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.


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"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.

 

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 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