Dr Nick Williams

In Aus­tralia, he has pro­vid­ed Roy­al Fly­ing Doc­tor Ser­vice (RFDS) evac­u­a­tions and com­mu­ni­ty med­ical ser­vices to remote Abo­rig­i­nal com­mu­ni­ties and cur­rent­ly works in a Com­mu­ni­ty Health Ser­vice in a mul­ti-dis­ad­van­taged area of Adelaide.

Dr Williams’ work out­side Aus­tralia has tak­en him to remote areas of Africa, a Cree Indi­an com­mu­ni­ty in Cana­da and Pakistan’s North West Fron­tier Province.

Here is his story.

Inspired to do med­i­cine by the GP in my home­town of Jamestown in the mid north of South Aus­tralia, my future was set after a stu­dent elec­tive in the high­lands of PNG in 1978. The ​“see one-do one-teach one” school of remote med­i­cine I expe­ri­enced there shaped my future career.

I learnt how to cross-match blood under kerosene lamp­light from a pid­gin-speak­ing Clin­i­cal Health Work­er; how to do a lum­bar punc­ture from the local nurse; and how to resus­ci­tate a flat neonate from the com­mu­ni­ty mid­wife. I was strong­ly drawn to Third World Med­i­cine.
With the goal of get­ting enough con­fi­dence with clin­i­cal skills to work in Africa, I com­plet­ed a Diplo­ma of Obstet­rics in Aus­tralia and head­ed off to Eng­land to do anes­thet­ics. Nine months lat­er I was the only doc­tor in a remote hos­pi­tal on the wild coast of Transkei, a home­land of South Africa. I was over­whelmed by the bur­den of ill­ness the com­mu­ni­ty faced. Cholera, mal­nu­tri­tion, tuber­cu­lo­sis, bil­harzia, were all new to me. Measles was a killer dis­ease with 40% mor­tal­i­ty in chil­dren. I watched neonates with tetanus con­vulse with every sound or move­ment in the nurs­ery until the seda­tives mer­ci­ful­ly relieved them of their pain. I will always remem­ber the expe­ri­ence of putting in a spinal block before per­form­ing an emer­gency cae­sar­i­an sec­tion and resus­ci­tat­ing the baby whilst a nurse assis­tant con­trolled the uter­ine bleed­ing. There was no knowl­edge or skill that was not taught and shared for pure­ly prag­mat­ic rea­sons. It was an expe­ri­ence. I moved on lat­er to work in pae­di­atrics in a large hos­pi­tal in Bul­awayo, Zimbabwe.

After four years in Africa I head­ed back to Aus­tralia to do pae­di­atric train­ing in Syd­ney. Work­ing in a First World Ter­tiary hos­pi­tal was a huge cul­ture shock. I was doing emer­gency retrievals of 600gm neonates across the State with more equip­ment and tech­nol­o­gy than I ever had at my dis­pos­al. My pre­vi­ous expe­ri­ence was that if a neonate could not sur­vive with a bit of head-box oxy­gen (when there was oxy­gen) then it had no chance. I could not see my future in hos­pi­tal medicine.

It was 1988 when I head­ed back to Africa to work in rur­al Zam­bia and in the three years I had been away AIDS had arrived. Many of the health advances of the pre­vi­ous decade were being lost. It was heartbreaking.

It was at this time that I final­ly realised that there was lit­tle point con­cen­trat­ing all my efforts in the hos­pi­tal when the caus­es of all the health prob­lems were in the community.

I start­ed to go ​“upstream” and try to stop peo­ple falling off the bridge rather than pluck­ing them out down­stream. We trained Com­mu­ni­ty Heath Work­ers and sup­plied them with ORS (oral rehy­dra­tion salts) and chloro­quine. We brought in Tra­di­tion­al Birth Atten­dants (TBAs) to spend two weeks in the mater­ni­ty ward with the mid­wives. The amazed reac­tion of the TBAs when they saw a LSCS (cae­sar­i­an sec­tion) is some­thing that stays with me for­ev­er: they would be gowned and gloved and lean­ing over me almost push­ing me aside to get a bet­ter look at ​‘this bag’ the baby had been in. It was the best train­ing I had ever been involved in. The inci­dence of women pre­sent­ing with a rup­tured uterus and babies with tetanus dropped dra­mat­i­cal­ly over the next two years.

Being one of two doc­tors serv­ing a pop­u­la­tion of 150,000 in rur­al Zam­bia was always going to be a hard act to fol­low, and per­haps it was inevitable that on return­ing to Aus­tralia in 1990 I end­ed up as a Dis­trict Med­ical Offi­cer in Alice Springs.

Work­ing with remote area nurs­es and Abo­rig­i­nal Health Work­ers was what I was accus­tomed to. Pro­vid­ing RFDS evac­u­a­tions and com­mu­ni­ty med­ical ser­vices to remote Abo­rig­i­nal com­mu­ni­ties had its own chal­lenges. These chal­lenges were huge­ly sup­port­ed by my involve­ment in the Cen­tral Aus­tralian Rur­al Prac­ti­tion­ers Asso­ci­a­tion (CARPA). I was and remain a pas­sion­ate sup­port­er of CARPA and was very involved in the first three edi­tions of the Stan­dard Treat­ment Man­u­al, one fin­ger typ­ing most of the first edi­tion. The ​‘bible’ has gone on to become a ful­ly entrenched part of health ser­vice deliv­ery in remote Aus­tralia. Dur­ing my time in Cen­tral Aus­tralia I con­sol­i­dat­ed my Pub­lic Health knowl­edge with a Mas­ters, so final­ly I was a ​‘mas­ter’ of some­thing and not just ​‘a jack of all trades’.

After eight years in Cen­tral Aus­tralia, inter­rupt­ed by a year in a remote Cree Indi­an com­mu­ni­ty in north­ern Man­i­to­ba, we made the ​‘kids’ edu­ca­tion’ deci­sion and end­ed up in Ade­laide for the high school years. Hav­ing seen the wheel re-invent­ed two or three times by health ser­vice bureau­crats in Remote Health, it was time for a break any­way! Work­ing in a Com­mu­ni­ty Health Ser­vice in a mul­ti-dis­ad­van­taged area of Ade­laide has been a change of pace. I have man­aged to keep in touch with remote area work with sev­er­al locums in remote com­mu­ni­ties in the North­ern Ter­ri­to­ry and through my involve­ment with the CRANAplus Remote Emer­gency Care (REC) pro­gram. I am a proud mem­ber of CRANAplus.

I have always want­ed to remain a true gen­er­al­ist, com­bin­ing clin­i­cal knowl­edge and skills with a pub­lic health pas­sion. I work in an ED one night a week and teach a lit­tle at University.

Inspired by CRANAplus mem­bers (Lib­by Bow­ell and Chris Cliffe) I became involved with Red Cross a cou­ple of years ago. I sub­se­quent­ly spent three months in 2009 as an ICRC Health Del­e­gate in the North West Fron­tier Province (NWFP) of Pak­istan dur­ing the com­plex emer­gency cre­at­ed by mil­i­tary action against the Pak­istani Tal­iban. I remain on-call for Inter­na­tion­al emergencies.

CRANAplus will remain part of my pro­fes­sion­al life into the future which will almost cer­tain­ly involve more remote work with peo­ple I love and admire and in envi­ron­men­tal set­tings that peo­ple nor­mal­ly pay to go to.