Afterglow

If I could have only one enduring memory of our time on Tanna, it would have to be the sunsets. They were spectacular, and we saw one almost every day. Some days were better than others of course. Many were seen from our backyard, gin and tonic in hand. Others were seen from mountain tops, from my paddleboard while gliding over the water,  or from the truck while driving over dusty back roads. Some we took in from the hospital porch while enjoying a storian with the staff, others from sedate kava bars, and even some from the ocean’s surface as we bobbed and swam in the sea. There is something about seeing the sunset every day that shapes your outlook on things. When you get in the habit, they become hard to go without. Sunsets makes you slow down, take time out, mark the winding down of the day, and often reminds you to appreciate the things that you should.

While the actual dipping of the sun below the horizon gets most of the attention, for me it's often the afterglow that really delivers. Especially with just the right amount of cloud in the sky to reflect all the soft reds and yellows, and the sublime blues filling in the rest, conjured up by the sunlight as it refracts around the curvature of the earth. Look away from it for a minute and you can have a whole new palette by the time you turn back again.

Many people get introspective and talkative while watching sunsets I find, but in my view they are best appreciated without too much thinking or chatting. It's a good time to let your mind be still and just attend to what you are seeing. As our time wound down here though, not thinking at these moments got harder to do. It seemed there was so much to think about, so much to digest. So many things seen, people met, moments shared. The overwhelming majority of these were great, and even the lows were the kind that we knew were part and parcel of what we had signed up for, and so were forgiven.  This experience had demanded a lot, and in many ways I had come to view it as a pinnacle for me on many fronts, at least for now. It had been a long time coming. The seeds had been germinating since medical school but the track of regular life often does not encourage one to roam outside the lines. The year 1995 seems a long time ago now. Still, it’s better late than never.

 Nineteen ninety-five was the year I graduated from medical school. In that year the movie “Pulp Fiction” had burst onto the scene. I, like many of my cohorts, were completely enamoured with its mix of noir cool, arresting violence and above all, spellbinding dialogue. Friends could recite long passages of quotes verbatim. Its soundtrack filled our gatherings.

At one point in the film, Jules, a career gangster played by Samuel L. Jackson, narrowly escapes being shot and becomes convinced that God had intervened so that he could now give up his life of crime for a new purpose. When his partner, John Travolta asks him,” So what are you gonna do now?” Jules replies,” I don’t know. I think maybe I’ll just walk the earth, like Kane in Kung Fu. Get in adventures and shit”. In the weeks before I graduated I gave that answer to a lot of people when asked about my future plans. Then, it was just something cool to say from a movie I loved. I’ve wound up travelling a fair bit in the years since then. I had also done some work similar to Vanuatu before going on this trip, but nothing even close to it in terms of scope.  In those last days of my time on Tanna, my thoughts kept drifting back to those waning days of medical school. Walk the earth. Get in adventures and shit. Indeed. 

As it all drew to a close, everything started to seem just that little more intense. Maybe it was just us, trying to hold on to every memory we could. Things that were routine in month three became things to cherish when the countdown began. We tried hard to savour things to the fullest. I became driven to somehow touch and feel as much of the land itself as possible. When swimming I would stand in the shallows and face the swell, hands open in front of me to feel the push of the ocean and the swirl of the crystal clean water flowing around my fingers. When out walking I'd let them hang by my side to feel the foliage brushing up against them. When driving I'd put my hand out the window to feel the force of the wind push it up and down.  And so it went; the heat of the black beach sand between my toes, warmed from a day in the sun, the sharpness of the volcanic rock, the grit of the ubiquitous volcanic ash, even the lushness of the soil itself, all the while resigned to the fact that I couldn't hold on to any of it, any more than you can hold on to that view of the sun in those moments before it disappears below the horizon. It will end, and then it will be over. You'll be left only with the memory of it, and if you are lucky you will have a long glorious afterglow to bask in.  As with any afterglow, perhaps it's best not to think about it too much, just let it linger, for as long as you are lucky enough to have it last.

                                                .        .        .        .        .        .        .        .
 

Gratitudes

We have so many people to thank that I can’t name them all. The VIVA organization has for 25 years supplied a Victoria physician to the island of Tanna. Our colleagues who comprise this group were essential to this endeavour. It is bittersweet that VIVA recently announced the project is nearing its end. Its work is nearing completion now that a Ni-Van husband and wife physician team has been stationed on the island. Dr. Jeff Unger is currently the Canadian Dokta on Tanna and he will be the last. We overlapped with Dr. Jeff and his family for a week before departing, in order to orient them to their new home. In that time we discovered that our families had a mutual love of the movie, “The Princess Bride". We joked about how the position of Dokta on Tanna was akin to a mantle to be handed over, like The Dread Pirate Roberts in the movie. When we said goodbye to Jeff at the airport I flashed back to a closing line in the film, from The Man in Black to the swordsman Inigo Montoya. "Have you ever considered piracy? You'd make a wonderful Dread Pirate Roberts".  I have no doubt that he will.

The staff at Lenakel hospital and so many of the people of Tanna made us feel welcome beyond our expectations. The experience wouldn't have been the same without it. There are so many we will miss. 

We have many extended family and friends who helped us prepare, looked after our home while we were gone and kept in touch by email. Some even visited us in our far off land. Thank you.

I also want to extend a special thanks to those who supported and encouraged me in the writing of this blog. I had never really intended to do anything of the sort. I remember starting to write the very first post and getting half way through a typical email-like recounting of what we had been doing, when I suddenly thought, “Why don't I try to make this just a little more interesting somehow? For once I've got some time on my hands." I just started writing; not knowing what might come out. I don't think I had written creatively since English 101 in 1985. Now, thanks to your encouragement, we have an invaluable addition to our family's memories of Vanuatu.

Finally, I need to thank my family- Anna, who blossomed in so many ways and Sasha who was a force of nature unto herself. All of the things that we hoped would happen for them did in fact happen. They coped with a lot, and they have so much to be proud of. This of course leaves only my amazing wife Andrea, without whom none of this would have even been possible. For her, I can find no words to write that could say enough.

Sean

Story On

Something was wrong. The place was deserted. It was supposed to be full of people, sick people who had been waiting for the dokta to come on one of his regular visits to their little corner of the island. Andrea and I had arrived at this rural health outpost, but nobody else had. Normally we drive up to a long line of smiling and waving patients but today the line was conspicuously absent. Even at the best of times the number of patients outside the clinic is only a fraction of what we wind up seeing when it’s all said and done. Once word gets out that we’re visiting, others start to trickle in leading to seemingly never ending requests for, “Just one more patient dokta.”  This however was unprecedented. A couple of days prior to the visit we had tried to contact the nurse aid who mans this post to let him know that we were coming on the scheduled day, but we had never heard back from him. This is not unusual though because many here often can’t afford the cost of making calls, even though they may own a cellular phone.

 

We waited around for a little while and the nurse aid did eventually show up. He hadn’t gotten our message and consequently had not arranged for any patients to come to the outpost. We visit a different rural outpost every Thursday and these outings are one of the really fun parts of our job here. Sadly problems like this came up all too often, negating all the work we put into prepping our medical supplies and everything else we need, not to mention the time it takes to drive there, often over some of the worst roads I have ever seen anywhere in my travels. When someone on Tanna tells you that there is in fact a road to where ever it is you want to go, take it with a grain of salt. It often just means that somebody, at some time in the near or distant past managed to get a truck in there and that’s all. I have however, grown to love the fact that the #3 item on my list to of supplies for these medical visits, behind only my stethoscope and my medicine bag, is my machete.

 

On his way here the nurse aid had managed to scrounge up a few patients that needed assessing so we set to work. It was nothing too demanding so it wasn’t long before we were finished. He then told us of an older fellow in one of the nearby villages that he had heard about. Apparently he might have broken his hip, or as one says in Bislama, his hip was buggarup.

You have got to love this language. It’s only a little over 2000 words altogether and is sometimes derided for its lack of complexity, but there is no doubt that sometimes simpler is clearer and often it cuts to the point in a way that English doesn’t. For example, the word storian (story on) is used to describe a kind of discussion between people. It refers to one that’s more than a casual chat, one that likely involved the exchange of stories in a light, unhurried way and implies that you connected somehow with the other person over them. Another great example, and one of my absolute favourite terms in the language is the word wantok. It’s an amalgamation of the phrase one talk meaning one language. Its breadth is larger than that though, referring to someone with whom you share not only a common dialect, but also a common sensibility and friendship as well. Often a wantok comes from the same geographic area as you, but not necessarily so. There are about 30 different local dialects on Tanna alone, and many more in the other islands of the country. The triumph of Bislama is that it provides a common language to allow people from different areas to communicate with each other much like the language of Swahili in Africa.

 

So this patient’s hip was apparently buggarup and sore bigwan (big one) so the nurse aid wondered if we could we possibly go and make a house call. He said the village was close up (nearby) which instantly made me suspicious. Close up can be an extremely fluid term.  Adding to my hesitancy was our plan to go to the nearby surf beach after the day’s clinic. My board sat strapped to the top of the truck and beckoned to me insidiously. In the end, my sense of obligation won out and I agreed to go see the patient, though I still wasn’t convinced it was as nearby as I was told, or that the road was a passable as he described. 

 

As it turned out the road was not too bad. It led downhill for a few kilometers and eventually into one of the largest and prettiest villages that I have seen here. Huts were scattered up and down either side of the valley but due to the thick cover of the jungle you would never be able to tell that unless you were standing among them. We stopped, got out, and made the short walk to the man’s hut. His little homestead was typical looking; a thatched roof hut, a pen for pigs, a small banyan tree to sit under nearby, and the surrounding earth flattened smooth and hard by the thousands of footsteps it had seen. The hut had no door. Once inside it took a few moments for our eyes to adjust to the darkness. Though it was the middle of the day, his hut, as is the case with most of them, lacked any windows and was quite dark. He lay on a hard wooden raised platform, softened by a few thin blankets and pillows. He grinned widely as his son introduced us and then he excitedly extended his hand for a welcoming handshake. He was nearly bald. What teeth he had left were severely stained from years of kava drinking. He wore layer upon layer of old tattered clothes, and had the moderately unpleasant odour of someone who hadn’t bathed in some time. He was also however, completely and utterly delightful. He happily told Andrea and I about his fall a couple of weeks earlier, about how he could not walk for quite a while afterward but that he had just recently started to take a few cautious steps with help. I wanted to examine him but he didn’t want to be moved at all so we didn’t get very far with that. By the end I was pretty sure that he had indeed broken his hip and urged him to come to hospital, which he cheerfully declined to do, though he was very grateful for the pain medication I left with him. Afterward I talked with his son who agreed to do his best to change his father’s mind. My hopes were not high though. We left his hut and strolled back to the truck.

 

We had been told that there was a beach just a little further down the road and we thought we might have lunch there. After a few minutes of driving we arrived at what I now consider the most beautiful beach that I saw in my whole six months in Vanuatu. An expanse of fine black sand lined the edge of a beautiful serene bay with a gentle point break to one side. The water was as clear and inviting as could be. It was lovely and we lunched from the tailgate of the truck before departing for a different beach that we had targeted for the day. As we pulled away I eyed the point break and knew I would be back, hopefully with the paddleboard.

 

As it turned out it would be a few weeks before I had another chance to return. Our time in Vanuatu was winding down and there was much to do to prepare for handing over to the new doctor arriving from Canada, but on the next available weekend off call we packed up the truck with provisions, and the paddleboard and set off. On the way down that same narrow road I recalled the old fellow with the broken hip. He never did turn up at the hospital and so I thought I might pay him another visit to see how he was doing. We stopped at the same place in the village. People were burning piles of brush and swirls of grey smoke filled the air, making tangible the sunlight piercing through the dense canopy of the jungle. Andrea was entranced by the effects of the light and the smoke and she remained behind with the kids to capture some photographs while I made my way through the village to the old man’s house again. None of his sons were around this time but one of his granddaughters greeted me and invited me inside the hut. The old man sat reclined in the same position, in the same dark corner and I think wearing the same clothes. He greeted me excitedly and shook my hand for a considerable length of time before he finally let go. He was so surprised and delighted that I had remembered him and come to check on him. It was in stark contrast to another house call I had done the previous week at another village. The fellow there was so afraid of me that he pretended to be unconscious the whole time, only breaking into laughter at the end when it was clear I was about to leave without hurting him.

 

The old man sat up and was eager to share how his hip had improved. “Pain go down. Hip ia sore smol still. Me walkabout smol” he said, laughing as he stamped his good foot down on the hard compacted ground, making it resonate like a drum. I was able to converse easily in Bislama with him and we talked enough for me to know that he would not be coming to hospital, despite his polite assurances that he would if warranted. I knew his broken hip would eventually heal in some fashion, albeit with reduced function most likely, but he would probably still be able to get around somewhat and like so many Ni-Vans do with so many other problems, he would just live with it, almost certainly still finding as much joy in each day as anyone I have ever met.

 

Before coming to Vanuatu I got this notion in my head about a benchmark for knowing when I had gone deep enough into the whole experience. We had seen many pictures of the people, the poorer, dirtier conditions that many endured, and it all seemed so different. They seemed so different. I thought I would know that I had reached that mark when I could sit with someone like this elderly fellow, talk to him in his language, and as I listened to his problems, think of him not as someone different from me, apart from me, but as a brother. My visit with him that day was a delight, but it was not so unusual. My time here has been rich with many wonderful patients. I can’t tell you why. Maybe it was just a function of the amount of time I’d finally accumulated here, or maybe it was the setting, but as I sat inside that dark hut, the smell of smoke from the village mingling with that of the old man, enjoying his marvellously stained smile and radiant happiness, I knew that I had reached that moment. It only took 5 ¾ of the six months I had, but beyond a doubt, I felt it, as sure as I felt the tendrils of smoke in my lungs. This man was a brother. We were wantoks. I stayed a while longer to storian.




Sean

Proof That Your Frame of Reference Has Shifted #5

When doing an invasive medical procedure, normally performed under strict aseptic conditions, you no longer feel deflated by the flies landing in the middle of your sterile field.

Proof That Your Frame of Reference Has Shifted #4

You think nothing of giving rides to large groups of hitchhikers consisting entirely of strong young black men weilding machetes.

Proof That Your Frame of Reference Has Shifted #3

Whenever you drive past a Caucasian you don't recognize walking along the side of the road you immediately feel compelled to pull over to ask if they need help.

Something More

The name on the front of the chart was Tom. In truth, I cannot remember his last name. Tom’s age wasn’t exactly known. He was probably in his mid-forties with a receding hairline to his afro. The chart also listed the home village. The name was long, and I didn’t recognize it, but then I don’t know most of them so I skimmed over it. I did know that Tom came from the area known as, “Middle bush”, which is pretty much any area not on the coast of the island. He seemed to have a wife and children though I didn’t really check. I don’t know what he did for work, or if in fact he did do anything other than tend his vegetable garden, and care for any pigs he might have owned, sustaining a hand to mouth existence. He wasn’t from a kastom traditional village or anything like that so he dressed like a pretty average guy on Tanna, wearing T-shirts and long shorts that were perpetually grubby from the dust and volcanic ash. While he may not have dressed differently, he did look different. It wasn’t obvious at first glance but as you got closer to him you would have first noticed that he was underweight. Then, as you got close enough to talk, you would notice that something wasn’t right with his face. You’d probably notice the eye first. His left eye was turned in, like it was perpetually trying to look at the bridge of his nose. Then you probably would have slowly realized that something wasn’t right with the left side of his face. The jaw was roughly the right shape but there was a lack of symmetry compared with the other side. The left was bigger, much bigger, and when you heard the difficulty he had speaking you would know that something bad was growing there. 

I think that in our core, primitive reptile brain we have a reflex that’s hard-wired in. It’s a reaction to the recognition of some signs of disease when you see it, a recoiling from it, and I think evolution made it flourish because it pulled us away from anything that might be contagious. You feel it when you see certain signs of illness, even when you may know intellectually that there is no risk of transmission. For physicians, this reaction gets hammered down over time like a nerve that’s goes dead. I don’t know what it’s like for other doctors, but every now and then I can sometimes still get an initial flicker of it, if only for an instant.  Psychologists have established a strong link between how symmetrical a person’s face is and how attractive they are perceived to be. Conversely, over the years I’ve noticed how a marked lack of symmetry in the face, from disease or trauma, reliably provokes this reflex in most people, sometimes even myself. 

 

I felt that flicker the first time I saw Tom on the ward. I don’t think he noticed, and I’m sure he had seen much worse. He had come to hospital because it had become too painful to eat. Tom had a cancer on the left of his face. It had wasted his body, disfigured his face, destroyed the nerve that pulled his left eye to the side leaving nothing to oppose the one pulling it to the center, and now the cancer had become infected. As awful as this sounds, it’s far from unusual here on Tanna. We’d been getting a couple of cases similar to Tom’s every month, many of them even much worse. Tom actually looked fairly normal until you got up close.  

 

At our hospital nurses do most of the admissions and the physicians will review the patient on the ward later. The first paragraph from the nurse pretty much told the whole story. Tom had a growth that had slowly progressed over almost 2 years before he finally went to Vanuatu’s capital on another island to seek medical attention. He obviously had had some surgery because he had a scar at the site, but he couldn’t tell us much more about anything else that happened there. The only other thing he remembered was being told was that there was nothing more the doctors could do. Trying to get any records from the capital is futile so we don’t bother any more. 

 

We were very busy that day and I pretty much just skimmed over the rest of the meager admitting documentation such as his social history or family history. His situation was obvious and so were our treatment options, both poor, so best to get on with doing what we can. We don’t have much to offer terminally ill patients here. At home, this area of medicine is a discipline unto itself, but in Vanuatu our offerings are pretty basic, mainly trying to fix any complications of the illness that we can, such as secondary infections. There’s nothing like prescribing Tylenol to fight cancer pain to make you feel inadequate in your treatment plan.

 

Tom was with us for about a week or so. His infection settled and he could eat small amounts of soft food. He said his pain became controlled but no matter if he said it was good or bad, I never saw any difference in his demeanor from day to day – stoic, but not in any angry, defiant way. I’d probably describe it as…….calm.

 

Each day I saw him we talked for a just a couple of minutes about how he was doing. These interactions were genuine but brief and relatively unremarkable. This whole month has been very busy at the hospital so between the time pressures and the language gap, I wouldn’t say I rushed, but I didn’t linger. I can at least say that I did show him what I figure is always the very minimum I can do - ask him, with my full attention, “How are you?”, and mean it.

 

I was able to do some investigations for Tom. A chest X-ray showed metastatic cancer lesions in his lungs. The ultrasound I did showed the same in his liver, big ones. Tom was going to die. It would probably be gradual, but it wouldn’t take too long now, especially once he could no longer eat. Tom would do what all the terminally ill patients here do, go home to their hut and be cared for by their family until the end.

 

The morning I discharged Tom was in the middle of a very unusual 36 hour stretch for me at the hospital. There were quite a few serious things to deal with, a couple of them just a bit too extreme to write about here. Suffice it to say I was in a bit of an altered state by the end of it, the kind where you know your brain needs a little time and distance before it can process what just happened. On top of this was the impending visit to the hospital that day from Vanuatu’s new Prime Minister. He was just elected a few months ago and is the first leader the country has had who originates from our island of Tanna. This is quite a big deal for people here as Tanna has a bit of a reputation for being a backwater of Vanuatu, and for being full of what they call Man Tanna, the Vanuatu equivalent of redneck.

 

The hospital was buzzing with excitement and activity. All the hospital staff were there, dressed up in their best clothes. Flowers were hung from the ceilings and from trees around the grounds. Even the road leading up to the hospital had been lined with flower petals on both sides. It was quite pretty. I took special note of a few balloons hanging over the front entrance. Consumer goods are pretty limited here and I had never seen a balloon on Tanna before.

 

The visit was fairly brief and perfunctory. More of a quick tour and a photo shoot than anything. The Prime Minister seemed nice and I had a chance to meet him and his cabinet. I wanted terribly to ask him if he could get the health ministry to finally pay me at least some of my outstanding salary, but figured I’d better hold back. Still, it was hard not get a little caught up in all the excitement.

 

The visit wound down after about half an hour. We went out back behind the hospital to take a few group photos and then the Prime Minister left with his entourage. Everyone was milling about, excitedly comparing and exchanging the pictures they had taken. I was in the midst of figuring out how to send a photo via Bluetooth when I happened to look up. A lone figure walking quietly down the petal lined path away from the hospital caught my eye. It might have been how calm he was amidst all the commotion, cutting through it like a stone protruding from a river of running water, or maybe it was the four brightly coloured balloons in his right hand.  His back was to me and in front of him stretched the falling coastline leading downhill to the beach and then the vast ocean and horizon beyond. I knew it was Tom, and I knew that I was watching him walking home to die.

 

My first thought was, “What could possibly make a man in that situation take the time to acquire those balloons?” My second, of how surreal this scene was - him walking away amidst all that excitement, through the crowd and the decorations and the picturesque backdrop to it all. My third was that I wanted to capture the image. I took out my camera but then stopped. It didn’t seem right to take the picture without asking so I called out his name. He stopped and smiled and came toward me. I asked if he was going home and he said he was. I told him simply that I wanted to take his picture. What he did next struck me at the time, but in the moment I didn’t know what to make of it. He tidied his shirt, made his back ramrod straight and lifted his head high and proud. It surprised me. I wouldn’t have expected a man under those circumstances to do that. I took the photo.

 

As I went to say thank you and goodbye I felt regret. I knew that there had been nothing wrong with my medical care for Tom. It had been…...” fine”. No one would have said I should have done anything different, but the unavoidable fact was that I knew I could have given more, and now I wished that I had. More what? I don’t know. Compassion? Time? I really wasn’t sure, just something…….. more. I tried to let him know by the way I shook his hand, putting my other on his shoulder and saying as kindly as I could, “Good luck. You can come back if you need to.” By his response, I’m pretty sure he understood what I was really trying to say. We turned and parted ways, each of us going off in our own different directions.

 

To be honest, ordinarily I would never write something like this for so public a forum. It’s just a little more personal than is entirely comfortable for me, and I always worry about the perception that I’m trying to glamourize things. However, as I sat here tonight, having had some time and distance to let the day’s events marinate, I think I came to understand what happened when Tom got ready for that photo. I think he was trying to say, “I’m still here. I don’t have to hide. I’m still human enough to care about presenting myself the best that I can.” I also think that he truly wanted me to take that picture, thinking that maybe, if he made it good enough, I might show it to others, and the more people that saw it, the more powerful his statement would become. I’m still here. I don’t have to hide. I’m still human. When I realized this, I knew I still had a last chance to do something more for him, and the idea wouldn’t let me go until it was done. It would start with this:

 

The name on the front of the chart was Tom……..

 
 

 

                                    .        .         .        .        .        .




Originally this essay ended with that photo I took of Tom; standing tall, balloons in hand. Showing it seemed like the whole point of the exercise. Ultimately though I felt that patient confidentiality prohibited me from publishing it, even if that patient lives in the middle bush of Tanna island and even if I know in my gut that he would have wanted it there. I removed the picture, though I desperately wanted to show it, and to as many people as possible. Hopefully after reading this you will also wish that it could have remained. While it's not the ending I envisioned, perhaps it's fitting that all of us are left wanting just a little something more.




Sean

 

Proof That Your Frame of Reference Has Shifted #2

Vanuatu woven basket, worn slung around the chest by males and females for carrying small items ............... 500 vatu ($5)

Sarong......................................800 vatu

 

Sunscreen that would otherwise have been wasted, absorbed by the leg hair you used to have, but now trim down...............10,000 vatu

Not caring that since you’ve come to Vanuatu you at times trim your leg hair, wear a skirt and carry a purse.............................PRICELESS !

 

 

Sean

A Queen Sacrifice

The queen is the most powerful piece in a chess player’s arsenal. The queen is unique in that it can move in any direction. It offers a great deal of protection and security and generally makes solving your opponent more straightforward. Players covet the piece and try to avoid losing it at all cost. Having ones queen taken by an opponent usually puts them in both a tactical and perhaps more importantly, psychological disadvantage.

A queen sacrifice is the term for a play in which the player purposely gives up his queen, expecting to win in return either multiple pieces from his opponent or a winning position. There is however, one celebrated instance in chess history where a chess master intentionally sacrificed his queen for neither of the usual rewards. He had always been renowned for his great creativity and resourcefulness, but on that day, playing one of the most important matches of his life, he could summon little of either. Then, for reasons no one at the time could fathom, he sacrificed his queen. He had realized what his game was lacking, and knew there was only one way to get it. It wasn't to be found in security. He had to be backed into a corner, he had to be pressured, pressured to create a solution when the most conventional means to do so were no longer an option and it worked. He won.


                                            .     .     .     .     .     .     .     .     .


"What kind of stuff do you see?”. Prior to our departure from Victoria, it was a question that I asked many of my physician colleagues in the ViVa organization, all of whom had worked in Vanuatu before. Common responses included pneumonia, abscesses, tuberculosis, malnutrition, dysentery, burns and meningitis, not to mention all the obstetrical problems that arise. After listing most of the usual suspects they would usually pause and then try to somehow come up with a name for the other stuff. They were thinking of all the things you would never see in the west, wildly advanced cases of cancer or other diseases, weird manifestations of known illnesses, and stuff you just plain couldn't make up.  You couldn’t because even though as a physician you might know the physiology of the problem, you could never have foreseen the effect that the swirl of forces on this island would bring.

 

Our hospital is about 100 m from our house, both of which sit on the top of a hill. On the way there’s a beautiful view of a lush valley nearby. “Time to put on the old suit and tie”, I often mumble as I don my Hawaiian shirt, surf shorts and flip flops to make the trek to work. The hospital itself is a square, one level complex with a central courtyard. It is undeniably a bit run down, and generally speaking, very far from the brightness and cleanliness we are used to in the first world.  This can be a little arresting when you first get here but fades with time as it quickly becomes apparent that you are not in Kansas anymore.   I think that many westerners that come to Vanuatu and similar places often carry a bit of white man’s guilt when they see the discrepancy between these living conditions and their own. Eventually you just get over it. It’s not your fault. You don’t have to be conciliatory or try to act like a Ni-Vanuatu. Respect their culture and their country but be yourself.

 

Usually there are lots of locals milling about the courtyard. They are mostly the family and friends of patients. Almost nobody arrives for treatment at Lenakel hospital without a large entourage. There are no designated visiting hours, partly because we rely on the families to do a lot of the care for their sick relative, and I think partly because no one would accept anything that restricted family contact any way. Sometimes it’s been the middle of the night when I’ve been called in, and when I arrive the whole hospital and courtyard were abuzz, filled with people, cell phone lights waving. It’s like I walked in on a rave. Then, the whole place turns to look at me and it’s time to be the dokta.

 

There are about forty beds in the hospital divided among 2 adult wards, a children’s ward and a well-used maternity ward. There are about 4-6 deliveries per day on average here, the vast majority done by our extremely capable and experienced midwives. We even have a small operating room and a labour and delivery room.

 

By now I know all the nurses so when I arrive on the ward to do rounds there’s always some good chit chat that happens first. In fact not much gets done around here without a chit chat and a laugh to go along with it. It would just seem rude to do otherwise.  People on Tanna take a lot of pride in this attitude and I think for them it comes down to this: given the choice, why would you do it any other way?

 

 

The Life Wisdom Of Gene Hackman

 So what’s it like practicing medicine here? Well at first there is a hell of a lot to get used to. There’s a lot of stuff we never see in Canada, the resources are a lot less, and the culture can throw a lot of wacky roadblocks in your way. Then, I had my Gene Hackman moment. The film Hoosiers tells the true story of a small town Indiana high school basketball team that comes out of nowhere to win the national championship. It’s a story we’ve all seen a hundred times but something about this film worked. There’s a great scene where the team arrives early at the stadium for the first time in the tournament. The stadium is huge, the stands are enormous, the roof is cavernous, and everything is so different from their tiny gym at home. The players are feeling completely out of sorts. Hackman, their coach, orders one of his players to use a tape measure to take the height of the basket, then the measurements of the foul line and the key. Not surprisingly, they are exactly the same as at home. The message was clear. The surroundings might be different, but the game’s the same. Similarly, the bodies of my patients here in Vanuatu worked just like the ones at home. Their lungs were in the same place. Their hearts worked the same. I could examine them exactly as I always had. They got the same kinds of aches and pains, colds and flus. They responded just as well to a kind word or a joke to make them laugh. They had all the fears, anxieties and personal strife as people do at home. It might sound silly, but after spending over a year preparing for how different Vanuatu was going to be, this realization actually surprised me for a second. The game was the same. It was just everything around it that was different. And boy can it be ever be different.

 

How do you convince someone to take precautions against giving their infection to others when they don’t believe in germ theory? How do you convince a parent to leave their child in hospital to treat their meningitis when they believe it’s caused by spirits. How do you go about persuading someone that the brutally aggressive kastom (traditional) massage they got didn’t help them, and in fact was responsible for the ruptured bowel that almost killed them? Similarly, the traditional practice of kastom cuts to the skin around a problem area do not let anything bad get out, but when covered by a dirty medicinal leaf, are a great way to get an infection.

 

How do you get a husband to stop hitting his wife and children when many males have traditionally seen this as part of their role as a husband and father? How can I assess a potential psychiatric patient that tells me they are a victim of spirits and curses, and that they feel insects crawling all over them when in fact many of the island’s populace believe in similar supernatural phenomenon and I pick ants off myself most of the time when I’m in our kitchen. The list goes on. I don’t mean to sound dismissive of these things. They are simply some of the realities here. In fact, frequently brushing up against beliefs in magic and spirits has given me a new insight into what life is like when it’s so influenced by such things. It’s really not as big a mental leap as you might think, and there certainly are some great things about it. It can be pretty comforting to believe that the spirits of your ancestors roam the bush outside of your village and can be called on for help. The world literally becomes a magical place.

 

Often it is the simple, mundane things about the job that can be the most confounding. For example, nurses at the hospital, many of whom are quite capable and do very good work, might not call you though when a patient is critically ill because they must use their own cell phone to do so, and no one wants to use up their credits. In general, nursing competence here can vary widely. Some are great and some can be exasperating and bewildering in what they do.

 

Most people don’t seem to know their age, or really care for that matter. This somewhat indifferent attitude towards the passage of time can also make it vexingly difficult take a history from a patient, or determine when a problem actually began. Bislama, the main language here, is a kind of pidgin English that initially developed to allow communication with the English colonials. It doesn’t have an extensive vocabulary, just over 2000 words. While this makes it easier to learn, it doesn’t allow for a lot of subtlety when describing something. Consequently, a patient will generally describe a pain or a problem as either, ”bigwan (literally big one)”, or ,”smol (small)” and nothing in between. You just have to roll with it, and above all, phrase every question for a yes or no response.

 

The keeping of records in the country, medical or otherwise, is generally quite poor, if they exist at all. A person could have their name spelled differently at different times. Sometimes the father’s first name is used as the patient’s last name and sometimes not. This can make tracking charts and records a nightmare.

 

Patient privacy is practically nonexistent. You might try to close the drapes around a patient’s bed to shut out the twenty other people and family members in the room only to realize that a dozen others are peering in through the windows, which of course, have no blinds.

 

People here have a very different attitude towards illness and death. I guess when you see it up close a lot you accept it more as a normal part of life.  They are however; by and large tremendously appreciative of whatever we do for them, even if sometimes it’s really very little. A walk through the town usually draws at least a couple of shouts of, “Hello Dokta!” followed by warm handshakes from folks, often ones I haven’t even met before.

 

 

Beds of Nails

What do we have to work with to treat these patients? Obviously, a heck of a lot less than we do at home. There is vastly less equipment, available tests, medicines and just fewer options in general. There’s no physiotherapy, no rehab, no social work, no mental health medicines or programs. There is even less at the remote medical outposts that we pack up and drive to on a weekly basis. In a way though, it’s cool to have to rely so much on your clinical examination skills and judgement. The common algorithm is that you formulate a list of potential diagnoses, and then you cross off all the things you can’t test for, and then cross off all the things you can’t treat for and see what’s left over. If there’s more than one, then treat for all of them and hope for the best. Here, expectations of what can be done are very realistic. No one expects you to know everything and be right all the time. Generally, even if you don’t get it right people are better off than if you weren’t here at all. The surprising thing was how liberating this situation can be. It was like taking off that wetsuit that is a touch too small and then realizing you weren’t breathing in fully all day, or that little hitch you never knew had crept into your baseball swing, only feeling its absence when you were no longer afraid of striking out.

 

Often something like abdominal pain, or shortness of breath, symptoms that make a doctor consider numerous possibilities at home, get treated repeatedly as one of a short list of things that we can actually do something about. It always reminds me of an old saying: when all you have is a hammer everything starts looking like a nail. Some days I feel like that’s all I have on the wards, beds and beds of nails.

 

                                          .        .        .        .        .        .        .

 

 The ViVa project has been going on for over 20 years, supplying the sole physician for Tanna island. When Andrea and I signed on we were expecting the same scenario but two months before our arrival, a husband and wife physician couple were suddenly posted here by the Ministry of Health. He is an ophthalmologist (eye doctor) and she an obstetrician. He was actually born on Tanna and they plan to live and work here permanently. This has significantly changed the experience for us. We had been expecting to have to handle surgical and obstetrical cases to some degree but now they would deal with the bulk of these patients. It’s nice, and they are great to work with, but a small part of me regrets not being as self- reliant as we had envisioned. Of course that’s only in the quiet times. When the shit is hitting the fan then I’m thanking my lucky stars I’ve got a surgeon nearby, even if he has done only eyes for the last eight years. Still, they do leave the island for days or weeks at a time and Andrea and I are left on our own. She handles most of the obstetrical calls and she’s good at it. It’s been great seeing her reclaim these skills. I’ll then handle most of the procedural and trauma related things. I’ll admit I do love getting a chance to say, “Prep the O.R. I’ll take him to the theatre.”

 

Honestly, I can’t say I like that kind of pressure, but ultimately it is one of the main reasons that I came here. I knew what that pressure would do. It would demand some things that I haven’t had to produce working at home. There’s so much support there that it’s hard for that to happen. It always makes me think of that famous chess match. I would have to give up that support, give up my best tools, just as he sacrificed his queen, in order to see if those things really are there to be given. I’d like to think they are, even if ultimately I don’t want to have to use them every day of the week.

 

With two months left to go here it’s still too early to claim success yet, but the endgame is looking good. My pieces are well positioned, the chess board is a lot clearer, and when the game is over I hope to be looking back without regret, at my queen sacrifice.

 

 

Sean