Happy new year

The first of January 1973. New year’s day and I woke with a feeling of keen anticipation. Every day I was learning new and fascinating aspects of the unique environment I was living in and I looked forward to a new year of discovery.
I had the day off work so thought “let’s go for a picnic.” Five degrees south of the equator there is no contradiction in a picnic on new year’s day.

I was twenty six years old and was revelling in what was happening to me. Only six weeks earlier I had arrived in the large open sided hangar which was Port Moresby’s airport and encountered sounds, smells and sights which were completely unfamiliar to me.

Papua New Guinea. I towered above the lively excited crowd, many of whom wore traditional dress. Women carried their babies and their loads on their backs in string bags called bilums, suspended from their head by a long carrying strap. Men and women had bright red mouths stained by chewing betel nuts with white lime powder and mustard sticks. People shouted excitedly in Motu and in Pidgin – Balus i kam pinis long Australia – The plane has arrived from Australia. Short, stocky Melanesian highlanders dressed with leaves over their backsides known as arse grass and carrying their umbrellas, looked uneasy in this modern environment. There were tall, blue black Bukus from Bougainville and elegant Polynesian islanders with red hibiscus flowers in their hair. There were beautiful people from New Britain with their fair skin and blonde hair and graceful Papuans from Hanuabada. There were groups of Australian expatriate businessmen and public servants in shorts and long socks meeting colleagues and families from Brisbane. A uniquely vibrant arrival hall.

I was working in Port Moresby Hospital as a paediatric registrar under the inspirational guidance of Dr John Biddulph.

My learning curve was a vertical straight line. In six weeks I had looked after children with malaria in all it’s manifestations like cerebral malaria and blackwater fever, I had treated children with kwashiorkor, marasmus, tuberculosis, leprosy, severe dehydration, meningitis, severe measles, hookworms, roundworms, anaemia, encephalitis, pigbel, nephropathies, filariasis, neonatal tetanus, and the list could go on and on.
I had learned the crucial importance for babies of breast feeding and the disaster that bottle feeding can be in unhygenic circumstances.
I had learned to communicate in basic Motu and Pidgin English but as there were more than seven hundred languages in the country there were patients who could communicate with no one in the hospital. I had learned that other people may have a very different perception from mine, that a nurse from one tribe may not always have the best interests at heart for a patient from an enemy tribe. I had found that many people believed that all illness was caused by poisoning by enemies or by angry spirits.
Coastal people would be miserable if they didn’t have sago to eat whereas highlanders must have their sweet potatoes. I knew how to treat snake bites, stone fish stings, arrow wounds, spear wounds, pig tusk injuries and shark bites. I knew the signs that a witchdoctor had previously treated the patient. I had learned to accept that a patient from out of town would have several guardians sleeping under the bed or in the hospital grounds.

Papua New Guinea was largely unknown territory at that time – that is unknown to Europeans. A million highlanders had been “discovered” by westerners only forty years earlier. Many areas had not yet been explored by Europeans. Cannabalism and headhunting were probably still practised in remote areas but Port Moresby the capital was developing. Driving through the town to the hospital I was moved by the beauty of the turquoise blue Coral Sea, the white coral sand beaches, the colourful people. But there were squatter settlements, and poverty and serious crime was already becoming a problem.
I had been warned that although most of the people were friendly and peaceful there were rascals who would rob and rape and that one needed to be careful about where one went and how one behaved.

My young wife, Jacquie, had arrived from England to this amazing place only a few days before Christmas. I suggested a drive and a picnic on my day off in my newly acquired but battered and well travelled Holden estate. There were few roads but I had been told that Brown River was a good picnic spot about twenty miles away. As we drove through the steaming tropical jungle along a dirt road we met the sounds of parrots and strange tropical birds. Huge cassowaries the size of ostriches strutted their stuff. We passed small traditional thatch villages where friendly people waved and offered drinks of coconut water. We felt excited and slightly nervous, as this was our first encounter with such exotic surroundings.

After driving for an hour or so through this stunning tropical newness we knew we must be approaching Brown River. Rounding a bend in the road there was a slight descent and the wide muddy river was in sight. There were still a few hundred yards to drive when we became aware of a blood curdling yodelling sound of many voices. Then running up the road towards us from the river was an approaching army of a hundred armed warriors, their bodies smeared in mud from the river. They carried spears and axes and bottles of beer. They were fast approaching and my heart was fast sinking. We were vulnerable in this tropical jungle and were about to be massacred by a warparty of cannabalistic headhunters. We hadn’t seen another car or another westerner since we left the capital. There was no help. I reversed the car with my right foot flat on the floor, desperately looking for somewhere to turn so we could escape.

But it was too late, the crazed war party was upon us. We were surrounded. They were shouting and screaming war chants and waving their weapons threateningly. Their eyes were glazed and bloodshot from the combined effects of alcohol and betel nut. They were smearing the car and the windows in mud, completely blotting the view through the windscreen. They were banging on the metal with their fists and shouting all the time. We were totally at their mercy.
Intense fear was now another new experience to cap all the others I had encountered in recent weeks.

But no windows were smashed with those axes. The car wasn’t being damaged, only smeared. Some of the men were smiling and laughing.

Suddenly it dawned on me.
Perhaps – this wasn’t quite as bad as I had feared.
The words they were shouting.
Happy new year! Happy new year!

Culture shock

I was dismayed when Ryan was brought back to the hospital in relapse again.
I was a trainee paediatrician, a registrar, recently returned to the UK from Papua New Guinea. I felt that some of the agressive medical treatment that was given to children with life threatening illnesses was pointless, unkind and unwise.
Young Ryan had suffered bravely from leukaemia for the last thirteen months. He had spent at least half of that time in the children’s ward and the ward staff all knew him and his family very well.
The small pale twelve year old child was completely bald from the effects of chemotherapy. His arms were scarred from numerous intravenous infusions. He was psychologically damaged, just accepting that the trauma of painful procedures and separations from his family was his lot in life.  His illness had separated him from his friends and disrupted his life in school in the London suburb which was his home. The adults around him didn’t know how to talk to him about the things that were really important and the child didn’t ask. Why was he having all these painful injections and yet he was still ill? What exactly did his illness mean? Was he going to die? What was death like?
Ryan’s parents, good people, everyday people, were not prepared for the way their lives had developed. Like most parents they had never contemplated the possibility that after marrying and having children their lives might be devastated by illness, and perhaps even more by the treatment. Decisions about treatment were made by others and they did not have the information or opportunity to question the decisions or to consider disagreeing with them. But they knew that things were not going well. Their little boy was having nightmares. He was miserable and cried a lot at home. He was unwell and listless. He didn’t want to play with his brother or his friends.
They dreaded him going into hospital. He would be hurt physically and he would be so distressed and unhappy. But they considered this was all necessary and in Ryan’s interests because this was what the doctors recommended and because they hoped his disease could be cured. They couldn’t face the dreadful prospect of losing their beautiful child. It seemed unreal and so unfair.
They had their lives to get on with. Trevor, Ryan’s father had to continue working as an electrician or the family would fall into debt. Shirley, his mother, continued with her part time job and looking after Sean, Ryans’s eight year old brother. No one really had time to consider what was the effect on Sean of Ryan’s illness and the huge amount of parental time and attention it demanded.
There was no counselling or discussion with the family about these things. The consultant haematologist and the staff on the leukaemia unit were expert in applying the most up to date treatment. But no one had a holisitic caring role to consider and advise whether all the treatment which was medically possible was likely to do good in the long run. The hospital team knew that Ryan would die soon from his illness but there was no discussion amongst the consultants and nurses, let alone his family, about the pros and cons of continuing active treatment to the end. It was the formula for leukaemia in relapse and therefore it was applied.
After several more days of painful drips, injections, bone marrow tests, lumbar punctures and misery, Ryan died. Trevor and Shirley were grief stricken. Sean his brother didn’t show much emotion. The nurses who had spent so much time with Ryan were distraught and some went to the funeral.
I felt confused. I didn’t share these emotions. This was a tragedy for Ryan’s family but not for me. I wanted to help them but did not feel the pain which they were suffering. I could switch off and I went home and had an enjoyable evening as any other evening.
For some months I had felt that the treatment Ryan was getting was futile and cruel but as a trainee I was not in a position to take the decisions. When he died I felt relief that the young child would not have to go through any more trauma.
In Papua New Guinea, at the age of twenty seven years, I had been one of five doctors for a population of two hundred and fifty thousand people. In London the same population had at least five hundred doctors. In Papua New Guinea I had seen many many people die of illnesses which could have easily been treated successfully if the infrastructure had been available. In the hospital there the doctors and nurses were used to the sadness of child deaths which were an every day event. The infant mortality rate was high and families were used to tragically losing their children.
I could not rationalise that such intensive and probably futile effort had gone into trying to save Ryan’s life when people I knew were not even getting basic health care. Ryan’s death was terribly sad but why should it command so much grief when life in other places seemed so cheap? I could not come to terms with these paradoxes.
Why should I feel more sad about the death of one child in London than one child in Papua New Guinea? I could not afford to be emotionally involved in every death that I had witnessed in Papua New Guinea or I would have been swamped and emotionally paralysed.
Was one life in London so much more important than a hundred lives a few hours flight away? Not to me. In Papua New Guinea death was accepted as an inevitable part of life. In London it seemed to me that death was not acceptable and that any quality of life, no matter how tortured was deemed to be preferable to death. I didn’t agree. Was I callous and uncaring because I wasn’t distraught about Ryan’s death? I  had no answers to these apparent contradictions but I felt aware of double standards and moral imbalance.
I was in culture shock and wasn’t prepared for life and work in London.

I booked my ticket back to Papua New Guinea.

The names and details in this article are fictitious.

Plastic teeth

A week ago our medical team was chased away from the village near the coast. Angry, dangerous looking men threatened us with spears and bows and arrows.

Later when tempers had calmed some of the team carefully approached the village again.
The villagers were angry and frightened because they thought we were a family planning team entering their compound. In 1985 some of our Kenyan people believed that family planning teams would kill or steal babies and small children. Many men didn’t want to use birth control anyway. They liked to have several wives and wanted plenty of children to look after them in their old age.
When we explained that we were a medical research team, not a family planning clinic, the village leaders agreed to listen to what the team leaders had to say and arrangements were made to return the next day with the full team.

The following morning, early, before the sun was too hot, the truck was loaded up with specimen pots, blood taking equipment, weighing scales, height measuring stadiometers, medicines, examination couches and all the other gear for the clinic. The doctors from England, the enthusiastic paediatrician, the fierce parasitologist, the trim nutritionist, and the African technicians and nurses all piled in. We crossed the Kilifi river on the trusty old ferry, bought freshly roasted cashew nuts from the riverside vendors, and the long drive up the coast road began.

This time when we arrived in the village although the reception wasn’t exactly friendly we were not threatened.  The day was hot and dry and the drive had been dusty. After we drank some coconut water the white paediatrician stood up under a large shady mango tree. The elders, men and women, sat quietly in a group on the ground under another tree at a safe distance of ten or fifteen yards. An excited group of younger women sat separately. A few older children played around the mud and wattle houses but the young children and babies were kept safely out of the way.
The white doctor speaking in very bad Swahili went through the ritual he had learned. Jambo. Habari. Salamat. The elders nodded.
Then through the lips of the interpreter he said that we wanted to help the people by finding out more about malaria, schistosomiasis and the other diseases that affected them and we hoped to find better treatments and vaccines. But first we needed to know more about which diseases were the main problems in the area and so we needed to examine the people and take specimens of blood, urine and faeces. He said we would see any sick people in the village and give them treatment.

After some heated discussion amongst the elders the big man of the village stood up to speak and the interpreter translated for the foreigners. Politely he welcomed the team to the village and apologised for the previous day’s attack. He said that the elders were interested in what the doctor had said but that there had been no mention of their main health problem which was that many of their babies were born with plastic teeth. The village people were very worried about this. The government was doing nothing about it and the local medicine men were removing plastic teeth from most of the babies in the area. This was done in the early months otherwise the babies became sick at around six months of age with diarrhoea and vomiting and many died. The villagers wanted to know why this was happening and what could be done to prevent the problem.

The foreign doctor was puzzled but we local health workers of course knew that village doctors were removing milk or deciduous teeth from under the babies’ gums saying they were plastic teeth. We thought this belief had started some years earlier in Uganda and had spread. People did not understand that it was normal for babies to have unerupted teeth under the gums. They believed that infant teeth started to grow only at the time they appeared through the gums.
Many babies had severe infections or bleeding after the operation and some died.
Of course the real explanation for the many babies who died at about six months of age was gastroenteritis caused by bottle feeding which was often introduced at that age. The foreign doctors and we African health workers said these teeth were normal and not the cause of the babies’ illnesses but the villagers of course didn’t believe us.

Three days later I was walking along the village road in the morning with my baby Margaret, feeling very scared. The rest of the team drove past and when they saw me they stopped the truck and said “Hey Nurse Elizabeth where are you going with your baby?” I was ashamed and didn’t tell them where I was going. But I could tell they knew. Well of course we all knew that the plastic teeth epidemic was based on a myth. We health workers taught that all the time. But I knew that most of the team had had their babies’ teeth removed to be on the safe side, just in case the medicine men were right. I was terrified that my baby would get sick after the operation. But what else could I do? I couldn’t afford to take any chances. If she died at six months and I hadn’t had those teeth removed, I could never have forgiven myself.