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.