After an exciting weekend of diving we made our way to our first day at the Palua or Belau national hospital. After riding our bikes through the rain we met up with our contact Dr. D who is the hospital administrator. He gave us a blitz tour of the hospital in between his ensemble of morning meetings. There is a brand new minister of health, and new president, so there is a lot of power realignment going on. The hospital is pretty basic, it's only one floor. There is a section for clinic where they run general clinics along with some specialty clinics. There is an inpatient ward that has about 30 beds, a surgical ward, a pediatric ward, L&D, and a well baby nursery. To my surprise there is even a hemodialysis unit, and a very basic PT unit. Radiology could do basic X-rays, CT, and mammograms. I was informed if someone needed an MRI they would be flown to Manila, not to mention that 7 rows of seats would need to knocked out of a plane to make room for a stretcher. So not too many people get MRIs. There is a lab that is capable of running the most basic of tests assuming they didn’t run out of the reagents. They have a pharmacy that at the moment is filled with mostly empty shelves.
In theory I think I am supposed to be on the Medicine service this week, there is little structure and less accountability. I rounded with one of the Internal medicine doctors on service Dr. L. We blasted through 14 patients in about a half hour. She was only there in the morning. In the afternoon I was asked if I wanted to work in the clinic. It was a general clinic that treated walk ins. I was holding up the wall in one of the exam rooms while a different physician interviewed patients and I observed. After about an hour she turned to me and asked “can you see patients?” I stumbled and said “sure”. She then said she was going to pick up her kids and needed me to see the rest, and that I could sign off with one of the other doctors. So for a couple hours I got my own exam room and stack of patients. When I was done I would tell the doctor in the next exam room what I had and wanted to do and they would pop there head in and sign off on my note and prescriptions. The following day worked the same way, Dr. L had her own clinic and gave me my own room with a stack of patients to see. When I was ready I would come get her. In a way it was like being a third year, she would come in the room and I would present the patient to her and my plan. But I quickly learned that this is not Medicine in the States, and no matter how great I thought my treatment plans were most of the time they were not practical.
The hospital was either out of the medication I wanted to give, or Dr. L knew that the patients would simply not be compliant with anything that made them pee more. They also treated more aggressive than I was used to, even if something is obviously viral everyone gets antibiotics and steroids. The argument was that its simply the protocol, they don’t seem too concerned about breading drug resistant bacteria, but being on such as small island to me it seemed like a perfect set up.
Basically the way I understood the nature of some of the issues was that the Belau hospital gets its drugs from outside vendors that are supposed to evenly distribute drugs between the hospital and private pharmacies. There was a mandate set up that prohibited anyone affiliated with the hospital to become the vendor. The only person that can overrule this is the ministry of health, apparently the last minister of health who was also a general practitioner saw the opportunity in this. He created himself as the sole vendor on the island and seeing that it would be more profitable to sell drugs to private pharmacies than to the hospital changed the distribution for his own financial gain. Over the last year the drug supply to the hospital has been slowly dwindling.
The hospital cannot circumvent the minister because he controls the hospital budget. So the situation becomes what I see today. They lack very essential drugs, the only thing for diabetics is Insulin, they have a hemodyalysis unit but no Coumadin, or heparin, and the lab ran out of the ability to check PT/INR. The day I was there the lab also ran out of the tests for hemoglobin A1c and microalbumin which are both fairly important tests to determine if a diabetic is well managed. If a patient needs a test or a drug that the hospital cannot offer they are forced to go to one of the private pharmacies, most people cant afford this, and they go without medicine. There is hope however, the new minister of health has based his campaign of resolving this, and there is a lot of faith behind him.
Despite these obstacles and short falls, Palau actually does a fairly decent job in providing health care to their island of 20,000+ in comparison with the other islands in Micronesia. There are islands with three times as many people that struggle to just maintain running water and electricity in their hospital. What struck me as interesting and frightening is that the international community has very little interest in helping to build up Micronesia’s struggling and in some parts obsolete health care system. In fairness, maybe I missed something, but I didn’t see any evidence of NGO involvement, or hear rumors of any. Going through med school all that you hear is chatter about Africa or Central America. Having been to some of these places it seems obviously apparent that the outer islands of Micronesia are in equal amounts of need.