The Andrew Dent Scholarship is offered each year to health sector students who need support to undertake volunteer work, electives or study trips that aid people in the Pacific Region. Katrina Hannan, a fifth year medical student at The University of Melbourne, was the recipient of the Andrew Dent Scholarship in 2010. Katrina spent four weeks at the Tupua Tamasese Meaole Hospital in Apia, Samoa. Her account of her time there is included below.
Pacific Health Fund Andrew Dent Student Scholarship - An account by scholarship recipient Katrina Hannan
“Take it easy! Don’t work too hard!” heralded my daily drop-off at TTM Hospital by Poe, the owner of my accommodation. While I was happy to oblige and slip into the relaxed ways of Samoan life, wearing flip-flops on ward rounds which started somewhere between 8 and 10am, my time there was nonetheless a steep and thoroughly enjoyable learning curve. It is astounding to reflect on how little I knew about the world of Samoa prior to going, and how now, after just six weeks, I feel intimately connected to it, having made a number of great friends there who welcomed me like one of the family. I have learned a great deal about the Samoan people, their lifestyle, environment, healthcare system and beliefs, and how these interact to either help or hinder the people tackle some of the problems facing the country.
I spent most of my time at TTM Hospital following the internal medicine team and also had a few days in paediatrics, surgery, the haemodialysis unit and A&E. While the medical students faced barriers with many patients not speaking English, ward rounds sometimes being conducted largely in Samoan, and many of the doctors being overworked with little time to tend to students, I found I gained a lot of valuable clinical experience by taking every opportunity to examine patients and look over their investigation results.
I encountered many presentations which I had rarely seen at such an advanced stage, or had rarely seen at all, in Australia. These included: rheumatic fever induced cardiac failure, several cases of bronchiectasis in young people, typhoid fever, injuries secondary to falling coconuts or falling while collecting coconuts, sacral pressure sores to the bone, extremely severe jaundice and yet to be excised breast lumps.
Overall, the standard of care and facilities at TTM were quite good. The main differences from Australia were: a lack in allied healthcare, with only one hospital physio for all wards and, amongst others, speech pathology, psychiatry and rehab workers being non-existent; a lack of very specialised or expensive medicine, with, for example, “supportive” treatment being the only option for children with leukaemia; and a lack of staff, with A&E queues often being 200 people long. The latter problem arose from a lack of funding and the associated difficulty of in-country staff retention, with the surgery team particularly under strain.
Despite the limitations, doctors and patients alike proved to be resilient and adapt to what was available: families showed patient dedication in their attempts to be surrogate speech pathologists and physios, helping with eating, exercises and pressure care; despite the lack of comfort and stray dogs which roam the hospital grounds, families from more distant parts of the islands camped overnight on the footpaths to be there for their relatives during visiting hours; several doctors volunteered their time, and had resisted the temptation of higher salaries overseas, opting for the Samoa to be with their families and to help out their country in need.
The main factors that led to the frequency of late and seemingly preventable presentations were Samoan health beliefs, food and exercise habits, poverty, lack of systematic screening programs and access. This was exemplified by a case that was presented to me by solemn nurses on my first morning on the wards, in the High Dependency Unit. A 32 year old mother of seven and carer of her blind husband from a tsunami-affected region on the other side of the island, had presented two days before with decompensated congestive heart failure secondary to rheumatic fever, as a result of her not taking her cardiac medications for two months. She had attended outpatients one month prior to get her prescription refilled, however had returned home without having a consultation as the queue was more than a day long and she had to tend to her family. She had presented two days prior with worsening dyspnoea on exertion and had passed away the night before.
Such tragic cases of young people succumbing to cardiac, respiratory and metabolic disease were common. In general there was a poor grasp of the importance of long-term compliance with treatment, with the expectation that a few pills or an operation was synonymous with cure. Many delayed seeking treatment despite unremitting symptoms because they wanted to try traditional massage first, or because their social situation precluded them from leaving their village/family.
Presentation was also sometimes delayed by the belief that misfortune was due to a higher power being disgruntled, evidenced by the “Samoa Observer” reporting claims that leprosy was due the wrath of God over an assault of a priest, and that the tsunami hit certain villages because businesses had failed to observe a day of rest on Sundays. Poverty with overcrowded houses, limited access to treatment and poor education regarding hygiene and the importance of treatment all contribute to typhoid, bronchiectasis and rheumatic fever being extremely prevalent.
Moreover, after school completion, participation in sports or regular exercises becomes a rarity, with reluctance to walk even short distances compounded by the humid heat and ubiquitous stray dogs. Often my walking a couple of kilometers was regarded with goggle-eyed, slack-jawed wonder. Combine with this attitude the normal diet consisting of very large portions of deep fried food and soft drink (with tinned corned beef and a stick of butter for good measure) and it is no wonder that a local GP considered a BMI of less than 30 exceptional. As such, although the haemodialysis unit has been highly successful (their operating hours going from 5 to 7 days a week in just a few years), the main obstacle seen in patients is the resistance to dietary change- even during dialysis sessions- with intake of large portions against advice causing high levels of intradialytic hypotension.
Although I have emphasised the Samoan characteristics that contribute to health problems, there are, on the other hand, aspects of the Samoan lifestyle and social structure which have great promise in tackling these health issues.
Large tightknit extended families interwoven into strong village and church communities where everyone knows everyone provide a climate for inclusivity and potentially a network for promoting positive change. Elderly and infirm members of the community are cared for by several relatives and great efforts are made to include them in gatherings for worship, celebration, mourning and, of course, feasting.
Indeed, a great deal of time is spent with the family unit. People feel connected to one another by bloodlines and there is a great sense of pride in one’s ancestry and generally about the country. While a huge proportion of the country are living, working and studying overseas, usually sending home financial support, many people return desiring proximity to their family and the slower, less stressful life of Samoa.
Poe and Filia, managers of my accommodation, where the employees were his nephews and nieces, are classic examples, having spent twenty years working in Australia, deciding to return home to Samoa so their young son could learn the mother tongue and culture. Poe was keen to escape the frenetic pace of Aussie working life, and while I agree there is a less stressful environment in Samoa, I think he is a little misled about there being less hypertension as a result - especially, as he frankly states, his weight has skyrocketed in only three years since he has been back in Samoa!
This couple, like every local I met in Samoa, were extremely generous, regularly offering us a lift or food or the invitation to participate in traditional family barbeques and to attend their church service where Poe is a Pentecostal pastor. The locals were often delighted to see “palagis” (a non-derogatory term for foreigners, meaning “burst from the heavens”).
The friendly, relaxed nature of the people bodes well for the tourism industry, which is starting to regain momentum again after the tsunami. The industry is the country’s main economic lifeline and beacon of hope, with other industries failing and the country being largely dependent on foreign aid, exacerbated by the tsunami and global financial crisis. Many improvements could be made in terms of signposting, advertising, sticking to opening times and maintenance of sites for tourists, which are often a source of frustration, however the endearing nature of the people and unique beauty of the sites makes up for the deficiencies. Most tourists are left fondly reminiscing over the quirkiness of the place, saying, as the locals do, “Only in Samoa!”. I certainly did after being stranded in a corner of one of the islands by flooded roads. Every wet season these particular roads reportedly become blocked off for days by swollen torrents. To my surprise, rather than finding it an annoyance locals regarded the procession of cars trying to cross the river as a fun spectator sport, with crowds gathering to cheer and assist on either bank!
Intriguing social change is also happening in Samoa, with ‘westernisation’ occurring, particularly affecting the mindset of the younger generations. A mobile phone company has entrenched itself in the islands, and their slogan, “All I need is my Digicel”, really seems to be accurate for many of the young people we met who spent much of their salary on credit. The one McDonalds restaurant in Apia was often packed to capacity with families. In villages sound systems are juxtaposed against the basic wood and coconut frond covered huts. These changes certainly created much employment, however there is still concern that they are changing cultural priorities unfavourably. Indeed, there is a growing discontent in the younger generations who, with exposure to more secular lifestyles overseas, are resentful of needing to observe the expected strict obedience to church and family and also their lack of material possessions.
Depression and other mental illnesses are not generally seen as treatable entities, however people understand that a dark moodiness may descend on people from time to time. Awareness of the Western medical view of psychiatric illness is slowly growing through exposure to Western media and international medical personnel, however a lot of improvement is still needed. A newspaper headline article, “Mental man shoots at priest”, reported that the uncle of the young man with psychosis had been relieved to be able to recompense the misdeed by giving thousands of tala worth of sheep to the church for not controlling his “mental” nephew. No psychiatric treatment was sought for the young man.
Nonetheless, some excellent initiatives are making great strides in the delivery of healthcare. I was lucky enough to go on visits to villages with two of them; the first was a paediatric outreach program to follow up children caught in the tsunami, and the second was a physiotherapy outreach program to children with disabilities.
The positive effect these programs had was profound. Under the paediatric outreach program, mothers, still living under tarps amongst rubble three months after the disaster, with children who had been caught up trees and lost in the water were given a chance to speak about their experience and openly grieve; they were encouraged in their efforts to deal with their children’s PTSD and help them overcome their phobia of high-tide; toddlers who were not admitted at the time of the tsunami due to clinics being over-run were screened and detected as developing respiratory disease from aspiration, and were appropriately treated.
Similarly, under the physio program, initiated by Epenesa Young, Samoa’s first physiotherapist who was accredited in 1988, children with disabilities such as cerebral palsy, Down’s Syndrome, autism, and muscular dystrophy were given weekly visits with physical and communication exercises, reading and arithmetic lessons, referral to medical services if necessary and general psychological support for the families - all for free. Nine-year-old children who had never been able to sit up had progressed to walking after six months of regular therapy. It is heartening to see the fantastic work done by these people, yet concerning that so much of it depends upon volunteers and funding from a grant that is now in jeopardy.
Encouragingly, the Ministry of Health has recently been promoting exercise, with inter-village competitions in volleyball, rugby and dancing having a great motivational effect. After reading an article about the success of church-based exercise programs in Samoan communities in New Zealand, I approached Poe to see if anything like this had been tried in his church or local area. He replied that he had been thinking such a program would be good- as he wanted to encourage his community to be health both physically and spiritually- but didn’t know how to get started. As he was enthusiastic about the idea, I spoke with him, local villagers, GPs and members of the Pan Pacific South East Asian Women’s Association for Peace, addressed the church congregation about the idea and we collaboratively devised a plan for a dance based exercise program to be run twice a week including the church and village community. What became evident was that the will and expertise (such as people with dance instruction and nutrition experience) were in the local area, however they needed an instigator. (We are currently awaiting a reply from the Ministry of Health to our submission for a health grant to fund a PA sound system so dance classes can be commenced.)
To end, my time in Samoa was an extremely valuable time during which I learned a great deal about the obstacles to achieving better health outcomes but also the great potential for implementation of preventative health measures and engaging the people if people with energy and patience put their mind to it. I plan to return to see my friends there and also to continue helping out with health promotion where I can. I would like to express my sincerest gratitude to the St Vincent’s Pacific Health Fund for awarding me the Andrew Dent Scholarship and providing the funding for this elective.