On Friday afternoon, all the doctors who work at Central Australian Health Service (CAHS) and happen to be in Alice Springs, meet up at 2 o’clock in the conference room in the Peter Sitzler building. It’s a chance to discuss cases, developments, and in recent times, talk with a specialist about an aspect of remote medicine.

All of us living in Alice Springs and Central Australia are very aware of the serious health problems of Indigenous people. On the roads or near a remote township, it’s common to look up at the sound of an aircraft engine and see a retrieval plane with their characteristic red belly. Anyone working in a small town in the outback will have seen the skin diseases, effects of poor nutrition, and disabilities of the many people who live there. As health professionals in the Centre, we treat people with the most severe forms seen in Australia, of diabetes, kidney and cardiac disease. The health crisis is no secret to anyone.

The causes of this burden of disease, premature death, and disability are multi factorial and therefore should be approached at multiple levels to have any chance of success. Putting as it were, all your apples in one basket is not going to work. Targeting all the money and your efforts in only supplying doctors and nurses cannot and is not, the only strategy. It fits with older ideas of targeting clinical disease but doesn’t it make more sense to have a global approach, a preventative emphasis. There is already an aggressive territory wide program of immunisation with uptake rates higher than many affluent regions in white Australia. There is also a strong emphasis on antenatal care, improving the intrauterine environment for the next generation and protecting the well being of all the mothers to be.

Nutrition that’s inexpensive and healthy, real home safety and security, clean, reliable water, and freedom from the consequences of alcohol (FASD : Foetal Alcohol syndrome) and drug abuse, are all going to have to be tackled to achieve the level of health we demand for our patients. However, these issues are out of our hands, and very largely in the legislative arena, needing to be backed up by targeted programs with clear, and long term goals utterly divorced from the usual three year cycle of funding.

But for all this, the science of remote medicine is in its infancy. It’s hard making definitive statements about what should and what should not be done without the science to back up decisions. Until you have solid evidence, it’s all opinion not fact. I cannot begin to imagine making sense of infectious diseases without knowing about bacteria and viruses, but this was the situation for doctors in most of the nineteenth century and for all of human history before then. How could surgery be contemplated or completed with any safety without understanding and applying principles of antisepsis and the science of anaesthesia? Done in desperation, it was so savage and so dangerous, that it gave lasting horror to any surviving patient and surgeon both. The more reliable science we have about health, and in particular about here in Central Australia, the better.

Addressing the social determinants of disease is essential and cannot be ignored but none the less, the science of disease has to be up to scratch too. At present we apply our clinical knowledge on Indigenous peoples, but our expertise was gained in other populations that rarely includes such peoples. The science we use to make clinical decisions about the best medical care has been largely developed by studying disease in other populations, and often in other countries. The necessary studies now being done on heart failure and diabetes, to name two common morbidities, are in their infancy. Major institutes including the Menzies foundation and Baker IDI are doing ground breaking research projects, which are beginning to clarify the ways we need to treat. It’s known that certain cardiac medications work best in black Americans and hardly at all in White Americans, and could it be that this is the case here too? Maybe there are some drugs that will only work in Australian Aboriginal people? There are so many questions which need to asked and answered.

However, one major piece of the puzzle of Indigenous ill heath is coming to light. A virus called HTLV1 may prove responsible for many of the poor outcomes we see amongst our patients as well as contributing to progressive neurological and lung disease. This virus is not a factor anyone needs to consider when treating middle class people in Sydney or Melbourne but here in Central Australia, understanding this virus and it’s effects may prove crucial to getting on top of Indigenous health. It’s early days but even now, there are tantalising clues to how important it could be. Okay, I’ve mentioned HTLV 1, now it’s time to be properly introduced and like the most interesting person at a party, it’s well worth getting to know.

HTLV1 stands for Human T Cell lymphotrophic Virus and its a cousin of HIV ( Human Immunodeficency virus) and just like it’s better known relation, it comes from monkeys as well as apes. Unlike HIV it is not a new arrival in a human population. It’s been in Northern Australia for at least ten thousand years, it’s origins are in Melanesia. Other strains of HTLV1 occur in Japan, South America and Africa. They cause similar diseases in all these places but the percentages wildly vary, causing mostly neurological problems in South America, T cell Leukemia in Japan, and Lung disease here in Central Australia.

This virus is spread from mothers to their babies when breast feeding, and is sexually spread. This accounts for the steady increase in the percentage of people as life goes by. Up to 50% of people in some parts of Central Australia have this virus. It seems that for the majority of people with this infection they are unaffected but a over a third of infected people have significant risk of complications that can disable or kill them.

How does it do this? And more importantly why does it do this? HTLV1 infects CCR4 cells, a type of T cell or defence cell. I won’t bother with the meaning of the acronym but suffice it to say, the virus infects these special cells which are a small but essential” part of the immune system, and upcodes itself into the DNA of the cell. It hides incredibly successfully, so well that it cannot be eradicated. It then drives the replication of these cells, their numbers get greater and thereby the numbers of the hidden virus increase too. Some people due to their genetics have the capacity to control the level of replication and these individuals suffer little from the infection. However those who cannot, can have high pro- viral loads. The term “ pro viral” refers to the pro or hidden form of the virus imbedded in the DNA. Those individuals with high levels of the pro- virus are the people who develop the serious health problems mentioned above.

When there are vast numbers of CCR4 cells, there is too much of the chemical they make. This chemical is called gamma interferon. Small amounts in the right place, delivered in the right time can help with fighting infection. Too much of this agent damages organs and tissues, including the spinal cord, and eyes in particular. And maybe other organs, we don’t know. The investment the body has been forced to make means less of the other defensive cells, less numbers, less diversity so the capacity to actually fight infection efficiently is hijacked. This means troublesome if not lethal infections; including tuberculosis, strongyloides ( a parasitic infection of gut and lung), bronchiectasis ( a damaging process that destroys the airways and increases the risk of and the severity of lung infections) and the most severe forms of scabies. If the number of CCR4 cells gets totally out of hand, this can lead to malignancy, T cell leukaemia. This is how the HTLV1 virus was first discovered in Japanese patients.

This propensity to trigger and worsen infection as well as produce tissue damage in its own right via its zombified T cells, CCR4, could be a factor in other diseases including Kidney disease. There is so much to find out. There are treatments for this infection but it’s complex and not without risk. Exciting, new agents seem to be effective but are terribly expensive and only just leaving laboratories to be studied in the real world. The costs of such treatments will need to be weighed up against the good they can do.

So, remote medicine is throwing up all sorts of challenges and it needs to tackled in all sorts of ways, including; innovative social policies, sustained government interest and support, improving antenatal care, continuing to improve the rates of immunisation, supplying and training interested, passionate doctors, nurses and health workers and lastly, investment in basic science to elucidate the mechanisms of disease relevant to this local Indigenous population.