Past performance is our only guide in suggesting how people might extract the greatest benefit from the resources at their disposal. The historical records of medical services are irritatingly incomplete: they tantalise but do not satisfy. The distinction between ‘well-being’ and ‘ill-being’ is itself arbitrary. Then medical officers record the information which happens to interest them, and historians compound the problem by selecting such information as seems significant in the light of present conditions and concerns. That arbitrary, narrow and doctor-centred record is nevertheless our only evidence on which to pass judgement and to guide policy.

Medical historians explain the evolution of policies and programmes by seeking change within the medical profession, or by reference to change in the wider society and economy. Writers about Papua New Guinea have located the initiative in one of four ways. The locomotive of change may be Great Doctors, or the medical profession on a world scale; or medical services may spring from the political economy of the country, or from the interests of the colonial authorities who (in the case of Papua New Guinea) paid most of the medical bills.

Great Doctor theories of public health excite not only doctors, who enjoy some vicarious glory, but also scholars who prefer simple explanations. At least five doctors have seemed to command events in Papua New Guinea almost in Wagnerian fashion.

On the face of it, New Guinea should have developed a more effective medical service than Papua. It was the first theatre of military operations for Australian troops in the Great War, and a substantial garrison remained until the Armistice. The plantation economy had been developed by German entrepreneurs into a genuinely profitable industry, which was then expropriated and distributed among Australian ex-servicemen, who also enjoyed preferential appointment to the sizeable peace-time public service. From 1914 onwards, therefore, the Australian Government paid it much more attention than Papua enjoyed. Then the 1930s were dominated by the growth of a great gold mining industry in the eastern fringe of the highlands, on a much greater scale than any enterprise in Papua; and it was from New Guinea that most of the highlands exploration was launched. Again, as a conquest state governed by ex-soldiers, its expatriate population was larger and more articulate and united than that of the sister dependency.

New Guinea was held under a League of Nations Mandate, and it provided a major new responsibility for the small federal bureaucracy, which had to share responsibility for most other functions, with the constituent states of the Australian Commonwealth. The mandated territory assumed particular significance for Australian health planners. The Commonwealth Constitution gave the federal government scant authority over the states in matters of health.

Although most of the personnel were new, and conscious of making a new beginning in public health, in one respect at least they persisted in old habits. Most of the activity of the department was correctly described as a series of assaults on specific diseases. The purpose of Gunther's survey of before he assumed the Directorship, was to identify the ‘killer-diseases’ which posed the most serious threats to health, and which were most amenable to treatment. His exasperation during the first years of his office was the shortage of personnel to attack the diseases which he had targeted. In retrospect this may seem to have been a strategic error; but the approach was shared by public health authorities throughout the world, and war-time habits of thought easily seduced medical workers to see specific disease as the enemy. During the 1950s that mind-set was, if anything, reinforced. Counter-insurgency campaigns during the 1950s often endorsed the medical image of communism and nationalist revolt as unnatural infections to be contained and eradicated by heroic effort. To be sure, the excitement of campaigning against specific diseases did wonders for the morale of ex-servicemen doctors, and evoked heroism in their work. Perhaps no other strategy could have been so readily understood by the medical workers, nor so enthusiastically implemented.

The early medical authorities in colonial Papua – whose own life expectancy was a matter of nervous doubt – had no opportunity to teach each other nor to instruct Papuans. Breinl's visit from the Institute of Tropical Medicine encouraged Strong's interest in the bowel parasites of plantation workers, but the official record makes no reference to formal teaching. Informally, though, doctors encouraged settlers to take their bitter quinine regularly, and through the Handbook on the treatment and prevention of disease in Papua when medical advice is unobtainable (that is, for most of the people, most of the time) to dress wounds, purge fevers, and remain cheerful. The hookworm campaign involved a programme of lectures on personal hygiene in Lambert's idiosyncratic pidgin, and government patrols encouraged the building (and use) of pit latrines, and discouraged traditions of allowing corpses to decompose in villages.

Their German counterparts were better equipped to embark on an educational programme, and in the few years before the Great War a number of heil tultuls received a few weeks' instruction in hospitals, before they returned to their villages. The vaccination programmes had an educational dimension as well; although some missionaries intruded more theology than therapy into their advice. The innovation of heil tultuls was one of very few German ideas to survive the transition to Australian rule:

The search for the mainspring of medical policies and programmes must begin with the colonial state, which employed most of the doctors who declared the policies and launched the programmes, and which influenced the behaviour of mission doctors and nurses. It is necessary, therefore, to describe the general purpose of the colonial state and its financial basis. This approach assumes that the colonial state directs its resources (including medical skills) towards the needs of the fledgling colonial economy. When we test that assumption, however, it proves unsatisfactory: it is impossible to construe medical programmes simply and mechanically as the state's contribution to capitalism. We adopt that approach to see how far it will take us, and to gauge the extent of doctors' autonomy in policymaking. Since there were two colonial states from 1884 until the Pacific War in the 1940s, we also take the opportunity to consider each on its own in order to seek out comparisons and contrasts. What follows, therefore, is an investigation of the ‘political economy’ of health policies and programmes setting matters of public health in the constitutional and economic circumstances of each of the dependencies.

British New Guinea, the south-eastern quarter of New Guinea, was a Cinderella among British dependencies. From 1884 when it became a protectorate, this ‘oddity of empire’ was administered by British officers, and paid for (grudgingly) by the Australian colonies. The new Commonwealth government accepted responsibility for Papua in 1906.

The ideas and techniques of medical care between the wars could be grouped together under the rubric of ‘tropical medicine’, an organising principle which gave those ideas a general coherence. The massive expansion of medical knowledge and drugs during the 1940s burst the limits of that organising principle: so many infections could be prevented or cured, that medical administrators need no longer rely on quarantine and segregation to defend the health of small enclaves of well-being. Scragg describes the post-war years as the ‘curative era’. The great campaigns of those years, when western medicine took the offensive against specific infections, asserted that tropical people need no longer suffer more intensely than temperate societies.

The emergence of a new organising principle lagged behind the technical changes which made it necessary. Meanwhile, medical planners were abandoning their earlier models of health and disease. They were responding not only to a more sophisticated epidemiology, which observed that much ‘tropical’ ill-health was a consequence of poverty rather than physical environment. They also responded to the political independence of many tropical colonies. The social tendency of tropical medicine – to protect privileged minorities and to acquiesce in the morbidity of the majority – jarred against the rhetoric of newly independent governments. There was also the intriguing example of China's barefoot doctors, and the collaboration of traditional Chinese and modern western specialists.

Much of the history of medical administration in Papua New Guinea may be read as the local application of universally agreed prescriptions. In one major area of therapy, however, there was variation within the country. At the risk of over-stating the contrast, it is convenient to present the work of the post-war medical missions as complementary to the department's work.

The department was, of course, responsible for the whole country, and the careers of doctors, nurses, and medical assistants (but not aid post orderlies) took them from one district to another, from rural extension work to headquarters administration or to research duties. Though the hospitals and health centres were fixed, the personnel were highly mobile. Each mission, on the other hand, ministered to a circumscribed area, and careers involved long periods in a single language community. Immobility (often intensified by isolation from other expatriates) encouraged familiarity with the language and society of the neighbourhood. Mission personnel who wished to specialise, commonly transferred to the department. Other kinds of specialisation – for instance Ed Tscharke's study of yaws – might entrench a mission worker ever more deeply in one locality. Tscharke built his own hospital on Karkar island, and ran it for thirty years, specialising in yaws treatment.

In the immediate aftermath of war, the missions were financially straitened: their personnel accepted lower salaries than their departmental counterparts, and they managed without expensive technology.

Public health institutions and practices were initiated in Papua New Guinea late in the nineteenth century. They were an integral element of the colonial state, and the administrators were instruments of German and British empires which had developed fairly clear ideas about the proper regulation of public health. By the turn of the century these imperial ideas included a distinct body of theory about the administration of health services in the tropics. There was little latitude for adapting ideas and practices to local circumstances, and the instituting of public health measures in Papua New Guinea is best understood as a local manifestation of a world-wide movement. In order to grasp the nature and purpose of these introduced services, we must digress to describe the perceptions and prescriptions which animated them.

Until the middle of the nineteenth century, western medicine had no particular advantage over the medical beliefs and practices of many other societies. Western medicine was an assemblage of techniques (especially surgical procedures) tested over time by an immense variety of universitytaught or self-taught practitioners, having some scientific basis but no unifying scientific theory. The significant advances in public health of the early nineteenth century in Europe were mainly the product of bureaucratic control over clean water, sewage, and pure food and drink. Medical practitioners operated in a legal limbo: sick individuals were free to consult whomsoever they pleased; anyone could advance a claim to be consulted.

The context of this enquiry is the health of the people of Papua New Guinea, and its transformation over time. Regrettably, health is largely a subjective condition – ‘well-being’ is how we actually experience it: a contented condition which includes the absence of infection but is also a positive state. A study of health therefore cannot proceed directly: instead it relies upon inference. One source of evidence is the behaviour and observations of medical specialists, who are essentially experts in ‘ill-being’ rather than health itself. To compound the problem, we know very little about those specialists in pre-colonial Papua New Guinea. A recent review confesses that ‘next to nothing is known empirically about the medical botany of Papua New Guinea. Even less is known about the full diagnostic and treatment regimes available traditionally.’

In order to establish some base-line for this study, therefore, we have to make even more tenuous inferences from the physical environment. Since the physical environment itself changes, and human beings both change it and adapt to it, this overview cannot pretend to completeness. Such evidence as we possess is best considered as the dozen surviving pieces of a vast jigsaw puzzle: they can only suggest the scale and tone of the whole picture.

The outline of New Guinea's environmental history is now fairly clear. About 10,000 years ago, as the most recent ice-age receded and released water to swell the oceans, Torres Strait was submerged, separating New Guinea from the Australian continent, and stretching the intervals between the islands of the western Pacific.

By the 1960s, health services were fragmented: each piece the product of historical conditions which were passing away. Each of the major mission societies operated an autonomous health care service, focused on the area where that mission predominated. Within the Public Health Department, the Division of Maternal and Child Health (with its own Deputy Director) ran programmes catering to quite distinct public needs; and the units (waging the campaigns) specialised in the control of one infection each. A District Medical Officer was simultaneously answerable to several regional supervisors of campaign units, and to the hierarchy of the department at large, centred in Port Moresby. If the District Medical Officer was baffled by competing demands on his time and resources, the aid post orderly was even more bewildered by the variety of medical specialists who passed through the village, sometimes offering assistance, sometimes demanding support, and at other times ignoring the aid post entirely.

If the dislocation was most acute in the department, it was in the missions that the strongest arguments were made for integration and a better planned service. One of the architects of integration, Dr Hakan Hellberg, recorded his impressions for the guidance of later historians. He identified several impulses towards change in the late 1960s:

1. Development towards self-government accelerated.

2. National churches started taking over responsibility from overseas mission groups.

3. […]

The Pacific War was slow to wind up in New Guinea. Japanese forces – cut off but still able to defend themselves – were harassed by Australian and Papua New Guinean soldiers, while MacArthur drove on to Manila. It was late in 1945 before all surrenders were accepted, all conscript labourers returned home, and most military detachments demobilised. During six years of war (including almost four of direct combat) many features of the 1930s had been obliterated. In particular, the post-war medical administration would be armed with a range of new drugs and animated by new perceptions of medical possibilities. Most obviously, penicillin became available. It was used widely in the armed services but more sparingly among civilians. The first instance of penicillin being used for a civilian's traumas, may have occurred in 1943: a young Milne Bay girl was carried by the missionary Cecil Abel to a military hospital, her arm so badly broken and infected that he thought she would lose it. The medical officer on duty administered penicillin lavishly – Abel was jolted by the unspoken calculation that several hundred pounds' worth of the drug had been administered – and miraculously the girl's arm was saved. Civilian doctors in peace-time were less lavish in prescribing it, at the price which it commanded, but gradually it became cheaper and more accessible.

The social study of medicine used to be inhibited by the awe which doctors inspired in lay people. Doctors would conduct their esoteric debates among themselves, confident that the leading issues were purely technical in nature. During the past generation, however, the caring professions have become less confident of their prescriptions, and correspondingly willing to discuss their concerns with a wider public. Meanwhile the soaring cost of medical services has provoked wider debate about health policies, and closer attention to the costs and benefits of programmes. The community as a whole now funds services which most individual patients cannot afford.

The new openness is especially marked in those regions roughly described as the ‘third world’, newly emancipated from colonial administrations. Colonial governments discouraged public debate on social policies generally, and consumers of those policies lacked a forum for canvassing their needs. Independence created forums for debate, and continuing poverty and low standards of living promoted discussion of the relative merits of health programmes as against education, or agricultural extension, or any other element of ‘development’. These discussions have also been internationalised, to match the international implications of any single country's health hazards. The present AIDS epidemic and the remarkable revival of malaria are only the most visible of many concerns which agitate researchers, practitioners and planners throughout the world.

Before colonial administration was attempted, it was already clear that Europeans and their servants would suffer acutely from malaria, and in some circumstances from dysentery. The first resident European, the Russian scientist (and disciple of Tolstoy), Nikolai Nikolayevich Miklouho-Maclay, was conveyed to the north coast in 1871, with two man-servants. The Polynesian soon died, and the surviving Swede fell chronically ill. Maclay's health was seriously undermined, and he concluded that

Within a few months, the Polynesian pastors and teachers established on the coast of the Papuan Gulf by the London Missionary Society, had to endure devastating mortality rates from malaria. They were familiar with mosquitoes – perhaps too familiar – but not with anopheles, and took quite inadequate precautions. And from the late 1870s there was a series of gold rushes from northern Australia. The prospectors were casual and hasty in arranging sanitation, and fell like nine-pins to dysentery. One vivid account (from a slightly later date, 1889) describes the complete collapse of a whole mining community

In the preceding chapter it was maintained that the O. A.P. A. 1861 did not explicitly permit therapeutic abortion but that this did not prevent the performance of the procedure by medical men: abortion was openly induced according to indications established not by the law but by the profession. When these indications expanded, so too did the performance of abortion, even though the law remained unchanged in its apparent restrictiveness. Only in 1938, after the law was challenged by a member of the medical establishment was legal theory unequivocally brought more into line with the realities of clinical practice. It is apparent, therefore, that medical men exerted a significant influence not only on the restriction of the law in the nineteenth century but also on its subsequent relaxation. Did the profession exert any significant influence on the more recent relaxation of the law by the Abortion Act 1967?

The Act came into force on 27 April 1968. It represented the culmination of a campaign led by the Abortion Law Reform Association (A.L.R.A.) to make abortion more widely available. The history of that campaign has been adequately documented elsewhere. It is the aim of this chapter to consider, against this background, the views of the representative medical bodies on the reform of the law and their influence on the Act as it finally emerged from the legislative process.

The 1967 Act placed therapeutic abortion on a statutory footing. Previously, it had been regulated by case-law in the form of the summings-up in R. v. Bourne (1938), R, v. Bergmann and Ferguson (1948), and R. v. Newton and Stungo (1958).