Stephen R Snell, MD
Family Medicine Resident
John Peter Smith Hospital
Fort Worth, Texas
Project: International clinical rotation/medical mission to Kudjip Nazarene Hospital
In December 2010, I had the privilege of serving at Kudjip Nazarene Hospital in Papua New Guinea. The hospital is located in the Western Highlands Province(WHP) which is situated in the central mountainous part of the country. The WHP covers about 8,500 square kilometers and has a population of approximately 440,000.
The hospital serves much of the southeastern portion of this province called the Wahgi valley. This area has a catchment area of approximately 75,000 citizens.
The population served by the hospital is primarily the indigenous people of the region, the majority coming from the largest tribes, the Sekeng and Kuma tribes. Most of the patients live in traditional communities and are subsistence farmers, growing crops such as coffee and kau-kau (a sweet potato).
The most commonly encountered health problems are diseases with a strong association with poverty. These diseases included tuberculosis, gastroenteritis and other diarrheal diseases, trauma, HIV, malnutrition, and complications during pregnancy and childbirth. These diseases run largely unchecked in this setting because of several factors. Tribal fighting accounts for a significant segment of traumatic injuries. Lack of access to care and the rising rates of HIV infected individuals put the population at a greater risk for tuberculosis.
Inadequately sanitized water and lack of education about proper hand hygiene lead to frequent diarrheal diseases. Malnutrition also plays a role in morbidity and mortality in this community, leading to disorders such as cowbell. The WHO estimates 1 in 25 women in rural areas, like Kudjip, will die of maternal causes. This is largely related to lack of antenatal care and lack of skilled birth attendants.
Health interventions implemented at Kudjip included both preventative, acute care, and chronic care. Cervical cancer screening seemed to be a preventative service gaining a wider acceptance within the local community.
Another important preventative service included ARVs for HIV positive pregnant women to prevent vertical transmission as PNG has one of the highest prevalences of HIV in Southeast Asia. Acute and chronic care involved treating patients in the clinic, emergency department and inpatient settings. One physician’s practice was sole dedicated to community health and education. Also on site was a college of nursing which is working to produce qualified nursing staff to meet the critical shortage that exists there.
Challenges in providing healthcare in developing countries are inevitable. One of the major challenges facing Kudjip was a shortage of qualified nursing staff. Lack of staffing of nurses had recently become an issue just before I arrived at Kudjip. Several nurses had recently quit, with some going to go to government hospitals where pay was supposedly better and there was less accountability concerning work. This created a shortage of qualified nursing staff which forced the hospital to close most of its services to patients outside the region.
At Kudjip, there are five main wards: pediatric, adult, surgical, maternity/neonatal and TB wards. Each week I was assigned to a different ward. In the mornings I would round on the patients in the ward until about 10am. Then I would spend the remainder of the day between clinic and the emergency room which was in close proximity to the clinic. There was no doctor assigned solely to the ED during the day, so as patients presented, the ED nurses would find one of the clinic doctors to evaluate the patient as needed. This maintained a good variety between chronic, non-acute care and true emergencies, helping to avoid burn out on either one.
I took call approximately once a week, with one of the full time physicians on back-up call if I had questions or problems. Call days were long and busy, as I covered any issues that came up in any ward after about 5pm along with covering the ED. There were almost always patients in labor which I would evaluate if someone’s labor was not progressing normally. As I have a particular interest in maternity care, I also took extra call for any complicated obstetrical problems that arose.
What problems did you encounter? How would you correct them? What are the needs/issues that could be addressed?
As in other developing countries, the majority of health problems encountered stemmed from the problem of poverty. Poverty leads to a lack of education. Without education, a population has decreased understanding about prevention and treatment of illnesses. A lack of knowledge of hygiene and water sanitation leads to diarrheal diseases, dehydration and, in some cases, subsequent death. For example many mothers attempt to rehydrate their dehydrated infants with oral rehydration packets mixed with unsanitary water, leading to further diarrhea and dehydration. Deficient understanding in the nature of chronic diseases results in poor compliance with effective therapies, as in the case of the hypertensive patient who stops his medication because he feels well, only to later suffer a stroke. Lack of education results in late presentation of illness, as in the case of woman with metastatic vulvar cancer who did not know that the lesions on her perineum were abnormal. High risk sexual behavior can occur in an uneducated population because they do not understand why certain behaviors are high risk. There is also a lack of understanding of the consequences of contracting various STIs and how to prevent transmission. Education is crucial to the health of a population.
Poverty lead to deficient preventative care, with so much of prevention, again, being linked to educating the population. While more women in PNG were recognizing the importance of cervical cancer screening, routine pap smears were still not the norm. Also, many women still receive little if any antenatal care. Approximately 20% of mothers have only one or no antenatal visits prior to delivery. Reasons for this are many; one undoubtedly being the shortage of skilled providers located a reasonable distance from these mothers. This leads to an unscreened population, a segment of which will develop preventable problems later on in their pregnancy and an increased rate of vertical transmission of HIV.
Access to acute care is a result of poverty and has a negative impact on health outcomes of the people of rural Papua New Guinea. Many people that I saw each day at Kudjip did not live in close proximity to the hospital.
While there were community health centers that provided a low level of care, they sometimes had to travel for days to reach a facility with diagnostic capabilities and surgical resources. This led to neonatal morbidity and mortality from extremely protracted labors. It also led to simple wounds progressing to a gangrenous stage, requiring amputation.
Not only does poverty impact health, but poor health can contribute to poverty. In many settings, medical care has some direct cost, such as medicines and procedures. But illness and disability also have an associated opportunity cost. Time and energy spent dealing with disease is time and energy stolen from efforts in economic development through various forms of work and industry. For example, one of my patients, a teacher and the primary bread winner for a large family, was diagnosed with hepatocellular carcinoma. His disease was likely end-stage. As his illness prevented him from working, his younger siblings could not, in turn, pay their school fees. Without a basic education, they were unlikely to obtain a steady job with decent pay to be able to afford clean water and basic healthcare, leading to more illness and disability and time lost from work. So the cycle foreseeably continues. Clearly, poverty and health are inextricably linked.
Solving PNG’s problems of poverty will be, at best, an incredibly complex task. Solutions would be difficult and would take many years to implement and many more to see results. Ultimately, I believe advances in the education of the citizens of PNG will be the catalyst for further economic development. But thinking more locally and in practical terms, I believe advances in the general health of the population could be made with strategic health education interventions. One intervention that might have a significant impact in Kudjip would involve education on water sanitation and hygiene. A significant reduction in water-borne illnesses would mean a significant reduction in the burden of disease. Care would need to be taken to carry out this educational program in a culturally appropriate way. This would likely involve the training and mentoring of community health leaders who could in turn educate their respective communities in an effective way. Another strategic intervention would be working with community leaders, especially prominent women in the community, to find ways to provide better antenatal and immediate postnatal care and to identify barriers to health women face during pregnancy. HIV education is an area that is being emphasized right now in PNG, and I would want to continue such efforts in any community with similar high rates of infection. A vaccine program would make a meaningful difference on pediatric morbidity and mortality. These are a few of the areas that I would choose to emphasize first.
How do you see this experience affecting/changing your personal and professional life?
My experience at Kudjip was immensely valuable on both personal and professional levels. Personally, my time at Kudjip deepened my desire to serve in full time medical missions. For years I have wanted to serve God as a medical missionary. While I had had positive experiences in the past as a student, part of me still needed confirmation that such a setting was my calling. During my time there, I believe the Lord gave me a glimpse of how he could use me in the context of a medical mission. Also, spiritually, I was blessed to see how followers of Jesus walk in His foot steps as they face very different challenges in a very different context. One such follower had lost his mother due to a senseless act of violence as a result of a land dispute. Over time, the Lord had worked in his heart to the point he was able to stand face to face with the murderers and offer forgiveness.
Professionally, my experience reaffirmed my decision to pursue extra training in obstetrics and neonatal care. So much of morbidity and mortality there and similar settings can be attributed to problems during pregnancy and labor, and problems in the immediate neonatal period. The ability to provide advanced care in these two areas will be an invaluable asset for me. Also, while there, I discovered areas in which will need further training to be more effective. For me, I learned that I need more training in managing acute fractures, including closed reductions, splinting and casting.
What have you learned that can be transferred to the U.S.?
Many lessons and skills learned in PNG will undoubtedly serve me well here in the U.S. Experience gained in surgical obstetrics is definitely transferable, especially for rural communities across the country where there exists a critical shortage of obstetric providers. I also gained knowledge of various tropical diseases and their presentation. This knowledge will expand my differential and improve my care of patients who travel. I also was exposed to various presentations of TB and HIV, two diseases which are on the rise in our country.
One of the more general lessons learned from my experience was a heightened awareness of unnecessary waste within the U.S. health care system. Spending a significant amount of time in a place where the effects of waste were quite immediate and tangible forced me to think more critically about ways I can reduce waste here in the U.S. where its effects are not always quite so evident.
What is the significance and probable impact of the project?
I believe I was successful in my goal of providing medical care in Jesus name to the people of the Western Highlands Province in Papua New Guinea, gaining experience in the practice of medicine in a very resource limited setting, obtaining further knowledge of tropical and infectious diseases, witnessing how medical missionaries integrate their faith and practice and learning how culture impacts health and healthcare. I believe the significance of the project will be evident in my future work in medical missions, as this was a formative, invaluable experience, one for which I am deeply grateful.
How has this experience expanded your world awareness?
Having traveled to several developing countries prior to my trip, I was already intellectually aware of the need that existed in these types of places. But during my work in PNG, I was reacquainted with that need on an emotional, spiritual and experiential level once again. It is one thing for me to read the statistic that one woman dies of postpartum hemorrhage every four minutes. It was a very different thing to experience the gravity of this often preventable tragedy as I cared for the orphaned newborn. These types of experiences were almost daily. I was also introduced to the typical Melanesian world view, culture and values. As always, seeing the world through another’s eyes somehow enlightens my own view of the world.
Posted on
Wed, May 11, 2011
by snell