Mathew Peck scholarship - Michael Nunan's report

This report is to serve as official documentation of my time in Vanuatu from late December, 2004 to late February, 2005 as part of the Mathew Peck Travelling Scholarship. Whilst not intended to be a 'journal' account of day by day activities this report nonetheless aims to give a feel for my roles during the trip, some background to the healthcare system of Vanuatu for reasons of contextualizing the experience and also offer some level of considered assessment as to the future direction of the scholarship itself.

It is worth noting first and foremost my utter pride and humility in receiving this scholarship. I have attended to as many aspects of it as possible with as much care and attention as I could reasonably have placed in a task. I see the future of the scholarship as a thing to be personally involved in and it is in that spirit that I have approached the entire experience. I have been extremely lucky, both in receiving this scholarship with its subsequent support, as well as in the timing of several events whilst here that I can honestly say simply put me in the right place at the right time.

To give some insight to the setting, Vanuatu is a country of roughly 200,000 people who live on around 80 inhabited islands. It is in the Pacific Ocean - east of the coast of Queensland - and it has a tropical climate that is as helpful for tanning as it is unhelpful for the storage and transportation of drugs. Adding to the difficulties of supply are the geographical constraints that become obvious as soon as one glances at an atlas. The abundance of small, volcanic islands means that supply of major orders is achieved almost exclusively by boat and the system can be unwieldy and unpredictable. It is the job of the Head Pharmacist of Vanuatu to oversee this supply and also monitor all aspects of drug usage in the country, such as the wider ramifications of medicinal trends and the monitoring of staff structure and competence, across the spectrum. Central Medical Stores supplies drugs and sundry medical equipment to every health facility in the country, though decentralisation of the process some years ago has eased the burden on this one facility.

The health system operates with a tiered system of Hospitals, Health Centres, Dispensaries and Aid Posts. These are staffed by a variety of medical officers, ranging from foreign specialist doctors to virtually untrained local aid post workers in villages. The Health Centres, Dispensaries and Aid Posts are supplied every two months, from provincial hospitals, which are in turn supplied by Central Medical Stores. There are several provincial hospitals around Vanuatu and 'decentralisation' was based around them - CMS will supply them and it is their responsibility to supply the facilities in their province.

Common diseases in the country include malaria, skin conditions (such as scabies) and a variety of infections, though so-called 'lifestyle diseases' such as diabetes, hypertension and asthma are also quite prevalent. You may also see some tuberculosis and tropical ulcers which you may find clinically quite interesting. The resources of the country are very thinly stretched and whilst huge efforts are made by many dedicated people to provide equality, the system of referral up the 'rungs' of the system can be slow and I personally witnessed problems, such as where people with serious infections simply arrived at hospital too late, resulting in fatalities. This also has to do with the fact that some people can be reluctant to present to hospital, unless their complaint is somehow impeding their daily activities and, of course, by this stage it can be too late.

I commenced my placement in late December, 2004 and was originally based at the Central Medical Stores (CMS), which are located at Vila Central Hospital in the capital, Port Vila, under the supervision of the Head Pharmacist, Amanda Sanburg. I spent a couple of weeks observing the processes of the CMS, including how health facilities do their ordering (i.e. how they are supposed to run their inventories and how they're actually run - much to the frustration of CMS staff!), how CMS conducts its own ordering, updating of their Essential Drugs List, storage, transportation and delivery, budgeting - the entire chain of supply. I was fortunate enough to be present when a 6 monthly order arrived - an entire shipping container's worth that staggered me moreover when I was told that it was a 'small order'. I installed the APP and the AMH on to new computers that were due to be sent out to the major hospitals shortly after my arrival. These programs were the result of donations from the two companies and represented a shining example of the generosity of such groups and the individuals within them.

During this initial time, I also worked in the hospital dispensary at VCH, taking a step away from the big picture and counselling, looking at stock management from the dispensary perspective, how their Imprest systems work within the hospital and the relationship they have with their supplier (CMS). And yes - the paracetamol syrup does come in 200 litre barrels! In fact, many of the experiences even in Port Vila required huge realignments in approach - such as the fact that syrups and suspensions are given out in recycled bottles that, especially on the other islands, the people are expected to bring themselves. So amoxicillin goes out in orange juice containers, bactrim in old bottles of Fanta. The ideals, however, of checking prescriptions, clinical decisions and patient counselling are all very much in practice and it is difficult - though extremely important - not to let changes in some aspects of your dispensing technique let you relax in other, more important areas. During this time, all of us were also fairly amused when a high ranking politician presented at the hospital with a broken hand, sustained in a fist fight - that occurred on the floor of Parliament!

After two weeks of all of this, with plans to travel to other areas pending, a huge opportunity came up to volunteer myself for a task. The pharmacy officer in Norsup, where the provincial hospital is one of the major 'satellite' centres for drug supply established during decentralization, was coming to Port Vila for further training. The man who was supposed to go and replace her could not get there in time - and in fact ended up pulling out altogether. The training program had been in planning for some time and its failure would have been a real blow to future educational initiatives. With no-one else available, I volunteered myself and after discussions and planning lasting all of 24 hours, I found myself running the third largest hospital pharmacy in Vanuatu, on the island of Malekula in Norsup. Malekula is an island without made roads that has one of the highest incidences of Malaria in Vanuatu. Norsup has one shop, a small Co-Op that does not have a fridge and I was placed in a room that was more like a prison cell with a hospital bed. The area is also largely Francophile, so that very few people can speak English and the island had been recently battered by a cyclone, the damage of which was evident over a wide area. Needless to say, the phones were unreliable at best and I was able only to speak to someone, on average, about once or twice a week. I had only three books and one of them was very ordinary.

In terms of experience, I'm not sure that I could have envisioned a better way to 'dive in the deep end'. I had to fill the orders for the surrounding health facilities, of which we averaged about 3-5 a day, run the Imprest for five wards in the hospital and dispense to outpatients, where we could process anywhere between 60 and 120 scripts a day. I had a young assistant, whose English was very poor, however he contracted malaria and thereafter his attendance was a bit unreliable - though I was far more sympathetic to his plight than some of the nurses, who expressed surprise that the malaria would keep him away for more than a couple of days! It was as steep a learning curve as I could have imagined and I was silly enough to mention to the cook at the hospital in my first couple of days that I thought island cabbage was 'quite tasty'. Thereafter, I was made to endure round after round of boiled island cabbage on rice, rationing out the one block of chocolate I had brought in an attempt to make the culinary situation bearable.

The clinical side at Norsup was also very satisfying - the hospital had run out of penicillin shortly before I' arrived and I had a great time working out antibiotic regimes, expanding my knowledge on malaria and getting over my initial reactions to tropical ulcers which I had initially reasoned must surely be gunshot wounds. The most humorous script I received (from a Med Student who arrived for my last few days) read 'Probable chest infection - you decide mate'. And so I did.

I can honestly say I wouldn't have traded a moment of it for the world. It is hard to describe many of the scenes and cameras proved themselves terribly inadequate mediums in my hands. Times ranged from paddling out on a canoe for a kilometer to the most beautiful island I have ever seen to go swimming, right through to watching as a doctor tried and failed to get an IV line into a baby boy who died shortly after of dehydration. I would spend several long moments during the night, especially initially, in a state of quiet shock, just sitting on my bed wondering how I'd found myself in this situation but at least as many longer moments staring at the most amazing sunsets over tropical rainforests, palm plantations, coral bays and tiny villages knowing my emotions would be impossible to describe.

After Malekula, I spent four days working in Luganville, on Santo - where I helped unload and check an order of 140 cartons that we took off the back of a tiny, old 'cargo boat', spent two days running the dispensary and generally did some odd jobs that timed well with the usual head of the dispensary on leave. I dispensed a large script for Ibuprofen that I raised my eyebrows over but eventually dispensed - to the relative of a man who had undergone a leg amputation just a few hours earlier. I stood on the hospital lawn on Friday afternoon, generally the most jovial time of the week in Vanuatu, and listened to the anguished cries, cutting through the hushed silence, of a woman whose husband had just died suddenly from an infection that had started from a simple tooth abscess and I wondered if I might, by good fortune, ever forget that sound as it floated over the grounds.

Back in the capital, Port Vila, I found my perception of what I had formerly considered a 'country town' had changed to an impression of a wonderland of luxuries. Due to initial plumbing problems, I had my first hot shower in over a month and ate a steak sandwich with embarrassing gusto. Back at the hospital, I returned to some of the initial projects I'd been set, albeit abridged versions owing to the unforeseen interruption. Encouragingly, Nicoletta's (from Norsup) training had started very well and Amanda was very happy that that had been allowed to occur. My return also timed well with the exams for the dispensing course that two of the employees at the CMS had been undergoing and I sat in on that assessment, helping from the 'patient's' point of view. As the year was progressing and schedules beginning to fall into swing, I was also able to attend Grand Round and Ward Rounds with the overseas doctors and it was great to see the professional relationship between the doctors and the pharmacist, who accompanied me on one such ward round - it was of definite benefit to the patients and a huge learning experience for me. I also spent some time in outpatients, where the Med Students from Australia are often responsible for first contact with patients, leading either to prescribing or referral - I offered my opinions regarding drug selection when asked, with great confidence, whilst gripping tightly to my AMH.

I can't go so far as to give myself any credit for finding myself in the situations I did in Vanuatu, as luck simply showed me a good hand far more often than I deserved. I was lucky to fall under the supervision of a wonderfully dedicated Head Pharmacist in Amanda Sanburg, who amazed me with her patience in the world of 'Vanuatu Time' and slow moving departmental funding. I worked with some of the nicest people in the world, in the Ni-Vans who made me feel incredibly welcome, happily showing me local sights and explaining local culture. I was lucky that the opportunities arose at the right times and that people like Amanda had enough faith in me to give me a go. I would like to think, however, that being prepared to put my hand up when required was a factor in my experiences, though I say this only as a suggestion to the recipients to follow me. Future nominees should be prepared simply to volunteer themselves for whatever they can, however crazy and scary it may seem at first. I honestly believe that the deep end is the best place to learn how to swim and as students we should be prepared to throw ourselves into that pool.

The future of this scholarship is not a foregone conclusion. It would be perilous to think that current enthusiasms were any guarantee of future support. The only thing that will provide ongoing success is a continuing dedication to promote international health and to strive for applicants who have an appreciation of that concept and for the importance of the scholarship itself. The scholarship must continue to stress its place within the framework of health development as a concept and in the future, this should be supported by appropriate curriculum in the pharmacy course.

I can provide very little by way of advice for future applicants. It is my fervent hope that, many years down the track, the recipients of this scholarship will have formed a long line of unique stories and wonderful experiences that they will be able to share with each other. In sharing my experiences, I hope I am only beginning the process. The committee overseeing the scholarship bears the responsibility to ensure they choose candidates appropriate to the role, though I feel at a loss to identify any one necessary characteristic. Perhaps more appropriately, successful applicants should simply try and stay faithful to themselves and the reasons they were selected.

More pragmatically, I also feel quite a lot would be gained from sitting down in a more formal sense with the successful applicant very early in the year to discuss timeframes with them and to give them a sense of some of the difficulties they may face establishing a placement. I was fortunate to have Greg Duncan as a sounding board throughout the year, without whom I would certainly have felt fairly rudderless at stages. It must be remembered, it is easy for the year to quickly slip in to second semester whilst we bend to tie our shoelaces in March, and August becomes late October very quickly. Some level of monitoring to make sure that their enquiries are progressing, whilst remaining mindful about being too intrusive in that supervision, can only be of benefit to any scholarship recipient!

I am grateful to the several hundred people who were involved with the fundraising and organisation of the trip. Especially, I am grateful to the Remedy group at the Faculty of Pharmacy and Pharmaceutical Sciences and the administration of Monash Parkville, Sarah Vincent and the Faculty of Pharmacy and Pharmaceutical Sciences Foundation, Greg Duncan, Amanda Sanburg, John Coppock and Marie Ritchie and the APP Company for providing me with drug software that is being installed on every available hospital computer in Vanuatu, the AMH for providing 15 text books and software for distribution to pharmacy officers throughout Vanuatu, my family and finally - and most importantly - the Peck family for allowing this wonderful tribute to Matt's amazing life to become a reality.

I was lucky enough to be friends with Matt Peck for what was an all too brief period of time. He was in my thoughts constantly in Vanuatu; inspiration enough to be able to say, 'What would Matt have done now?' and I was away. Amongst many, many lessons that I will never be able to appropriately communicate, this experience has affirmed for me some very clear concepts; I believe strongly in the place of pharmacists in International Health, I believe in the position of leadership the Faculty of Pharmacy and Pharmaceutical Sciences should play in this regard and I believe very firmly in the future of this scholarship as a cornerstone of that role - as well as a tremendous legacy to Matt's life.

It was an honor to be involved and I thank you for the opportunity.

Yours Sincerely,

Michael Nunan
2004 - 05