My Elective in Vanuatu – Before the Storm

In Vanuatu, the phrase "Welcome to Paradise" can, for once, be used without the superlative excess we know from lottery advertisements or Richard Branson's pearly white smile. In 2006, Vanuatu topped the New Economics Foundation's Happy Planet Index as the world's happiest country. When I visited Vanuatu at the end of 2014, the small island-nation of 270,000 people offered unique Melanesian culture, stunning natural beauty and exciting tropical medicine in relative proximity to Australia and New Zealand. As a previous resident of the Pacific, the attraction was obvious.

While cruise ship tourism has brought wealth and ongoing foreign investment to Port Vila, the nation's capital of 47,000 people, Vanuatu remains poor and chronically under-resourced. Estimates from 2008 put the physician density at 0.12/1,000 population, hospital bed density at 1.7 beds/1,000 population and the percentage of GDP spent on health care at 4% (less than half the OECD average). Combine this with a tropical climate, parasites, trauma, TB, neglected tumours and mysterious auto-immune diseases – and a student's scope for learning and useful participation is significant.

Organising a placement

Thanks to the efforts of Port Vila local, Dr Basil Leodoro and the volunteer coordinator, Mrs Asha Sine, organising a medical placement in Vanuatu was easy, but at least three months’ notice is recommended. Commonwealth citizens enjoy 30-day visas on arrival and the hospital's close contacts in the Department of Immigration mean extensions can be arranged within days once in the country.

It’s equally easy to establish contact with the country's second hospital, the Northern District Hospital on the island of Espiritu Santo, through Dr Leodoro. A combined visit to both hospitals is highly recommended, and not only for the world class diving! Accommodation in Port Vila ranges from five-star luxury to basic hostels or home-stays, which should be organised well in advance, while the Northern District Hospital provides basic accommodation for visiting medics/volunteers at a heavily discounted rate.

Vanuatu’s idiosyncrasies

Yes, paradise has its price. Punctuality, reliability and commitment are hard to find. Social appointments can be made in "local time" and hospital efficiency data is most likely found stuck to the bottom of a coffee mug. Port Vila Central Hospital has two theatres with laparoscopic facilities expected in 2015, as well as new radiology, emergency, pathology and outpatient departments. Investigations are basic: x-rays and ultrasounds only; basic blood pathology may take two days but only when reagents are in supply. Histopathology specimens are sent to Australia for analysis once every six months. While time may slow to a coconut crab's crawl, the diseases certainly don't.

Life at the hospital

For visiting students, a typical week during a surgical attachment included femoral lines for severe paediatric meningitis (patients typically displaying a GCS of four or five), radical mastectomies, tubal ligations under local anaesthesia, skin grafts, more abscesses than you can poke a stick at, and orthopaedic trauma ranging from machete to coconut induced. Student to patient ratios are fantastic as local medical students attend university in Fiji, but the regular stream of elective students mean you're rarely entirely on your own. All this means clinical skills are heavily relied upon and students can't help but improve.

Due to the shortage of local doctors, Cuban, Chinese, Ukrainian, British and Australian doctors bolster the ranks and enrich the working environment. In general, the doctors are often eager to teach (or learn themselves) and are always inclusive of inquisitive students in clinics, theatres or rounds. Weekly grand-rounds are open to all departments and presentations are typically based on local data gathered by audits from visiting medical students or WHO workers who are making a tangible difference to hospital policy and patient outcomes.

Witch doctors and rotting bananas

One case in particular illustrates the complexity, remoteness and importance of surgical care in Vanuatu. A middle aged epileptic woman presented for treatment of severe burns to her hands, lower arms and face after falling during a seizure into an open fire and pot of boiling water. The patient had been non-compliant with phenytoin, citing costs and her witch doctor's advice, despite having experienced an identical accident one year previously. The journey from her remote village on a neighbouring island took two weeks, by which time an infection had developed. The extensive third degree burns and progressing wound infection indicated the need for amputation. The patient, however, would not consent to the procedure due to her traditional beliefs that women require their fingers for work in the afterlife. After a further two-week delay, four general anaesthesias for debridement and curettage and the inevitable onset of gangrene, the patient finally consented. The key conversation that convinced the patient involved the analogy of a rotting banana.

Opportunities in Vanuatu

Vanuatu presents a refreshing opportunity to exercise creativity, an open minded and tolerant approach to foreign cultural values, and good humour. Attempting to learn basic Bislama alone requires a dose of the above. To any western foreigner, the paucity of investigative tests highlighted the importance of perfecting clinical examination and reasoning to determine not only a single diagnosis but likely differentials. More than once during this visit, our team's initial clinical reasoning proved to be incorrect which served as a lesson to keep differentials in mind and the importance of monitoring a treatment course through to completion. The success or failure of an empirical treatment alone can be as good a test as a CT scan.

Cyclone Pam

On a parting note, many of you may have seen or heard the news of Cyclone Pam’s destruction as it swept across most of Vanuatu’s central and southern islands in March 2015. While the death toll was mercifully low at a few dozen, the loss of infrastructure and damage to the economy has been immense. Port Vila Central Hospital moved to a new and very solid building – however, the low-lying paediatric and surgical wards were thoroughly flooded. Several international aid agencies actively called for help, mostly in the form of funds.

Jakob Koestenbauer
University of New South Wales