Angaur

Updated: Nov 23, 2020

Once a month a team from the Palau hospital ventures out to one of the remote islands in the Palau archipelago know as Angaur. They do a variety of different things each time they go. Sometimes they do general checkups, other times they administer vaccines. Last Thursday a boat departed on a cold raining morning heading to Angaur to do cancer screening for prostate and cervical cancer.


A couple days before Vanessa and I got invited to tag along if we wanted. I jumped on the chance to break the already redundant routine at the hospital. We were told very little before we left, we only knew it was about a three hour boat ride, and we would possibly be sleeping in some kind of clinic. We assumed things like food and water would be taken care of, we turned out to be only semi correct.


When we got to the dock it was raining with no signs of letting up. There were 15 of us going in total and about 10 of the women were clustered around some of the gear we were taking not looking very enthused about the impending boat ride. It turns out they were actually debating about cancelling the trip because apparently our boat captain had never been out to Angaur, or had never navigated in rough seas, not sure which one, maybe both. The boat finally pulled up and it was a shell of the boat I thought it would be. It had a fiberglass hull and could sit maybe 8 or 9 people comfortably, there was a canopy for rain, but it wasn’t much, it didn’t matter anyway as the rain likes to come down sideways here. For two hours I sat there curled over my backpack inside my green poncho trying to stay warm and dry. I learned that it wasn’t really that waterproof after all.


The clinic we were working at was right next to the dock, it was no more than a couple random 2-3 room buildings by the sea. The town itself was a intermesh of backstreets that cut through the jungle housing around 200-300 people. I got mixed reviews every time I asked how many people lived there. The only one thing I got was that there are 23 families on Angaur. As we sat on the dock an ambulance approached to pick us up, you have to pretty much let an western idea you have of an ambulance go to understand this thing. It was some kind of minivan from maybe the early 90’s with two folding benches in the back that could comfortably sit about 5 people and lay someone down on the floor. There was of course a working siren and light. I kept thinking, but never asked what they would do with an ambulance here. Where are they taking someone besides down the street to a clinic that has no supplies and is usually ran by a nurse practitioner. The ambulance took us to a house were all 15 of us would be sleeping, it was a decent size ranch with about 3 bedrooms, naturally there were mattresses scattered everywhere.


The clinic was run out of both buildings, female exams in one, while the other was going to be used to question the males about prostate cancer and STI screening. Naturally the male side was only staffed by males and vice versa. We set up a series of tables were patients would come in have their history taken, get blood drawn for Prostate specific antigen, pee in a cup to screen for STIs, etc. Lastly they would come see me off in a separate room where I would ask a series of yes or no questions that addressed prostate cancer risk factors. Some where pretty personal like does it hurt to get an erection, or can you still get it up, while others were basic like how many times a night do you pee. Most of their English was pretty good, but of course the one word they didn’t understand was erection. I resorted to charades, making my finger limp then straight while saying “during sex?” They understood this, but I found it much easier to learn the palauin word for erection which is Deorse, bringing my vocabulary to two words. I’m not sure what kind of native conversation I can have if all I know how to say is erection and thank you, or at least I don’t want to imagine the conversation.


During these questions I noticed some actual pathology a couple of times and attempted to play doctor rather than erection linguist. One guy had some simple contact dermatitis which I gave him, or to my disbelief sold him a tube of hydrocortisone cream. Another guy was complaining of shoulder pain. It turned out that it was actually coming from his neck and his left arm was starting to go numb in the pattern of one of the nerves. This can happen if any of the tunnels that your nerves travel through going from your spinal cord to there final destination are narrowed. It suggested that this guy might have a real neck injury that could get much worse and might have some permanent nerve damage if not careful. Once I discovered this I knew the text book answer about what needed to be done next, what imaging he should get and what other fancy tests and drugs to give. But, I was on Angaur, we had Advil and the best diagnostic machine we had was limited to the sensitivity of our fingertips. The guy of course didn’t want to go to Koror where he could have got maybe half the tests he needed, for the other half and possibly surgery he would need to be shipped to Manila. So I did what I could, instructed him to take the highest dose of Motrin, use warm compresses (he did have some real shoulder stuff going on as well), and that if it got any worse he had to take action for himself, I did my best to scare him. Outside of that I had nothing to work with. I’ve learned that the lesson is always the same and it stretches from the jungles of Nicaragua to some lonely Island in a tropical paradise. No matter how much advancement are made in Beaumont hospital in Texas or what new procedure is thought of at Methodist in Houston, most of the third world will never experience such care. The true challenge we face is not advancing technology or our puppeteering of drugs, but figuring out how to spread existing treatment and technology across the globe. Access to health care, be it New Orleans or Palau is and always will be the paramount world health issue.


After the clinic was over at 5pm there was a break before the women’s side opened up again to see if any women came in after work. Everyone was hanging out and some of the nurses told the story how they had a problem with sex education in Palau because they used to show people how to put on condoms in school by using bananas, much the same way they do at home. I guess something was lost in translation because kids started thinking all they needed to do before having sex was to put a condom on a banana which I guess they then put by the bedside. It wasn’t until they hired one of the local wood carvers to build a carving of a penis that they could use in sex Ed. I guess there aren’t too many carvings of penises in the grocery store, so the message caught on.


For dinner that night people from the village brought us traditional Palauin seafood that had a wide variety of edibility. There were crab cakes, whole crabs, rainbow runner fish, fresh tapioca, and some other things like sea cumber bathed in vinegar I didn’t quite get.

That night we all got in the party ambulance and went to the one local bar. The place was more of a fabricated patio then a bar. It was a small slab of wood about 30x30 feet that someone had just built that could function as a bar. It was however very well done and the attention to detail was impressive, there was a pool table, a karaoke machine with speakers that could reach to the far sides of the Island and some pretty nice patio furniture. The two Palauins that came were desperate to get the karaoke machine running, and it was a celebration followed by 3 hours of misery when they did get it working.


The ride home from Anguar was the opposite of the way there. It was a rare sunny day without a cloud in the sky. I sat at the front of the boat, and even though the ride was only about two hours and I put sunscreen on once, my face burnt to a crisp and I learned my lesson about equatorial sun.


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