Return to Paradise
It is a requirement for vocational registration as a rural hospital doctor to work at least one week each year at another hospital. This year, I decided, I wanted to go back to Vanuatu, where I had worked for two years in the 1980s, and spend two weeks at Northern Provincial Hospital in Santo. More than 30 years after my first visit, I found that much had changed.
The island of Santo is the largest of the country’s 80 or more inhabited islands. It was named by the Portuguese explorer Pedro Fernandes de Queirόs, who established a settlement there in 1606. He believed the land he had discovered was the edge of the long-searched-for great southern continent, and called the island group La Austrialia del Espiritu Santo.
The American author James Michener was sent there as a war correspondent in 1940, to the country then called the New Hebrides, since renamed Vanuatu. He was stationed mainly in Santo, a major base for American and allied troops during World War II. While there, he wrote his first book of short stories, Tales of the South Pacific. He starts by writing about his surroundings:
“I wish I could tell you about the South Pacific. The way it actually was. The endless ocean. The infinite specks of coral we call islands. Coconut palms nodding gracefully towards the ocean. Reefs upon which waves broke into spray, and inner lagoons, lovely beyond description” (1) p.9.
The book was adapted by Rogers and Hammerstein into the musical, and later film, South Pacific. Michener was fascinated by the strange mix of cultures he encountered, especially the dual colonisation by Britain and France. He came back to the islands after the war to write Return to Paradise (2) and Rascals in Paradise (3), and went on to write more than 40 books selling over 75 million copies.
From Santo, Michener looked out to a high island in the east, often shrouded in cloud. Bougainville and Cook, and the early missionaries, called it Leper’s Island. The local name was Aoba or Omba, and is now Ambae. Michener called it Bali Hai. He imagined it as populated with beautiful women, mainly the daughters of expatriates in the New Hebrides at the time of the war, but it was also the site in the musical of the libidinous “coconut feast” with local Melanesian women, and of the fictional romance between Lieutenant Joe Cable and a Eurasian girl Liat, the daughter of the scheming Bloody Mary.
Back in 1983 and 1984, I found myself a job on Ambae, based at Lolowai, a former Anglican mission hospital at the eastern end of the island (4). Michener never went there, and it is a bit different from what he described, but it is indeed a special place, and working there as a doctor was a wonderful experience. Michener was right about the beautiful women. My wife, Joan, is from the island; her people have been in the area for thousands of years.
This year, the volcano in the middle of Ambae started erupting. The entire population of the island – numbering more than 10,000 – was evacuated, with people leaving behind their homes, schools, churches, possessions, food crops, livestock, and in some cases small businesses. But that’s another story.
We have returned many times to Ambae over the years to holiday and visit family. I have also been back to Vanuatu on other occasions. In 2015, we attended the Pacific Medical Association conference in the country’s capital, Port Vila. Another time, I worked as a volunteer doctor at Vila Central hospital. This time, it was Santo.
Santo, as compared with Port Vila, has a feeling of capacity and potential. It is becoming an increasingly popular tourist destination. The main town of Luganville has a wide main street, left over from the war. There are two bigger hotels in town. One is the Espiritu; the other is the Hotel Santo. We stayed at the first one. There are smaller less comfortable places. The Espiritu is a modern establishment, owned by a young couple, one of whom is a New Zealander, and comes complete with a big screen at the pool-side for watching All Black test matches.
The hospital in Santo is older and less well staffed than the one in Port Vila. There are four ni-Vanuatu doctors. One is a surgeon; one is a specialist anaesthetist, but works mainly in administration; the others are an obstetrician and a physician in training. There is one paediatrician from Papua New Guinea. For reasons that nobody understands, there is also a Chinese doctor working in each specialty. Most of the clinical work, especially in the emergency department and the non-communicable diseases clinic, but also including some low-risk anaesthetics, is done by nurses.
Most of the time at the hospital I worked with Dr Lawrence Boe. He is a medical registrar working towards specialist registration as a physician, but with no real opportunity for supervision. Lawrence is from Maewo, an island to the east of Ambae. I had visited his village regularly while working at Lolowai. He had been delivered by the nurse at the clinic there a few years after I left.
The first patient I met on the ward was a twenty-year-old girl who had come in the night before in status epilepticus. She had had life-long epilepsy but while on an outer island had been well controlled on Phenytoin dispensed by a nurse at the local dispensary. She had moved to Santo to a “custom village” where the residents had rejected the trappings of a Western life-style, and had stopped her medication. The seizures had been terminated in the hospital with intravenous Phenytoin, and she had been started back on pills, but was unhappy about remaining in hospital. She started calling out and having bizarre brief twitching of the left side of her body. In between times she was normal. We couldn’t tell by looking at her if these were seizures, or some odd behavioural episodes. Phenytoin levels are not available. While we were contemplating whether to increase her Phenytoin to more than her previous dose, or start another anticonvulsant, her father insisted on taking her home to the village to try traditional medicine. This would have consisted of a mixture of herbs and measures to combat magic spells. It may or may not have been more effective.
Next was an older woman who continued the theme of non-compliance. She had diabetes and had previously had a below-knee amputation. She and her husband had gone “to the bush” without her insulin, which up till then had been injected by her daughter. She had turned up at the hospital with hyperosmolar coma. The first two days we saw her she was aphasic. Once she regained the power of speech, she complained bitterly and constantly, mainly to us about not having a “fake” leg. She got into a heated discussion with the ward charge nurse, who told her she was “lazy” and not having an artificial limb was “just an excuse”. The woman argued that it was her family, who were sitting around her bed at the time, who were “lazy”, and not looking after her properly. The other patients in the four-bedded room, and their families, found all of this hugely entertaining, and kept laughing and interjecting. Eventually, a truce was called, and the woman went home.
After the ward round, we were supposed to see patients who returned for review. This did not always go to plan. The first day, six patients were booked for review. Only two of them showed up, but one of them had no records. The staff seemed relieved about one of the no-shows. She had been admitted two weeks before with chest pain and uncontrolled hypertension. She had written in her own notes about “too much noise” on the ward increasing her blood pressure, demanded a private room, then had locked herself in so that the nurses were unable to get in to do her observations. She did turn up three days later and was briefly reviewed by one of the doctors.
There has been a huge change over time in the pattern of disease in Vanuatu. When I worked at Lolowai, we had to work with the effects of communicable diseases, such as malaria, tuberculosis, filariasis and leprosy. Now, a little more than thirty years later, at least in the town, people have mainly non-communicable diseases. There is a huge burden of hypertension and diabetes, much of which is unrecognised or poorly controlled. Half of the patients on the ward had heart failure. They had presented at a late stage, which meant that treatment was mainly palliative, but Lawrence and the team did their best to manage them. To make things worse, there is no cardiac monitor, ECHOs can only be done in Vila, and pacemakers, angiography, and cardiac surgery have to be done for selected patients in Australia or New Zealand.
An additional problem with limited resource is that there is no public provision of physiotherapy or rehabilitation services. A young woman with paralysis from the waist down was discharged into the care of her family, with no additional supports available, and had to buy her own wheelchair. She probably had a transverse myelitis, but it is hard to say without the benefit of further investigations – there is no CT or MRI in the country. Amputations are common. Many people have poorly-controlled diabetes and present late with sepsis, which leaves few other options. The limb clinic has only one staff member, who does not have the materials to make or supply prostheses.
The country is moving from subsistence agriculture to a cash economy. People no longer grow all their own food. Starchy staples such as taro and yams, which are difficult to grow and prepare, are being abandoned for imported foods such as sugar and flour and white rice. It is easy to buy bread sticks and donuts in the shops. The change in life-style is obvious from the litter on the street. It is about a twenty-minute walk from the town to the hospital. The path is strewn with Coke, Sprite, Fanta and beer cans, lolly papers, biscuit wrappers, and cigarette packets. If archaeologists investigate the site in a few hundred years, they will have no difficulty determining how all the people died.
Towards the end of the first week, I met Dr Basil Leodoro, the director of medical services. He had been down to Port Vila to operate on three patients who could not be safely anaesthetised in Santo the previous weekend. We had an enjoyable lunch at the Espiritu. We have much in common. Basil is from Lolowai. My wife’s family are distant relatives. Basil knows a few of my colleagues in New Zealand and in other Pacific countries. Over lunch, we shared many memories, and some ideas about how we could do more things together in future.
Basil invited me to his house to drink kava with his father, Albert Leomala. This was not something to be turned down. I had fond memories of drinking kava with my father-in-law on Ambae. I had less fond memories of its unpleasant taste and its strange numbing effects. The actions of the drug are augmented by eating, sometimes to the extent that the recipient is unable to move. Once we had finished the kava, Basil dropped me back to my hotel, where I would be safe, with a parcel of food.
Albert had been born at Lolowai, but had moved to Port Vila a couple of years before I worked there. His father, also called Basil, had trained in Fiji, and came to work at the Anglican mission at Lolowai as one of the first indigenous doctors. Albert had become a teacher and was also an inspiring and influential poet. An early work (5), prior to Vanuatu’s independence from Britain, displayed a strong rejection of the colonising efforts of the Christian missions.
“Cross, I hate you
You are killing me.
You are destroying
I hate you Cross.
You thought you were clever
But you never thought
Of my cleverness.
Take your ideas
And your civilisation
And go back
Where you belong.”
Another poem (6) cleverly contrasted the previous two colonial administrations, with their two-word names for the country – New Hebrides or Nouvelles Hėbrides – and the proposed independent single government, with its choice of a one-word name: Vanuatu.
“Land of my fathers
Should I kiss you, or should I spit on you?
Should I spell you one, the black way,
Or two, the white way?
Forced to swallow
And money-sucking kangaroos?”
This was a man I had always wanted to meet. We talked into the evening of our different lives, of the connections between us, and of how I had come to marry Albert’s younger relative. I guess that makes me a lecherous kiwi.
I had time at the weekend for some tourist activities. On Saturday, I took a taxi out of town to one of the “blue holes” – fresh water springs in the bush naturally coloured by copper salts. On Sunday, I took a ferry to the resort on Aore Island, where tourists are happily imprisoned for a few days in seaside bungalows. The beach is kept in pristine condition by hard-working ni-Vanuatu men with rakes and wheelbarrows, and there are an unnaturally large number of tropical fish feeding on the dying reef.
Also on the ferry was Dr Yan Guowei, the physician on call for the hospital. Dr Yan spent three years in Tanzania prior to coming to Vanuatu, so he speaks a few words of English. His surgical and anaesthetic colleagues worked instead while in Africa in the francophone country of Cameroon, so attempt to speak in what the ni-Vanuatu doctors call “French” – using their fingers to indicate quotation marks – or “some French words”.
There are still a few French people in Santo left over from the colonial days. The country remains a popular destination for French tourists. A genuine French couple, Patrick Dancel and Cėcile Paintoux, from Tours, in the Loire Valley, run the excellent Aore Art Café (6). The food is good, and the view through the garden across the harbour is one of the best in town, but their real passion is photography, and they have travelled the world creating beautiful images. Patrick made a living in France selling pictures to doctors for their waiting rooms. Cėcile took the photo of Port Olry that I have used to illustrate this story, and gave me permission to use it for this purpose.
Our last evening on the island Joan and I spent at le Village de Santo, a resort on the edge of town, which sounds French, but isn’t. Strangely, the owner is Egyptian. To add some symmetry to our experience of the European occupation of the country, the restaurant is called 1606. It serves island food with a Portuguese or Spanish twist, and has interesting drawings of de Queirόs around the walls. It was a fitting end to our time on Espiritu Santo.
James Michener, writing in Return to Paradise, gets the last word:
“Of all the islands in the Pacific, Santo has made the most profound impression on me. There are lovelier islands, true, but the main reason why I like Santo is its zany life … I was sorry to leave” (2) p.215.
I was pleased to have again had the opportunity to visit the island and experience the strange mix of cultures that Michener and others have found so endearing. I got back on the plane to snowy Queenstown, happy to have had another opportunity to spend some time back in the country that has given me so much over the years.
– Trevor Lloyd
Trevor was born in rural Southland. He has been a GP and rural hospital doctor in Vanuatu, Central Otago and Northland, and now works at Dunstan Hospital in Clyde. He and his wife, Joan, have three children and live on a small farm near Bannockburn.
Image reproduced with permission © Cécile Paintoux, Aore Art Cafe and Photography
(1) Michener J. Tales of the South Pacific. London: Collins; 1947.
(2) Michener J. Return to paradise. New York: Random House; 1951.
(3) Michener J. , Grove Day A., Rascals in paradise. New York: Random House; 1957.
(4) Lloyd T. Rural health in Vanuatu. New Zealand Family Physician 1983; 10(4): 205-6.
(5) Leomala A. Cross. In Wendt A, editor. Some modern poetry from the new Hebrides. Suva: Mana; 1975.
(6) Leomala A. Land of my fathers. In Wendt A, editor. Some modern poetry from the new Hebrides. Suva: Mana; 1975.