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A WORLD OF DIFFERENCE
175
The Student
Speaks
WHAT DID WE
DO?
Rabaul is the capital of New Britain, one of the most volcanically active islands in the Pacific. Colonised in the A WORLD OF DIFFERENCE 1880s by German missionaries, who described the people " R. A. LUCAS as incorrigible savages ", and since the late war under Australian administration, the town remains a prosperous R. E. JENNER MEDICAL STUDENTS cosmopolitan port, the centre of a large copra trade. Owing to the risk of volcanic disturbances, the hospital ST. MARY’S HOSPITAL MEDICAL SCHOOL was built five miles from Rabaul in a delightful setting by "Travel, in the younger sort, is a part of education."—BACON the sea. We had imagined a simple native-style building THE headman’s words obviously had no effect. During with crude amenities. In reality the hospital was a comthe night all the men in the village deserted, leaving us plete antithesis to this preconception. The clean, modern with no bearers for the medical patrol. It was vital that buildings accommodated over 300 patients in comfortable we left without delay, because the rivers were swelling wards. Air conditioning was provided in operatingfrom the recent rains. Our health survey was taking us theatres, pathology laboratory, and X-ray department. through 90 miles of tropical rain-forest to remote villages, Built only six years ago and costing almost EA1,000,000, to be approached only by crude native tracks. Sitting it serves as the central hospital for over 150,000 people silently around us, and gazing apathetically at our gear, throughout the region. were those villagers who had not absconded, mostly The hospital is staffed mainly by Australians, with a women, children, and the elderly. We were not sure specialist physician, surgeon, and gynxcologist, besides whether they could carry the formidable loads, but after the non-specialist medical officers. A few Australian some brisk bargaining we persuaded them to take our nurses run the wards, which are largely staffed by indiequipment. genous trainees. In the out-stations, where we spent We had come to do a year’s voluntary medical service several weeks, the nursing staff consisted mostly of in New Guinea. What were our motives, and how did we " doktor-bois "the local medical orderlies. manage to spend a year abroad whilst undergraduates ? At first we felt doubt of our usefulness because our Our adventure started on a drab afternoon after a medical knowledge was so slight. As assistants to the registrar’s teaching-round. He told us he was going to overworked surgeon and physician, each supervising about 80 beds, we gained insight into the local pattern of disease, learnt the language, and then, more important, interested ourselves in the people themselves. At Nonga we were well received by the staff, who had occasionally been visited by Australian medical students in the long vacation. We were given the run of the hospital, and we assisted at operations, attended ward rounds, and discussed the diseases we saw. After three months, because of shortage of staff, we were asked to run the outpatients and casualty department. At the start of this new role, the responsibilities seemed frightening. To admit, or not to admit ? To which ward ? With what diagnosis ? For what investigations ? These fears quickly vanished in the bustle of a department seeing about 100 new patients daily, of whom 6 might need to be admitted. When not working in outpatients we spent Nonga Base Hospital, Rabaul. time following up cases in the wards and helping out work in New Guinea and he suggested that there might where needed. The scope was almost unlimited; under be splendid opportunities and much work for two students supervision we were able to do a great many procedureswith some clinical training. The idea appealed instantly. such as lumbar puncture, paracentesis, intravenous We wanted to go out and work in an emerging country, pyelography, and barium-meal examination. We saw where we thought the medical knowledge and personal a wide range of disease; and in outpatients we were able to experience to be gained would be immensely valuable. Since the abolition of National Service, we felt that something was lacking in our education-a break from the academic walls1 of school and university. It was at this time that Voluntary Service Overseas (V.S.O.) was conceived, and the reason for its inception was obvious. With help from a consultant at St. Mary’s Hospital and with the encouragement of two other students who had spent the previous year abroad, we placed our services at the disposal of the V.S.O., who kindly accepted the responsibilities for our travel. We were also fortunate in that the public health department of New Guinea agreed to sponsor us while we were working in the Territory. Our education grants were put into abeyance for one year and we set off for New Guinea. On our arrival in Port Moresby, the capital, it was decided to send us to Nonga Base Hospital, Rabaul. 1.
Beck, P., Foster, D. Lancet, 1963, ii, 730.
The staff, including six
"
doktor-bois ", of Namatanai Hospital.
176 seek advice and then treat the patient accordingly (most modern drugs were available). Regular visits from Australia by specialists-for example, a cardiologist and an ophthalmologist-enabled the staff to discuss patients who needed an expert opinion. The diseases we saw were as varied und (to us) exotic as the flora of the islands. Malaria, leprosy, elephantiasis, yaws, and ankylostomiasis were endemic, and we had a chance to see kuru (probably a genetic disease peculiar to New Guinea) and necrotising jejunitis (possibly a rare form of food-poisoning). All these were set against a background of pneumonia, chronic bronchitis, tuberculosis, and cor pulmonale-those diseases which fill British hospitals. We never ceased to be amazed at the powers of endurance of the islanders, especially in the face of acute septic and traumatic conditions. Lack of communications between village and hospital often meant a journey of two or three days, part of which would almost certainly be made on foot, so that by the time the patient reached hospital the disease was advanced and the physical signs very striking. Clinical signs were very important, since history-taking was an exacting process, often involving two interpreters (there are more than 500 languages in the territory), and it might be quite useless, since the islanders often had no real idea of time 01 the importance of events. Apart from our work in outpatients, a number of other duties came our way. We found ourselves giving lectures on first aid and rudimentary tropical medicine. In the evenings we sometimes went with the sister from the Red Cross Transfusion Service to stock the blood-bank by collecting in the villages under the hissing light of Tilley lamps. Here we saw and talked to the people in their own homes. Now and then an emergency would mean an overnight voyage to the trouble spot: rioting amongst native plantation workers, a pneumothorax from a spear wound, an
explosion on a fishing trawler, one dead, one seriously injured. Once by light plane to collect a man stabbed in the stomach after a quarrel over ownership of the weapon. Occasions like these impressed on us what can and should be attended to on the spot, and which matters can wait. For a time we found ourselves running outstation hospitals (of about 40 beds) as a result of staff shortages (in New Guinea the patient/doctor ratio is 25 times greater than in the United Kingdom). Here life was totally different, more what we had expected in Rabaul, and quite removed from anything we had experienced before. The community consisted of a handful of Europeans leading quiet and easy lives in their microcosm apparently oblivious of the world outside. We had to do everything ourselves-X-rays, blood examinations, gram-stains, tooth extractions, paying the staff, organising stores and supplies, and, of course, ward rounds. Regular radio contact was maintained with Rabaul, and in a surgical emergency we could request evacuation of the patient by air to the base hospital. Preventive medicine was part of the health programme, and here we were able to help by routine medical patrols. The aim was not only to inspect the population for disease bur to encourage improved hygiene in the villages. This was not easy, since deep-rooted superstitions and ignorance
have first
to
be
overcome.
Although the people themselves were unsophisticated, prophylactic measures (to safeguard their health) were by no means primitive, as, for example, in the vaccination of remote island populations against measles. This is cer-
tainly one of the first times adults have been given measles vaccine. Furthermore, this was the first time that these islanders had had a medical examination, which, besides measurement of height, weight, and heemoglobin, included a clinical examination, and an examination of stools and urine.
Blood
was
taken to
the measles antipurposes. Again, con-
measure
body titre and for ethnological current anthropological studies proved indispensable, particularly when examining the population figures. The results of the original field work in which we took part have yet to be analysed. Living on a small leaking trawler for a month, with a tropical ulcer on one’s toe; specimen bottles containing tea, coconut juice, and rainwater, all supposedly urine; and meals of giant clam and turtle meat, consumed while watching Polynesian dances, left colourful impressions. IN RETROSPECT
It is difficult to
assess the value of this experience or surmise what effect it may have on our future. The mass of clinical material, seen under the guidance of specialist doctors, provided us with a medical students’ Utopia. The informal and friendly atmosphere encouraged frank discussion of medical problems; and easy access to the pathology laboratory enabled us to correlate the clinical condition with the pathological changes-a synthesis rarely achieved in our normal medical education, even to
except during necropsies. Responsibilities allotted to us increased our eagerness to learn (from the well-equipped hospital library), and by heuristic methods in outpatients we quickly became confident of our clinical findings. Many people have asked us whether a year away from medical school is too long. Bearing in mind that three years’ clinical study is the minimum required for final M.B., and that the journey there and back was almost 30,000 miles, we would say " no ". Student clerkships abroad are valuable to some extent, especially in countries where the English language is spoken. But three months is not sufficient time to learn a language, nor understand the culture of a race completely different from our own-an understanding of paramount importance to medical workers trying to bring better standards of hygiene to a primitive community. What was in fact gained ? The amount gained depends on the enthusiasm put into the undertaking. In the situation we found it would have been hard not to be zealous. None the less, a previous knowledge of basic clinical medicine is necessary, for there is little to be gained by a preclinical student versed only in anatomy and physiology. We feel that at least one clinical year should have been completed before such an expedition. We returned with a far greater practical knowledge of medicine, perhaps beyond the horizon of final examinations, yet the privilege of assisting in original field work, organising a medical patrol, or conducting a mass vaccination campaign are complementary to medical education. The meta" morphosis from the near " doctor-status we were given in New Guinea to medical student again has not been as our
difficult as we imagined. Not for one moment do
we suggest that every student Some abroad. have no desire to, others spend year may have obligations that prevent them. But, those students who go can make a rewarding contribution and gain abundant experience. We should like to thank Dr. R. F. R. Scragg, Director of Public Health, Konedobu, New Guinea; Voluntary Service Overseas, who made this venture possible; and the Dean of St. Mary’s Hospital for allowing us to go. a
The Student
Speaks
WHAT DID WE
DO?
Rabaul is the capital of New Britain, one of the most volcanically active islands in the Pacific. Colonised in the A WORLD OF DIFFERENCE 1880s by German missionaries, who described the people " R. A. LUCAS as incorrigible savages ", and since the late war under Australian administration, the town remains a prosperous R. E. JENNER MEDICAL STUDENTS cosmopolitan port, the centre of a large copra trade. Owing to the risk of volcanic disturbances, the hospital ST. MARY’S HOSPITAL MEDICAL SCHOOL was built five miles from Rabaul in a delightful setting by "Travel, in the younger sort, is a part of education."—BACON the sea. We had imagined a simple native-style building THE headman’s words obviously had no effect. During with crude amenities. In reality the hospital was a comthe night all the men in the village deserted, leaving us plete antithesis to this preconception. The clean, modern with no bearers for the medical patrol. It was vital that buildings accommodated over 300 patients in comfortable we left without delay, because the rivers were swelling wards. Air conditioning was provided in operatingfrom the recent rains. Our health survey was taking us theatres, pathology laboratory, and X-ray department. through 90 miles of tropical rain-forest to remote villages, Built only six years ago and costing almost EA1,000,000, to be approached only by crude native tracks. Sitting it serves as the central hospital for over 150,000 people silently around us, and gazing apathetically at our gear, throughout the region. were those villagers who had not absconded, mostly The hospital is staffed mainly by Australians, with a women, children, and the elderly. We were not sure specialist physician, surgeon, and gynxcologist, besides whether they could carry the formidable loads, but after the non-specialist medical officers. A few Australian some brisk bargaining we persuaded them to take our nurses run the wards, which are largely staffed by indiequipment. genous trainees. In the out-stations, where we spent We had come to do a year’s voluntary medical service several weeks, the nursing staff consisted mostly of in New Guinea. What were our motives, and how did we " doktor-bois "the local medical orderlies. manage to spend a year abroad whilst undergraduates ? At first we felt doubt of our usefulness because our Our adventure started on a drab afternoon after a medical knowledge was so slight. As assistants to the registrar’s teaching-round. He told us he was going to overworked surgeon and physician, each supervising about 80 beds, we gained insight into the local pattern of disease, learnt the language, and then, more important, interested ourselves in the people themselves. At Nonga we were well received by the staff, who had occasionally been visited by Australian medical students in the long vacation. We were given the run of the hospital, and we assisted at operations, attended ward rounds, and discussed the diseases we saw. After three months, because of shortage of staff, we were asked to run the outpatients and casualty department. At the start of this new role, the responsibilities seemed frightening. To admit, or not to admit ? To which ward ? With what diagnosis ? For what investigations ? These fears quickly vanished in the bustle of a department seeing about 100 new patients daily, of whom 6 might need to be admitted. When not working in outpatients we spent Nonga Base Hospital, Rabaul. time following up cases in the wards and helping out work in New Guinea and he suggested that there might where needed. The scope was almost unlimited; under be splendid opportunities and much work for two students supervision we were able to do a great many procedureswith some clinical training. The idea appealed instantly. such as lumbar puncture, paracentesis, intravenous We wanted to go out and work in an emerging country, pyelography, and barium-meal examination. We saw where we thought the medical knowledge and personal a wide range of disease; and in outpatients we were able to experience to be gained would be immensely valuable. Since the abolition of National Service, we felt that something was lacking in our education-a break from the academic walls1 of school and university. It was at this time that Voluntary Service Overseas (V.S.O.) was conceived, and the reason for its inception was obvious. With help from a consultant at St. Mary’s Hospital and with the encouragement of two other students who had spent the previous year abroad, we placed our services at the disposal of the V.S.O., who kindly accepted the responsibilities for our travel. We were also fortunate in that the public health department of New Guinea agreed to sponsor us while we were working in the Territory. Our education grants were put into abeyance for one year and we set off for New Guinea. On our arrival in Port Moresby, the capital, it was decided to send us to Nonga Base Hospital, Rabaul. 1.
Beck, P., Foster, D. Lancet, 1963, ii, 730.
The staff, including six
"
doktor-bois ", of Namatanai Hospital.
176 seek advice and then treat the patient accordingly (most modern drugs were available). Regular visits from Australia by specialists-for example, a cardiologist and an ophthalmologist-enabled the staff to discuss patients who needed an expert opinion. The diseases we saw were as varied und (to us) exotic as the flora of the islands. Malaria, leprosy, elephantiasis, yaws, and ankylostomiasis were endemic, and we had a chance to see kuru (probably a genetic disease peculiar to New Guinea) and necrotising jejunitis (possibly a rare form of food-poisoning). All these were set against a background of pneumonia, chronic bronchitis, tuberculosis, and cor pulmonale-those diseases which fill British hospitals. We never ceased to be amazed at the powers of endurance of the islanders, especially in the face of acute septic and traumatic conditions. Lack of communications between village and hospital often meant a journey of two or three days, part of which would almost certainly be made on foot, so that by the time the patient reached hospital the disease was advanced and the physical signs very striking. Clinical signs were very important, since history-taking was an exacting process, often involving two interpreters (there are more than 500 languages in the territory), and it might be quite useless, since the islanders often had no real idea of time 01 the importance of events. Apart from our work in outpatients, a number of other duties came our way. We found ourselves giving lectures on first aid and rudimentary tropical medicine. In the evenings we sometimes went with the sister from the Red Cross Transfusion Service to stock the blood-bank by collecting in the villages under the hissing light of Tilley lamps. Here we saw and talked to the people in their own homes. Now and then an emergency would mean an overnight voyage to the trouble spot: rioting amongst native plantation workers, a pneumothorax from a spear wound, an
explosion on a fishing trawler, one dead, one seriously injured. Once by light plane to collect a man stabbed in the stomach after a quarrel over ownership of the weapon. Occasions like these impressed on us what can and should be attended to on the spot, and which matters can wait. For a time we found ourselves running outstation hospitals (of about 40 beds) as a result of staff shortages (in New Guinea the patient/doctor ratio is 25 times greater than in the United Kingdom). Here life was totally different, more what we had expected in Rabaul, and quite removed from anything we had experienced before. The community consisted of a handful of Europeans leading quiet and easy lives in their microcosm apparently oblivious of the world outside. We had to do everything ourselves-X-rays, blood examinations, gram-stains, tooth extractions, paying the staff, organising stores and supplies, and, of course, ward rounds. Regular radio contact was maintained with Rabaul, and in a surgical emergency we could request evacuation of the patient by air to the base hospital. Preventive medicine was part of the health programme, and here we were able to help by routine medical patrols. The aim was not only to inspect the population for disease bur to encourage improved hygiene in the villages. This was not easy, since deep-rooted superstitions and ignorance
have first
to
be
overcome.
Although the people themselves were unsophisticated, prophylactic measures (to safeguard their health) were by no means primitive, as, for example, in the vaccination of remote island populations against measles. This is cer-
tainly one of the first times adults have been given measles vaccine. Furthermore, this was the first time that these islanders had had a medical examination, which, besides measurement of height, weight, and heemoglobin, included a clinical examination, and an examination of stools and urine.
Blood
was
taken to
the measles antipurposes. Again, con-
measure
body titre and for ethnological current anthropological studies proved indispensable, particularly when examining the population figures. The results of the original field work in which we took part have yet to be analysed. Living on a small leaking trawler for a month, with a tropical ulcer on one’s toe; specimen bottles containing tea, coconut juice, and rainwater, all supposedly urine; and meals of giant clam and turtle meat, consumed while watching Polynesian dances, left colourful impressions. IN RETROSPECT
It is difficult to
assess the value of this experience or surmise what effect it may have on our future. The mass of clinical material, seen under the guidance of specialist doctors, provided us with a medical students’ Utopia. The informal and friendly atmosphere encouraged frank discussion of medical problems; and easy access to the pathology laboratory enabled us to correlate the clinical condition with the pathological changes-a synthesis rarely achieved in our normal medical education, even to
except during necropsies. Responsibilities allotted to us increased our eagerness to learn (from the well-equipped hospital library), and by heuristic methods in outpatients we quickly became confident of our clinical findings. Many people have asked us whether a year away from medical school is too long. Bearing in mind that three years’ clinical study is the minimum required for final M.B., and that the journey there and back was almost 30,000 miles, we would say " no ". Student clerkships abroad are valuable to some extent, especially in countries where the English language is spoken. But three months is not sufficient time to learn a language, nor understand the culture of a race completely different from our own-an understanding of paramount importance to medical workers trying to bring better standards of hygiene to a primitive community. What was in fact gained ? The amount gained depends on the enthusiasm put into the undertaking. In the situation we found it would have been hard not to be zealous. None the less, a previous knowledge of basic clinical medicine is necessary, for there is little to be gained by a preclinical student versed only in anatomy and physiology. We feel that at least one clinical year should have been completed before such an expedition. We returned with a far greater practical knowledge of medicine, perhaps beyond the horizon of final examinations, yet the privilege of assisting in original field work, organising a medical patrol, or conducting a mass vaccination campaign are complementary to medical education. The meta" morphosis from the near " doctor-status we were given in New Guinea to medical student again has not been as our
difficult as we imagined. Not for one moment do
we suggest that every student Some abroad. have no desire to, others spend year may have obligations that prevent them. But, those students who go can make a rewarding contribution and gain abundant experience. We should like to thank Dr. R. F. R. Scragg, Director of Public Health, Konedobu, New Guinea; Voluntary Service Overseas, who made this venture possible; and the Dean of St. Mary’s Hospital for allowing us to go. a