am. That's the kind of level of adjustment, not much more substantial than that.
K: We have another question, thank you.
A: Thanks, Susan, great paper as always. I’ve got a question that goes to discomfort, I think, and maybe [lifts] 52:26 a little bit off the last question and that is did you ever get the feeling looking through all these materials and drawing the conclusions that you have that these kinds of themes aren’t banished to the past and to another place because my overriding sense is that even though it’s quite easy to think of this as an historical observation made of archival materials some of the things you were talking about seem awfully present to me in terms of the ways that particularly female bodies are dealt with and not only in the health service. So I wanted to get your remarks on that and wondered if you had any discomforting feelings while you were observing these things yourself and to also get you to draw out a little bit more about what it was like for you to deal with these papers when – with the presence of your great-aunt around you and in those things.
S: Thank you. So I can answer that in a few ways. One of the things that came to mind immediately was one of the reasons – ‘cause I’ve got three children – one of the reason I found breastfeeding so easy was because I’d watched them do it in Papua New Guinea so that story about oh they just lay there and they just feed whenever they want, that’s my experience of how people breastfeed in Papua New Guinea. When I was having my first infant they were trying to tell me look, you need to have it – this amount of time between feeds and they should be longer and so that kind of teaching is still happening and in some senses it might be becoming popular again ‘cause I was talking to someone and they said their daughter had been taught it’s gone back to much more sort of rigid timescales and so forth.
So it’s interesting that the – clearly the teaching certainly has not altered breastfeeding practices in some places in PNG because when I was there and I was observing they were still repeating things that were being done in the 1950s which I think is a good thing. So yeah so I think it’s not that we just exported these ideas about shaping the maternal body and the relationship with the child, we’re doing it here as well so it’s being imposed here too.
And it’s kind of – in terms of my great-aunt it’s really funny because I sort of – I was thinking of this as almost like a separate project when I came here and thinking this was quite different and it was quite shocking to find that letter from my great-aunt ‘cause I didn’t expect to find it and it was like oh I have a family member in the archives which was really nice. So – and then what I was doing as I was reading was realising how – because I had that in-depth knowledge of a particular mission and a particular kind of ways of doing things I could then see how different sort of some of the Public Health Department was and could have been done better. And it was nice to find that the work that my great-aunt did was actually quite supportive of women and really focused on maternal health as well as children so yeah, it’s been a nice process.
K: Thank you. It always surprises me how many people actually discover a personal connection when they’re doing research that perhaps they didn’t expect to find or they see something in one of our galleries that connects them to their family as well. The personal’s always there, isn’t it? Thank you. We may wind up for today. I think Susan again has shown us what extraordinary stories and people and resources are in the Library’s collections and opened up a part of the collection that perhaps none of us have ever looked at before. If you’d like to know more about our collection I do encourage you to pop online and look at some of our research guides and try putting a search term in the catalogue and just seeing what you come up with, you never know what you're going to find. Our website too is the place where you can listen again to Susan’s lecture, we’ll get it up there as soon as we can but there are also many other stories and lectures up there for you to explore.
Thank you for joining us today and thank you especially to Susan for sharing her research with us. Thank you, Susan.
End of recording
In this fellowship talk, 2022 National Library of Australia Fellow Dr Susan Hemer presents research findings on the establishment and practices of maternal child health services in Papua New Guinea after World War II. Material including original papers, diaries and reports written by public health workers and missionary doctors and nurses, particularly from the period 1946 to 1975, as well as secondary compilations of data and interviews with key public health figures from the period have been analysed by Dr Hemer to document a chronology of events. Research has also highlighted the work of key individuals, the spread of the services and any gaps throughout the country, shifts in policy, and debates about service provision. The aim of Dr Hemer's project is to understand the historical underpinnings of the contemporary health status of women in Papua New Guinea.