It was early morning when we arrived at Siroga clinic. For some, we were greeted by familiar sights, vividly evoking experiences of last September’s visit. For the newer team members, the sky blue wood panels of the clinic’s exterior, the front veranda – now empty, but soon to be crowded with patients, and surrounding forest-green stilt houses were seen for the first time.

As the major health post under Liz’s care, Siroga was one of the better-equipped clinics, consisting of various consulting rooms, in-patient areas, a lab, and well-stocked pharmacy. There was even air-conditioning in some of the rooms! We split up throughout the clinic, and the building was quickly filled with the constant flow of people moving in and out of rooms, passing messages and arranging various aspects of care for each patient. Patients waited on benches and corners all around the building, fighting heat and flies outside on the veranda, or in crowded corridors indoors.

As resident young-pleb-person, I floated back and forth, lending a hand where needed and becoming well-acquainted with the general activities of the clinic. Hours passed by drawing vaccine vials, listening to doctor consultations, seeing the drug dispensary, taking photos, helping out with visual acuity measurements.

Darlene (left) and Fiona (right) in the drug dispensary

The way that sickness touches not only individuals, but families is incredibly striking. And it is often in these settings that the doctor’s greatest asset is not their technical expertise, but their empathy and ability to reach out with words of reassurance. I watched my mum consult with a man whose wife had died from complications of hepatitis B, who continues to look after a family of many children and worries about their future, whether they too have hepatitis B. Immediately he was given a kind listening ear, reassurance that his wife’s passing was of no fault of his own, and arrangement for him and his family to be tested that day for hepatitis B.

Another of the patients I met at Siroga who made a vivid impression on me was a softly-spoken lady in a yellow dress. She had nodules/bumps on her face, and the fingers on her left hand were locked into a bent, rigid position. She has a disease virtually forgotten to the developed world, one that has become something of “fiction” or past history, and remains classified as a “neglected tropical disease”. This is leprosy. It has not disappeared. It is not eradicated, indeed there are over 200 000 people living with highly stigmatising disease.

Meanwhile, lucky Moe Moe (paediatrician) was being swamped by screaming children… she put on a brave smile and soldiered on for hours, seeing pikinini after pikinini (pikinini – child) come with fevers, watery diarrhoea, chronic cough (TB), and the characteristic swirly-skin pattern of grille infection.

Marcel, a community health worker at Siroga (left), a family, and Dr Moe Moe (right)

Rex, the lab technician, gave me a tour of his laboratory, explaining the tests he ran for TB (A real life Acid Fast/Ziehl Neelson Stain, my nerdy dreams come true!). A poster illustrating how to do the AFB stain hung over a violet-dye-splattered sink, and on a bench to the left lay rows of sputum smears waiting to be examined under microscope. Rex also spoke about what his work involved, trips out to the other health posts to collect samples, his accountability and reporting to national health officials, and his anticipation of a CD4+ count machine (for HIV detection).

Rex, his microscope and rows of sputum smears on the desk (right)

In the office next to Rex’s lab, there works another highly motivated officer named Morris, Siroga’s young TB officer. Fiona (pharmacist) and I spent some time talking to Morris about his work, Fiona and Morris barely containing their excitement as they shared stories about how TB is treated in PNG and Australia. They compared their “Bibles” – a highlighted and annotated copy of the PNG Standard TB Protocols for Morris, and a pink pocket-sized Thearapeutic Guidelines for Antibiotics for Fiona.

Morris was enthusiastic in talking about the various medications he gives to patients (Directly Observed Treatment Standard Course – DOTS program). The TB meds stood out brightly in red pockets, each pill containing a combination of the 4 first-line drugs Rifampicin, Pyrazinamide, Ethambutol and Isoniazid. Standing on the shelves, the boxes of drugs weren’t labelled with patient names, but rather numbers. Morris explained that he did this to protect his patients from the stigma that still pervades about TB. There are still many people that believe in sorcery, he said, and I educate children in schools about health and diseases. Things will change, but it will take time.

Day 1 5/7/15

Sydney to Port Moresby 

Our adventure starts at 6am. It’s a chilly 6 degrees in Sydney, and we rendezvous at the airport just after the sun has risen. We’re a team of 9 this time – 2 doctors (Alice/mum, Moe Moe), 2 nurses (Mel, Jodee), Sue, 1 pharmacist (Fiona), 1 optomestrist (John), 1 bioinformatician (Magda) and me – the resident pleb, aka documentarian/student. We’re a mix-and-match multi-disciplinary team, a lot of newcomers. But some things never change – the massive trolleys piled with suitcases, travel backpacks, bulgingly obese duffel bags; crammed full of medical supplies.

We touched down in Port Morseby just after 2 o’clock in the afternoon. Today heralds the opening day of the 2015 Pacific Games, this year hosted by PNG’s very own Port Moresby capital. It’s a momentous occasion, with athletes here to compete from 24 countries including New Caledonia, Fiji, Vanuatu, Fiji, Tahiti, Australia and New Zealand. Signs of the event are everywhere – from the freshly renovated airport interiors, to the Australian girls rugby team dressed in green and gold who we spotted on our flight, to the orange traffic cones marking the inner lanes of the main roads for speedy passage of athletes. Driving through Port Moresby we were pointed out to the games village, build on the grounds of the university of PNG.

Everytime we come back there are signs of new development. The streets are cleaner, the roads busier, and high rise buildings more abundant. Joe – a manager at the Lutheran guest house where we stayed overnight – told me that the crime rates have dropped too, and the population has grown to about 600 000. He comes from an industrial city on the north coast called Lae, where he used to be a schoolteacher – he gave us (John and I) a geography lesson on some major landmarks in PNG. He was sincere and enthusiastic in sharing his knowledge, answering our questions about PNG, and it made me wonder about the circumstances that would have shaped his journey from pedagogy to hospitality, and on the other side of the country.

Despite the physical, aesthetic improvements in infrastructure, other features are familiar and stir a sense of nostalgia and curiosity. It was the afternoon when we arrived, and in PNG afternoon means burning, much like in other countries around the world. Mist-like billows of smoke emerged from ditches along the highway and plots of land beside smaller roads; glowing piles of burning rubbish. We passed gravel fields where children were playing soccer; markets where women were selling drinks, packaged food, BBQ meat; and scores of buses and trucks where people ride open-air. In the back of one of these trucks there was a group of women dressed in vibrant traditional costume: feather headdresses in black, red and yellow plume, with matching coloured skirts. They were a “sing-sing”, Joe told us, on their way to perform at the Pacific Games opening ceremony, which we watched on an ancient television later that evening. Performers from all across the country had come to showcase their province’s unique cultural songs and dances on national television, a celebration of diversity with a sense of unity – national pride in one’s incredible rich culture and traditions. As part of the Oro Province’s performance there was a man dressed in bright green butterfly costume, depicting their native Queen Alexandra butterfly (the largest in the world at a whopping 30cm!). Tomorrow we head to the Oro Province.

***

Day 3, 7/7/15

Popondetta Clinics

The team set out on our maiden clinic voyage this morning, full of hope and excitement. It was the beginning of our third day in PNG, and although the first two days had been great for relationship building and planning meetings, we were itching to get our hands dirty and start the work that we came here for.

The clinic we worked at today is called Saiho, it is one of the major community service providers in the Popondetta area. Saiho clinic is run by a highly dedicated (if not overworked) staff team of 13 Community Health Workers (CHWs) and one nursing officer. The clinic itself is a cluster of buildings painted green and blue, each block dedicated to a specific purpose, be it treatment/medication distribution, inpatient beds (a small room with 6 beds lined by worn mattresses, family members hovering around bedside and children seated on the floor), a TB clinic building from which the DOTS (Direct Observed Treatment, Short Course) program is coordinated. In between the buildings is a grassy plain bordered by trees, the shade of which gave refuge to patients waiting for the eye clinic.

We practically leaped out of the 4WDs at 8:30am and were received by community elders who warmly greeted each one of use with a smile and friendly handshake. A small crowd gathered outside the TB clinic building and both the Hep B Free team and each of the Saiho staff introduced themselves and their roles. A Provincial Health official named Dr Toro also addressed the community and explained our purpose and the set-up of the clinic. The people gave 3 hearty cheers of “Oro, Oro, Oro!”, meaning “Welcome!” And we scurried off to our respective positions.

As Sue put it, each clinic we run is a little different – to an extent we don’t really know what to expect before it happens. There are features common to our set-up: registrations (Mel), triage, immunisation, outpatient/treatment clinic (Mum + Moe Moe), drug dispensary (Fiona), wound dressings (Sue/Jodee), eye clinic (John). We adapt to the space, the available supplies, the time and the people. Being my third trip, there was a sense of familiarity in our rhythm and drill, mixed with a sense of excitement about what was different.

I’ll try write up a few snapshots of some things we saw in today’s clinic. There was a woman with asthma who had been taking salbutamol tablets. When offered by the doctors on our team, she declined a salbutamol puffer. This stemmed from a cultural fear that people who start using the asthma puffers will die. Considering how commonly asthma puffers are used in Australia, and with virtually no ill-effects, we postulated why she might feel this way. Was it because only people with really severe asthma were given puffers, who might be more likely to have a fatal asthma attack? Despite some gentle encouragement and reassurance, this lady’s opinion was firmly established and she left without accepting the treatment. It’s difficult to swallow…but ultimately it’s her health and her right to choose, and whilst we can try to educate and provide reassurance, sometimes cultural assumptions and beliefs can be complex and deeply entrenched.

There was an elderly man with deafness in both his ears, he came accompanied by his wife, who throughout the consultation, interpreted to her deaf husband using a combination of mouthing, speech and hand gestures. The man previously had otitis media (middle ear infection) with perforation, and this had presumably contributed to if not caused his deafness. He had come with an expectation that he would be able to have his deafness cured. The sheer disappointment on his face when he was told that we didn’t have the equipment or expertise to help him was heartbreaking. It made me wonder whether we were close to his last hopes of some kind of recovery. There’s very little that is comparable to the hopelessness of telling someone, “sorry, there is nothing we can do.”

In most of our clinics, we get about one acute/emergency case. On this particular day we met a young man who had walked 3 km to the clinic using a self-made wooden crutch, where he presented with severe abdominal pain. The multi-disciplinary team of doctors, pharmacist and CHWs hustled to their action stations – after brief examination it was determined that this man’s appendix had developed an abscess and ruptured, leading to very dangerous and painful peritonitis. He needed surgery – urgently. After the exertion of his journey to clinic, he was laid to rest on a simple cot in the corner of the treatment room while waiting for transfer to hospital, and administered IV fluids containing gentamycin, the first of a triple antibiotic series to cover a broad spectrum of bacteria (gram pos, neg and anaerobic). This was to act against a barrage of nasty critters that could have escaped into the peritoneal space as the appendix ruptured.

These are just a few stories out of what happened today. Overall it was an encouragingly positive start to our work here, and there was a good sense of team morale as we faced challenges together, shared laughs bumping over crooked roads, worked together in the clinics and collapsed with satisfied exhaustion at the end of the day. We felt so warmly welcomed by the local people who had travelled from the surrounds to attend this clinic, and by the CHWs who were so friendly and engaging. But at the same time, it's utterly frustrating and disillusioning at times to encounter people suffering for no fault of their own. Each person who arrives at the clinics comes with some degree of hope - no matter how big or small - that they'll be helped or cured. And sometimes that's just not the case, because we don't have the equipment that we can access so easily back home, or the knowledge to correctly diagnose and treat the problem. Sometimes it's just too severe. Often people expect a simple solution - a tablet, a drug mostly - that can cure them. But there are many patients waiting, so the best we can do is to hear them out, apologise that there's nothing to be done, and send in the next person, hoping this time there'll be something we can help them with.

Friday, September 19 - Karkar Island

Our time on Karkar Island ended not with a bang, but a whisper.

The morning began on a hopeful note. The weather was calm and beautiful. Over a breakfast of tropical fruit, we chatted about marine wildlife on Karkar. Brett was telling us about what they had encountered in the waters - green and leatherback turtles to sharks of all kinds – reef sharks, grey nurse, the occasional school of hammerheads, whaler shakers and less commonly, tiger sharks. The animals here are not protected, but that also means that traditional hunting keeps their numbers down without driving them into extinction.

Today the plan was to join the regular day of the immunisation team here as they travel around and service the island, as well as to return to the CHW school later in the afternoon for Mel/mum to deliver the gastro presentation. It seemed simple enough.

On the way to Gaubin hospital, Pablo gave us a crash course in Pidgin. Over the last few days, and especially today, I’ve really come to love this language; its straight forward, easy-to-pick up manner (at least compared to some other languages *cough* Chinese). It rolls easily off the tongue and makes a lot of sense. For example, when leaving, you might say, “mipela go, yupela stap” which literally means “we are going, you are staying”. Another way to say goodbye is “lookin yu” or “lookin yu behind”. One of my favourites is “sun cooking me”, which means sunburn. When greeting a group of people, you would say “Mornin al geta, yu stap alright?” Don’t forget the chirpy little inflexion in “Mornin!” Another one of my favourites – “lik lik”, meaning a little bit, and our crowd favourite “pikinini” (child). Some other phrases Pablo taught us were “bugger up”, which is like damage or break, and “em tassol” which roughly translates to “that’s all”. Pidgin is a fun, easygoing, laid-back language to pick up, absolutely beautiful.

When we arrived at Gaubin at 9am, the transport for the mobile immunisation clinic was yet to arrive. (PNG time runs a little on the slower side, its part of a generally laid-back culture). We killed time by going for a wander around the nearby market, where there were people selling all sorts of food and knick knacks – dried fish and octopus, fresh fruit, clothing, stationery, toys, betel nut and other smoke-able things…

We came back and waited for the vehicle to arrive. During this time we had a chat to Christina and the head of the Maternal Child Health clinic, Sister Alexia about the Hepatitis B vaccine coverage in the hospital. Doses are given on Mondays, Wednesdays and Fridays in batches of around 10 (the vaccine comes in 5mL bottles and a child-size dose is 0.5mL). Somewhere in between, Jodee befriended a little boy (his name is Shane) who had an injured toe, and they communicated in a mish-mash between English and Pidgin. She disappeared for a while and it turned out that she met his mother and siblings.

Anyhoos, we did make it out to the clinic eventually (yay!). I called it a “scouting trip” to Ragon village, a beautiful little village about 5 km out from Gaubin hospital. We tumbled up the mountainside in the hospital four-wheel drive (the “ambulance”) up a steep, bumpy dirt road lined by tall grasses. It became a little cooler as we headed higher up and deeper into the forest. A decent amount of bumping around later (all the while staring warily at the amber yellow “empty fuel” light and thinking any minute we’d be out of gas), little huts and gardens came into view. We pulled into a small dirt-floor clearing around the base of a tall tree, behind which were rows of huts (the villagers later told me it is a Talis nut tree, and you can see the reddy-brown ripe nuts hanging high above your head).

To my surprise-yet-not-surprise (as we’d encountered similar before on the plateau) we came across at least two albino children. Albinism is a congenital condition in which a person is born without melanin pigment in their skin, giving them a snow-white appearance that is quite easy to recognise amongst their darker-skinned community. They are much more susceptible to sun damage as their skin lacks the natural protection. There were also a few children with measles in the village, apparently there had been an outbreak in a neighbouring village.

Visiting this village was the highlight of our time on Karkar, if not one of the highlights of the whole trip. It was really special to have the opportunity to meet and talk to the people who live in Ragon about their daily lives, take photos with the children – extremely shy at first, but with a little bit of time, become more comfortable and giggly. 

Most of the people gathered were women and children visiting the regular clinic, where health care workers recorded details, took weights and delivered vaccinations (we didn’t see the vaccines, which were likely given after we left). Mothers carrying babies in colourful, hand-woven billum bags weighed their babies on a scale hanging from the tree – it’s always so interesting to see the head of an adorable baby pop out of a bag. It’s not as though they’re going to have a lot of prams out here.

I’ve been really interested to hear about the education system and the kinds of opportunities the children have to go to school in PNG. James, who lives in Ragon, said that their village has an elementary school, primary school and secondary school (he pointed to the high school across the road, which looked like a medium to large sized hut with exposed wooden framework, a little higher off the ground). Just taking one look at the structure makes you wonder what kind of resources (if any) they’d have out here to learn. He said that there are 200-300 students and about 5-6 teachers, which would make about 1 teacher per 50 students.

After spending some time in Ragon, we bundled back into the vehicle to return to the CHW school for the presentation. There were a lot of exchanges of goodbyes, “lookin yu” and “yupela stap, mipela go”, and even after we pulled back out into the road there were a group of children running after the car and calling out “Byeeee!” We rolled away and tumbled back down the dirt road to the hospital. (Thankfully we made it back to the hospital even with the fuel light still shining bright.)

The afternoon was a little bit of an anti-climax, or if you’d like, a bit of an expectations vs reality situation. The hope/expectation was to test the hospital staff and CHW school for Hepatitis B using the test kits we had brought, which would be an opportunity to train the health workers on how to use them. Vaccines would be offered to anyone with negative antibody results (which means they don’t have immune protection against Hep B). Then we’d deliver the gastro presentation to the CHW school. In reality, because it was the “Friday fortnight” (aka. Payday and end of the week), the lab tech staff and students had gone home, it was difficult to get into contact with the Provincial government for official approval, there was hesitancy about possible cultural barriers. We did end up testing the hospital administrator Dr Cephuly, but the other parts of the plan kind of disippated into the air.

In our final moments at Gaubin hospital, I met a mother and son waiting outside the outpatients clinic. I had seen the young boy from inside the room where we were testing, and asked him for his name, “Nem belong yu?” (To no success, all I managed to do was scare him away – do I really look that frightening? O.O) A few minutes later, he ran past the door and called out something at me. I went outside and sat down with them – his name is Andy, his mother Rame (pronounced Rah-meh). He is in Grade 1 (elementary school) and she is a CHW at the hospital who has lived in Karkar all her life. With 3 other children spanning ages of 1 year to 16 years, all she wants is for her “children’s wishes to be true”. I gave Andy the “Liveright” (Live right/ Liver right) wristband and told him about how it means to look after your liver and be healthy and happy.

The day finished early and quietly, bringing a close to the working part of this journey in PNG. Now we are relaxing and waiting in Karkar to return to Madang by boat today, where we will stay a night before flying onwards to Port Moresby and then home to Sydney. It feels strange to travel so far when I’ve met people who may never have left their village or their island for their whole life. I feel so incredibly lucky to have had this experience, to have met the beautiful people who live on this island and understand lik lik about their lives here. They are honest, resilient people with a strong sense of family and community identity and an instinct for survival, ripened under harsh conditions.

[And here's a series of pictures taken from the port on the main island, after returning from Karkar. Yes - the water was that blue!!]

I’ve also been coming to understand a little bit more about the concept of aid work and volunteering overseas. When you’re working on a grass-roots level and carving out new paths, new projects and partnerships, it is of utmost importance to have absolute moral clarity, clear priorities and objectives, strong local partnerships, focus on sustainability and a lot of patience. It’s the perfect match between intention and action, where you need both in the right place for it to work. There simply isn’t enough money and time in the world to parachute in, build a school or a building somewhere just to abandon it under poor/no management after a year or so.

Now I’m just blabbering. In attempt to wrap up this chapter, the story ends here for now, but there’s a long way to go. A lot of work remains to be done, and there will be new adventures to come. Here ends my perspective of our journey, but with any luck (fingers crossed) I’ll be trying to publish some interviews with the other team members to share their perspective too. Each time we go on these trips/medical missions/whatever you want to call it, our eyes are opened a little wider, our experiences broadened a little further, and we come back slightly different people. 

Tenk yu tru, PNG, lookin yu soon.

Carrie