A pathfinder for improving rural healthcare
Dr Bob Cooter was a procedural GP in Port Augusta from 1956 to 1972. This experience fashioned him into a pathfinder for improving rural healthcare and the lot of rural Australians.
He has been active for almost 50 years in the Royal Flying Doctors Service (RFDS), Aboriginal health, procedural training, accreditation and the maintenance of rural doctors’ skills. He was the first person in the world to make and confirm a clinical diagnosis of amoebic meningitis.
Bob Cooter was born in a midwife’s home at Mile End, South Australia, on 2 April 1927, the youngest of one brother and two sisters.
His mother, Ivy, who was of Cornish extraction, had been brought up on the land at Moonta in the Yorke Peninsula. His father John and four uncles were butchers.
Some of his medical friends joke that this association with butchery must have influenced his decision to study medicine.
Becoming a doctor
Bob’s early schooling was at Thebarton Primary School and then at Adelaide High School. He obtained a state government bursary which enabled him to enter the medical school at Adelaide University. There he received a sports blue for rowing and a reputation for singing and sleeping. His ability to sleep, even whilst standing, achieved legendary status. He became part of a study group of George Mutze, Ken Westphalen and Fred Geisler and this undoubtedly contributed to his graduation in 1951. All became long time rural doctors and remained life long friends.1 Residency years were at the Royal Adelaide and Queen Victoria Maternity hospitals. This was followed by 9 months of locum work in urban general practice which reinforced his desire to be a rural doctor. He entered rural practice in Nuriootpa in the Barossa Valley and stayed for 2 years. But the area was over-doctored so Bob moved to the under-doctored town of Port Augusta.
There he worked in a harmonious four doctor practice with doctors John Thompson, John Mickan and John Bampton. Bob maintains that this busy practice was one of the most interesting and diverse to be found in Australia. He and his partners describe their time up to the mid-1970s as ‘the golden years of medicine in Port Augusta’. They provided services for a population in excess of 10 000 people with a wide hinterland. There were no procedural specialists in Port Augusta so the doctors in the practice did all the minor and major emergency surgery (1000 operations a year) and averaged 350 deliveries a year. When new techniques became available, or they felt that there was a gap in their knowledge, they would dispatch one of the partners to Adelaide to learn how to do them and he would return and teach the others. A classic example of see one, do one, teach one. These experiences sowed the seed for Bob’s later commitment to implementing a rural training program within The Royal Australian College of General Practitioners (RACGP). He was the first chairman of the South Australian Rural Health Committee which ran the first GP rural training program in Australia. He also developed continuing medical education for rural doctors under the auspices of the South Australian Post Graduate Medical Education Association.
Bob enjoyed the cut and thrust of midnight confinements, caesarean sections and appendectomies. But he was appalled by the number of motor vehicle crashes involving young people who were not wearing a seatbelt. He also hated being called by the police at 2.00 am to examine drivers charged with driving under the influence of alcohol. Breathalysers and blood alcohol testing were still in the future and the diagnosis of inebriation was made on the basis of the driver’s ability to pronounce without slurring ‘the Leigh Police dismisseth us’. This was followed by a standardised physical examination centred on the examinee’s ability to balance on one foot and walk heel-to-toe with his eyes closed. The process took 45 minutes. At the end of one busy week Bob was so irate that he had both the drunk driver and the policeman in tears. He told the young policeman off by saying ‘why are you calling me at 2.00 am when you could arrest any number of drunk drivers outside the Pastoral Hotel at 9.00 pm’?
Port Augusta was the centre of a new form of aseptic fulminating meningitis, which affected the olfactory area of the brain and was thought to be due to amoebae. GPs were asked to refer any new patients to the Royal Adelaide Hospital for investigation. In 1966, a 10-year-old Port Augusta boy presented with the classic picture. Bob performed a lumbar puncture and he and his partner, John Mickan, were the first in the world to see a live Naegleria amoeba on direct microscopy.2
There is some debate about the conventions for naming eponymous diseases. But there is little doubt that Bob was the first to make a confirmed clinical diagnosis of this rare but fatal disease. Bob and John Mickan discovered the living organism but also directed researchers to the source of the infection based on their research of local environmental factors and the case histories of several victims. He correctly postulated that the amoebae were carried in the new domestic water supply that came from the Murray River. These pipes were above ground and in summer the tap water was often between 35 and 45°C – the temperature at which encysted amoebae become vegetative and pathogenic. Bob could therefore be described as the Australian counterpart of John Snow, who diagnosed the Broad Street water pump as the source of the London cholera epidemic of 1853–4.
Bob met his future wife Marie in the operating theatre at the Queen Victoria Hospital, where she was a midwife. It is said that she assisted by keeping Bob, the intern anaesthetist, awake!
Marie had a strong rural background. She was born at Tumby Bay, South Australia in 1927, the eldest of six children, and her farming family later settled in Queensland’s Darling Downs. An attractive, capable and practical woman, Marie is the mainstay behind Bob’s achievements.
Bob and Marie married in 1954 and raised five daughters – Anne Bosio, Jane Stanley, Sue Shaw, Liz May and Robbi Tims. The girls between them have introduced five sons-in-law, six grandsons and five granddaughters to the family, all of whom can rise to the challenge of a day’s fishing with ‘Bob-Bob’ (Bob-Bob originated 21 years ago with the first grandchild as he didn’t want to be called Grandpa).
Most country doctors with school-age children are faced with having to make the decision between their love of rural doctoring and lifestyle and the education and parenting needs of their children, and so it was with Bob and Marie. By the 1970s Bob and Marie had three daughters who were already at boarding school in Adelaide. They decided that they had to move to Adelaide and Bob commenced practice at the Regency Medical Group in Sefton Park where he stayed for 20 years.
But Bob has always looked back on their life in Port Augusta with much nostalgia. This has been behind his constant motivation to help country people and country doctors. Under the auspices of the South Australian branch of the Australian Medical Association (AMA), he organised a 1976 survey of rural practice in the Eyre Peninsula and far north of South Australia. He strategically chose as his coinvestigators the state president of the South Australian branch of the AMA and the first South Australian state director of the Family Medicine Program. The team found many deficiencies in the work force and in standards of practice.3
In most instances their solutions were adopted. Unfortunately this study was not written up for wider publication in the peer reviewed Medical Journal of Australia and so it remained unknown outside of South Australia. A previous 1964 report by John Bampton in Western Australia also suffered a lack of acknowledgement for exactly the same reasons. It was not until the late 1980s that rural doctors began to realise the effectiveness of peer-reviewed documentation in defining and addressing their various problems.
Bob became convenor of the RACGP Presidential Task Force on Improving Aboriginal Health. He visited 24 remote Aboriginal communities and prepared the discussion paper ‘Strategies to improve Aboriginal health’. He also had a 32-year involvement with the RFDS as an honorary flying doctor (1956–65), was a member of the governing council (1977–2000) and President of the Central Operations (South Australia and Northern Territory) from 1985 to 1988. He was the driving force in raising standards of care by insisting that the doctors and nurses were adequately trained, especially in accident and emergency care, obstetrics, anaesthetics, paediatrics and aviation medicine. He ensured the formation of a medical review committee to examine the outcomes of air retrievals. He was also a successful advocate for the purchasing of faster and pressurised aircraft and the rationalising of emergency retrieval services by absorbing the South Australian Air Ambulance operation into the RFDS.
The above principles also guided his involvement with the development of continuing medical education, the delineation of clinical privileges for rural hospitals and the provision of financially subsidised locum relief for isolated country doctors.
In 1976 Bob established a rural locum service in the South Australian branch of the AMA recruiting doctors from city practices. This service was transferred to the RACGP in the Rural Practice Training Program that later became the basis for the South Australian Rural Doctors’ Workforce Agency (RDWA). Bob worked with the RDWA for 10 years (1992–2002) performing locums for rural doctors in many rural towns between Ceduna and Mt Gambier.
Lions International involvement
Bob was a charter member of Port Augusta Lions Club in 1996 and was District Chairman of Health and Welfare, organising many projects in the 1970s and 1980s, which are outlined below.
Heart Research Foundation – overseas fellowships for cardiologist in training.
Save Sight Foundation – glaucoma screenings.
Provision of mobile education units for the Heart Foundation and Anti-Cancer Foundation (now Cancer Council SA).
Community health screenings for early detection of hypertension and diabetes – 50 000 people screened in the malls of Adelaide and rural town halls.
Provision of the first rural mammography screening unit in South Australia
Bob’s persistent terrier-like approach to community and medical problems has been recognised by his peers through various awards, which include:
- Fellowship of the AMA (1977)
- Membership of the Order of Australia (1996)
- life membership of the RFDS (1999)
- an inaugural life membership of the Rural Doctors’ Association of South Australia
- three international and several district awards for Lions Health projects.
Bob has been a true champion of rural medicine and rural doctors.
Max Kamien - Discipline of General Practice, University of Western Australia
This article originally appeared in: Aust J Rural Health, 2006;14:43–8.
Adapted and reproduced with permission from Wiley Blackwell.