Introduction

My clinical elective was based at Rumginae Rural Hospital, Western Province, Papua New Guinea (PNG). This is a remote 60 bedded hospital, located in the heart of the Aekyom tribal area, close to the Waimaeri River.

The hospital has four wards (Special Care Unit, General, TB and Maternity Wards), an outpatient service, theatre and antenatal clinic. It oversees five health centres and ten aid posts further out into 'the bush.' These are manned by community health workers (CHWs), who are trained in treating basic medical problems. The hospital is home to a CHW training school.

The hospital is staffed by CHWs, nurses and four doctors. It is a Christian hospital, run by ECPNG (the Evangelical Church of PNG). It is funded partially by this organisation, and partially by the government. It is also supported by the Mission Aviation Fellowship (MAF) who maintain an airstrip and aeroplane, for transporting supplies and patients.

They treat medical and surgical, obstetric and paediatric cases. They treat whatever they can, with the limited resources they have. As well as medical treatment, the hospital provides a Christian community, caring for the spiritual needs of staff and patients.

Objectives

My aims were to:
1. Gain an understanding of the challenges of delivering healthcare in a resource-poor country.
2. Gain insight into the poverty in which most of the world's population lives, and the impact this has on health and disease.
3. Understand how attitudes to sickness and death differ in a different culture.
4. Gain an understanding of how medicine can be delivered in a Christian context.
5. Grow in my personal Christian faith.

Work undertaken

I undertook many activities; medical, cultural and spiritual.

Medically, I joined the doctors on the wards and in theatre. This included ward rounds, reviewing inpatients and outpatients, assisting in theatre, teaching staff, and assisting in complicated labours. I also joined a trip to a remote village where we delivered immunisations to children.

I saw a broad range of sicknesses, for which there was often not a clear diagnosis. The most common diagnoses were Malaria and TB (both pulmonary and extra-pulmonary). However I also saw cases of buruli ulcer, snake bite, anaemia, malnutrition, pneumonia, meningitis, limb fractures and miscarriages, to name but a few.

I also spent time learning about the Aekyom people; how they live, the challenges they face, and their attitudes to sickness and health. I stayed overnight in a local village with a family, who involved me in their activities of fetching water, cooking and planting crops. I spent time talking with patients about their families and villages, and attended the bi-weekly local market.

The spiritual aspect to my elective involved attending morning devotions in the church, Sunday services and weekly Bible studies. We prayed before theatre, and there was a weekly prayer meeting to pray for the staff and patients.

Example case

Malaria is extremely common in the Western Province. This case is of a man who was treated for Hyper-reactive Malarial Splenomegaly (HMS). It demonstrates a common presentation in this area, with up to 80% of people having splenomegaly (1).

The case:

A 40 year old man presented with a distended abdomen, early satiety and left upper quadrant (LUQ) pain for one month. Apart from this, he was generally well; he was afebrile, wasn't vomiting, was passing stool and urine normally, and hadn't lost any weight. He had been treated for TB in the past.

His observations were normal (HR:88, RR:24, BP:126/64).

On examination, he looked well apart from having some abdominal discomfort. He wasn't jaundiced or cachectic. His chest was clear and heart sounds were normal. His abdomen was tight and tender across the right and left upper quadrants. He had hepatomegaly (7cm below the costal margin) and splenomegaly reaching the umbilicus. There was no shifting dullness.

The most likely diagnosis was HMS. The differentials were hepatitis B/C, TB abdomen or splenic lymphoma.

His haemoglobin, white cell count and platelets were all normal, and his ALT and AST levels were only mildly raised. Hepatitis and HIV screening were negative.

Once hepatitis was ruled out, he was treated for HMS as the most common cause of splenomegaly in this area, and something that can be treated at the hospital (unlike lymphoma). He was treated with regular paracetamol and Malarone 250mg daily for at least six months, with regular outpatient review to monitor for reduction in his splenomegaly.

Reflection on the case:

Compared to the UK, Rumginae experiences a lack of resources to investigate and treat illness. As a result, the approach to treating disease is very different. Instead of finding an exact diagnosis, they will treat all the differentials they have the resources to, whilst focusing on the most common causes. The staff follow guidelines in the 'PNG Standard Treatment Books'. These cover the most common illnesses that can be treated, but they do not go beyond that. Things that could be treated in the UK, cannot always be treated in PNG.

There is also a difference in the caseload seen. This is not only because of the very different environment and standards of living, but because patients present much later on. This is due to lack of access to healthcare facilities, less education, and because of different beliefs in the role of sorcery to treat illness rather than medicines. Diseases were much more advanced than typical of the UK.

The above case demonstrates this. This man had had malaria many times, and it took him sometime to present. The diagnosis was made purely on history and examination, with only some blood tests to rule out hepatitis. If he had presented in the UK he would have had many more scans and tests, especially to rule out lymphoma. The recommended treatment for HMS is proguanil. The hospital didn't have any, so they used donated Malrone, which contains proguanil. This case also demonstrates the principle of being able to treat what is treatable, without confirming a diagnosis.

Such an approach took some time to get used to. It was difficult to understand why some treatments were given, and to be content with not having an exact diagnosis. However I realised that without the resources to fully investigate everything, it was better to offer treatment for the treatable things, than to satisfy my own curiosity as to what the disease was. Most of the time, patients got better with such an approach, even if we didn't know why. I believe the staff did their best with the resources they had available. It was personally challenging to stop relying on investigations, and to develop confidence in my history and examination findings.

Reflection on my aims

Aims 1 and 2:
During my stay, there was the beginning of a drought. When I thought the hospital was fully stretched, it was stretched even further. Without water, boats couldn't get up the river to deliver goods and fuel. The staff faced the challenge of delivering healthcare with limited resources, knowing that those resources would gradually reduce. From this I saw something of the challenge of working in a developing country.

Being faced with such poverty, made me appreciate all that we take for granted in the West. Access to healthcare is much poorer; many people walk for days to reach an aid post. Spending a night in the village was a humbling experience, and through that I saw something of what I hoped in regard to my second aim.

Aim 3:
Encountering a new culture, and living amongst new people, showed me how our worldview alters everything we do. I realised how many people still hold to beliefs about sorcery as the cause and treatment for illness. Instead of thinking that a mosquito bite gave them malaria, they would ask what evil spirit had caused the mosquito to bite them. This experience will help me to better relate to patients of different cultures.

Aims 4 and 5:
I really enjoyed was working with staff who shared my faith. I felt valued as a member of the team. Seeing the love and generosity that the staff showed towards their patients, demonstrated practical Christian care. In my future practice, I hope to be able to show such selfless care for my patients.

The thing that I gained most was growing in my faith. It was a big challenge for me to travel alone to other side of the world, and adapting to the culture, was incredibly difficult. It was in these difficult moments that I learnt to trust God more, a lesson I hope to carry forward into the future.

Concluding reflection

My elective has been the most challenging, but also most rewarding aspect to my degree so far. I have learnt far more about medicine and my own values, than ever before. As well as meeting my aims, I learnt many other things that I did not anticipate.

I grew in confidence both clinically and as a person. The hospital was short staffed, meaning that I gained lots more experience in a shorter time than on UK placements. Under supervision, I was able to do ultrasound scans, assist in theatre and do a pleural tap, all of which I had little experience of before. This confidence will help me as I face the responsibilities of becoming a newly qualified doctor.

Some other skills that I developed were working with new people and communicating with those who didn't share my language. Sometimes it was frustrating when plans failed or people didn't respond how I expected them to. However I grew in my ability to be adaptable- another important skill to have as a busy foundation doctor.