A couple of nice gigs

Sunday 26 November 2006
Sheffield Showroom 7 Paternoster Row, Sheffield, S1 2BX – 0114 249 5479 11.45-2pm.
Steve with Pete Moxley on piano and Graham Jones on double bass.
Don’t miss this one. The last gig at the Showroom was a great event. Lunch, friends, jazz – what more do you want on a grey November Sunday lunchtimeThursday 7th December 2006 – note Thursday this time
The Strand, Dale Road, Matlock 01629 584444
Steve at regular haunt playing cool and hot jazz.
Lovely restaurant. Booking recommended. 01629 584444

Open sesame. by Steve Salfield. October 2006

In 1970 a medical degree was a passport. A key to many doors. Medicine was, scarily, scarcely regulated. A doctor’s freedom to practice as he or she saw fit was sacrosanct and it was assumed that would be in patients’ best interests. Medical negligence and medical litigation were terms rarely if ever heard. Bureaucracy although already invented was, in retrospect, in it’s infancy. The National Health Service had not been reorganised – not even once.
After passing finals I was required to spend a year in hospital practice as a junior houseman, nominally under supervision, and then was free to practice in whatever field or place would employ me. Doctors were in short supply so there was ample choice.
One evening at the end of my houseman year in Newcastle upon Tyne, standing next to me at the bar of the Medical Institute a genial elderly doctor sipped his malt whisky. He was a general practitioner as it transpired, with a practice just around the corner from my home. I overheard him saying to his drinking partner that he needed a holiday but couldn’t find a locum.
“I’ll do your locum for you” I said flippantly, and introduced myself.
“Fine, start on Monday morning” said Dr Black.
I was concerned for the doctor and his patients at his casual way of appointing staff so I asked him whether he would need some evidence that I was qualified and suitable for the job.
“Oh I suppose I should” he said, “what are the green and black tablets?”
“Librium” I said, naming the ubiquitous tranquilliser of the time.
“That’s all you need to know. The job’s yours” he laughed.
On Monday morning in a side street I found Dr Black’s neglected brass plate on a scruffy brown door next to a small sweet shop. I climbed the steep stairs to the surgery. You had to be fit to be a patient in this practice. In the large dingy waiting room twenty or thirty people sat and behind her desk was small, plump, white haired Mrs McTaggart the receptionist. She was a friendly, motherly woman and showed me into the small shabby consulting room which contained a large oak desk and chair and two hard backed upright chairs. There was no toilet, wash basin, or examination couch.
Pale green peeling paint swung towards me as my first patient entered through the squeaky door. I had a sensation of adventure into the unknown. This was to be my first clinical encounter outside the protected environment of the large Victorian hospital building with mile long corridors and Florence Nightingale wards, which had been my training ground. This felt very different from working in the hospital. I felt exposed. Would I be able to deal with the problem with no advice from a registrar or consultant? No nurses. No equipment. Just me and the patient and this room. I ventured outside to ask Mrs McTaggart for the patient’s records.
“Oh Dr Black doesn’t really bother with those” she said. “He knows all of his patients. But there is some correspondence in that cardboard box over there under the table”.
The people I met were friendly, respectful, sometimes deferential and unquestioning of my ability. I was the doctor after all so I had the answers. Most patients wanted repeat prescriptions – black and green tablets or more of the purple tonic that had no active ingredient but made them feel so much better. The little white lie, now obsolete, since full information, honesty and informed consent robbed the placebo of its effectiveness.
I thought I was learning general practice quite quickly. I took a brief history from each patient and made notes as I had been taught in medical school. I even tried to prod or peer at the problem part of the body without the benefit of an examination couch or getting the patient to undress. I suppose I was spending five to ten minutes with each patient. After a couple of hours I realised that the waiting room was still full and that some people had already been waiting for two hours. At morning coffee time Mrs McTaggart was looking a little anxious so I asked her how Dr Black could cope with such a large number of patients in a session.
“Well” she said “He comes into the waiting room in the morning and counts how many people are waiting. Say there are thirty, he says to them, “there’s thirty of you and I’m here for an hour so that makes two minutes each.”
I was beginning to suspect that this type of general practice was not the pinnacle of quality that I, still young and idealistic, aspired to. But I soon discovered that his patients adored Dr Black.
“He’s a wonderful, kind Doctor” they would say, “If he thinks there’s anything at all wrong with you he sends you straight to the hospital”.
This was the kind of GP we young hospital doctors, perhaps arrogantly, used to despair of. The type who wouldn’t take any responsibility and clogged up the hospital system with unnecessary “rubbish”. Yet here I was seeing it from the other side of the hospital doors and the patients loved and valued him.

“Locum GP for three months wanted for the small town of Towawa, Saskatchewan, Canada” said the ad in the BMJ.
“Good pay and all expenses paid”.
I sent off a letter of application and a few days later the phone went at six in the morning.
“It’s Bill Jiaomeng and I want you to come as soon as possible. I need a holiday.” said the voice in English with a strong French accent. It appeared that appointment procedures in Canada were no more rigorous than in Newcastle but that is where the similarities to my previous post ended.
A few days later as I flew across the Atlantic at someone else’s expense, well dressed and with a smart new briefcase, I felt, self importantly, that I must have something special to offer. I spent a night in Montreal which seemed a very suave modern city. Next day I caught the internal flight to Regina in Saskatchewan where Dr Bill Jiaomeng was waiting for me. He was an enormously fat Chinese man who had spent his early life in Mauritius and later moved to the UK. He and his young family now lived in the sticks in Canada. I later learned that he spent most afternoons on the phone to his stockbroker. He wined and dined me before we drove the two hundred miles of Saskatchewan prairie and parkland in his large Buick. Towawa was a small Canadian “town” with a population of five hundred and another fifteen hundred farming people living in the surrounding area. A village in reality, it had one street with a few stores and a few scattered wooden or fibro houses. The next day Bill handed over to me his house, his cars, his premises, the small hospital and then he was gone. Perhaps I had overstepped the mark this time. I had been qualified eighteen months and now I was in the back of beyond in charge of a hospital and the only doctor for two thousand people was me! The nearest other doctor was fifty miles away and if I wanted to send someone to hospital it was a two hundred mile drive or in an emergency a flight.
This was indeed a new experience for me. Next morning as I walked down the wooden sidewalk past the stores, the bar, sherrif’s office and the funeral parlour, to the doctor’s office I felt I was in a movie set for a western film.
“Hi Doc” said the cowboy as he got out of his truck at the hardware store.
After doing the ward round with matron in hotpants in the modern twelve bedded hospital, I spent a few hours seeing patients in the well equipped doctor’s office with an efficient appointment system, an examination room and a smart nurse receptionist.
That night, my first night on call in Canada was the night of the graduation ball at the local high school. At three in the morning I received a call to go to an automobile accident on the highway. Two kids were killed and two were injured, one with a fractured pelvis and multiple other injuries. I certified the dead and resuscitated the living before an ambulance took them the 200 miles to Regina hospital. I was in the deep end but fortunately that was the worst disaster I had to deal with in Canada. Finding that I was coping, I was gaining confidence and thoroughly enjoying being a proper family doctor in the old fashioned sense. I delivered a baby, set many fractures, sutured lacerations, did minor surgery and saw many people with general medical illnesses. I reduced a dislocated knee joint, a very rare injury and fitted intrauterine devices (which I had even been trained to do). I began to feel that I was a competent doctor. When I had my first patient with appendicitis I had to call Dr O’Leary from Greenfield, fifty miles away as two doctors were needed for major surgery.
“Do you want to do the operation or the anaesthetic?” he asked.
Never having done either before, this brought home to me how theoretical and lacking in practical experience my training had been. I opted for the anaesthetic. The operation was successful and what’s more the patient survived.
I heard about the GP in a nearby town who enjoyed appendicectomies and the accompanying fee. Anyone he saw with bellyache had their appendix taken out. When there were no more appendices in the area he moved into the next state and started the task of removing the population’s vestigial organs and filling his own coffers.
This was proving an epic teach yourself practical medicine experience for me with the local population as my learning material. As far as I know I did no harm and the patients and nurses seemed to like me. Even though I was inadequately prepared for what I was doing, I felt justified because I was the only doc in town. If I didn’t do it no one else could.
After the appendicectomy, I suggested a drink back at Jiameng’s.
“Yes. let’s drink Jiameng’s whisky” said Dr O’Leary, a garrulous Irishman who seemed good humoured enough. I hadn’t yet discovered that he was on the wagon and that I was about to start him on a binge of drunkenness which was to last for months. Over the next few weeks I received many calls from Dr O’Leary’s secretary asking me to cover his practice as “Dr O’Leary was “unwell” that afternoon”. I met him several times and discovered that his good nature was intermittent and that he also had black moods and a biting wit at times.
Once a week I drove in Jiaomeng’s Buick to the next little town to do a clinic. This really was the wild west. Farmers and cowboys and their families would drop in to see me with their complaints. These people were old fashioned and stoical and showed huge respect for the doc. I also had the privelege of visiting some people in their homes.
I and my twenty six year old wife were invited to homes for barbecues. We spent weekend afternoons at the lake, boating and swimming in hot summer weather. We spent one unforgettable evening at the home of an eccentric German veterinarian, Baron von Hagen, who clicked his heels and saluted when we met. He kept an index card system with details of everyone he met. His wife was away and after dinner he put on soft music and insisted on dancing cheek to cheek with my wife while I sipped schnapps and plotted how to escape from what I feared was an ex nazi war criminal.
I thought this was a grand life. My wife had the use of Jiaomeng’s second car, a convertible, Dodge. She was invited to play tennis and socialise with the local ladies – a mixed blessing for her. She learned of the high suicide rate of doctors’ wives in these small prairie towns, presumably related to boredom and social isolation. She soon talked me out of any ideas of this way of life in the longer term. She had her own career to develop and was not the type to be a professional “doctor’s wife”. She was writing a book and was happy to spend a summer working here but the Canadian winters were hard with snow and ice for six months. After three months in Towawa and a short stint working for Dr O’Leary we left Canada to tour the USA.
My appetite for novelty was stimulated and shortly afterwards I travelled to the other side of the world to Papua New Guinea.
The door to an even more exotic experience was opening.

Aftermath – cargo cults and treatment failures

It was seven o clock in the morning on the seventh day of the seventh month of ninenteen seventy one. In the cool early hours of the morning thousands of local village people had made the arduous climb through the forest to the summit of Mount Turu in the Sepik District of Papua New Guinea (PNG). At the summit were two concrete triangulation posts which years earlier had been placed there by an American geographical survey team. The villagers were all paid up members of the Peli Association, a cargo cult. They believed that at this auspicious time, they should remove the Americans’ concrete posts and the mountain would open and disgorge for the membership masses of cargo, a term for manufactured western goods, and money. Crops would flourish where they had recently failed, birds of paradise would return in plenty and the members would be rich.
The big man of the area, Mathias Yaliwan was the leader of the Peli Association. Yaliwan had been preaching for many years that Peli members would be rewarded on this date when the mountain would open and be full of cargo. To become a member entailed buying “shares bilong Jesus Christ”. The cult grew to huge proportions and eventually most people in the area joined. Even educated local people, though sceptical bought shares, not wanting to risk missing out. The disappointed members were not refunded their subscriptions and thousands of dollars were unaccounted for. Yaliwan, who was quite possibly a sincere man later became a member of the national parliament.
Of course there were those who realised the impossibility of the prediction. The European expatriates were worried that they would be accused of conspiring with God and Jesus Christ to prevent the local people from getting their cargo so they themselves could profit. This concern proved unnecessary. Some of the Europeans understood that uniquely complex cross cultural dynamics had led to this bizarre situation. However some redneck Australian administrators and businessmen considered the local people to be lazy “bush kanakas” who wanted something for nothing by subscribing to this corrupt organisation rather than working hard.
What was the background to the social aberration of cargo cults? The people of PNG had been more or less isolated from the rest of the world for thousands of years until contact with Europeans started in the late nineteenth and early twentieth century. Then Christian evangelical missionaries started to arrive, but for years made contact with only a tiny minority of the people. Tribal warfare made travel impossible for most people and many had no contact with the outside world except for neighbouring tribes, who were often dangerous enemies, until the mid twentieth century or later. In the 1970’s I met tribes whose first contact with outsiders had been seven years earlier.
After World War one a League of Nations declaration made PNG a protectorate of Britain who delegated the role to Australia. In the first half of the twentieth century most people still lived a stone age traditional village life of subsistence agriculture and hunting. Their homes were built of wood and palm leaves. The men hunted with bows and arrows and spears and used stone axes to chop down trees while the women worked in the vegetable gardens using wooden tools. Neither the wheel nor flights for arrows had been invented.
Gradually a few imported axes, saucepans and the like were acquired from missionaries or bought from trade stores.
Later a Westminster style national government was introduced to govern the country of 700 tribes with 700 languages, most of whom were living literally in the stone age.
In Melanesian societies status was gained through giving and the big men tended to be those who were able to give most. Melanesians believed that their ancestors spoke to them in dreams and could come back to life bringing gifts. Some came to believe that missionaries and other white people were reincarnations of their ancestors.
The missionaries of course taught that the people should believe in the Christian God and thatJesus Christ was the son of God and that traditional pagan icons should be destroyed. Christianity was difficult to reconcile with traditional religions, which consisted of ancestor worship and belief in spirits which had to be placated in order to ensure good harvests and safety from enemies.
Soon after the white people came to live amongst the Papua New Guineans, enormous ships and planes started to arrive disgorging amazing cargo such as radios, cars, refrigerators, beer, and many other things which had never before been seen. These were out of context and the people had no concept of how they could be produced by humans. The goods were destined for the white people and never for the local black people. Some of the local people put two and two together and began to believe that the goods were sent to the white Christians by God and that if they became Christian they too would receive shiploads of cargo. When the goods failed to arrive for the black people, some began to believe this was a conspiracy by the whites. But some local leaders developed large followings when they predicted that the ancestors would send ships and planes with goods for the local people. These beliefs were known as cargo cults.

The superimposition of a twentieth century western culture on a stone age society produced a situation ripe for misunderstandings at an interpersonal level and also at a national level. In his autobiography “Ten thousand years in a lifetime” the then minister for health the late Sir Albert Maori Kiki graphically described the immense personal cultural conflicts and difficulties in his transformation from a child in a stone age village, through missionary school, training in Fiji as a health worker and finally becoming a Westminster style politician and a cabinet minister.
During the three years I spent as a doctor in Papua New Guinea in the 1970’s I often encountered situations in which I had made unconscious assumptions based on my western background only to discover that the people I was relating to had a very different way of viewing the same event.
At the end of a day of hospital clinics and wardrounds, Joseph, a hospital porter who had been friendly with me said he wanted to talk. I invited him for a beer and we sat in my tropical garden under the Frangipani tree, the gentle waves of the South Pacific breaking on the coral reef a few yards away. We chatted in New Guinea pidgin and after a few polite preliminaries he asked me what money really was and where it came from.
“Long wonem yupela Europeans kisim dispela mani na yupela inap baim planti cago na mipela kisim liklik mani tasol?”
How was it that I and other Europeans were able to get plenty of money and buy goods, whilst the New Guineans only got a small amount of money. He wanted me to explain the source of the coins and notes so that he could obtain more for himself.
I tried to explain that money had no intrinsic value but was merely a token paid for services, that my skills as a doctor were rarer and more in demand by the government than his as a porter and so I was paid more money and could obtain more expensive cargo. As I explained I became acutely aware of the limits of my own understanding of economics.
Joseph listened politely and asked questions. After I had explained as clearly as I could he said that this was a very interesting story but now would I give him the true explanation of where the white people got money from. Clearly he believed that the whites had secrets we were unwilling to divulge thus preventing the local people from obtaining wealth. He had no concept of factories producing goods or mints producing coins. Money and goods were given to the white people probably by God or gods and ancestors sending them to the country by ship.

Each morning I would stroll along the breezy point of land projecting into the south pacific and which was the grounds of Wewak Hospital. The basic wood-built hospital was well maintained by the Australian administration and supplies and equipment were adequate. The nursing staff were mostly Papua New Guineans but matron in charge was Australian. The four doctors were, like me, expatriates.
One morning I arrived on the ward to do the rounds. By chance I went into a side room and found a desperately ill old man lying in the bed. I hadn’t been told about this tribesman who spoke no pidgin or any language in common with the hospital staff. I started emergency resuscitation.
When I asked how long he had been in the ward and was told he had been there for about three days and had received no treatment I became rather angry and incredulous. How could it be that a very ill man in hospital was not seen by a doctor for three days and received no treatment? Moreover it seemed that this would have continued had I not entered the room by chance.
The old man died and I tried to discover what had happened. Gradually I understood from Isaac, the charge nurse, that the man was from a tribe which was a traditional enemy of the tribes of most of the nursing staff. There was a feeling that it would be no bad thing if the man were to die. This event was pivotal in my awareness that my own, often unconscious assumptions, did not always hold true in another society.

Today it is recognised that even severe dehydration in children can be safely treated with rehydration by mouth using the correct electrolyte solution. In the 1970’s dehydrated children were treated with an intravenous infusion and there was great emphasis on the correct amount of fluid to avoid under or over hydration. Often the intravenous needles for the infusion would become displaced from the vein and need to be replaced. Every evening in the children’s gastroenteritis ward in Port Moresby we had a ward round to ensure that the night nurses understood the treatment for each child.
One morning I came to the ward and found that the young nurse who had been on duty overnight had placed the displaced needles not into the children’s veins but had run the fluid into the mattresses rather than into the children’s veins.
I was completely puzzled by this apparently strange behaviour. It became clear that the Papua New Guinean nurse had misunderstood me the European doctor. I had emphasised the importance of the level of the fluid in the infusion bottle, assuming that it was obvious the fluid needed to go into the child. Unable to resite the needles correctly into the veins, she was satisfied to get the fluid to the correct mark in the bottle by whatever means. This seems impossible to us with all our assumptions about medical treatment and our background of a western education but it reflects a completely different cultural background.

A middle aged man who had his initial treatment for pulmonary tuberculosis in hospital improved, stopped coughing blood and was stronger. I advised him to go back to his remote village for his eighteen month course of treatment to be completed at the local health aidpost.
A few months later he returned to hospital complaining that he was again coughing blood. X rays confirmed that the disease was producing new cavities in his lungs and sputum microscopy showed that many tubercle bacilli were again present. His treatment card showed that all the right boxes were ticked three times each week indicating to me that he had received all his treatment. My initial thought was that his TB had become resistant to the drugs, a problem which was starting to emerge in the early 1970’s but was rare in the Sepik district of Papua New Guinea.
On further enquiry I discovered that although the man had been to the aidpost three times a week and the aidpost worker had ticked the boxes, no treatment had been given. It seemed that the aidpost had run out of the medicine and the orderly had not been to town to collect more. Later when I discussed it with the aidpost orderly I discovered that he thought the most important thing was to tick the boxes to show that the patient had attended even though the medicine was not given. Maybe there are some lessons for the UK’s health service where important government targets can be met by massaging waiting lists even though no more patients are treated.

Although we westerners do not understand all the causes of diseases we have an underlying assumption that they have a biological or a psychological basis. When I went to Papua New Guinea as a 26 year old doctor I was unprepared for the beliefs about illness held by the people who would be my patients.
All disease was believed to be caused by poisoning or “sanguma” either by angry spirits or by enemies. If it was found that the sanguma was caused by an enemy then revenge would be appropriate especially if the person died of their illness. One night in a village next to the Sepik river, I sat up all night with the village people in the “haus tambaran” or spirit house. A child had died following an illness. The people were gathered in the haus tambaran and the elders and important people were engaged in heated debate, singing, shouting, crying and wailing all night while they tried to determine which spirit or which enemies had been responsible.
Often one could tell the location of a patient’s symptoms by numerous small cuts or scars over the area. The traditional doctor had cut the skin with a sharp stone or a knife to let out the spirits causing the illness. If this did not work the patient would come to the hospital to try western treatment. Sometimes I was very frustrated after my treatment was starting to be effective when the patient would one day disappear. I was told that because they had started to improve they had gone back to the village for the village doctor to complete treatment using their traditional methods.
I believe that the presumption that others are thinking in the same way as oneself, whether within one’s own cultural group or in another, leads to conflict, either interpersonal or on a larger scale. Perhaps awareness of differences in thought processes would avoid some of the horrific problems caused by misunderstanding.