I’ve now got a mere three days to wait before I set off on a series of flights that leave the UK on Monday at 10pm and arrive in Madang on Wednesday at 4pm… theoretically. Maybe things have changed since last time but I don’t ever recollect an internal flight in Papua New Guinea leaving anywhere near the scheduled departure time. Either way I think I may be a little tired when I arrive.

Once in Madang I’ll need to find myself some accommodation and a mobile phone SIM and then I’ll be set to get in touch with Sophie, the existing doctor at Eichel Hospital, to work out my next move. I think it will involve buying a lot of food to take to the island.

But, to précis the start of Basil the Great Mouse Detective (I am the only one who thinks that it’s an under-rated part of the Disney canon, by the way?), I’m getting ahead of myself. Maybe I should start by telling you where I’m going.

Papua New Guinea (PNG) is the eastern half of a big fat island which sits above Australia. Here is a map. I’ll be working at Eichel Hospital, a hospital run by Lutheran missionaries, on Silsil island. Google shows it up as a featureless blob but in reality there are a few settlements on the coast and a great big volcano in the middle. Kath and my parents will no doubt be delighted to know that Silsil Island is part of a chain of volcanic islands known as the Ring of Fire. Thankfully the volcano on Silsil hasn’t erupted recently and hopefully someone will tell us if it’s about to.

So now you know about as much as I do.

Oh, one thing I should say just before I go: each post is categorised so you can filter out the aimless witterings that don’t interest you. All vaguely relevant posts to this trip will be in the Papua New Guinea category and if you look to the right you’ll see a Papua New Guinea link under the categories heading. Just click on that to restrict posts to those about PNG. I’ll try to match the standard of what I hold to be pretty much the acme of medi-travel-blogs, namely Anu’s journal about his time in the Central African Republic with Medecins Sans Frontiers. Even if you don’t know Anu I highly recommend it, purely as a great piece of writing.

It was the smell that first drew me back in, the strange sweet smell of Papua New Guinean sweat, so different to the acrid tang of a European’s. The smell comes in waves off the locals and permeates the grubby torn seats of the PMVs (Public Motor Vehicles – the local (mini)buses). With the smell came a rush of memories and a feeling of being somewhere good. I hoisted my rucksack onto my shoulders and walked out of the tiny airport.

The journey had been long, 36 hours of flights on four planes, and I was looking forward to a hot shower at my hotel so it was somewhat distressing to discover that the hotel shuttle bus was nowhere to be seen. There didn’t really seem to be any taxis or buses either. I meandered towards the far corner of the car park in the vain hope that the shuttle bus might be hidden there, knowing full well that it wasn’t going to be. This is PNG: I hadn’t phoned to specifically ask for the shuttle bus and so there was no way that it was going to turn up. My salvation came in the form of a Canadian VSO volunteer whom I’d been chatting with on the plane. She must have been keeping an eye on me because she came over and offered me a lift into town and so, with that well-timed piece of luck, I escaped a 7km trudge into town.

At over 300 Kina (~£40/$75) per night for a standard room the Coastwatchers Hotel is at the high end of the market in PNG. To put it into context, the doctors I’m working with earn K900 per month (the same salary as a state-employed doctor but without the tax relief benefits of being a state employee) and are relatively well off here. I felt rather guilty the first time I heard that statistic; in the past week I have probably spent what they would earn 3 months. This also goes to show that, unsurprisingly, there is a huge disparity between the rich and the poor here. (Remember, that the doctors are relatively well paid.)

The room was large, if spartan, and I wasn’t too surprised when the shower’s hot water tap came off in my hands when I turned it. What did upset me, though, was the pair of rats nesting inside of one of the beds. I chased one out but the other managed to hide somewhere in the bathroom. I reported this to the duty manager who promised to get things sorted out but quickly became distracted by chatting to a friend. Too exhausted to care I collapsed into bed only to be woken at regular intervals by what sounded like a pneumatic drill going off in the bedroom but was in fact the plumbing vibrating. As I tried in vain to get back to sleep (it was too hot) I’d hear the rat scuttling about, making a rather sinister slithering noise. The next morning I happened to bump into the hotel manager who I’ve not seen before or since and did something terribly uncharacteristic: I complained. The next thing I knew I’d been upgraded to a premier room which has, joy of joys, a fan above the bed. So in the end I’m quite grateful to the rats.

Moments of good fortune like the rat-induced upgrade and the Canadian airport rescue service have certainly made my trip easy so far but the other major factor that must not go unremarked upon is the extraordinary friendliness of the people here. On the first day one of the cleaning ladies, Rose, took me into town and showed me how to find the supermarket and the next day the night watchman, Edward, took me on a rather lengthy mission to find a local SIM card for my mobile after the end of his shift. There is no way I would have found one without his help (most shops were out of stock so they would suggest another store which I probably wouldn’t have located). Most people in the street will greet you with a cheery “mornin” or “apinun” and, much to my surprise no one tries to cheat me by adding a tourist markup to their prices. There is of course the old ‘no change’ scam but it’s not really practiced without any conviction – you only have to ask people if they have change before opening your wallet. Even the guy who pocketed my mobile phone when I left it on a table gave it back, though perhaps that was because I could hear my ringtone coming from inside his bedroom.

I spent the first two days touring various tourist attractions in villages around Madang with the aid of a wizened old man called Jowa. He knew enough English for me to understand him but not enough for him to understand me. Nevertheless he was an excellent companion. He seemed to take great delight in explaining how people buy vegetables or buai (betel nut) from the villagers and then transport them to market to sell them at a higher price. As he described the process his eyes would light up as if he were imparting some cunning and mystical technique. He also had a habit of telling me the distance to our destination (always in terms of the time it would take to get there) to an astonishing degree of precision but also to a wild degree of inaccuracy. “It is 25 minutes to the village” – one and a quarter hours later… Not that any of this mattered because the real pleasure came from the journeys to get there and not from the “attractions” themselves. (The ‘Nature Reserve’, for example, turned out to be 6 turtles in a sulphurous pool and 2 eels who were resolutely unimpressed by the banana chunks that the reservation owner lobbed at them).

The trips started with a long ride in the back of a trucked pack with coconuts, buai, greens wrapped in sago palm leaves and people, all destined for nearby markets. We would disembark at a nondescript layby and walk up into the hills to the villages where these things were. The trails are surrounded by lush vegetation, life bursting from every cubic inch of space. The colours are so bright and the sounds of the cicadias, birds and other animals piercingly loud. From time to time there are breaks in the trees from where you can look out and see that you are surrounded in all directions by lush jungle without a single sign of human habitation.

Yet, every so often you meet people coming the other way; women carrying huge loads in string bags called bilums whose single strap runs across their foreheads, or men carrying little more than a bush-knife or a radio. There is no word for feminism in Pidgin. However, despite the huge gender inequalities I found that the women would have no hesitation in cheerfully greeting us as we walked passed. Whilst they are expected to have sex whenever it is demanded and are on the receiving end of frequent bludgeonings at the hands of their partners it seems that the women are allowed to talk to strange men, something that surprised me.

The villages, when we finally came to them, were uniformly beautiful with plants clearly planted in a decorative fashion. Fat little children ran around, full of energy; a far cry from the African dustbowls inhabited by skeletal children with pot-bellies and sorrowful eyes that we were repeatedly shown during our Tropical Medicine course (DTM&H). I got very excited by the first man I met because he appeared to have a something called Bitot’s spots, a heaping up of the transparent membrane covering the eye caused by Vitamin A deficiency. However, he was clearly in good health and as he was going to guide us down and through a bat-infested river cave (this was one attraction that really lived up to the name) I doubted he had problems with his vision. Eventually I could restrain myself no longer and asked him about his sight. It turns out that the lesions were scars from metal welding without eye protection.

I will admit that comparison between the villages I visited and the ones shown in our lectures is slightly silly: the PNG villages were relatively close to town and attracted tourists (albeit only about 60 per year paying K10/£2 each), whilst the African pictures undoubtedly came from the worst (worse?) case scenarios but nevertheless I think the comparison highlights something important. Whilst many of the health problems here are the same as in Africa the reasons are more to do to with human factors than anything else. As one of the doctors I later met said, “This is a blessed country. There is plenty of water all year round and the soil is very fertile – people only starve if they don’t plan properly.”

Everybody (well, every man) has a a ‘blok’ a piece of his land that is his birthright and people will use this for the trees to build their houses and to grow crops, or as they say in Pidgin ‘make a garden’. They might come down to town for a while but if their job doesn’t pay enough they will just retreat back to their village and start growing their own food and perhaps some cash crops. There is also your wantok (lit. one talk – the people who speak the same language as you, your clan) to look after you and in turn you look after them. If one person in a clan is doing well then his other wantoks will come and live off his earnings. This has tremendous advantages of course but is also the source of many of PNG’s problems.

The New Guineans only gained independence in 1975 and so the politics here is relatively immature, dominated by people looking after themselves and their wantoks, rather than the whole country. You can see how this might make for a dysfunctional health system, especially allied with a culture when people are used to working only when they need to and going back to their villages if their job doesn’t suit them for whatever reason.

These factors also make this a difficult place to work in as an outsider. All the doctors I subsequently met at the weekend Lutheran Health Services (LHS) medical conference mentioned how frustrating it can be do get things done here – “You fall into holes here that you cannot get out of”. The wantok system also means that it is extremely difficult to integrate effectively with the locals (because you are not from their wantok and therefore to be kept at arm’s length). Though, whilst decrying this one of the doctors also exclaimed, “But if you do get close then they start asking you for money for all sorts of things all the time.” It seemed to me that he might have been achieving some degree of integration but then wasn’t prepared to take all the things that came with it. If he’d been a native then, as someone earning good money each month, he would have been expected to give all his money to his wantoks.

The conference was absolutely brilliant and an excellent introduction to working here. The LHS is an organisation run by Papua New Guineans but which largely recruits from abroad. They have four hospitals of somewhere in the region of 60-200 beds each which tend to have only one doctor each, though in one hospital they had three doctors. Most of the eight doctors are German (being Lutherans) though their were two PNGeans and Dr Antoine, who will be working with me at Eichel Hospital, is from Mauritius (rather than France, as I’d previously thought). We had en excellent series of lectures from our guest speaker, Dr Matthias Muller, a German obstetrician working at a Catholic hospital, on topics such as the Misgav Ladach technique for doing a caesarian section (it apparently leads to less surgical trauma and faster post-operative recovery) and how to deal with post-partum haemorrhage (a mother who is bleeding heavily after having given birth). We also had a fascinating talk on the Ugandan HIV/AIDS programmes and what they’ve discovered there. Reassuringly, a lot of the messages were the same as the ones we’d learnt on the DTM&H.

Just as valuable, however, was listening to the doctors talking about the problems they had experienced, not only in treating patients in the hospital (no blood tests, no blood transfusion in one hospital but still expected to caesarian sections and catastrophic bleeding, a reference laboratory for HIV tests that takes 3 months to return a result but they are always negative, even if the patient clearly has AIDS) but also problems trying to educate people about various health problems and also problems related to working and living in PNG. One doctor who has been here for six years put it beautifully: “I view my time in PNG like a relationship. For the first two years I was in the honeymoon period and everything was great. Then I started to see uglier things and after 4 years I wanted a divorce so I had a separation and went back to Germany for a while. Now I am back and we’ll see.”

Many of the problems they described were those described time and time again on the DTM&H course: logistical problems, failiure to build sustainable services (anything handed over to the locals seems to have collapsed due to factors mentioned above), failure to maintain equipment, failure of neighbouring NGOs (non-governmental organisations) to communicate and cooperate effectively, failure to change health practices because whilst they can give people information until they are blue in the face they cannot make them understand at the deeper emotional level required to get people to change the way they behave. (And when you hear that on Silsil island, where I will be working, men apparently have around 7 different sexual partners per week, yes per week, that wasn’t a typo) you can see what an uphill struggle it might be to control the transmision of sexually transmitted diseases.) These have reaffirmed ideas that I started to develop whilst on the DTM&H course and I’d like to lay them out here, both to provoke discussion and as a record for myself. I am sure these ideas will evolve or even be discarded entirely in due course but I find it interesting, personally, to see the journey of that thought process.

The first idea is one I’ve previously mentioned, that of a meta-NGO. PNG probably doesn’t need another NGO coming along to set up health programmes of its own. What it needs is information transferral between those organisations, co-operation and widespread dissemination of best practices both in terms of medical knowledge but also in terms of management techniques and cultural sensitivity etc. If you are an obstetrician and you think that your patients need an HIV programme rather than doing all the donkey-work yourself why not call on a neighbouring NGO to come and do that work for you, or at least to explain to you what they’ve discovered in setting up their programme so that you don’t have to reinvent the wheel? (Yes, there will be all sorts of financial implications but these should be surmountable one way or another and would probably be minor compared to the political problems that you’d encounter setting this up.) My putative meta-NGO would also ultimately serve as some sort of monitoring organisation in an ideal world but now my cloud castle is really getting quite fantastical.

The second is perhaps more controversial. The mantra of today’s NGOs is, sustainability, sustainability, sustainability and so they aim to hand back projects to the locals as quickly as they can. In places where a small leg-up is all that is required this is fine but in many places it seems to me that it’s cultures and attitudes that are the real source of the problem. You won’t change people’s way of living and working with a 5 year project. That’s completely ridiculous, these things take generations to change and the desire to change has to come from the people themselves.

People will often comment incredulously that you can find people who have hardly any money spending what little cash they have on mobile phones. Then later they may bemoan the crushing penury that means that people can’t avail themselves of mosquito nets or whatever. To me the point is glaringly obvious: people perceive enormous benefit from owning a mobile but very little from a mosquito net. If you gave out mosquito nets to Europeans living in Africa you can bet that they’d all come running if they didn’t have them already because they see them asimportant. It’s not a question of intelligence or education, it just different priorities arising from different cultures and experiences. My response to all this is that the NGO-run hospitals shouldn’t aim to hand things over to locals, they should plan to be here for hundreds of years quietly providing the best quality healthcare they can. They should have a training mission, of course, but this shouldn’t be with the aim to hand things over in the short or even the medium term.

At one point or another the politics of the country will change and so will the behaviours and attitudes of people. At that point the NGO hospital will become redundant and probably die a natural death. Some might say this is a very patronising world-view to which I would respond that it’s merely viewpoint free of the current hypocrisy. If you’re coming to a country to tell people that they should change the way they live and to run hospitals for them, by definition you believe that you know better than they do.

Right, enough justification. I shall don my flame-retardant suit and await any comments that may come. In the mean time I will go and get ready to buy food tonight in preparation for the boat-trip to Silsil tomorrow and the start of some actual work. It’s been a great first week in Paradise.

“Doctor, emergency!” the nurse called insistently from outside the screen door. Sophie jumped up from the dinner table to go. I thought of joining her but the memory of the night before was still raw in my mind. I kept quiet, watched her leave and then turned back to dinner, trying not to think about it. Luckily Matthias and his wife Halima were at the table with me so I was kept occupied talking to them. Later, when the generator switched off for the night, and I was back in the quiet darkness of my own home I let the episode unravel again.

It had started in much the same way with Sophie, the German doctor who works at Eichel Hospital, calling across the compound that she was going in because a patient needed a Caesarian section and would I like to come. Matthias, the obstetrician who had lectured us at the doctors’ meeting happened to be on Silsil Island for a week’s holiday with his family and so he would do the the operation. This was an excellent opportunity to start learning the operation that has saved more lives than any other so I jumped at the chance. Ten seconds later I was padding across the compound with the two doctors.

In the side room outside theatre lay a young pregnant girl. She had gone into labour but the baby had not turned around as it should and it was still lying sideways across the abdomen. When this happens you can try and turn the baby around by pushing it from the outside but often, as in this case, it does not work and the only option is a Caesarian section. Matthias examined the lady and after a brief word with Sophie turned back to the mother. “You want me cuttim dispela way or dispela way?” he asked her, tracing out two lines across her abdomen. The only response from the mother was the addition of a confused expression to the pre-existing terrified one. “OK. Me cuttim dispela way.” Matthias demonstrated a line running down from the belly button towards the pelvis. The mother looked relieved and without further discussion or explanation she was walked into the operating theatre.

After removing our sandals we crossed the theatre, bare-footed, to get changed in a tiny supplies cupboard at the back of the room where the surgical scrub trousers and dresses lie alongside the syringes and sterile packs needed for surgery. Sophie went first and by the time I’d got changed she was already in position to start inserting a needle into the mother’s spine to give her the anaesthetic. There was no explanation or warning, just the instruction to sit up straight with the shoulders hunched forwards. As one might expect the first needle prick took the patient by surprise and she almost jumped off the bed. The procedure went downhill from there.

It’s often difficult to give sufficient local anaesthetic to make the introduction of a spinal needle completely painless but the amount that the girl was given seemed truly paltry to me and it must have been quite painful indeed as Sophie tried to locate the epidural space into which the operation anaesthetic must be injected. She could not find it. From my vantage point I could see that the needle had entered the back at the wrong angle and that was why she was missing the space. I tried to explain this quietly but Sophie either ignored me or was so focussed that she did not hear me. I did not press the point as I did not want to be the whippersnapper doctor who parachutes in and starts to tell the local experts how to do the job they’ve been doing for years before him. I contented myself with squeezing the mother’s hand and trying to calm her as best as I could. Eventually Sophie straightened up. “We will have to use Ketamine,” she announced.

Ketamine is an excellent anaesthetic and is widely used in the developing world setting because it does not suppress the patient’s gag reflex and therefore you do not need a ventilator and breathing tube during the operation to protect the patient’s breathing. In addition, in contrast to most (all?) other anaesthetics, it raises blood pressure, which is very useful in patients who have lost a lot of blood or are very dehydrated. Its main side-effect is nightmares so it is not used much in the West where we have the luxury of taking such considerations into account.

Whilst the nurse prepared the Ketamine we went behind a glass screen to scrub up for the operation and put on some theatre shoes. Five minutes later Matthias was making the first incision with I acting as his assistant and Sophie as the scrub nurse. He skilfully divided the muscle and connective tissues to get down to the bulging uterus which spilt open like an over-ripe fruit with a gentle stroke of his scalpel. The waters surrounding the baby burst out and splashed down the bed. Now I understood why we’d been given heavy aprons and boots to wear. Matthias worked quickly and pulled out a limb, the right arm. In went his hand again trying to locate both feet but only one would come. “Scheiser!” The other foot would not come and too much time was passing. “Scheiser!!” he muttered again. Sophie now joined in and finally managed to grab the second leg. She pulled the baby out and it appeared, horribly purple and horribly silent.

She rubbed its face with a towel and held it upside-down to stop any fluid in the mouth going down to the lungs. Still nothing. She swiftly clamped off the umbilical cord and cut it, lifting the baby away to what looked like a wire shopping basket lined with dirty old towels. Whilst she and the nurses worked on the baby Matthias continued with the operation, pulling the uterus out of the abdomen and scooping out the placenta. It was about then that the mother started to scream. I looked up to her head and her eyelids were fluttering as she shrieked. At that moment the baby was resuscitated and it too started to cry. I noted with a sense of irony that both mother and child were screaming in perfect unison.

I turned back to see Matthias still scooping out the last bits of placental debris and trying to stop the torrent of blood gushing from the empty womb. “Squeeze it harder,” he instructed as the bowel contents pushed their way around the sides of the uterus. Normally this would not happen but the lady was reacting to the pain by tensing her abdomen. I started to imagine the agony she must be in, the pain and terror of waking up to find yourself cut open with someone scooping out your insides. I wanted to vomit. I forced the bile down and concentrated on holding the retractor. I was now sweating heavily and could feel myself becoming dizzy. “Not now,” I said to myself and gritted my teeth, focussing as best I could on helping Matthias suture up the uterus. Sophie was back at the operating table now and I could see her from the corner of my eye looking at me in a concerned way. I must have looked about as green as my scrubs. “I will not give up and I will not faint,” I thought but the sweat was really pouring now and I could feel my hearing starting to go. Eventually pride gave way to reason, the last thing this poor patient needed was someone fainting and ripping out her stitches or falling into the abdominal wound. I relinquished control of the retractor and forceps to Sophie and stumbled away. Despite more Ketamine and some Diazepam the woman was still screaming as I left the theatre.

So that was my rude awakening to the realities of Tropical Medicine or more precisely that was the moment that I really knew what I already understood theoretically from lecturers and reasoning things out. You do your best and people hopefully get better but sometimes your best is barely adequate and when that happens there is no friendly colleague to ask or consultant to call, there is just you and a lady going through an operation half awake.

It would be remiss of me not to mention three facts before leaving this story. The first is that had it not been for the opeartion, the mother and child would have done badly and possibly even died. The second is Ketamine, through its nightmare side-effect can end up giving you a ‘bad trip’, especially if you have a negative stimulus whilst you are under its influence, so some of the screaming as I was leaving, when the patient had been given more Ketamine, was probably from the nightmares rather than from pain. The third fact is that when I questioned the mother two days later, mercifully, she had no recollection of the operation. All that ends well end well… ?

This emergency caesarian may be the most striking single thing I’ve seen so far but that is not to say that I have not seen other things in the hospital that gave cause for reflection. The range of conditions that Sophie treats single-handedly beggars belief. From tumours to TB, from fractures to foetal distress, Sophie takes them all on, armed only with a poor-quality X-ray machine and a microscope. In the next couple of weeks the hospital is due to get a biochemistry blood test machine so we will be able to see if the man we are treating for heart failure and renal failure really does have problems with his kidneys and whether our treatment has pushed his potassium dangerously low. We can’t even do an ECG as a surrogate marker of deranged potassium because the machine broke down ages ago and has not been fixed.

Lack of maintenance leading to the eventual destruction of useful and expensive bits of equipment will be a familiar theme to anyone who has studied Tropical Medicine. To look at Eichel Hospital now with its filthy walls and flaking paint you would never have imagined that in its heyday it had a farm which provided two meals a day for all the patients (their families now have to provide food) and enough pig manure to run a biogas generator that provided piped gas to the hospital and every house in the compound surrounding it. With time the biogas generator broke down because it wasn’t cleaned out, the pipes were broken and now we are obliged to use a generator that runs on diesel and is only switched on between 8 and 12 in the morning and 6pm to 10pm at night, the minimum time required to keep the interiors of the vitally important medicine fridges cool. It’s terribly sad really. However, I’m looking forward to really getting my teeth into things during the coming week as I only spent one day, out of a possible two, in the hospital last week. I used the other to climb the volcano that sits at the centre of the island along with Matthias.

It was an 11 hour trek, mostly in torrential rain and through the densest jungle I have ever seen: at one point we were obliged to crawl on all fours through a small tunnel hacked out by the teenage guide we had comandeered from the TB ward. The medicine he was receiving was obviously working because he all but sprinted up the mountain. I can perhaps best summarise the experience with a series of tips for any of you considering anything similar:
1. When choosing a guide look for someone taller than you, that way you won’t be pulling sticky threads of spider silk off your face every 20 paces.
2. If you have an old Gore-Tex raincoat make sure you have rewaterproofed if before taking it into a tropical storm otherwise it will quickly become as sodden as the sweat-soaked T-shirt you are wearing underneath it.
3. Be prepared to fall over often, lulled into a false sense of security by the agile manner in which your guide and his schoolboy friends negotiate the terrain.
4. If you are at the top of a volcano which the locals may consider to be sacred in some way, don’t lob your banana skin into the crater.

There are so many other things that I could write about but my bed is calling and so I will content myself with one last image, the one that stands out to me above all others today; a day where I have helped rescue our truck when it was stuck in the mud, seen a tame cassowary, swum over a coral reef teeming with life, visited a cocoa plantation and driven the 85km around the circumference of the island. Imagine yourself in the back of a pickup truck with six others speeding through the warm, dark night. A few stars are peeping out through clouds and the only other light comes from the glow of the instruments illuminated in the dashboard. Every so often you can make out the dim silhouette of a hut behind the trees with fires flickering beside them. There is a noise beside you but the car has already passed it. You look back and against the Prussian blue sky you see the a waterfall of orange embers falling from the smouldering palm leaf torch held by the villager you just passed. They seem to hang motionless in space for a while then bounce and scatter across the road. You could almost shout for joy. The closing lines of Desiderata have never seemed truer:

For all its sham and drudgery and broken dreams,
It’s a beautiful world.

‘Papua New Guinea: Land of the Unexpected’, it’s a phrase that has rolled off the tongue of so many people that I almost began to wonder whether it was the official national slogan. Initially I took it to be a euphemism for “PNG: expect things to break down” (or bagarap as they would say in Pidgin) but this week has demonstrated that the title is well earned: I certainly did not expect to find myself here today, all alone in Sophie’s house.

The first surprises of the week were only surprises for me. One of the disadvantages of not speaking a language fluently is that, even if you can understand people when you are spoken to directly, you tend to miss out on information carried in peripheral chatter that you do not make the mental effort to translate. So I was somewhat bemused to be told that Wednesday afternoon’s ward round was starting at the front of the hospital.

After a hurried lunch I arrived at the entrance to find one of the hospital trucks waiting. Dr Sophie (as I have now got into the habit of calling her, because all the staff do) appeared shortly after me, carrying a cardboard box of assorted medicines. She explained that the ward round was not of the wards in the hospital but of the three health centres dotted around the island, each of which caters for about 6 inpatients with minor complaints not needing a hospital with full facilities. Before long a few nurses arrived and, as no truck ride in PNG is complete without one, there was someone with a large bilum of food to sell at market.

The afternoon was spent in a most pleasant fashion driving around the entire circumference of the island, stopping off for 20 minutes or so at each health centre. The most time-consuming patient of the day, however, was not found in a health centre but in a large house on one of the island’s many cocoa and coconut plantations. Sophie had apparently received a stream of panicked phonecalls that day from the (Australian) wife of the plantation owner and so we can come to investigate.

We found our patient lying in bed, not in the clutches of some deadly tropical disease, but rather from dizziness, probably brought on by overenthusiastic prescription of medication for her blood pressure. We stopped one of her medications, spaced out the others and our work was done. The real healing came in the reassurance and discussion that trickled on over the course of half an hour and climaxed with coffee and cake in their sitting room, soothed by the gentle breeze wafting in off the sea. The whole interaction might have come straight out of a Jane Austen novel with the country doctor going to visit the local gentry. All that was missing was a trio of somewhat frustrated daughters sewing and playing the piano.

If I thought that Wednesday’s ward round was exotic, Thursday’s surpassed it in every way. Thursday’s ward round started on the beach, an hour after sunrise. This time Sophie stayed at home and Dr Antoine, her Madagascan successor-in-waiting, lead the team of doctors, nurses and joyriders to the banana boat that was to take us on the hour-long ride to the health centre on Bagabag Island. The sea was choppy enough to be exciting without being too rough and by the time we disembarked we were all covered in crystals of salt from the spray. The trip was further enlivened by the accompaniment of shoals of flying fish. I’d always imagined the “flying” that they do to be short leaps out of the water. In actual fact they can fly for about 20 or 30 metres and could easily outrun the boat, even when it was powering along at top speed.

From the white sandy beach and azure sea it was a short walk up to the health centre where we arrived to find not a single patient awaiting us. The health centre director promised to send word up to the local villages to summon the sick and, whilst we were waiting, one of our nurses suggested going to visit the local school. I was slightly mystified by her choice of tourist destination, the beach seemed like a lot more attractive option, but I figured that she must have her reasons so I trotted along with the rest of the team to investigate.

The school consisted of a single long building on stilts, with a large football field separating it from the beach. The headmaster invited us into his office for a chat. Rather comically, all official letters, whether they were of any relevance to others or not, were fixed to the wall under a section marked Memos. They seemed to me to be there more as a status symbol than to disseminate information. My mind wandered as the headmaster conversed with the head nurse at length in Pidgin and I was glad when we finally we were ushered outside after being asked to sign the visitors’ book. I remained confused about the purpose of our visit until we got back to the beach where one of our two Papua New Guinean doctors explained to me that the school had been expecting us to vaccinate the children, except we had not brought any vaccines with us. To quell their disappointment we had apparently volunteered to give a health promotion talk once they had assembled all the children. The designated subject was HIV/AIDS.

I looked dubiously at the gaggle of small children who had followed us, wide-eyed with curiosity, down to the beach. “How old are these children?” I asked. “Oh, about 10 or 11,” came the reply. I pointed out that it was difficult to talk about HIV without mentioning sex and these children seemed a bit young. The native doctors agreed and we decided to change the topic to smoking. Ten minutes later I found myself standing in front of 120 pupils, aged from 10 to 16 years old, starting my health talk.

One of the constant frustrations when trying to explain medical information to patients here is that people have very little concept of what goes inside their body. This is reflected in their language by the dearth of Pidgin words to describe the organs. My talk, whilst ostensibly about the dangers of smoking, was really a tour of the organs of the body (in English), starting from the head and working downwards, explaining what each organ does in a sentence or two. This approach had the advantage of ending with the bowels and urinary systems so, just when they might be getting distracted I could make the younger children giggle by saying “piss piss” and “pek pek” (pooh). My whistlestop tour complete, I asked them to guess which organs might be affected by smoking and, in doing so, we went through all the organs again. My talk was followed by Maylin, one of the PNG doctors, reiterating some of the things I’d said (but translated into Pidgin) and also applying them to the dangers of alcohol. Interestingly her talk came from the angle that the body is God’s holy temple and you should not defile it.

When she had finished both the children and teachers looked quite satisfied and I was about to wrap it all up when Dr Antoine stepped forward and announced that he wanted to talk about HIV/AIDS. The message that he delivered, in his characteristic heavily-accented mumble, was so hilarious (unintentionally so) that I had to bite my lip several times. Apparently you can avoid HIV with the simple act of avoiding pre-marital sex and the easiest way to do this, according to Dr Antoine, is to commandeer another girl to come along with you whenever your boyfriend encourages you to slip out on a romantic stroll. “Never one boy and one girl,” Dr Antoine intoned sternly, “Always one boy and two girls.” He finished up by announcing that HIV testing is free and so the children should come along and get tested – he and his wife had been tested and they were both negative. The latter fact prompted the teachers to making the students give him a round of applause.

Dr Antoine’s novel approach was followed by Scholastica, the second indigenous doctor, delivering the more orthodox ABC (Abstain, Be faithful, Condom) message that is the official PNG line. I was heartened to hear that it included a bit on the need to respect your spouse, which is an important message here.

Our labours earned us lunch on the beach, courtesy of the school, which consisted of several giant bowls of fish, rice and plaintain, with coconut milk to wash it all down. Then it was back to the clinic to find that 30 patients had arrived for our ministrations. Of these, 20 or so were middle-aged women came with a 1-2 year history of lower back pain caused by the way they carry their bilums. These huge bags have a single strap which the women place across their forehead. It gives them two hands to work with but over time plays hell with their spines. I have never prescribed so much paracetamol in such a short space of time.

Out of the remainder of the patients there were a few interesting cases, the chief of which was a lady who came with pale patches of her skin which were devoid of sensation. There was another person in her family with a similar set of symptoms. I made a diagnosis of leprosy and asked her to come over to Eichel Hospital because we did not have any anti-leprosy drugs in our box. She put up a lot of resistance to coming and, as she has to come of her own free will and with her own transport, she may not come at all. Here again come the frustrations of a doctor working in a foreign language – you have no skill or subtlety in your communication. It wasn’t the diagnosis that scared her, if any of you are wondering about that. There is no Pidgin for leprosy: all I could tell her was that she had ‘bigpela samting’ and I only used that phrase after she refused to come. Even after comandeering native Pidgin speakers to help she remained reluctant but they were unable to discover why.

After the drive round the island, the trip to beautiful Bagabag and the joy of encountering a rare disease (well rare in the West, anyway) I thought that the week could not get any better. I was wrong. On Saturday evening, just when Toni was about to show me his recipe for homemade pizza bases, something even Sophie couldn’t have predicted happened; a small helicopter landed outside the hospital. Being good Papua New Guineans we did what any indigene would do, we went to stare at the people who might emerge. Out stepped the former health minister, Sir Peter Barter.

It turned out that he and Sophie were good friends and, as he knew that she was leaving imminently, he had decided to come in his helicopter-bearing yacht to say goodbye and would we like dinner. Well, exciting as homemade pizza is, we felt that we might forgo it, just this once. About an hour later we were on the starlit shore of the lagoon, in which the boat was anchored, flashing our torches to indicate that they should come and get us. This confused the local fishermen somewhat, who also had a group of their friends flashing torches at them, but we managed to get on the right boat in the end.

Aboard the yacht there were a number of friends and extended family, many of them already tipsy. The chef had been dragged off the boat earlier in the day by his wife, who had tracked him down and harangued him soundly for neglecting his family but the food cooked by one of the sister-in-laws could have hardly been bettered. It was so incredibly surreal to spend an evening, whose schedule would normally be determined by the generator and the duration of running water, in a plush air-condition yacht sipping chilled white wine. Eventually it was time to say our goodbyes and I reluctantly got up to leave. As went aft Sophie nonchalantly asked, “Can you drive us home, Tim?” “Oh yes,” I replied sarcastically, “The dinghy looks quite easy to drive.” “No, I mean, drive the car. We have been invited to go to the Sepik.”

The Sepik is to PNG what the Amazon is to Brazil and the chance to cruise down it in any boat, let alone a luxury yacht, was an amazing opportunity, especially as the Kleins had never been there and only had two more weeks in PNG. They needed to pack some clothes and they planned return immediately with me as their chauffeur so that there was someone to take the truck back home afterwards. And that is how I found myself at midnight on Saturday night driving alone, along the most treacherous part of the island’s unlit road, in a car whose lights would spontaneously turn off. My mind was whirring with the thought that I was going past the site where the car had previously got stuck (albeit in wetter weather) and my ears were filled with Toni’s warning not to stop the car for anyone, lest they hijack it.

Well, the potential for hijack was expected, so of course it didn’t happen. This is the land of the unexpected you kn–

Eichel Hospital was set up about 50 years ago by a man named Edwin, an Australian with German ancestry. Interestingly, though he practiced as one, he was not trained as a doctor but rather as some sort of medical orderly in the army. The army provided him with three things, exposure to medicine, organisational skills and a take-no-prisoners attitude. This weekend I was sitting across the breakfast table from the chairman of the Lutheran Health Services board who recalled with a smile how Edwin would start Monday mornings by, in the chairman’s words, “kicking the arse of anyone who hadn’t been to church the previous day.” Well there’s no arse-kicking these days but the fact that this is a Christian hospital is very much emphasised. This has two effects, the first is that Christian ritual is part of the daily workings of the hospital and the second is that the staff are told that, as members of a Christian hospital they have to attain higher standards of practice than those in the secular hospitals.

Every day starts at 7:45 with morning devotion in a big hall opposite the hospital. A number of songs are sung, some in English, some in Tok Pisin, and there is a prayer or Bible reading, usually delivered at a volume inaudible to me but obviously quite fine for the other staff who all respond in the right way at the appropriate times. There are no instruments used for the morning hymns but the Papua New Guineans have an amazing ability to spontaneously harmonise and they sing with great warmth and feeling. The singing is truly beautiful; sometimes I feel that I could listen to it for ever.

Devotion completed we cross over to the hospital for handover from the two night nurses who cover the 9 wards. The main hospital building is laid out in the shape of a stuttered huff ( H-H- ) with wards branching off a central walkway that has a roof but is open-sided. Each ward contains about 25 beds, most of which are occupied at any one time. On the bed itself lies the patient and underneath the bed sleeps at least one family member who is expected to do the main bulk of the caring for that patient. The nurses dispense the drugs and take everybody’s temperatures but the relatives wash, dress and feed the patients, both providing and cooking the food. It is only in this way that the hospital can run with so few staff.

However, it is not only pragmatism that has given rise to this solution but also culture. The Western paradigm of leaving your sick relative in the care of strangers (albeit professionals) whilst you get on with your day-to-day life is incomprehensibly neglectful to the Papua New Guinean mindset, where your wantok, your family, is everything. This also gives rise to situations which I, in turn, find difficult to imagine living through. For instance we had an old man who needed to be transferred to the big district hospital on the mainland for an operation we could not do. I was surprised to see him still on the ward two days later and asked what had happened. It was only then that I learnt that whether or not he has an operation is not his choice. His family decide if and when he will have the operation. They are the ones who decide whether the little money they have should be spent on house-keeping or whether they can afford the fare for the boat trip, bus and subsequent treatment. Treatment here is nearly free, with each patient merely paying a 2 Kina (40p/$0.20) ‘bed fee’ irrespective of how long he stays or what treatment he recieves. Nevertheless some patients struggle to find this money, leading to the strange situation where they are forced to stay in their hospital bed (thereby blocking it for a new patient) until they pay their bed fee. The reason being that once they leave for the village there will be no way of bringing them back to pay the money. But I digress, I was talking about the night report.

I always find the night report quite funny as it starts with a list of meaningless stats: number of patients with a fever, number of bags of iv fluids put up, number of patients catheterised. In the same meaningless litany some significant events are also reported so for instance I was shocked out of my reverie the other day when the nurse started with, “Night duty report Wednesday. Fever x4, IDC (in-dwelling catheter) x2, NG tube x1, death x1, iv fluids x2.” Death? Death! Hold on a second, just back up there!

It was the first death in the hospital that had occured since my arrival. The patient had been a young girl in her mid-twenties who had been admitted to the medical ward with fever and delirium. In the UK she would have received a battery of blood tests, an urgent brain scan and a lumbar puncture at the very least. In Eichel I have no routine blood tests of any use available to me. The lab can do a screen for malarial parasites and a white blood count (raised numbers of white blood cells are a marker of infection usually) but both are pointless in practice because by the time the blood is taken for the malaria screen the patient has already received artemether, a drug which clears the blood of parasites rapidly, and the white cell count will not really affect my decision to give antibiotics either way if the patient has a high fever. Furthermore the blood tests are only done at times when there is power and the nurses have time to take the blood. This means that they are usually done 24, if not 48, hours after admission.

I contented myself with a lumbar puncture as this is advocated in the PNG National Guidelines handbook. A lumbar puncture is a procedure where the some of the fluid which bathes the spinal cord and the brain is taken. In the UK we would examine it under a microscope to look for the number and type of white cells, the presence of blood, bacteria, fungi or viral DNA and levels of protein and glucose. All these taken together would allow us to come to a diagnosis of whether a meningitis is present and if so, what the cause is. In Eichel I have none of these so I had to content myself with looking at the colour of the fluid. If it was clear I could tell nothing but if it was cloudy then bacterial or TB meningitis was likely, and if it was heavily bloodstained then I would know one of the arteries to her brain had ruptured. Sadly the fluid was clear so I gave her, like we give virtually all our patients, antimalarials and chloramphenicol, an old antibiotic not used much in the West but one with an ability to kill many different sorts of bacteria. Over the next day she seemed to become more lucid, though she complained of some generalised abdominal pain for which I could find no obvious cause. Overnight she had suddenly deteriorated and died, despite interventions from Sophie. Even now we are none the wiser as to what her illness was.

The next day, being a Wednesday, was a ward round day: Mondays, Wednesdays and Fridays are ward round days. On Tuesdays and Thursdays we do surgery in the morning and see the TB patients in the afternoon. I am covering the medical wards and so my ward round that day was carried out to a background of haunting ritualised wailing coming from behind a screen erected around the dead lady’s bed. I finished the round and was just leaving the ward when her father arrived. “Me sorri tru long pikini meri bilong yu, em dai pinis (I am so sorry that you daughter has died)” I managed to get out. He did not seem at all upset and replied in rapid Pidgin. I wasn’t sure that I fully understood but I made what seemed like appropriately positive noises and shook his hand. When he was gone I turned to the nurse.
“What did he say?” I asked.
“He said that it’s not your fault. He says they should have brought her sooner instead of keeping her in the village. The medicine didn’t have time to work.”
Later I saw three flat-bed trucks, each with a red ribbon running in a V from windscreen to bonnet and each overflowing with people. “What are these?” I asked a bystander. “Funeral cars,” she replied, “Come to take the body away.”

Most of the patients and relatives in the hospital must have known that the lady had died. There is no privacy on a PNG hospital ward. There is no real privacy on a UK ward but we generate the illusion with the aid of curtains around the bed. In Eichel there are no curtains and the screen is a scarce resource so only used on special occasions. Hence all the patients and relatives can see and hear everything I do. My ward rounds are often accompanied by giggles from other beds when my Pidgin is faulty. Sometimes they even help me find the correct word or scold a patient if they are not answering my questions – ladies not infequently just smile bashfully when I ask them questions, either confused by my accent or unaccustomed to speaking to a white man. All the patients and their families watch me examine all the others and all would have seen what had happened to the lady.

I found myself struck by the apparent cheerfullness of the father but I think here people are hardened to death and, especially to pain. I would not go so far as to say that life here is cheap but its weight is certainly carefully measured: the length of mourning is prescribed by the head of the clan, based on the perceived importance of the deceased. Pain, however, is given little currency. The Papua New Guineans have an incredible pain tolerance and their invariable response to questioning about the severity of pain is that it is merely liklik (little). Furthermore if a patient, even a child, cries out in pain whilst I am examining them the relatives will almost invariably scold them soundly, often raising their hands as if to smack them.

I remember one of the first patients I saw with a fracture. He was an old man, at least 70, who had fallen out of a tree whilst trying to collect mustard to chew with his betel nut. He was sedated with ketamine for the fracture reduction. The sedation was light and the patient moaned lightly whilst manipulated his arm. Despite the light sedation I noticed that the oxygen levels in his blood were dropping. I adjusted the position of his head and put my fingers under his chin to pull it upwards and open up the airways to his lungs. This worked well and the oxygen saturations quickly came back to normal. The reduction was time-consuming and inevitably the ketamine started wearing off before we were finished causing the patient to howl. I was focussed on pulling the arm and so it was some time before I noticed the patient’s son pushing his father’s mouth closed. He’d obviously mistaken my intentions when I was performing the chin lift and thought that I was trying to shut the patient up.

The insensitivity to pain seems to extend to the staff, who do not seem perturbed when their anaesthetics wear off mid-procedure. I think part of this partly comes from helplessness. When you don’t know how do things better you just accept the unacceptable. I’ve noticed that even I have become less sensitive to screams of pain during my time here. Neverthless I try to ensure that patients who I’m involved with get good anaesthesia. The problem is that I don’t know very much myself and the books I have are frustratingly opaque on many details. My inadequacies in this area were clearly displayed on Thursday when we had a patient in theatre scheduled for an investigative laparotomy, an operation where you cut open the abdomen to see if you can determine the cause of someone’s pain or fever.

We have no ventilator so all conventional general anaesthetics are impossible. Instead we use a technique called spinal anaesthesia. For every bone in your back there is a set of nerves that leaves the spinal cord supplying sensation and muscle control to structures in the general vicinity. Spinal anaesthesia is where anaesthetic is injected into the space around the spinal cord resulting in a numbing of the nerves which it comes in contact with. It is quite simple to do if you know how to do a lumbar puncture, which I have done plenty of times. I had already given one patient a successful ’spinal’ on Tuesday and, flushed with success, I was keen to do this one too.

We had to wait for an hour or so before I could do it because the patient came into theatre with a low blood pressure (80/40) and needed lots of intravenous fluids to get it up but after 3 litres she was starting to improve and so I went ahead. (Note to medics: the normal resting BP here is about 90/60 anyway, because everyone is so fit.) The procedure itself went smoothly but whilst I was explaining the principles to a nursing student I had a sudden panic. The previous spinals I’d seen were done with the patient sitting up straight and on Tuesday I’d also the patient sitting upright. This time, however, I’d done the procedure with the lady lying on her side. If the anaesthetic floated up too high then it would reach the nerves supplying the diaphragm and paralyse them, at which point the patient would stop breathing and die. Maybe that’s why Sophie had done this others with the patient sitting.

“Quickly, sit her!” up I said and the nurses and I supported the patient for a minute or so. The problem was, in my panic I hadn’t stopped to think about where I had injected the anaesthetic. You inject the anaesthetic quite low so you actually want it to float upwards a bit because the nerves that supply sensation to the abdomen are above the injection site, not below it. Whilst avoiding diaphragmatic paralysis was certainly important sitting the patient up for so long was the wrong thing to do as the anaesthetic fell with gravity and I ended up anaesthetising her legs, not her belly.

Dr Antoine, who will be the medical chief from Monday onwards, kept pinching the lady’s abdomen distractedly until I asked him to stop. The anaesthetic clearly wasn’t going to work.
“Can we give more spinal anaesthetic or could we use ketamine” he asked Phillip, the theatre/anaesthetic nurse.
“We’ve given 4ml of anaesthetic and the maximum is 5ml so we can’t do another spinal now and no, you can’t do a laparotomy under ketamine, it’s not good enough. Anyway, I’m only prepared to give a half dose now that we’ve done a spinal.”
The news that ketamine was inadequate seemed a bit funny to me. I remembered lectures on how it was used all the time and after all we’d done that horrible caesarian under ketamine. At the time I’d put the pain down to inadequate dosing of the ketamine but maybe all ketamine operations were all like that and Phillip, like me, hated to see the patients in pain during operations. That would make him unusual but then he seemed a bit more together than a lot of the staff.
Dr Antoine hesitated and pinched the lady with his forceps a few more times, causing her to cry out.
“How long does the ketamine last?”
“About half an hour,” replied Philllip.
“If it is appendicitis I could do it in half an hour.”
Having seen Dr Antoine operate, I sincerely doubted that. Every case I’d assisted with him had been punctuated by him tutting and muttering, “A very difficult case. Very difficult.” However, I remained silent.
Dr Antoine made up his mind.”OK, give the ketamine.”
Phillip duly did as he was instructed and the lady slept, unresponsive to further pinches. Dr Antoine seemed satisfied. “It’s working,” he pronounced.
I could contain myself no longer. “This is totally illogical. If full dose ketamine isn’t good enough then half dose certainly won’t be adequate. Ketamine doesn’t interact with the spinal so you’ll be safe to give the full dose. But what if this isn’t a simple case? What if you need more time, what will you do then? Can we not wait until this evening and just redo the spinal?”
Dr Antoine didn’t answer directly. “I could just cut here,” he said tracing lines across the abdomen, “If it is appendicitis I could do it in half an hour.”
“Well OK but what if there are complications, what will you do then? Do you need to do this operation now? You need to decide soon because time is ticking by whilst we wait.”
Dr Antoine’s only reply was to ask about the blood pressure, which had previously been low but would now be artificially boosted by the ketamine and then to lapse into silence. As no further information was forthcoming I took that as a sign that he wanted to continue.
“Give the rest of the ketamine then, Phillip,” I said with a resigned sigh.

We stood there all gowned up, the patient draped in sterile drapes and all the instruments shining under the theatre light. It would cost the hospital a fair amount of money if it was wasted which we could ill-afford to do, given that we are now at the stage of resterilising plastic syringes for reuse because stocks are low. As we stood there I reflected the cost but also on how wrong this all was: I was not going to help put another patient through a lot of pain unnecessarily. I needed an answer to my question. Dr Antoine moved for the scalpel.
“Stop.” I said putting my hands over the abdomen. “Do we need to do this operation now or can it wait until the evening?”
“Are you saying that you want me to postpone the operation?” Dr Antoine bleated.
“I’m not a surgeon and I’m not an anaesthetist. I don’t know. The patient looks to me like she could wait another six hours but I don’t know. All I’m saying is that if she can wait then why not do the operation with a proper anaesthetic and then you’ll have all the time you need to do a proper job.”
“Well, OK, if you want to do the operation at six then we’ll do it at six.”

So the operation was cancelled. I was happy that I’d ultimately done the right thing but felt wretched because it was also my mistake that had caused the problems in the first place and my weakness that had meant that we’d given all that ketamine before I’d really put up a strong fight. I immediately went to the textbooks to find out what I should have done but whilst they described the needle insertion technique and drug doses they were silent about potential complications and how to avoid them. My only solace came from learning that you can safely do the procedure with the patient lying on their side. I had to wait for Sophie to return from her trip away to ask her. She told me that you simply keep checking the level of the anaesthesia and put a pillow under the patient if it is getting too high. Furthermore she had done loads of laparotomies with Phillip, both under ketamine and under combined ketamine plus spinal, so he had been lying in the operating theatre. She muttered something about him getting big ideas but didn’t care to elaborate.

In the end we didn’t do the operation. The abdominal pain, though not the fever, had subsided by 6pm so Dr Antoine felt that an operation was unnecessary. We will see.

The whole episode served to illustrate a number of things: a) how little I know and how much is being asked of me; b) when I go out on a limb in the UK I’m merely going out on one of the branches sprouting from the trunk and so there’s a bit of excitement with no real danger, here the limbs I’m out on are distinctly twig-like and it’s not fun at all; c) I, along with the whole hospital, are really going to miss Sophie. When she goes I’m going to feel like no-one’s got my back anymore, an unpleasant prospect.

Thursday also had the distinction of being my first day being on-call so the evening brought further challenges, further revealing how much I need to learn and what a poor substitute textbooks are for experience. I was so glad to be going to the mainland on Friday.

That is where I am now; I am sitting in a hotel bar, cooled by a sea breeze, taking delight in the simple things, like 24-hour electricity and water. I spent yesterday at the Madang Show, a festival of traditional dancing which was a beautiful demonstration of the ingenuity of the Papua New Guineans and how they can take the things from the forest around them and weave them into the most elaborate and wonderful things. These people really are incredible.

In the afternoon I wandered along to the sea front. I just wanted some peace and respite from the insects bedevilling my attempts to read in the open air. I carefully negotiated across the cruelly jagged boulders to get right up close to the water. Few people come out to this part of the shore, preferring to go to a beach where you can stand barefoot without being cut and swim in a sea that is not so rough. I stood in silent appreciation of the waves hurling themselves against the rocks, sending up giant plumes of spray: just me and the rawness of Mother Nature – what painters of Turner’s generation would have called ‘the Sublime’.

I became aware of a person coming towards me. A young man wearing a knitted hat, despite the blazing sun. He came right up to me.
“Do you want to hear some good news, brother?” he said handing me a damp magazine. I looked at it dumbly and ran over the Pidgin title a few times in my mind, attempting to translate it. Wastaua. Wastaua? Watchtower.

Jehovah’s Witnesses! They get you wherever you are!

“I’m leaving for Madagascar on Friday and I don’t know when I’ll be coming back. Whilst I’m away you’ll be in charge of the hospital.”

I would like to say that I remained undaunted in the face of this news from Dr Antoine, delivered in an casual manner at the start of the week, but, whilst a small fantasist part of me was excited, the majority was quite worried by the prospect. Reading the autobiographies of doctors who have boldly gone before, you get the impression that occasionally things were a bit hairy but in the main they were mostly having good clean fun, heroically saving lives, with the occasional adventure to spice things up. What they tend to gloss over is the initial feeling of bewilderment and insecurity that comes with being adrift in a new culture and trying to communicate in a new language with people who may or may not share your underlying concepts of how the world is. And that’s before you consider whether you are operating within your medical comfort zone.

Maybe the tropical doctors that write autobiographies were operating largely within their comfort zone or maybe they just don’t mention that initial steep learning curve. Almost everyday at some point I find myself thinking that a patient in front of me would be better served by one of my friends: Jenny, the Accident and Emergency registrar, would be right at home resetting broken bones, suturing up gashes and generally taking on all comers; Helen, the radiologist, would be able to use the ultrasound machine to actually diagnose things rather than saying, “Hmmm, I can’t really see much, what’s that blob?”; Kate, the obstetrician, would not be viewing the antenatal and postnatal wards with the extreme trepidation that assails me every time I poke my head around the door; and all my friends who have trained in General Practice would be far, far better suited to working in this environment, where you need to know a little bit about everything and treat your patients with virtually no investigations whatsoever.

After hearing Dr Antoine’s news, these thoughts came more frequently than ever and I had to content myself with the thought that the girls, at least, wouldn’t be able to stick it out here because they wouldn’t get on with my sometime flatmates, a small mouse, a pair of geckos and a spider the size of a dinner plate. At the end of the day I would have to be good enough, because in Dr Antoine’s absence the patients would just have me and a junior doctor from PNG, Scholastica (or Scholar for short). If things got really tough I could always ask Sophie for advice, though she was officially off duty. However, I wouldn’t have her support for long as she was leaving for Germany four days after Dr Antoine’s departure.

The week wore on and Dr Antoine was none the wiser as to when he might come back: my anxiety levels rose steadily. They were not helped by Sophie’s mischievous suggestion that accompanying his supposedly sick (but mostly hypochondriacal) wife back to Madagascar might be a ploy to escape from Eichel for good. Friday came and, even as he left to catch his plane to the mainland, Dr Antoine did not know his return date. As I watched him disappear off into the unknown, I could feel the set of master keys hanging round my neck threatening to become a millstone.

After morning devotion I gave my first ever toksave (announcement), a little pep talk about how it was business as usual even though Dr Antoine had gone, with the exception of elective surgery. I felt doubly justified in doing this when we went across to the handover room to discover that the night staff were nowhere to be found. As I had feared, they had taken advantage of the absence of the boss to go home early and not do their job properly.

My feelings towards the staff here fluctuate between sympathy, admiration and sheer frustration. One the one hand they are often working at the level of a junior doctor and I have learnt a lot from some of them. Some staff more than others are called upon to do a lot of work: the lab technician and X-ray technician, for instance, are theoretically on call every single day. I say theoretically because this untenable state of affairs has lead to a state where they come and go largely as they please. Today, for instance, we had no X-ray service because the X-ray technician had decided to go to his village so anyone coming in with broken bones would just have to wait until the following day to have the fractures properly reduced.

Even if the staff are here, they can vary from active and interested to a state of stubborn passivity. For instance I found a patient today had not been receiving the prescribed treatment. When I asked why not, I was told because they didn’t have the drug on the ward. The pharmacy is less than 100 metres away and the nurses know that it is their responsibility to get drugs from the pharmacy. However, I often find that if I do not specifically tell them to get the drug from pharmacy they will happily go for many days without administering the prescribed medicine. All patients should routinely have a White Cell Count and Malaria Screen done before surgery but almost every single time you schedule a patient for emergency surgery, you have to make a point of reminding the nurses that they have to take the blood straightaway and the results need to be collected on the same day. It’s not that the staff don’t know these things, they are all very much routine. I must confess that I find it incredibly irritating to have to continually check that they are doing what you’ve asked them to do.

One thing that I have seen with crystal clarity whilst I have been here, is that all behaviours, however strange they may seem, almost always have an understandable rationale underlying them when you look closely enough. For instance, time and again people bemoan the fact that villagers in the developing world will not take simple precautions to improve their health, such as wearing long trouser, sleeping under mosquito nets, not going barefoot and so on. Well, I can tell you that I wear shorts and T-shirts without fail and walk barefoot most of the time that I am off duty, despite having open cuts and blisters on my feet, because when it is hot the less you wear the better and walking barefoot feels nice. All in all, I do pretty much everything that the public health people have spent decades telling people not to do. My only concessions to health are sleeping under a mosquito net, taking malaria prophylaxis and not sleeping with the locals.

In the same vein, I am sure that the nurses have very understandable reasons for the way they behave and so I try not to lapse into criticism, either internally or externally. I don’t feel that I have got to the crux of the matter but I have some preliminary theories. The obvious reason, inadequate numbers of staff, doesn’t fully explain things. During the daytime there are two nurses per ward and they don’t appear to be overburdened with work. I think some of their attitudes can be explained by them having a different conception of what a nurse should be. The nurses seem to see themselves more as guardians of the thermometer and drug trolley than people responsible for the wellbeing of the patient. The doctor is responsible for the medical wellbeing of the patient and the family is responsible for everything else. So, for instance, I never bother prescribing pain killers to be given only when needed because it is very rare that the nurses will enquire whether the patient has any pain. Likewise, we have many semiconscious patients who are inadequately fed by their relatives. I am thinking of doing a little talk on nutrition for the staff but I get the impression it will fall on deaf ears because I do not think the nurses see it as their responsibility to keep an eye on things like nutrition, even in the case of severely malnourished patients.

We have a heartbreaking case of an adopted baby who was brought in with severe dehydration and malnutrition. He looks like a newborn rat, all pink and tiny with eyes that are barely open and covered in downy lanugo hair. He weighed 2.1kg on admission but has continued to lose weight in hospital, remaining terribly dehydrated for days because the adopted mother kept pulling out the feeding tubes (to be fair they did make the baby cry). It didn’t help matters that the nurses wouldn’t check that the iv fluid drip kept running. Eventually I changed how the iv fluids were going through and corrected the worst of the dehydration but even so the mother would only give the child 100ml of milk per day. Every day I explain to her that the child will not put on weight if he is inadequately fed and she must try giving the child small amounts of milk little and often. However, every time I come back I find that very little has changed because the adopting mother obviously feels that she knows best and so gives the child two big feeds a day, stopping when he vomits. It would be nice if the nurses would help reinforce the message but, as far as I can see, that’s not in their conception of what they do. If the baby doesn’t gain weight that is the fault of the mother and the doctor and nothing to do with them.

I wonder if some of this comes from the fact that when you get used to things being suboptimal – drugs not being on stock, investigations not being available, and so on – it is very hard to maintain within yourself a desire to see things through to a high standard. At night time there are only two nurses with kerosene lamps for nine wards so it’s impossible to maintain close scrutiny of all the patients, maybe that rubs off after some time and you feel that if you can’t do a perfect job at night then why try by day? I also have to remind myself that for them this is everyday life, they are not on some special mission, they are just doing their normal job. I think back to UK hospitals where at least once a week a nurse who is meant to be on duty calls in sick at the last moment and all work stops whilst the remaining nurses frantically try to find a substitute. I wonder if we drastically reduced the number of nurses on the wards in a British hospital whether the nurses might not start behaving in a similar way, frustrated by the demands made upon them.

However explicable the nurses’ behaviour might be, now that I was nominally responsible for the hospital I found their truancy on the first day quite dispiriting. I was going to have enough to contend with with all the surgical, paediatric and obstetric emergencies without having the staff run amok. However I knew that I had to keep my fears supressed because things really deteriorate on a ward when the nurse doesn’t have confidence in the doctor.

Mindful of this I put on my bravest face and went out to do the routine ward rounds. Scholar took the obstetric and surgical wards whilst I covered paediatrics and medicine. The paediatrics ward took a long time as most of the patients were new to me but by the end of the day I felt happy that I’d done a reasonable job with everybody. In the evening someone came in with a gash in their leg and blood spurting from several small arteries. I must confess to being rather agitated by the rate of blood loss but Scholar took it all in her stride and we fixed the patient up together. I found myself thinking that maybe this week alone wasn’t going to be so bad after all!

Saturday was different.

It started with a young woman admitted with severe abdominal pain and no periods for the past five months. I thought might have an ectopic pregnancy or perforated bowel. I duly requested a pregnancy test but also thought I should get some X-rays to check for distended bowel. Thankfully only a few moments before the X-ray technician arrived Scholar appeared with the ultrasound machine and diagnosed a living foetus. Ordering the X-ray before getting the pregnancy test result was a fairly basic mistake and it set the tone for a day where almost everything I did went wrong. Even simple things like catheterisation and placing nasogastric tubes, things which I would expect a nursing student to be able to do, became epic trials, usually ending in failure. Almost every severely ill admission required me to go and ask Sophie for advice. If this was to continue what would happen when she left? (To be fair every patient that I asked her about ended up being transferred out to the mainland but she was able to ultrasound them and advance the diagnosis a bit.)

The day drew to a close and I wanted to go home and crawl under the covers but I had one more error to make and this one was the biggest of them all. In an effort to wind down a bit I started to ask Scholar and a nearby visitor a few questions about PNG customs and culture. Unfortunately, due to a combination of a poor choice of words and the apparent difficulty that people have here with the hypothetical, I manage to offend both of them, though I did not realise this at the time. Just when Scholar was starting to tell me that I had to be careful how I spoke to patients I got called away to see someone in pain.

Subsequently, it became abundantly clear from the way that she deliberately avoided any contact that Scholar was very cross with me. I couldn’t even get close enough to her to ask her what I had done to upset her and so I was left racking my brains to think of some patient that I might have not taken time over but could think of none. It didn’t occur to me that questions about the value of land and electricity and my statement that I would love to see what changes in PNG over the next 30 years would be seen as critical of their culture. (In retrospect I can see how that might be misinterpreted but I do think there was also a misunderstanding of what I was actually saying.) All I knew was that without Scholar’s help I would be totally unable to manage any patient with fractures or obstetric problems. I didn’t feel that I could ask Sophie about every little thing as she had plenty on her plate and was clearly getting stressed by the major undertaking of packing up her house after four years of living here.

I think it’s fair to say that I have never felt so lonely or miserable as I did on that Sunday. I was both upset that I had offended Scholar and upset that I could resolve it because she did not want to talk. In addition, I felt that I had made a fool out of myself in front of the nurses by not being able to do simple procedures or diagnose patients without help and now they were probably even less inclined to listen to me. All this at a time when I had any number of potential disasters heading my way.

The dark mood that descended made me suspicious of everybody, fearing they either disliked or distrusted me, and took the pleasure out of everything. So much so that when a young boy came in with massive flaps of skin torn off his scalp and blood everywhere I barely noticed the significance of the fact that, with the able assistance of one of the nurses, I managed to suture all the skin back, immobilised his fractured arm in a cast and spotted the blood pooling in his ear to make the diagnosis of a base of skull fracture. I only needed to call Sophie to arrange a helicopter to transfer the boy to the mainland.

Now I’m not going to pretend that this was the world’s most difficult case. I’m sure anyone who has spent any time working in an Accident and Emergency department would have done all this and more but I have never done an A&E stint and probably even the day before I would have panicked and called the cavalry. However, on this occasion I had had the chance to observe Scholar calmly tying off the bleeding vessels so I knew what I had to do and I just got on with it. In terms of personal milestones it was a significant one but I was feeling too awful to notice it.

If Saturday was about the descent into despair, Monday was about redemption. I finally managed to corner Scholar long enough to find out what I had done and after repeated assurances that I had intended no criticism and an extensive apology we moved on. Dr Antoine also called to say that he would be returning on Tuesday, the day that Sophie would be leaving, so in the end there would be no period where I was without senior support. With these two pieces of news my world started to brighten once again and the filters, which distorted everything I saw, started to fall from my eyes.

If you had set out to deliberately construct an exercise to show me just how little I know without actually every putting me in harm’s way, you could not have done better than that long weekend. Throughout my time here I have constantly been asking myself what my role is here and as a tropical doctor. The latter has not been answered definitively, though at times I am tempted to say “very little” but as far as my role here goes, I have come to some conclusion. At the time I organised this trip I imagined that I was coming mostly to help but also to learn, now I realise that I am here mostly to learn but also to help. I may have fancy letters bracketing my name but in this environment I am very much starting afresh. There are undoubtedly many skills that I already possess and am using here on a daily basis but for each of these there are a multitude of skills that still I need to acquire. This does not come as a surprise but it is easy to get fired up with passion, especially after the Tropical Medicine course and reading those heroic doctor autobiographies. The skills and knowledge that I need will come with time, I am sure. In the meanwhile, when the going gets tough and I feel that I am floundering there is always family and there is always poetry.

When despair grows in me and I wake in the middle of the night at the least sound in fear of what my life and my children’s lives may be, I go and lie down where the wood drake rests in his beauty on the water, and the great heron feeds. I come into the peace of wild things who do not tax their lives with forethought of grief. I come into the presence of still water. And I feel above me the day-blind stars waiting for their light. For a time I rest in the grace of the world, and am free.

— Wendell Berry

I was awoken on Saturday morning by the sounds of people chattering and emerged blinking into the morning sun to find a large pig lying outside my house, its four legs trussed up around a tall stake driven into the ground. I went over to examine it and it looked back at me with an eye that seemed almost human and an expression that seemed to suggest that it had come to an acceptance of whatever vicissitudes life might throw at it. I might have been surprised that it was still alive and tied up in such a manner were it not for the fact that I’d read about this exact ritual in a book written by a missionary who lived on Silsil in the early 1900s. A feast was being prepared.

The occasion was the departure of the Klein family, after four years of working at Eichel. The departure of anyone merits a farewell kaikai (food/dinner) but only very special occasions merit the roasting of a pig. For this farewell there would be not one but two pigs. Cooking a pig takes quite a while so the day before is spent digging the mumu pit and collecting firewood, vegetation and big stones. On the day of the feast itself, the pit is lines with stones, a fire is started and the pig slaughtered. Having killed the pig, boiling water is poured over it to scald the skin, aiding its removal. Then, once the offal has been removed, the pig is lowered into the pit of hot stones accompanied by vegetables wrapped in banana leaves. Finally, the pit is covered with more leaves and vegetation to form the lid of the oven and the food slowly cooks over the course of the day.

Sadly I did not have the time to watch every stage of the process as I was on call, having the weekend that I described in last week’s post, but by 4:30pm on Sunday I was back at my house, watching the benches and trestles being laid out in a big square around the edge of the compound’s central lawn. Huge pots of food started to appear one by one, covered with large, glossy leaves, and before long the bare tables had been transformed into a river of green, guarded by a few of the male nurses, languidly waving leaf-fans to keep the flies away.

The farewell ceremony was a typical PNG affair. It started with some prayers and a sermon from the pastor and concluded with long speeches from anyone deemed to be of importance. The PNG style of oration generally involves shouting at the audience and making the same point five different ways before moving onto the next one. We had nine speakers and they all made the same points more or less, so even with my imperfect grasp of Pidgin I was able to get an impression of how much Sophie and Rudi have meant to this community. The speeches were concluded by the Chairman of the hospital board who gravely thanked Sophie for her hard work before joking that she was contributing to the island’s population crisis through her work in saving the lives of all the children.

Dinner was eaten during the speeches. I’d like to say that it was delicious but I’m afraid that I ended up slipping half of it surreptitiously to the mangy dog who likes to sleep in the chair on my verandah. I think it suffered rather from the cooling down whilst the pastor got fired up. What I was delighted to see was dessert, ice-cream, which was spooned into each guest’s cup from a large plastic-lined cardboard box. This was followed by buai (betel nut) and daka (mustard stick) being given to all the guests. Interestingly lime, which is made by burning crushed coral and is the third ingredient necessary to chew the betel nut, was not doled out. I believe this is because lime is considered more personal and not shared out in the same way that the other two are.

Finally, after all the food and speeches were finished, the choir sang a song they had composed for Sophie and then the family were invited to make speeches and receive gifts. One by one staff came and hung bilums (traditional PNG bags) across the forehead of Sophie and Rudi. Some also gave presents to the three children, Ida, Julia and Tom. Before long Sophie was festooned with so many bilums that they had to be removed to make way for more. Most touching of all were the final set, one from the patients on every ward of the hospital, each presented by an inpatient of that ward. Folliowing the gifts, Sophie her husband, Rudi, made short speeches and then everbody dispersed into the night.

Two days later came the time for the final goodbyes. I was given a whirlwind tour of their house with explanations of how to charge the solar batteries from the mains, regulate the water supply to the house and shown the office, which contained more keys than there are doors in the hospital. Finally with the parting gifts of the more keys and a clasp knife, I was bequeathed the house. I use the word bequeathed advisedly because their departure was more akin to a funeral than anything else. Staff and other women streamed across the compound, wailing openly. They reached out and clasped the children as if they would never let them go and then fell into the arms of Sophie, weeping ever more volubly. I was so absorbed by the scenes of grief that I was almost surprised when Sophie came to say goodbye. It seemed quite unreal in some way that she should be going and so our parting was done with all the weight of two friends who will see each other the next day, belying the immense contribution that all the Kleins have made to my time here. Later, when all the off-duty nurses had piled into a truck to accompany the Kleins to the airstrip, I moved all my possessions into the Klein’s house, feeling strangely like an interloper.

The funereal atmosphere was finally heightened by the appearance of the two haus girls at the end of the day. Eliza and Wanette came to the door and knocked shyly just after dark. I invited them in and they proceeded to wander slowly round the house, stroking the walls and curling round the doorframes like cats, crying all the time. “I’ve lost my mother and father,” wailed Wanette. “My own parents have died but at least I had Dr Sophie and Papa Rudi. Now they are gone I have nobody.” I could think of no appropriate response and so I sat there dumbly watching her and Eliza until they calmed down. After a while Wanette brightened, “When I see you here, I feel that the father of the house is still here” and with that I was adopted. Since then Eliza has come round every day to tidy up, do the laundry and generally look after the place. Rudight, the night of my 30th birthday, she is even cooking for me. (She’s about 50 years old, before you get any bright ideas.)

If you’d asked me a year ago what I might like for my 30th birthday I would probably have listed a whole string of gadgets. Little would I have expected to be delighted by what I have got in actuality. To date my treasure trove includes: the use of this palatial house, with its solar backup battery (so I am not entirely at the mercy of the generator) and phone line (for internet); a silk sheet sleeping bag given to me by my friend Tom before my departure; a large birthday card from Kath; a good trawl of lovely emails; the hot water system unexpectedly bursting into life this morning so I could have the first hot shower that I’ve had in ages; and, best of all, all the food left behind by the Kleins. There’s meat in the freezer, several jams, a large block of cheese, tins of vegetables, canned tuna, spices, three huge buches of bananas (about 30 bananas per bunch), a selection of cereals and even a small tin of London tea, just to mention a few of the highlights. I feel like I’m living like a king (irrespective of the fact that the water smells of rotting vegetation sometimes).

All this largesse from the Kleins comes at a price, the price being their departure. They have been the unsung heroes of my trip, welcoming me into their family and providing both support, advice and entertainment. Rudi, a machinist by trade, is one of those people who would make you feel completely inadequate as a man were it not for the fact that he is such a warm person that you could not imagine any criticism crossing his mind. He is the sort of person you could imagine wrestling crocodiles before breakfast, before building a jeep from bits of metal in the back of his shed and then driving said jeep over the world’s toughest terrain to find a mountain river catch a fish for dinner using little more than his bare hands.

My evening ritual would be to go round to the Kleins on some feeble pretext at which point Rudi would be sure to say, “Tzso! (So! with a Polish accent) You will stay for dinner(?)” I was never quite sure if it was a statement or a question but I always readily acquiesced because Rudi has built up a wide-ranging and inventive repertoire of dishes, all of which are delicious and belie the fact that half of their ingredients originate from a can or packet. I would make some attempt to help but he always had everything under control so quite quickly I relegated myself to the position of setter of the dinner table and childrens’ entertainer.

Interestingly, during my time I here, I have often felt much more comfortable in the company of children than adults. I think this is largely because, no matter what culture you are from, children behave in much the same way. Even right at the beginning, with hardly any words of Pidgin at my disposal, I was able to teach the local kids how to play tag, piggy-in-the-middle and one-touch football. I find it quite easy to enter into their world, so much so that one day, when I was playing with the Klein’s 6 year-old, Tom, Rudi was motivated to ask, in a surprised tone, “You know the rules?” In fact there were no rules. We were playing with a pie-shaped piece of plastic, some thread, a few pieces of card and a couple of boxes. Without much discussion Tom and I had instinctively turned this into an Indiana-Jones style rescue mission to open the boxes and release the bit of fluff resting inside. Being in a situation where you understand all the rules is strangely comforting and playing with the children, both the Kleins and the locals, has been a valuable way of winding down at the end of the day.

Another important source of solace has been Sophie, of course, with whom I could discuss medical problems or cultural issues intersecting with our work in the hospital. She was also a living example of a tropical doctor and thus a role-model of sorts. It is very easy to get fired up and blindly dogmatic about what roles doctors from the West should play in the developing world, when sitting in a lecture theatre or pub back home. The idea most fashionable at the moment is that, outside of humanitarian emergencies, doctors should mostly be involved in roles where they set up sustainable projects, with the aim that when they leave their role will be filled by someone native to the country that they are working in. The idea of sustainability and ‘health-system strengthening’ (supporting the projects of the goverment’s health department) are so in vogue that I’ve even heard lecturers deride the work of surgeons who “parachute in” to do specialist operations for a short while before leaving again, almost to the point of denying that their intervention brings any benefit whatsoever.

Sophie’s post here would fall into the derided category. Her post has been filled by another expat, Dr Antoine, and apart from the TB treatment program that she set up, there will be little evidence in the hospital that she ever worked here. Indeed, even the TB programme may slowly run down in the same way as her predecessor’s Pap smear project (checking women for cervical cancer/pre-cancer) has suffered from Sophie’s lack of active interest. Yet, listening to the speeches, and watching the presents mount up and hearing the wailing of the staff when she left, there can be little doubt how much her work has been appreciated by the local community. The Lutheran Church Health Service, though run by Papua New Guineans, recruits all its senior doctors from abroad and seems to have little intention of changing this, at least in the short term. They are trying to recruit more indigenous junior doctors but as their hospitals tend to be quite remote and the pay is no better (and in some cases worse) than the government hospitals, there is little incentive for junior doctors to come and work in these places, making the Lutheran hospitals more dependent than ever on foreign doctors.

Over the past month I have I thought long and hard about what role a tropical doctor should play. I have grappled with the complexities of trying to consider the work not only terms of his sphere of influence, from the individual patient at the smallest, to the health of the nation at the largest, but also the longevity of the effect of his work. Quite quickly I came to see that any lasting change on a large scale would necessitate changing the underlying behaviours and beliefs of the people which is not only difficult, but in some cases ethically dubious. For example, the tendency of people to leave paid jobs and go back to a self-subsistence lifestyle, growing the food they need in their gardens, is probably bad for the country’s economy and in all likelihood also makes the individuals financially poorer. This poverty will in turn lead to lower levels of health and education. As a doctor should I try and stop people living this way, with the idea that the richer they are the healthier they will be? Should I encourage them to give up a life where they are beholden to no man, except their clan members, for one where they are wage slaves? I think not. Leaving aside the question of whether my shaky thesis that having reliable employees would indeed lead to more businesses, a bigger economy and a generally higher level of wealth for the populace, is it the place of an outsider, however well-intentioned, to start trying to get people to change their lifestyles en masse? Interestingly most people here seem to regard town life as harder and resent the idea that everything has to be paid for, in contrast to the village, where most things are free. It doesn’t seem to bother them in the slightest that they don’t even have the option of electricity in the village.

I wrestled with these ideas but, hydra-like, as soon as I had answered one question two sprang up in its place. Watching Sophie’s farewell ceremony I realised that the question as to the role of the tropical doctor is unanswerable because there is not one single role to be filled. Any solution to the health needs of a developing nation will involve doctors working on all levels with different aims. Some will come to help the health minister devise long term goals and projects whilst others, like Sophie, will come to fill a post where a doctor is needed to serve a small community. Is Sophie’s work here any less valuable than that of a public health advisor in Port Moresby (the capital)? I would contend not. In the end the most valuable question to ask one’s self is, “What am I going to do as a tropical doctor. What will my role be in this place and at this time?” Even this is not readily answerable because the instant temptation is to change the question into, “How can I do the most good?” which quickly gets you back to considering the role of the archetypal tropical doctor.

Yesterday, fed up with living inside my head, I grabbed my snorkel and went down to the beach. Previous explorations had allowed me to find a channel of deep water and dead coral so that my unique swimming style, which I have christened ’shark bait’, did not result in me cutting my feet. I swam out round the first reef and headed into the blue haze for the second reef. Halfway there the ocean floor dropped away so that it was barely visible and it felt for a while like I was floating in space. Fragments of poem my father sent me drifted through my mind:

…when we lie in silent contemplation of the void
they say we feel it contemplating us…
There is something vast and distant and enthroned
staring through your mind, staring and staring,
like a black sun, constant, silent, radiant,
with neither love nor hate nor apathy
as we have no human name for its regard.

Part of the value of this trip, on a personal level, is to be stripped of as many support structures as possible – physical, emotional, psychological – and hang there in the unblinking regard of the void which watches how I respond. It’s not always easy and it’s not always pleasant but it is certainly illuminating. Now, with the Kleins gone, another crutch has been kicked away. How will I respond?

The other day a gecko ran up the leg of one of the nurses during morning devotion. He reached down to brush it away causing the startled reptile to shed its tail and scamper away. I was amazed on two counts: firstly by the fact that the tail detached instantaneously, with no tearing or tension needed, and secondly, after the tail had fallen off it continued to thrash around on the floor in a most energetic fashion for well over a minute, presumably to give the impression of being alive. I can’t help thinking that Eichel Hospital is now like the tail of the gecko, apparently alive but really operating in a headless fashion.

Sadly Dr Antoine is no leader. His problems start with the language barrier. Despite being in PNG for five months now, his English and his Tok Pisin are still very poor, sadly. His communication difficulties are compounded by his tendency to think rather tangentially, which often means that you are unsure that he has understood what you are saying. To give an example, one of the nurses complained in the handover report that the security guard was nowhere to be found and they had had a confused, psychotic patient trying to break into the hospital and drag a tree into one of the wards. The nurses had had to fend him off themselves, which they did successfully, but they were rather shaken up by the event and upset that the security guard had not been around. Dr Antoine’s first response was to ask if the man was still here because he would like to see him. However, when rendered in broken Pidgin it gave the impression that he had not understood at all. After all, the nurses’ problem was the lack of security. Eventually it transpired that what Dr Antoine was trying to say was that if the patient was mentally ill then he should be found and treated, quite a sensible thing to say. However, had he started by addressing the nurses’ concerns and then moved on to the medical message he would have carried them with him. As it was, I think his message fell on half-open ears as the nurses were more interested making sure they had reliable security. When motivated and guided properly, the nurses are capable of excellent work. However, when a guiding hand is not present they tend to lose their drive and focus. I can’t help but notice that since Dr Elisabeth’s departure the attendance at morning handover has become rather sporadic, not helped by the fact that sometimes Dr Antoine himself wanders off halfway through it.

The communication with patients is also pretty haphazard. The villagers are often too polite or too scared to show that they do not understand so they will almost invariably nod as you talk to them. It is only by looking at the expression in their eyes that you can tell whether they really understand or whether they are just humouring you. Dr Antoine seems oblivious of this and I can only imagine what his ward rounds must be like. Maybe the nurses translate what he says for every patient, though sometimes they do not understand what he is saying either so this would not work in every case.

Most difficult for me personally is the third way in which patient care is impacted by this poor communication. It is impossible to have a discussion of any complexity about patients because Dr Antoine’s thinking either spirals off onto tangents or into repetitive eddies, and that is if you get anything sensible out of him at all. This means that for adult patients on the medical wards, the patients I feel most comfortable treating, it’s pretty much just me and the textbooks. This does not bother me too much as my pre-existing experience of treating adults with medical problems has given me a reasonable clinical judgement in this area. The problems come when I am trying to deal with patients who are not adults or have problems requiring surgical treatment.

There is a certain machismo about many Tropical Medicine anecdotes, with the heroic doctor bravely struggling to save a patient’s life, operating with one eye on the patient and the other eye on the textbook. What these stories fail to explain is that, in many of these cases, the doctor is operating only just outside his field of expertise and so the textbook becomes a reasonable aid to extend the doctor’s capabilities. However, when the doctor is firmly outside his area of expertise then he is bereft of the experience that gives him that all-important clinical judgement. If textbooks and the ability to read really were all that was needed then any medical student with a good textbook would be just as capable of managing patients as an experienced doctor. This clearly isn’t the case. The problem is that textbooks often outline the possibilities but are either not detailed enough in terms of the practicalities or do not assign any weight to the various management options, leaving you unsure as to what to try next. At this point, unless you have the backup of an experienced colleague, any further management decisions you take are little more than experimentation. Sadly at Eichel my backup is less than perfect. The case of the child that came in on Wednesday will illustrate why.

I was on call on Wednesday night and came to the paediatric ward to find that a 5 month old baby had been admitted with a distended abdomen. From the story it was pretty clear that the child’s bowel was obstructed, a relatively common problem in young children whose bowels can telescope in on themselves, a condition called intussuception. I have read about intussuception but have never actually seen a case so I was quite relieved when I came to the notes and found that Dr Antoine had already seen the child and written a plan. The boy was to have intravenous fluids, a nasogastric (NG) tube and to be referred in the morning to the mainland. I went back to the nurses to check the plan was being carried out and found that all that remained was the insertion of the NG tube. I had a few goes and then the experienced paediatric nurses all had a few goes. After seven attempts which all ended the tube going into the lungs instead of the stomach I told them to stop trying as the child was not vomiting and seemed reasonably well, all things considered.

I came back just before lights out to check on the child and he was still comfortable so I went to bed. The nurses did not call me until 7:45 the next morning when they burst into morning devotion to say that the child was vomiting yellow liquid. I came to the ward with Dr Antoine and Scholar to find the child much worse, with an abdomen that had distended further. In addition he was dehydrated because the drip needle had fallen out overnight and the nurses had had trouble getting another one in but had not called me.

Dr Antoine took one look at the child and declared, “We must operate!” “Don’t you think we should try an enema first?” asked Scholar a number of times but she got no reply as Dr Antoine had moved his focus to putting in an NG tube. Unbeknownst to me, the ward now stocked three types of NG tube (two weeks ago the hospital had only one type in stock) and one of the more rigid tubes went down quite easily. It was then that the recently-inserted drip needle fell out again.

Sadly the nurses had tried most of the baby’s veins during the night and, having been punctured, they were now unuseable. A series of increasing desperate attempts at inserting a drip needle began: at one stage three people were at various stages of inserting three needles into three limbs. The efforts of the staff were getting increasingly ridiculous but everybody was too hellbent on sticking needles into the child to answer my query about whether we should try putting a needle into the bone marrow (an option in children). I have never actually seen one of these interosseus needles done, maybe it really is a measure of extreme desperation and thus a ridiculous suggestion to make at that stage. I did not know and so upon receiving no response to my suggestions I shut up and contented myself with handing things to people who thought that they could see veins. I myself had given up a long time ago as i could find no viable candidates. Eventually Dr Antoine straightened up. “I will do a cut-down,” he announced.

Cut downs are a pretty archaic procedure in which you make a deep cut in one of the patient’s limbs to reveal the deep veins, at which point you can put a needle straight into one. They carry a risk of infection and they ruin the vein for future use so they are very much a last resort. Nevertheless, despite Scholar pointing this out and suggesting that we try and interosseus needle first, Dr Antoine appeared hellbent on doing a cut down. I chimed in, agreeing with Scholar but nonetheless we got little reply, just some mubling about how a cut down makes it easier to find the vein. In the end I figured that the best procedure was the one that he was most familiar with and so we started the cut down.

The procedure had all the features of a Dr Antoine procedure; carelessness, poor communication and the inevitable muttered, “This is very difficult”. I have yet to see him do an operation where he does not drop a piece of sterile equipment on the floor and snap the suture thread when tying knots. However, these are minor flaws compared with the fact that his carelessness means that he often does not plan ahead or make adequate provisions to guard against mishap and so it was with this cutdown, which just ended with a T-shaped cut in the child’s ankle and a vein multiply punctured because the iv needle had gone through the side wall. Subsequently I have looked at a textbook and the method they recommend, through it requires some dextrous operating, avoids the risk of making multiple holes in the vein. (You make a small nick in the wall of the vein with a scalpel and thereafter everything introduced into the vein is blunt.)

One ankle vein ruined, Dr Antoine shifted his attention to the other, at which point I protested ever more strongly that we should try inserting an interosseus needle, which Scholar said she had done twice. Of course, we don’t have the proper needles but you can do it with standard needles according to the PNG paediatrics guidelines. Dr Antoine actually responded this time but only to ask whether Ketamine could be given via the interosseus route. I know that fluids can but I was not sure about drugs, especially anaesthetic drugs, where the time of absorbtion and the distribution in the body is very important. I had to admit this and so he started on his second cutdown, which failed too. Scholar came and tried the interosseus needle but obviously hadn’t learnt the technique well enough because her attempts were unsuccessful.

So, after 5 hours of work, we had achieved little more than dehydrating the baby further by putting it under a hot operating lamp, damaging all visible veins and cutting into both its ankles for nothing. By then the administrator, who is the the only one who can organise emergency transport to the mainland, had gone to court (to defend himself in a rather ridiculous libel case) so there was no possibility of discussing transfer options. The child would have to wait for transfer to the mainland the following day getting ever more dehydrated in the meanwhile.

I accompanied the child on the boat the following morning. We hired a special boat to go an hour earlier than the normal ferry, with an ambulance to pick us up on the other side. I was not in the least bit surprised to find no ambulance waiting for us but after an hour of waiting (this is PNG time) I called the administrator and asked for the number of whoever was providing the ambulance. Sadly, the responsible clinic officer was was more interested in sleeping than working, judging by the confused button pressing that preceded my call being redirected to voicemail, and so when a PMV (bus) turned up I decided to use it as our transport. We reached Modilon Hospital without any further mishaps. I handed over the patient and slunk away as fast as I could, ashamed that all we had done is make it harder for the paediatricians to help the child properly. After leaving the hospital I met up with Dr Elisabeth, who was still on the mainland, dealing with a few final affairs (made harder by the fact that the province’s (country’s?) entire banking system has been crippled by a failure of the telecoms equipment). I recounted the sorry tale and as I did so she was continually interjecting, suggesting countless things that we could have done or should have done.

Given that the judgement of the person who is meant to be supervising me is often questionable I am disinclined to go and ask him for help, unless I have to. This in itself poses a problem and brings me to the next flaw in the whole “no guts no glory” approach. The one type of doctor who is worse than the one who knows very little, is the doctor who thinks he knows something when he does not. Buoyed up with false confidence he will end up making poor decisions and endangering patients. In the heavily-supervised Western healthcare system this sort of mistake is usually caught relatively early because most people’s work is checked by their colleagues at some stage. When that supervision is absent then the safety net is gone.

I was reminded of this rather forcefully when I saw a boy whose arm I’d sutured up unaided on the weekend that Dr Antoine was travelling back to Madagascar with his wife. The boy returned with his father, complaining, with typical Papua New Guinean understatement, of liklik swellap (a little swelling). The banadage was tough to remove but when I finally pulled the last turn free I was horrified to see pus gushing like milk out of the suture wound. The swellap in question was an abscess under the skin flap and I had to get Dr Antoine to come and drain it.

The problem had arisen because I had closed what is classified as a “dirty wound” too early. I had previously read that dirty wounds should not be closed immediately but had misunderstood the term “dirty wound”, thinking that as I had cleaned the wound thoroughly and put some iodine on it, I had transformed it into a clean wound. My error will seem terribly basic to anyone who has done any time in Accident and Emergency but I never did an A&E stint and the textbook that I read to try and learn about the management of cuts did not go into details about the definition of a clean wound and a dirty wound. In this case I was fortunate that my mistake will not have any long-term sequelae but it haunted me all week. The most important rule of doctoring is Primum no nocere (first, do no harm) and I had broken it.

I had already been quite nervous about seeing paediatric cases on call, as I feel bereft of the comfort of my clinical judgement. Children respond to illness in a very different way to adults, so when they don’t seem to be responding to the treatment I have instituted I am never quite sure if I just need to be patient or whether I have missed something. Seeing this child was a realisation of my worst fears and it sent me into a vortex of self-doubt. What about the other paediatric cases I’d seen? Were they surviving more through luck than judgement? I did not come here to experiment on people, especially not on children. My low mood was compounded by feelings of isolation as I have no-one here that I can discuss these complex matters with – Pidgin doesn’t allow for any nuance or subtlety so if people here wanted to have this sort of discussion will revert to their Tok Ples (local language), which I cannot speak. Furthermore this sort of ethical and conceptual discussion is not something that most people here seem very comfortable with*. I could not even get solace from those back home as the internet connection was down for most of the week.

So I was left with myself and my often ineffective pep-talks: “Pull yourself together and stop being such a wimp. None of your other Tropical Medicine friends needed to email you for support, did they? Don’t be so pathetic.” Having been in similarly isolated situations before, I knew that I had to fill my evenings will relentless activity so I wouldn’t have time to wallow in self-pity and self-criticism. Fortunately, my sister-in-law had been talking about needing a new logo and I decided to focus on trying to design one. My nervous energy transmuted into an unexpected but totally delightful burst of creativity, which resulted in, amongst other things, the much improved logo for this page. My mood started to improve and the final turnaround came on Thursday night.

I was standing in line to buy tea from the hospital store when a nursing student called me away. “Emergency, dokta.” “Wanem emergency?” “Snekbite.”

As we hurried to the ward I couldn’t help marvel at my luck. The snakes on Silsil must be angry because this was the fifth snakebite this week. They go to the surgical ward so I don’t normally see them but my ward round had been interrupted the previous day by an anxious nurse coming to ask me how to give anti-venom. Apparently in the past Dr Elisabeth had always adminstered the anti-venom but Dr Antoine had just written it up and walked off and, as is often the case, he was nowhere to be found. I looked in the textbooks, talked to Scholar and determined that it the only special measure was that it had to be given slowly because there is a risk of anaphylaxis, a severe (and sometimes fatal) allergic reaction, when giving the drug. I gave the anti-venom uneventfully and mentally filed away all I’d learnt about snakebite and what signs to look for when trying to determine whether the bite had been poisonous. Now it looked like all that information was going to come in very useful.

Even if I hadn’t read the guidelines I think I would have suspected envenomation. Even from the end of the bed, it was clear that this man was seriously unwell. All trepidation and doubt fell away, there was no time for that. The experience gained from years of treating sick adults made the initial stages automatic. Airway, breathing, circulation. The heart rate was slow at 40 beats per minute. I started giving instructions to the nurses: “Check the blood pressure. Get me a big drip needle and some fluids. Matron please go and find the keys to pharmacy and get the polyvalent anti-venom from the fridge. Lavlene, please draw up 200mg of hydrocortisone.” Back to the patient. Carry on assessing him for other signs that venom had reached the circulation. “Joe are you feeling any pain? Have you vomited? Does anywhere feel numb?” His legs felt numb. There was now absolutely no doubt that venom was in his system.

The nurses were working smoothly and efficiently, galvanised by the emergency in front of them. The hydrocortisone came, shortly followed by the all important anti-venom. I sat by the patient with the syringe squeezing in small amounts every minute or so, whilst continuing to guide the nurses. Everything was going well except, even as I was giving the anti-venom, the patient’s heart rate and blood pressure continued to drop. His heart rate was now 36 beats per minute, worryingly close to a cardiac arrest, and his blood pressure had dropped to a horribly low 70/40 despite all the fluids that were running into both arms.

How long would the anti-venom take to work and what was an adequate dose? The guidelines in the books and the leaflet that came with the bottle of anti-venom talked about giving the whole vial but yesterday Dr Antoine had only prescribed 5ml for one his patients, whilst Scholar had talked about giving 10ml. I’d already given 10ml but nothing seemed to have happened. I decided that giving too much was better than giving too little so started infusing another 5ml. Still not much effect. “Please go to to the emergency box and get the adrenaline,” I asked one of the nurses. We had no facilities for monitoring the patient’s heart rhythm or delivering an electric shock if his heart stopped, so I wanted to avoid a cardiac arrest at all costs. If things got much worse i would start giving him small doses of adrenaline to try and maintain his blood pressure and heart rate. I had just finished drawing up the adrenaline when blotches appeared on the patient’s chest and he started vomiting blood. He was having the much-dreaded anaphylaxis (compounded by poor clotting due to the venom).

Thankfully the mainstay of treatment is adrenaline, which I had in my hand. I followed this with a few more drugs to calm the vomiting and the itchy weals. With this treatment the patient seemed to improve, his pulse and blood pressure rising. However, his tongue still seemed a bit swollen and the oxygen saturation monitor started showing that his oxygen levels were dropping. I suspected this was probably an error, as the patient’s hands were cold which makes the machine give a falsely low reading but it was better to be safe than sorry and we got the oxygen cyclinder. This was great, except there was no mask. The normal way oxygen is given on the wards here is via a small tube inserted into a single nostril. This is not ideal as it only delivers a low concentration of oxygen and, furthermore, it irritated the now semi-conscious patient who kept pushing it away. I insisted on a mask, which, to my consternation, caused some debate as to whether we had any oxygen masks at all. However, eventually one was found and a little while later, as the patient’s hands warmed up, the reading on the machine returned to normal. We could relax.

This was an important case for me for two reasons**: firstly, it was quite amazing to see the nurses working so efficiently and made me realise what a difference proper motivation makes to their work (their motivation in this case came from the recognition of the emergency, not from anything I did) and secondly, it was a perfect contrast to the fiasco of the little boy with intussuception. It showed that I can be useful out here, over and above just treating the patients in a kind and thoughtful way, but I do need to work in an environment where I can get sensible support when I stray outside of my areas of expertise, because I am not happy to blindly stumble through the management of patients, hoping that I did not miss a relevant chapter in the textbook. Seeing this with clarity helped me make a decision I have been pondering for the last fortnight: in a week’s time I wil go to Braun Memorial Hospital, another Lutheran Hospital staffed by some of the German doctors I met when I first arrived. Not only will I have more medical support but also people to discuss things with and the pleasure of seeing a hospital whose history I have read much about.

So, after leaving Silsil next Monday, I will travel overland to the Birmingham of PNG, a town called Lae. From there I will catch a boat to Finschafen. The hospital is actually on the mainland but you have to go by boat because no road connects it to the outside world.

It sounds interesting, doesn’t it?

*The closest that I’ve heard to a discussion of the abstract is when people stand up and give sermons in morning devotion. Most of the time they are in Pidgin and I am afraid to say that I do not always make the effort to mentally translate them but there was one delivered in English the other day. The sermon was on a reading from the beginning of the Gospel according to John (”In the beginning was the Word and the Word was with God” etc). The sermon started conventionally enough with the speaker talking about the power of the word of God and what it can do when it enters a person. However, I was surprised to hear him explain that the way it works is that the word of God enters the body and goes to the bone marrow, because that is the place where blood is made. From there it can then go all round the body. Based on this, I wonder whether the abstract is often made concrete for the purposes of discussion.

**Well, three reasons actually. The third reason is that I get a tale, where I can cast myself as the heroic doctor, saving lives with one eye on the patient and the other eye on the textbook. You wouldn’t believe this was a proper Tropical Medicine blog otherwise, would you?

My last patient at Eichel was dead when I first met him. A man in his mid-forties, he had been brought into the hospital with severe breathlessness and, in the short time that it had taken for the nurse to cross the corridor from the minor theatre-cum-emergency room to the main theatre, both his heart and his breathing had stopped altogether. I started resuscitation, running round the body demonstrating to the staff how to massage the heart and blow air into his lungs with an Ambu-Bag, whilst trying to give further instructions to the nurses and discover from the family what had lead up to this. It is quite hard to try to juggle all these things at the same time and our efforts were not aided by the fact that the seal around the oxygen mask was broken so most of the gas was escaping around the side of the mask rather than going into the patient’s lungs. Consequently, by the time we had got a drip needle sited and given the first milligram of adrenaline the patient’s face had developed the bluish tinge of hypoxia. It all looked pretty hopeless. I decided that after the statutory two minutes of CPR required to give the adrenaline a chance to work we would stop. Without the proper equipment to monitor the heart rhythm and administer electric shocks, if needed, the whole affair seemed somewhat farcical. I was entirely unsurprised when there was no pulse to be felt two minutes later.

I was interrupted in the middle of explaining to the family that the patient had died by the patient’s heart spontaneously restarting, its beat visibly pulsating through the man’s chest wall. So we restarted the resuscitation. I intubated the patient (put a tube into his lungs to deliver oxygen and to protect the airways from secretions and vomit) and after a few minutes of proper ventilation the man started breathing on his own. His heart rate was now normal, his blood pressure was normal, and our sole item of electronic monitoring, an oxygen saturation monitor reported sats of 98%, also normal. The patient was even moving a little. It was about as close to a miracle as I’ve ever seen. Flushed with the joy of witnessing the first successful resuscitation of my entire career, I removed the tube from his lungs and started making preparations to transfer the patient to the Intensive Care Unit on the mainland.

Sadly it was a false dawn. Whilst we were in the back of the ambulance truck, mucus mixed with saliva, and possibly bile, started coming out of the Guedel airway guard that I had placed inside the patient’s mouth. It was only at this stage that I discovered that our emergency bag did not contain a syringe with a nozzle that fitted onto the suction tube. I could not reintubate the patient because his teeth were tightly clamped around the Guedel and none of the drugs in the case could be used to sedate the patient effectively. The only option left was to roll the patient onto his side and let gravity do the work. When we went uphill the sputum-bile mixture would spray out of the airway, not infrequently into my face, and when we went downhill it would merely bubble resentfully. Incredibly the oxygen saturations never dipped below an acceptable 90% and most of the time they were completely normal.

Given this situation, I was feeling quite anxious by the time we reached the airstrip but this anxiety quickly transmuted into a bitter anger when I realised that no plane had arrived, even though we were half an hour late for our rendezvous. Luckily the driver had a mobile and Telikom, the monopoly land-line telecoms company, had finally reached an agreement with Digicel (the only mobile network with reception on Silsil) so that the two networks were finally linked and we could call the hospital and ask the administrator to find out what was going on. A fortnight before it would have been impossible to make that call and we would have had no way of communicating with the hospital whatsoever.

Whilst the administrator made his enquiries we had to wait. We sat for an hour in the back of that truck, surrounded by a cloud of flies who had come to feast on the sputum spray as well as the pool of blood that had accumulated where the drip had disconnected during turning the patient. By the end of the hour the anger had subsided into a tired resignation. There were no drugs worth a damn in the emergency box, the blood pressure cuff had burst when I tried to use it and the patient had begun to display an abnormal stiffness of the muscles so that the only way to keep him on his side was to put his head in my lap and sit in the pool of blood, water and secretions that had trickled down the metal stretcher.

When the plane finally came it seemed too small to fit the patient in but we managed it eventually by collapsing all the seats, save for those of the pilot and co-pilot. When I clambered in myself I was delighted to find an oxygen cylinder, a suction machine and a sensible emergency box. I suctioned out the patient’s airway and then focussed on giving him oxygen during the flight. The cylinder was only small so instead of running continuously it had a small button which needed to be pressed every time the patient breathed in. When he exhaled I had to let go. After a while I got into the rhythm of the man’s breathing and the whole procedure became almost automatic.

Amazingly, an ambulance was ready and waiting at the airstrip when we arrived at the mainland airstrip and the driver rushed us to the hospital. We burst through the doors of the Accident & Emergency department to find a solitary nurse. There was no on-call doctor present, let alone an on-call anesthetist. According to the staff, the emergency doctor had gone home, which was at least 15 minutes away, so the driver had to be despatched to find him. Except it turned out that he was not at home and nobody knew his mobile number. After I had given him a few drugs that I found in the emergency room, the patient was as stable as I could make him so I decided to inspect the Intensive Care Unit that was adjacent to the A&E.

It was staffed by a single nurse and contained only one patient who was sitting upright in an armchair, looking in a better condition than I did at the time. A shiny new ventilator was carefully tucked away in the corner under a dust sheet. I doubt it was ever used. I felt like such a fool. How naive of me to think that the Intensive Care Unit would run anything like the ones back home. How silly of me to bring the patient all this way. There would be no sedation, no intubation, no monitoring of blood parameters.

The on-call doctor came after about an hour. Had he cocked his leg up against the wall and pissed on it he could not have made it more clear that he wanted to establish the hospital as his territory. He listened to the patient’s history and the progress of the resuscitation and when I had finished he declared without a moment’s hesitation, “We’ll treat for malaria. It can present like this.” The patient died a few hours later.

He was doomed long before the time of death though. A whole litany of obstacles prevented him from ever having a real chance of survival starting from the moment he fell ill: his family had tried to save money by not bringing him to hospital until he was on death’s doorstep, the hospital equipment was inadequate and faulty, the staff was not trained in resuscitation, the emergency box was put together without an understanding of what should go in one, the plane was late, the doctors on the mainland were as unreliable as the rumours suggested and they had little or no expertise on Intensive Care. All ultimately due to poverty. And what had my contribution been to the situation? I had further impoverished the hospital by however many hundreds of Kina it had cost to charter the plane and I had further impoverished the patient’s family as they now had to buy a coffin to bring the patient back to the island. The road to hell truly is paved with good intentions.

The final irony of the whole situation is that when I first arrived at Eichel and Elisabeth had told me that their policy was resuscitate patients I had argued against this practice, pointing out that without a defibrillator to give electric shocks and monitor the heart, most resuscitations would end in failure and for those where we did get the patient back we did not have an easily accessible intensive care unit, which is where such patients should go. However, Elisabeth remained quite convinced that it was the right thing to do, if only for staff training. In the end I decided to bow to her opinion as she had been there longer than I. Anyway, it was all academic, I’d never seen anyone actually come back from an arrest…

This episode also serves to highlight the other theme of the week, the relationships that I have built up during my time here. Later that night the ambulance driver came to the Lutheran Guesthouse along with the relative that had accompanied the patient and a note which informed me that the patient had died and I would need to organise getting the body back to Silsil. I had never done this before. If someone had given me that note a fortnight ago I would have probably been quite worried. As things were, I merely thought to myself, “Oh well, tomorrow should be interesting.”

Over the last two months I have built up relationships with all sorts of people, both expats and locals, both hospital workers and non-staff. My Pidgin has also improved to a state of fluency. These two factors have made life here so much easier: it is true of any place in the world, but especially of Papua New Guinea, that once you know people then all sorts of doors are suddenly opened to you. However, more important than the ease of life is the joy that comes with forming these relationships. When on a trip like this there is a certain tendency to focus on the differences between yourself and the people of the culture that you meet. This provides a constant source of fascination and wonder as you learn a different world-view. However, a deeper pleasure comes from travelling half way around the world, meeting a person who is as different from you as can be and reaching out to him and in doing so acknowledging the common humanity which you share.

I am reading A Divided Self at the moment. I have only got 40 pages in but already a wonderland of new ideas and insights has been laid out. One sentence has particularly struck me so far: ‘Here we have the paradox… that our relatedness to others is an essential part of our being, as is our separateness, but any one person is not necessarily a part of our being.’ More than anything, I have felt that to be true this week. The most wonderful thing about the practice of Medicine is that you get the opportunity to experience this hundreds of times a day, as it is an integral part of being a doctor to approach each patient with openness and to acknowledge that relatedness between you. Without it you are little more than a mere diagnostician and pill-dispenser.

I saw the patient’s family again when I returned to Silsil. It was a chance meeting as I was walking along the beach past their village. I did not detect any resentment or anger in them. Maybe they looked had beyond the outcome and seen my intentions and gained some small measure of closure in knowing that everything possible had been done to save their relative’s life. I hope so. I hope it was enough.

The morning of departure had come. My bags were piled up by the door; I had chosen the food to take with me to Amselhafen; I had given away some of my clothes to Eliza, the haus meri; I had even written about house-related topics that might be of interest to any future occupants, from how to charge the solar power system, to the oddities of the plumbing, to the voracious appetites of the ants that live behind the cutlery drawer. I was ready. It was 07:30, nominally the time the boat leaves, but this is PNG, there was plenty of time for a cup of tea.

A slight rustle at the door announced the arrival of the board chairman. To knock loudly seems to be against the New Guinean culture, with the result that many a time people have waited at the front door for ages without me realising that they were there. I invited the chairman in to join Eliza and I for a farewell drink and he gladly accepted. I was so engrossed in tea-making that I did not hear the further rustling that signalled the arrival of the nurses. Luckily PNG ears are far sharper than mine and Eliza let them in.

The nurses entered hesitantly, almost too afraid to cross the threshold of the Big House. It was the first time that any of them had been inside and for them it seemed to be an experience akin to me being invited inside Buckingham Palace. (When I tell you that I am treated like royalty here I mean that quite literally, with all the advantages and disadvantages that this relationship entails.) The nurses had come to present me with a bilum, the traditional token of thanks and farewell. They had woven one in the Silsil fashion, which involves using fibres stripped from the long, fleshy leaves of a local plant which are dried and then dyed magenta and purple. To cement the bilum’s status as a ceremonial gift, a stick had been placed inside to fan it out and fresh flowers had been woven into the tassels. It was a princely gift indeed.

24 hours later I was packing away the bilum into a bag to be left in Madang. I had just about got everything prepared when Sussi, the guesthouse manageress, reappeared to let me know that she had called a PMV to take me to Lae. Unfortunately she had called it far too early and it was only a quarter full. If I had known what was to come I would have asked the driver to return later but at that stage I had not fully appreciated the process of filling the bus.

PMVs going on long journeys will only depart once they are completely full. To fill the bus the driver does not merely wait at the PMV stop, he drives around, with the bos cru (boss crew, ie: conductor) hanging out the side of the bus shouting the destination, “Laelaelae! Laelaelae!” This behaviour sounds reasonable until you realise that the circles are about 25 metres in diameter and there are three or four other buses making exactly the same circuit. At times they are pretty much nose-to-tail. Strangely there is no animosity between them nor attempts to poach each others passengers. Occasionally the driver would get bored, or perhaps dizzy, and break off to drive around town but quite frequently his route would take him down several roads almost completely devoid of any pedestrians. On these trips the bos cru would optimistically call out to people crossing in front of the bus, as if someone would suddenly decide to take a 7 hour bus ride on a whim.

There is one final twist to the process: the bos cru will often fill up the bus with his wantoks (friends, clan members) so that it looks like it is full and thus nearly ready to go. This attracts customers, because no-one wants to drive in circles for ages if they can avoid it. However, when the genuine passengers get on the wantoks get off. I wasn’t aware of this at first and couldn’t understand why the bus always had two empty seats, no matter how many passengers we picked up. The bus is filled agonisingly slowly by this method.*

By the time we had been circling for three hours I was almost at exploding point. I had expected some delay in filling the bus but not three whole hours and we still were not full. Thankfully I managed to drift off to sleep and when I awoke we were speeding out of Madang. Only to stop 10 minutes later for a break at the closest out-of-town market. I dissipated some of my agitation by wondering aimlessly through the stalls. Quite unusually some of them were selling pre-cooked meat and fish. I found this discovery diverting enough to occupy me until it was time to go back to the bus and back to sleep.

The next time I awoke we were in the mountains with the engine sounding close to breaking point. We were inching up an impossibly steep road and for a while it looked like we would not make it. The driver was clearly accustomed to driving these roads, however, and he started driving in zigzags across the whole width of the road to flatten the gradient enough to permit the bus to keep moving. Eventually we made it to the summit, only to hurtle down a precipitous downhill and then to be faced with yet another equally steep incline. The Romans, I thought, would have approved of these roads: no concession to geographic obstacles, just the straightest route possible.

To relive the tension the bos cru started telling a series of stories which soon had all the passengers shrieking with laughter. I drifted in and out of sleep, waking at intervals to find us crawling up another hill or speeding down another descent. Sometimes we would pass vehicles broken down by the side of the road but we never stopped to help. You never know if it might be staged by raskols who want to rob passers-by. On one occasion we passed a huge container lorry lying on its side at the base of a hill with scores of people sitting on top of it. I wondered how they would right it again, they would need a crane with a pretty powerful engine to get it there in the first place.**

Shortly after the stricken truck we came to the crest of the final hill and the great Ramu Plains, flanked by majestic mountain ranges, spread out ahead of us. An involuntary, “Ayo-o-o!” (Pidgin for wow) escaped my lips, causing my neighbour to chuckle. From that moment there was no possibility of sleep and I sat pressed up against the window in rapturous contemplation as we descended into the valley and started our long journey across its floor, past sugar cane and oil palm plantations, past the scruffy town of Ramu and its tired inhabitants, past mills and isolated little huts and past slanted columns of smoke billowing from the burning fields. All against the background of glorious mountains; some crenelated, soft and verdant, as if they had been covered in a layer of green velvet, and others distant, craggy and blue, promising hidden adventure.

The plains took an age to cross but when the driver turned on the radio I knew that Lae must be close and indeed shortly afterwards milestones appeared, indicating that Lae was only 30 miles away. The final stretch of road was measured out by markets and shops named after their proximity to Lae – 10-Mile Market, 8-Mile Motors and so on – and with each mile my excitement was mounting. Nine hours in a bus is more than enough for anyone. However, my excitement was premature: I had not anticipated the oddities of the drop-off procedure.

Most PMVs in PNG will take you directly to your door, with the exception of short-route town buses, and so it was with this bus. I decided to follow the route the driver took on my Lonely Planet map of Lae to try and give myself an idea of how the city was put together. To my utter despair the driver took the most illogical route imaginable; several times we were tantalsingly close to the Lutheran Guesthouse, only to turn around and drive back to within a block of where we had dropped off a previous passenger. After an hour of eddying around it was finally my time to be released. Freedom has never tasted so sweet.

The day and a half that I spent in Lae was more than enough. In colonial times it was known as The Garden City and indeed there still remains a sign proclaiming this by the side of a shorefront road. Ironically this is surrounded by rubble and detritus washed out of the litter-choken harbour but these piles of rubbish are almost ubiquitous in the town that locals now jokingly refer to as Pothole City. The roads here are so awful that drivers frequently mount the central reservations to avoid gaping craters and the trucks are contantly surrounded by clouds of dust which become strangely picturesque around sunset.

Notwithstanding the photogenic Lae traffic, I was glad to be disembarking at Amselhafen on a balmy Thursday afternoon to be greeted by Dr Matthias and his wife, Angela. My pleasure only increased when I discovered that there was no space in the cab of the pick up so I would have to balance on the tailgate as we sped down the unsealed roads from the wharf. Give me sun, some scenery and the chance to sit in the back of a pick-up and I am immediately transported to the seventh heaven.

Amselhafen turned out to be my idea of paradise: mountains, jungle, caves and rivers. What more could anyone want? However, these delights and the joy of exploring them by foot and outrigger canoe were all but eclipsed by the relief at finally finding someone with whom I could fully discuss my Eichel experiences. Matthias and I chatted about the various aspects of medicine in PNG almost non-stop throughout dinner preparation and consumption. I had just finished describing the cardiac arrest of the week before when the phone rang and Matthias left to answer it. He came back about a thirty seconds later. “That was hospital. A patient has come into the outpatient department with a cardiac arrest. How’s that for a coincidence?”

We reached the hospital about five minutes later to find a man even younger than my Eichel patient lying on a trolley. He had come from an island in the vicinity of Amselhafen and had been ill for a few days before the health worker had finally decided to bring him over. Despite the fact that they had radioed ahead from the ship, the ambulance had not been waiting for them at the wharf and they had been obliged to wait for an hour and a half for a PMV to take them to the hospital. The patient had died five minutes before they had arrived. This resuscitation attempt was even more futile than the last and after about ten minutes we stopped.

The family were the sole occupants of the dimly-lit waiting room and I watched Matthias as he emerged from behind the curtain to deliver much the same speech as I had started the week before. The wife looked numb with shock and her only response was to clutch her sleeping baby ever tighter to her chest. The silence was broken by the father’s high-pitched wail, a thin, sharp sound that cut me to the quick. Strangely, despite all the pain and suffering I have seen here, it was the first time I’d heard a New Guinean cry spontaneously.

We walked back to the truck and drove home in silence. Above us thousands of stars glimmered in the indigo sky and around us the jungle was alive with chorus of a million insect voices singing their nightly song. One day all this will be gone; the stars blotted out by the glare of street-lights, the trees felled to make way for tarmacked roads and the chirping insects drowned out by televisions, radios and the siren of an ambulance racing a critically ill man to hospital in time to save his life.

*Nevertheless my experience tells me that there must be some advantage to this method which outweighs the waste of fuel. There is always a good reason that people do things and whilst it is sometimes tempting just to dismiss things as stupid it is only because one hasn’t fully understood the thought processes of the locals.

**Obviously such cranes things exist because the container and lorry had disappeared a week later.

I can tell you the exact moment everything changed. It was Saturday night and I was tired after a day of exploring caves whose entrances were holes in the riverbed and exits were behind waterfalls. I wanted to read a little but my book was too dense for my energy levels at that moment. I went to Matthias’s bookshelf in search of something lighter. Sadly most things were in German and so I was left with a choice of Obstetrics Illustrated, Public Health, or Setting Up Community Healthcare Programmes in the Developing World. The latter had cartoons. It was an easy choice.

I idly flicked through it until I came to a chapter on the characteristics of the leader of a community health project. After an introductory preamble came a bullet-pointed list of qualities. The first one was, ‘is genuinely committed to facilitation’. Was I? I wondered. I hurried on, lest reflection revealed that I didn’t even possess the first attribute on the list, and the chapter turned to the more comfortable topic of the requisite qualities of other team members. Quite rightly it pointed out that many people who join the team might be doing so for personal gain or perhaps they were chosen because their relative was someone important. Obviously it was less than ideal to have such people on the team and the book advocated giving further education sessions about the role of a community health worker if people seemed to be choosing based on spurious reasons. However, the author also felt that it was important that the health workers should be chosen by the community which they would serve. This seemed to me something of a double-standard. On the one hand you should allow the villagers to choose their own health worker but, on the other hand, if they were about to choose the “wrong” person then you should try and “educate” them to do otherwise. It seemed to me that educate was just a euphemism for something short of coersion. How could this be compatible with facilitation?

The final section of the chapter laid out the stages through which a typical health programme progresses through. First there is the inital burst of energy, then the hard work comes in the second stage. This is followed by a period of decline, where all the people who didn’t want to be health-workers really start to leave, but, with any luck, this finally leads to a core of true volunteers who will carry the programme forward and are committed to its success. I found this quite a comforting message. Many of the staff at Gaubin and Baum Memorial (Amselhafen) hospitals seem to me to be those who would leave at Stage 3. Except that it’s so hard to fire them that they can effectively do whatever they like without any repercussions, so they stay and are paid for doing their work half-heartedly. Knowing this state was “normal” in the life of an insititution and that there was potential for a Stage 4 gave me hope.

I went back to my first question. Was I really committed to facilitation? Could I bear to watch people make decisions that I thought were terribly wrong, despite all my attempts at gentle persuasion? Was I so committed to facilitation that I would rather a project collapsed completely than I started taking a more active leadership role? The truth is that I think I would find that very hard. Wanting to make a difference can be both altruistic and selfish. It would be hard to work for years in a place and then have nothing concrete to show for it at the end. Most of us want to leave a legacy. If a commitment to a pure facilitation role is what is needed then I do not think I am ready. (However, I wonder how many people would truly satisfy that criteria. A minority of tropical health volunteers I would imagine.)

Two days later I was walking up a mountain path with the three (New Guinean) members of the hospital Mother and Child Health (MCH) team. It was a glorious day and the walk was made all the more pleasant by the fact that the previous day’s downpour had turned the path to sludge and so it became easier to walk barefoot through the mud than to try and avoid it in sandals. I love the tactile nature of walking in bare feet. Furthermore, one of my ambitions of the trip has been to learn to walk like a Papua New Guinean. No matter how many times I see them, I remain in awe of their sure-footed gait and ability to walk across any terrain in bare feet. This would be good practice and the soft, warm mud meant that any discomfort would be diminished.

After an hour and a half of walking we arrived in the village of Gaweng Labu, little more than a handful of huts clustered round a central quadrangle of brilliant orange soil. We sat in the large haus win (a meeting house with half-open sides – literally, house of the wind) and waited for the mothers to arrive with their children. The aim of the clinic was simple. We were to vaccinate and weigh the children, check they were growing appropriately, and educate the mothers of those who were malnourished. If the child had an illness that was amenable to treatment by one of the five basic drugs we had then we would dispense medicine and if the child was seriously ill then we would bring them back to the hospital. To run the clinic all we needed was, a set of scales, a book in which to record the statistics, the five drugs and a cool-box of vaccines. (Patients look after their own health records, which contain a growth chart if they are children.)

I remained as hands-off as possible, preferring just to observe how the staff worked. The clinic ran like clockwork. It was beautiful. First the child would be weighed, small children placed inside one of their mothers bilums (traditional string bags), the larger children reaching up to hang off the large hook at the base of the scales. After this they would move to the table where their weight would be plotted on the growth chart and recorded in our statistics book. Next the child would be examined quickly and the mother interviewed about any problems. Finally vaccines were given if needed. At the end of an hour we had seen all the children and it was time for the long walk back to the road and the equally long wait for the hospital driver to collect us. That day was pobably the most satisfying day of this entire trip: we set out do something that will have a big impact on the health of that community and we did it well. The contrast to inpatient work (small impact on the overall health of the community, a great many things done imperfectly) could not have been more pronounced.

If I had turned around on Monday evening and gone back to Lae, my trip to Amselhafen would have already been worthwhile. As it was I spent a pleasant week, gently working in a comfortable hospital environment in the mornings and relaxing, exploring the neighbourhood or battling the pig in the afternoons. Germany, as the pig is called*, seems more like a dog than a pig. His eternal quest is to escape from his sty and it is not uncommon to be standing in the garden and suddenly feel a wet nose nuzzling the back of your leg, in the search of food or affection. If you bend down and rub his belly then he will immediately drop to the ground and roll onto his back, his eyes half-closed in ecstasy.

It was easy enough to end his escapes by raising the height of the sty fence, using bamboo cut from a thicket near the river bank. However, the problems started when I took on the task of replacing the rather tatty chicken-wire gate. I fished around the pieces of lumber that Matthias kept in his garage and came across what looked like the side of a baby’s cot (several bars surrounded by a frame). Happily this had exactly the dimensions to act as a gate if stood on its side. I decided to use this as a sort of portcullis, reasoning that it would be hard to fix a hinged gate securely to the bamboo fence and I wasn’t sure if we even had hinges. With Matthias’s help I drove to gateposts into the ground and fixed some cross beams near the top and bottom, between which the gate could slide up and down. It was easy to use and seemed quite sturdy. The only problem was that Germany, who was roaming around the garden, could not be induced to go back into his sty, even when his favourite bananas were thrown in. He seemed to be quite inhibited by the lower crossbar. We were just about to give up when I had the idea of covering the red paint with mud and this seemed to do the trick. In the future I will avoid wood painted red when building pig sties.

Sadly I had underestimated Germany. He worked out how to raise the gate and wedge it open after only one night. So I passed a length of bamboo between the slats of the gate and underneath the top crossbar. The gate was now impossible to open without removing the bamboo. It only took another day for Germany to work out how to dislodge the bamboo and open the gate. From then on every day became a battle of wits with Germany, with a new fastening method tried each day and each day Germany learned how to get round it and scamper out into the garden. I’m afraid to say that I never won.

I may not have helped him with his pig but by the end of the week I began to feel that I might be helping Matthias in other ways. I was not the only one who needed some release. It seems that whilst there are three doctors at the hospital they have quite different ideas about what were the priorities and how they should be tackled. Matthias is interested in public health programs, where you do basic (and therefore cheap) things (like the MCH clinic) which affect a large number of people, whilst the other two are much more interested in their inpatient work and building up the hospital facilities. This is expensive and only benefits a relatively small number of people. Unfortunately the dialogue between the three doctors about the best way forward was not always effective.

Listening to Matthias’s stories of frustration and conflict I finally realised why many NGOs have the air of being something close to religions, an aspect that I find quite off-putting. The model of healthcare which relies on a steady stream of expat doctors to run the hospitals also relies on those doctors being not only competent but also having the same ideas about how healthcare should be provided. If they don’t then the project tends to be taken in a different direction each time an new doctor starts. One way of ensuring this does not happen is to have a very strong organisational ethos so that you only accept people whose beliefs coincide with those of your organisation. The Lutheran Health Services seem to have only two criteria for choosing who they put in posts: first that they are a doctor and second that they are a Christian. This is not the best way to ensure smooth transitions and continuity. In fact it tends to result in a huge waste of time, money and effort as one doctor sets up a service and then his successor neglects it because it does not interest them.

The week was full of small insights like this. Nothing earth-shattering but all the same they provided food for thought and offered an interesting context within which to reconsider my experiences at Gaubin. It was exactly what I had come to Amselhafen hoping for. Throughout this trip I have been battling with the various ethical dilemmas that are presented on an almost daily basis by what I see and hear and because many of the questions do not lend themselves to a simple answer I had ended up tied in knots, never able to reach a satisfactory conclusion. By the end of that week a sense of peace had come over me.

I think much of the turmoil comes from the fact that the service we provide in these hospitals is not fully supported the facilities available. The MCH clinic worked well and was satisfying because our means matched our aims, whereas in the hospital we aimed to treat diseases using a healthcare model that broadly corresponds to the Western model but without resources of a Western hospital. So, for instance, I found myself in a real hole with one patient that we had diagnosed with tuberculosis of the spine and lymph nodes, a diagnosis made on examination of the patient rather than on any lab test. She started to get terrible pain in her liver when taking the medication and seemed to be deteriorating. The medication can cause liver dysfunction but it can also cause liver pain without dysfunction. The former demands that you stop or change the medication, running the risk of letting the tuberculosis become resistant to the drugs. However, if the liver is not actually malfunctioning then you would try and keep the medication going and relieve the symptoms by other means.

On top of this there was the question of whether the pain was caused by the medication or by the disease infiltrating the liver – the liver was certainly enlarged. In a Western hospital you would be able to use various tests to answer all these questions and come to a satisfactory conclusion about the best way to proceed. Here, that is not possible leading to the agony of indecision. It would have been easier to accept from the outset that we could not treat this woman, and that our job would be more palliative care than cure. Does that mean that we should not have started the treatment? Just because it is emotionally easier for me not to treat does not make it the right thing to do. If we had ensured that we had appropriate monitoring techniques in place when setting up the TB treatment programme then this situation would be made much easier. (The problem is that if we had waited for appropriate monitoring before setting up a treatment programme then many more patients would have died of tuberculosis.)

It was a real gift to have some time and space to consider these things but before long the week had come to an end I was back in a PMV trundling across the magnificient Ramu plains. This time, knowing what to expect, there was a lot less frustration, especially as I had something to read. On my return to Lae, I had had the good fortune to meet a German expat who had discovered a second-hand clothes store that also sold books.** In a country seemingly bereft of bookshops, save for Christian book stores, this was a gem of a find indeed. She was kind enough to lend me a few novels from her collection and so I was able to pass the journey most pleasantly.

My last few days in Madang were spent with a Swiss family, Marc, Emmanuelle and their three young children. I had only met them once before*** when they had come to Karkar to say goodbye to Sophie. At that point they mentioned that they had a spare room if I ever wanted to stay. This generosity and instant rapport between expats is very much a feature of life here. Marc and Emmanuelle are both doctors by training but are working on a malaria research project with the PNG Institute of Medical Research, a reasonably well-funded and well-run organisation. It was interesting, though not surprising, to hear that many of the problems encountered in running the Lutheran hospitals were also mirrored in the running of their research projects. What was surprising was that I would act as a doctor one more time before I left PNG. The patient was Zoe, the eldest daughter of the family.

I awoke on my final day in Madang to find Marc and Emmanuelle in a state of high anxiety. Zoe had developed a fever the night before. It was a mild temperature but, as her parents had told me, she is inordinately sensitive to fevers and tends to feel very sick. Despite being given antibiotics for the infected insect bite on her arm, which was almost certainly the source of the fever, poor Zoe had spent a large part of the night vomiting and this was worrying Marc and Emmanuelle greatly. The family had planned a trip to Goroka, a town in the highlands, leaving that morning. Marc had an important meeting there and the rest of the family had been looking forward to spending some time in the mountains. However, now this was all thrown into doubt. Should they all go or should Marc go alone? He was frantic by now and didn’t want to leave Zoe’s side.

They tested Zoe for a malaria with a rapid test. This displays a positive result in a similar way to a pregnancy test, with a coloured bar appearing across the strip if it is positive. The test was clearly negative but by dint of holding it up to the light at a certain angle they could see a hint of a shadow of what might be a line. This was enough to start them down the road of considering malaria. Could the test be reflective a very low-level infection that it was only just sensitive enough to pick up? Should they take her to the hospital and get them to look at Zoe’s blood under a microscope? I listened to their plans with a sense of bemusement but did not feel it appropriate to intervene, apart from saying that the malaria test seemed negative to me. Eventually Marc turned to me and asked if I would mind having a look at Zoe to give them a second opinion.

Zoe was lying on a mattress on the floor of her parents’ room. I started examining her gently, explaining to her what each test was for, in an attempt to allay her nervousness. I gradually moved through the examination sequence until I came to checking the lymph glands under her armpits. As I was checking them I suddenly tickled her, resulting in a squeal of laughter, and click, there it was, the moment of connection between doctor and patient that makes all things possible. From that point on everything was easy. Zoe was fine, the vomiting had passed, and in the end all I did was act as her mouth-piece, articulating what she felt so that her parents could actually hear it and feel reassured.

I may not have made a clever diagnosis or instituted some complex treatment but treating Zoe (or Zoe’s parents, to be precise) was just as rewarding as treating any other patient that I have met here because there was that click. For me that is where the real joy comes and that human connection can happen anywhere in the world. To recognise that, if nothing else, has made this trip worthwhile.

*I was quite surprised by the name at first, as I imagined that the German Keller family would one day enact the strange scene of sitting around a table eating “Germany”. However, they informed me that when the time comes to eat him, they will swap him for a pig from one of the villages so that they don’t have to eat their pet.

**This seems to be quite a common combination. Sadly the second-hand clothes shop in Madang only sold second-hand magazines. Had I wanted to I could have bought a copy of Time magazine from 1997. Nothing is wasted in PNG.

***But I had actually seen them twice. The first time I had seen them was at the Madang festival. The sight of a family of white people was about as arresting as all the dancers in their traditional costumes and I very nearly went up to them to find out who they were and what they were doing in Madang.

Later than intended I have anonymised the blog, at least to some degree. Anyone in the least bit familiar with PNG or the Lutheran Health Services will have little trouble in identifying the hospitals. I briefly considered a more substantial edit to further disguise the hospital but concluded that this would be impossible without substantially altering what was written. After all, how many islands with a volcano have a hospital on them and are run by some church denomination? A determined investigator would easily work things out. In the end the purpose of anonymising the places and people is merely to avoid the blog coming up in a casual search for “Eichel” or “Silsil” as I feel that potential visitors should come to the place with their mind uncluttered by my own perceptions.