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Frontier work in the remote highlands of Papua New Guinea.

I EMBARKED ON ONE OF THE MOST AMAZING journeys of my life on December 23, 2013. Leaving Los Angeles airport at 11:30 p.m., crossing the international dateline and landing in Brisbane, Australia, 14 hours and a day later was a year without Christmas Eve.

Virgin Australia Airlines gate personnel were very gracious in not charging for the extra 265 pounds of excess baggage I was checking. It consisted of medical and surgical supplies that had been purchased or donated.

The only other family physician on this trip, Dr. Martin Davey from Adelaide, Australia, and I met at the airport in Brisbane and flew to Port Moresby, the capital of Papua New Guinea. We transferred to Air Niugini and flew to a small coastal town called Madang, on the north shore of the country, 5 degrees south of the equator.

The total travel time was about 27 hours, but, surprisingly, I did not feel tired, just exhilarated with the sense of upcoming adventure. After meeting the organizer of our trip, Vincent Kumura, MBA, and one of his relatives who would be our host and part-time driver, we began our first medical mission into rural life.

Our first visit was to a small island village of about 1,000 people, half of whom were under age 10. The island is typical of the isolated communities offshore of the mainland. We were taken on a tour of the village, met the elders of the community and had an opportunity to practice our medical skills.

Our group changed depending on who joined us as we traveled from village to village. The assistants who sometimes joined us could be local community health workers with minimal training or more experienced community health officers trained in first aid, diagnosis and treatment. We were also accompanied by five to 15 volunteer students who were on break from school or work. These men and women, mostly in their 20s, assisted with cooking, cleaning and carrying our supplies and packs.

In 2 1/2 weeks, we passed through many villages on our frontier hikes and conducted medical clinics in six Highlands villages. We also spent time at a provincial regional hospital, a sub-district health center, a supply dispensary and a local pharmacy.

Most villages are small, with fewer than 1,000 people and multiple generations of extended families living in them. The smallest villages we passed had a few hundred people, and one town had a population of 10,000. Melanesians identify more strongly with their clan links and their origins than the people they come to live with.

Interestingly, there are no skilled nursing facilities, convalescent hospitals or assisted-living facilities anywhere in the country. The sick are cared for by relatives, and if there are no relatives, then they return to the village of their birth where the locals care for them.

The names of the villages where we held clinics were exotic in themselves--Tarr, Snowpass, Bundi, Konoma and Kundigawa. At Snowpass, nearly 200 people showed up to be treated. We planned to stop at Pomie village on our way to Tarr but we ran out of medical supplies. We covered a relatively small portion of the country in Simbu and Madang provinces, partly by design and partly because of the lack of roads. The Highlands villages are generally situated between 6,000 and 10,000 feet, and many are accessible only by foot.


PATIENT CARE--We treated post-delivery complications (70 percent of women deliver in their village), ear and throat infections, tooth decay from betel nut staining and tooth loss. Many medical issues were from musculoskeletal injuries including back and knee pain. One farmer had sustained a ruptured Achilles tendon and foot drop.

We saw a 2 1/2 -year-old baby at Bundi sub-health center who did not talk, sit or communicate in any way. We were able to get a consult for her, and she was seen and admitted to Kundiawa General Hospital Pediatric ward.

The Sir Nombre Memorial Hospital in Kunigawa was the most sophisticated of the facilities we visited. The hospital was built in the 1960s by the Japanese to honor an ambassador from Japan who served in Papua New Guinea. The hospital has 200 beds and 18 staff physicians including one OB/GYN, one surgeon, one internist and two pediatricians. Villagers will walk for two to three days to be treated there. The hospital averages 70 deliveries a month, of which 12 are C-sections.

The hospital has no cardiac capabilities, no ortho surgeries and no psych services other than minimal counseling on a sporadic basis. Surgeries are performed Tuesday and Thursday with emergencies scheduled as needed. The emergency department averages 70 pediatric and 30 adult visits per day. The hospital provides rural outreach twice a week. There is no ambulance service.

Those requiring more specialized care are referred to Australia, the Philippines or Singapore as private-pay patients. The government does not offer assistance so almost no one can afford private pay.

The provincial hospital recently was awarded a five-star rating by the Papua New Guinea Department of Health's Standards Division. Metrics evaluated included patient care, management and administration and infection control. For this award, the hospital gained an additional governmental subsidy to underwrite patient care. For example, a baby delivery was $10, but with the subsidy it dropped to $5.

Pathology is very basic. The hospital is hoping for funds to expand. There is no microbiology or histopathology. Basic X-ray is available, and copies of films are sent to the capital by fax. Housing for staff physicians is an issue, and they are often housed in locals' homes. The hospital is hoping for funds to build additional staff housing.

The next lesser level of facility is the sub-health center, basically a rural clinic. We delivered our donated medicines and supplies to the sub-health center at Bundi. Bundi consists of a small surgical suite, a delivery room, and a supply and pharmacy area. The Bundi sub-health center serves a population of 10,000.

At the time we visited, the facility was unmanned because there was no electricity and no funds to buy a generator. It has been intermittently unmanned for the past seven years.

Last in order of sophistication was a community worker's dispensary at Konoma consisting of a few bottles of antibiotics, antimalarials, antifungals and very basic first aid equipment. The community worker recently came out of retirement at age 71 to continue running the dispensary, which he has been doing for 31 years.

DEMOGRAPHICS--The people of Papua New Guinea and the Solomon Islands are almost all Melanesian, but increasingly European and Chinese blood is in the mix, particularly in the towns.

There is a cynicism about politics, especially among people living in remote areas where roads and services are in serious decline and politicians are viewed as corrupt. Chinese, American and Australian money is flowing into the country from copper, silver, gold, cadmium, iron and liquid natural gas mining, but the flow seems to stop short of the villages. Considerable portions of the profits are also taken offshore. These industries employ large numbers of foreign nationals and relatively few locals.

The median age of the population is 19, and life expectancy is 64. Most of the rural people we visited are subsistence farmers and traders of betel nut, tropical fruits and a multitude of vegetables. Some produce cash crops such as coffee and bananas. Most have very few possessions and often no cash income. Fruits and vegetables are plentiful and are bought fresh every few days since most villagers do not have refrigerators or freezers. Processed food, candy and sweets are nonexistent.

Papua New Guinea is one of the earth's most diverse regions due to its topography. Isolated mountain ranges are home to fauna and flora seen nowhere else. The lowlands are jungles with terrain that is not that different from Southeast Asia. Yet the animals are often startlingly different--cassowaries instead of tapirs and marsupial cuscus instead of monkeys. Most of our time was spent between 6,000 and 10,000 feet, and it was often cold. Above 9,000 feet snow can fall and ice coats the puddles.

Other than a mediocre national highway there is no significant road network. Papua New Guinea's mountainous terrain and the many islands offshore mean that communities are isolated from each other and the internal transportation system is almost nonexistent. There is almost no manufacturing base so just about everything is imported from Australia and Asia, and everything is expensive.

The universal language is Tok Pisin. Most of the people I had contact with spoke English, and each village also has its own local language. Twelve percent of the world's languages are spoken here. Interestingly, even though Internet and WiFi are very limited, almost everyone we met had a cellphone and some had smart phones. Cellphone towers were abundant.

The people were amazing. I was most impressed with their warmth, general good humor, day-to-day optimism and genuine hospitality. The sense of familial and village ties was very evident, and the natural beauty of the country was breathtaking. We hiked along scenic ridges with amazing views, razor-sharp mountain tops, distant pristine valleys, waterfalls and untouched rainforests.

Papua New Guinea is called the "Land of the Unexpected," and it certainly was a series of amazing adventures.

* Marc Richmond, MD, MMM

Marc Richmond, MD, MMM, is regional medical director of health care services at Blue Shield of California in Costa Mesa, California.
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Title Annotation:Medical Missions
Author:Richmond, Marc
Publication:Physician Leadership Journal
Geographic Code:8PAPU
Date:Mar 1, 2015
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