An Australian GP in Papua New Guinea: Part 1

Papua New Guinea (PNG) may be Australia’s closest geographical neighbour but, in many ways, it could be part of another world.
 
A place rich in natural beauty and home to generous, friendly people, PNG also contains challenges that would be unimaginable to many in Australia, including lack of infrastructure, tribal warfare and endemic family and sexual violence.¹  
 
Dr Mills is Medical Superintendent of Kompiam Rural Hospital in the Enga Province, one of the most disadvantaged areas in PNG. His work there has involved building a hospital from the ground up and implementing a general practice training pathway for local students, with some help from RACGP Rural through the Near Neighbours program.
 
‘There’s so much you take for granted in Australia. The foundations of infrastructure, administration and government are to a large extent already there, so you can just focus on the things that you were trained to do as a doctor,’ he told newsGP.
 
‘In PNG, you really have to get the foundations right before you can even look at some of the bigger issues, like maternal mortality or dealing with HIV or TB [tuberculosis].’
 
Building a hospital
More than half of rural health services in PNG are run by non-governmental organisations, such as churches or groups like Save the Children.²
 
The Baptist Union church in the Kompiam–Ambum district of the Enga Province took over the local health centre at the request of the provincial government in the late 1990s. Finding themselves without a doctor, the Enga Baptist Health Services reached out to Dr Mills in Australia.
 
‘I was just finishing my Fellowship, working up in the Northern Territory,’ he said. ‘We went across to PNG for a look in 1999. I went back home to finish my Fellowship exam in November of that year, packed up the family, and we arrived in early 2000. We’ve been here pretty much ever since.’
 
Once on the ground, Dr Mills soon found that taking over the medical centre and turning it into what is now the Kompiam Hospital involved far more than medicine and some administrative duties.
 
‘We had to pretty much build it from scratch,’ he said. ‘[The PNG government] committed to a certain staff allocation and a bit of money each month, but we had to do almost everything else.’
 
Even Dr Mills’ experiences working in remote communities in northern Australia were not comparable to the challenges of PNG. Many obstacles healthcare professionals face in Australia, he discovered, can be viewed as relatively minor.
 
‘We all complain about government in Australia but, in reality, you’ve got very competent administration behind you. The problems that are more complicated to deal with are the issues going on in communities themselves,’ he said.
 
‘But in PNG you’ve got near total absence of government footprint. Even things like the road to the hospital, we have to keep that open ourselves; or if the bridge falls down or collapses, we have to rebuild it.
 
‘The basics of keeping the services surviving and running, much more of that depends on you as the doctor.’
 
Dr Mills also found it was important to become accustomed to a different pace of progress.
 
‘You’ve got to get used to making incremental change and then building upon it from year to year, rather than expecting that in a couple of years you’re going to turn the situation upside down and make a massive impact,’ he said. ‘You have to either learn to be patient or go home.’
 
Working together with local people in a consultative and inclusive fashion has been vital in efforts in building up the hospital, as well as managing any mistakes or mishaps that have happened along the way.
 
Dr Mills altered the hospital’s management style, removing himself from the chief executive officer role and instead having a ‘round table’ group of people, many of whom are local to the area, who discuss important decisions and share the burdens of management. This proved a literally life-saving idea.
 
‘Having local people on the management team has probably saved my life more than once and got us through so many pitfalls,’ Dr Mills said. ‘They understand what the local people are thinking and are able to find ways of dealing with it that are a bit more tactful and a bit less direct – Westerners are very direct in the way they communicate.
 
‘It takes some time to develop that level of relationship, particularly in Melanesian cultures, which are very deferential and polite.
 
‘Building confidence that you have a team of equals, who all feel they can say what they’re thinking, takes some time. But now we have that, it is the big strength of the service that keeps it going.’
 
The relationship certainly goes both ways, however, and Dr Mills has found the local people to be very tolerant and understanding.
 
‘We weren’t taking over a service, we were starting something from scratch,’ he said. ‘So even at those times where we stuffed up and had bad outcomes, people appreciated the fact that we were trying and working hard because prior to that they’d had nothing.’
 
One of the most difficult aspects of managing local relationships is navigating times of inter-tribal warfare, something usually well outside the remit of an Australian GP.
 
‘Because we’ve got 50 or 60 different tribes around the district, there’s probably always conflict going on somewhere,’ Dr Mills said. ‘There was a conflict this year that was literally right on the doorstep, so we were all bunkered down for about five or six months.’
 
The lack of government presence in the PNG highlands means the hospital is on its own and must work with the community to get through such fighting. Relationships with the tribes must be carefully managed to ensure the hospital can maintain its neutral position.
 
‘Nearly all of our staff are indigenous, so they are linked through blood relations to the various groups,’ Dr Mills said. ‘So people [in the tribal community] can start to get a bit paranoid and think, “Is the hospital secretly sending medicines to the other side? Are they using their salaries to buy ammunitions for the other side?” 
 
‘If the traditional people really start to feel the community service is working for the other side, their way of dealing with it is, “We have to destroy the service so we are all on the same level again”.
 
‘Throughout the highlands region, unfortunately, a lot of services get destroyed for this particular reason. So our main objective, apart from treating the injured, is to do our best to keep everyone in the middle so that both sides have a sense the service is something they need to protect, and come out the other side with the centre intact.’
 
The second part of the series will look at how Dr Mills worked with the local government and RACGP Rural to establish a general practice training pathway in PNG.

kompiam-hospital near-neighbours-program RACGP-rural