When I was offered the opportunity to work in Papua New Guinea (PNG), I wondered why MSF wanted to send me to a remote Pacific island where there is no war or recent natural calamity. Being a first-timer with MSF, I wondered whether it was a joke on me. I wanted to know more about the place. When I sifted through the literature on PNG, the phrase which glared at me from every tourist brochure was “Expect the unexpected”. I found out in no time that it was true.
© MSF The MSF Tari medical team with traditionally dressed
Huli wigmen.
On landing in Port Moresby, I wanted to know how far it was to Tari, my work destination. But nobody seemed to know. Then I found out that the capital city does not have any road connections to Tari, to any of the highland areas, or to Lae, the second largest city in PNG. There is no point in talking about distance when you do not have the roads to measure it.
On my first morning in Port Moresby, I was woken up by shouts from the street. A young man was being beaten up by some tough looking guys before managing to run away. Later I found out that he was the son of a local landlord and was being beaten up by the landlord’s men. I heard that the landlord had more than 14 sons, by several wives, and was alleged to have killed one of his sons. This was my first taste of domestic violence PNG-style.
The next day I left for Tari. I was to travel by a small propellerdriven aircraft, and I made the unwise decision of sitting by the window to watch what was happening outside. People were walking about as though they were in an amusement park. One guy was resting in the shadow of the plane. Another was playing with the propeller blades. . But the plane flew properly and landed at Tari airport, which was more like a green field than an airport.
At Tari, I saw a big crowd outside the wire fence enclosing the airport. They had come to receive two dead bodies which had arrived from Port Moresby by the same plane in which I had travelled. As I boarded the MSF van which had come to receive me, there was a big commotion outside. There was a clash between two groups of people come to claim the bodies and people were running here and there with long knives. To avoid further violence, the bodies were taken back to the airport. Before leaving for PNG, I was told that people here fight over land, money, pigs and women; now I learnt they fight for dead bodies also.
People in the highlands are fairly isolated from each other as the roads connecting different areas are very poor. Some people did not arrive at the MSF hospital until a few days after receiving grievous injuries, saying they had problems with transport. One of the workers in the hospital walked a few hundred kilometres over a week to go to his mother’s place and come back. Because of the inaccessibility and the culture of violence here, outside agencies are very reluctant to provide any type of services, including health services. Interestingly, even the native people living in other parts of PNG are averse to the idea of coming to work in Tari.
PNG has more than 800 spoken languages. People in one tribe cannot communicate with other groups because they do not understand each other’s language. One of the most common languages is called Tok Pisin, which has its roots in English, German, Portuguese, Malay and local languages. We used the national staff as translators when interacting with the patients, but even this did not work out sometimes as the staff did not understand all of the individual languages that patients spoke.
PNG is in a region highly vulnerable to earthquakes. It is part of the Pacific ‘Ring of Fire’, where 90 percent of the world’s earthquakes occur, and which is also home to 75 percent of the world’s active and dormant volcanoes. When I asked the local Tari people about earthquakes, they said they do not usually feel them during the daytime, as they are engaged in work, but sometimes feel them at night. I asked a nurse what she does if tremors occur, and she said she closes her eyes for a few minutes and the tremors disappear. No major damage has happened so far in this area, so people do not bother much about it. Sometimes landslides occur following tremors as it is mainly a rainforest area. The buildings here are usually built with wood and light materials – even if they collapse, I was reassured, they do not cause much damage.
Once I felt tremors at about 11.30 pm which woke me from sleep. I saw that nobody ran out and there was no disturbance outside. I did not want to create a nuisance by running outside. Just as the locals said, l closed my eyes, and it worked: the tremors stopped after about two minutes. Then I went back to sleep. The next day some hospital staff asked me whether I felt the tremors. Otherwise nobody seemed to give a second thought to it.
The shops in Tari are built like high-security garrisons for fear of violence. People cannot access the seller or the commodities freely. They have small windows for making transactions. The only exceptions are the roadside vendors who sell cigarettes and betel nuts, and the weekly open air market. Tari has very few shops and there is very good scope for new shops. If you are open to a bit of risk,, you can set up shop here and do lucrative business.
© MSF Figure The interesting tree kangaroo
The most interesting animal in PNG is the tree kangaroo. A long time back, when Australia and PNG were one land mass, they had a common species of kangaroo. After the land masses separated, the kangaroos in Australia became terrestrial and in PNG they became tree dwelling. They are the size of a large rabbit, but look and behave like kangaroos in every other way.
When you walk along the road in Tari, you see a number of men carrying ‘bush knives’, which are sword-like knives about three feet long. They do not seem to hesitate to cut each other with these knives. Sometimes you see adolescents and schoolboys carrying them. We are told not to stare at them and, if possible, to smile and shake hands with them. Then they become friendly with us.
The amount of violence and brutality in the Tari area is beyond anybody’s reason. It broadly falls into two groups: domestic and tribal violence.
© MSF At a Huli gathering.
With tribal violence, the reason is often trivial or old enmity, at least as seen with my outsider’s eyes. They fight with bows and arrows, spears, bush knives, axes, country-made guns and even stones. Suddenly we get a spate of cases with arrows piercing patients’ chests, abdomens or some other part, and we have to do emergency surgery to save their lives. Sometimes, these patients say their enemies are around the hospital seeking to finish them off. We put some of them in the ‘isolation ward’ where access by unauthorised people is controlled. Once in a while, some grievously injured men disappear at night. We learn they have run away to the forest with their wantok men [people from same tribe and language-group] to escape from their enemies who are waiting around the hospital to kill them. Weapons are banned inside the hospital campus. Still, once in a while we see people strutting inside the hospital with bush knives and we call the security guard to clear them.
© MSF Huli men on a ritual procession, armed to the teeth.
With domestic violence, the victim is commonly a wife, chopped with a bush knife by her husband. The injury can be anything from cut-off fingers, hands or legs to multiple fractures and intraabdominal bleeding due to kicks. Some women die on the way to the hospital. You also get brothers chopping their brothers or sisters, and uncles and aunts chopping each other. We also get cases of women stabbing their husbands, women stabbed by their sisters-in-law or their husbands’ other wives, women assaulting other women with stones. The brutality is such that multiple fractures and deep injuries which can cause death are common.
We wanted to meet some of the tribal people native to PNG, and visited the Huli wigmen. They showed us their way of life and the articles they used. We saw the bows and arrows and the spears they fight with. What was surprising was the polished stones which they used as weapons – either independently or as part of a weapon with a wooden handle like an axe or knife. It was a rude shock to realise that primitive Stone Age implements were still in use in these areas.
© MSF Patients and attendants relaxing in the lush green
Tari hospital campus.
Surgeries are done under various anaesthetic techniques including regional blocks, spinal anaesthesia and general anaesthesia, depending on the nature of the surgery. All general anaesthesia is usually based on ketamine with some diazepam, narcotics etc, and oxygen enhancement with oxygen concentrators. When people need laparotomies or thoracotomies, mostly due to violencerelated injuries and gut perforations, we induce with ketamine, do endotracheal intubation and ventilate manually with bellows. I had only ever seen these manual ventilating bellows, used 70 or 80 years ago, in books on the history of anaesthesia. This technique is used in MSF projects in the most remote places where high-tech equipment cannot be brought in or, more importantly, where the regular maintenance of such equipment is not possible. One of the major constraints in adopting modern anaesthetic techniques is that a steady supply of oxygen and nitrous oxide cylinders, which are essential for present day anaesthetic work, is simply not possible in these remote areas.
While I was in Tari, I anaesthetised more than 400 patients, and in none of these cases did we undertake investigations such as blood sugar, urea, ECG or X-ray, because these facilities were not available. To a person like me who has spent decades in high-tech tertiary hospitals with extensive pre-operative investigative workout, it was a very different experience. I have attended lectures on ‘anaesthesia in field situations’ by various eminent anesthetists of high standing, but those lectures now look silly and superficial compared to the field work I was doing.
The local milieu I was living in and my professional work started giving me the impression that I had gone back in time and that the outside world I had left was ages ahead of me.
I also developed a new perspective on what a doctor is. In urban centres, our success is usually measured by the money, name and fame we earn; the good service we do becomes secondary. But in Tari, the situation was entirely different. MSF’s Tari hospital is the only place in the entire district which can do lifesaving surgeries and give critical care to the people who need it. People with potentially lethal injuries to the chest, abdomen or other parts, with abdominal perforations, and pregnant women with obstructed labour all rush to our hospital for intervention, the only option available to them. The surgeries we do are lifesaving: without them they would be bound to die. One national staff, a nurse, became emotional and broke down during one such surgery. She started talking nonstop, saying, “You MSF people are like angels from heaven. Before your arrival these people would have been sure of death…” We were forced to stop her rant as it was disturbing our work.
This MSF assignment gave me a new identity, self-worth and satisfaction as a doctor which I did not get in my decades of professional work.
– Azhar Hussein
