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International practice

Near neighbours

Author: Amanda Lyons

Australian GP Dr David Mills faced incredible challenges when working to establish vital primary healthcare services and training in Papua New Guinea. 

Papua New Guinea (PNG) may be Australia’s closest geographical neighbour but, in many ways, it might as well be part of another world. This can be especially true for overseas doctors working in PNG, who will often be forced to move well outside of a more standard healthcare comfort zone.

‘The job can often entail such things as barbed wire around the hospitals to protect staff and patients from the tribes who are conducting warfare nearby,’ Dr Peter Joseph, GP and former Provost of RACGP Rural, which established the Near Neighbours program for PNG in 2010, told Good Practice. ‘It means being able to handle the mechanics of a generator so that you have power and light for your operating theatre.

‘It means dealing with horrendous injuries that a Fellow of a college of emergency medicine or our general surgeons wouldn’t anticipate seeing in their lifetime. One of the most vivid examples of this being the slash of a jungle knife through the forearm when the arm’s flung up to deflect the heavy blade. Or, in one case, a patient’s face being neatly excised through the nose and lower jaw, all being pinned back together by a GP.’ 

PNG is a land of extremes. It is a place rich in natural beauty and home to generous, friendly people, but it contains challenges that would be unimaginable to many in Australia, including lack of infrastructure, tribal warfare and endemic family and sexual violence.1

These things touch every aspect of daily life in PNG, including general practice.

Dr David Mills is an Australian GP who 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 almost single-handedly implementing a general practice training pathway for local students, with some help from the RACGP 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 Good Practice.

‘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

Unlike Australia, 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 for the centre, the Enga Baptist Health Services reached out to Dr Mills at the top of Australia.

‘At that time 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 discovered 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’ experience working in remote communities in northern Australia was not quite comparable to the challenges of PNG. Many of the obstacles healthcare professionals experience in Australia, he soon discovered, can be viewed as relatively minor.

‘We all complain about government in Australia but, in reality, you’ve got very competent administration and government 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.’

Taking care of everything involved with running the hospital, from building staff housing to managing wages and salaries, was sometimes frustrating in terms of the time it took away from Dr Mills’ clinical work. He also found it was important to become accustomed to a different pace of progress.

‘Things move very slowly,’ he said. ‘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.

‘You have to either learn to be patient or go home.’

Working together with local people in a consultative, inclusive fashion has been vital in Dr Mills’ efforts in building up the hospital, as well as managing any mistakes or mishaps that have happened along the way.

In order to assist with this process, 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 turned out to be 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, so they would usually let the white person take control, even if they can see it’s a bad call.

‘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 of the ‘outsiders’.

‘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.

‘So they were very generous, very forgiving of our errors and, generally speaking, have been very supportive of us. That’s very rewarding.’

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 that the hospital is on its own and must work with the community to get through such fighting. But, according to Dr Mills, the hospital and its doctors are largely bystanders rather than active targets of the violence. Regardless, relationships with the tribes must be very 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.’

This is a balance that Dr Mills has been working to maintain in the region for a long time, as his Near Neighbours colleague Dr Joseph recalled.

‘David said he knew the locals were getting the message that the GPs and their hospitals were worthwhile when he saw signs going up in the marketplaces saying, “No tribal fighting this week, doctor is on holidays”,’ he said. 

Building a pathway

Dr Mills has also contributed to primary healthcare in PNG by implementing a specific pathway for general practice training, designing the curriculum for and setting up the Masters of Medicine (MMED) (Rural) postgraduate program at the University of Papua New Guinea (UPNG).

‘It is probably the equivalent of a Fellowship of general practice in the RACGP or ACRRM [Australian College of Rural and Remote Medicine], and it’s really the only general practice training program in the country,’ he said.

Prior to the establishment of UPNG’s MMED, medical graduates tended to specialise in other areas and remain in the city of Port Moresby, leaving the more inaccessible rural and remote areas of the country largely doctorless. What doctors there were often came from overseas and didn’t tend to stay long.

To rectify this situation, Dr Mills negotiated with the PNG government to recognise general practice as a specialty. This paved the way for the establishment of the six-year MMED program, delivered by the UPNG in partnership with the PNG Society for Rural and Remote Health and the Churches Medical Council.

Dr Mills did much of the work of establishing the program and designing the curriculum. He also connected the program with RACGP Rural’s Near Neighbours initiative. Through Near Neighbours, UPNG MMED trainees are provided with honorary overseas membership of the RACGP, access to journals through the John Murtagh Library, and to the gplearning online learning resource.

In addition, Near Neighbours provides exam support by sending Dr Ken Wanguhu, GP and RACGP Rural Censor, to PNG to oversee the annual UPNG MMED exams. His role involves quality assurance of the exam questions, marking, and writing a report about the process for the university.

The general practice medical skills taught in PNG are more focused on procedural medicine than they would be in Australia, with an emphasis on skills such as ultrasound and anaesthetics, which are necessary to all doctors in the more remote parts of the country. Assessment also varies.

‘Students have a real patient who has pathology; they do ultrasound on real patients. And, because the student numbers are small, we can use the same patients time and again,’ Dr Wanguhu told Good Practice.

In line with Dr Mills’ hard-earned experiences as a GP in the PNG highlands, students are also tested on a range of non-medical skills.

‘For example, a GP [in PNG] must be able to be the hospital manager; they have to do good spreadsheets, because they’ve got to make a budget and then run the money,’ Dr Wanguhu said. ‘We would never test that in Australia.

‘[GPs in PNG] don’t have technicians for their fridges for their vaccines or their solar panels. They have to do the maintenance work themselves, so that’s a skill you’ve got to have.

‘Another skill they are taught is public speaking and debating. They have to go out and talk to the community, then they’ve got to go and talk to the politicians.

‘So all of those things are tested in the exam. It’s not just medical knowledge.’

Dr Wanguhu believes that the establishment of the MMED program, which took in its first entrants in 2008, has had a clear impact on the health and wellbeing of the people living in the PNG highlands and other remote areas of the country.

‘It is massive, because there were no doctors,’ he said. ‘By having doctors in those areas, things improve. Because if there’s a doctor, then there’s got to be a facility that will support the doctor, so the facilities improve. You get better outreach teams, you get more money.

‘So there are lots of measurables that we can show in PNG that have improved.’

Although helping with the exams is hard work, Dr Wanguhu feels it is well worth it in order to contribute to the development of primary care in PNG. However, he reserves his strongest praise for Dr Mills, whom he credits with making it all possible.

‘He’s the one that set it up,’ he said. ‘Yes, we support him, but he’s done an amazing amount of work and he’s an amazing human being.’

Dr Mills, of course, would never describe himself in such terms. While very modest about his achievements in PNG, he is very clear about the rewards.

‘The [Kompiam] hospital is the heart of the district now and the people do hold it in very high regard,’ he said. ‘And we have a big role to play in most of the community issues. You have this amazing opportunity to play a huge role in shaping the attitudes of the next generation.

‘And then, of course, every time you can take someone out of the bush who’s in obstructive labour and deliver their baby, or just get someone out of pain, or do something that heals someone, it is a very rewarding thing.’

 

References

  1. Department of Foreign Affairs and Trade. Development assistance in Papua New Guinea. Canberra: DFAT 2017. Available at http://dfat.gov.au/geo/papua-new-guinea/development-assistance/pages/papua-new-guinea.aspx [Accessed 30 August, 2017].
  2. World Health Organization. Health service delivery profile: Papua New Guinea. Geneva: WHO, 2012.