Island Psychiatry

Updated: Nov 23, 2020

For my very last week of med school!! Whoohoo!! I thought I would check out the Behavioral Health unit in the hospital. Palau has one of the highest rates of schizophrenia in the world toping out at somewhere around 2-2.5 people/100, and has been the focus of several international behavioral health studies trying to figure out why.


The behavioral health unit is an isolated wing alone on the north side of the building. Ward 5 as it’s known as consists of a central office, a small nursing station, a females only room with 3 beds, along with a male room with 3 beds. There are also three other “isolation rooms”, that are the exact same as a concrete prison cell, bars and all. In the isolation rooms they sleep on a wood platform with no mattress. I can’t understand how this would be productive to someone’s state of mind. However, that was the worst part of Ward 5. There were a lot of things I thought they did right, and actually I would say better than in the states. Clearly with only 9 beds, most of behavioral health in Palau is outpatient. They approach the outpatient mission from several angles. Patients are scheduled to come into the clinic every so often to meet with Dr. Wally, who is the one and only doctor who staffs the clinic, and rounds on the patients in the mornings. When she meets with the patients in the clinic and she takes about 45min to an hour with each one. She talks to them, gets them to open up, they usually cry and then she offers advice. It was what I wanted to see on my Psyc rotation at Tulane and never did, true behavioral therapy. The clinics I worked at in New Orleans were nothing more than cattle calls for people coming in to get meds, and I always wished we could just talk to people instead of refilling their Prozac without ever making eye contact.


Dr. Wally would try to speak a mix of Palauin and English so that I could at least catch some of it. The first patient we saw was a lady in her mid 40’s who was having trouble controlling her aggression at home. She had a pretty tragic history of physical abuse when she was young and had been through a good amount of therapy back in the day and generally doing well for the last 10 years. This year however was the year her daughter turned 11, which was when she was abused, so it was all rushing back. She also had this history of her oldest daughter who was in her 20s sleeping with both of her former husbands. I’ve learned that there seems to be a lot of that going in Palau.


After the first patient, Dr. Wally told me to start seeing my own patients. The first guy I talked to had been having personality issues ever since he was in a car accident a few years ago and suffered some kind of brain bleed. From what I could tell his personality issues had pretty much resolved, and he seemed stable to me. His only complaint was this massive headache that he couldn’t seem to shake. After talking to him for a bit I learned that he met just about every criteria for diagnosing a migraine. I presented this to the doctor and she was a bit taken back because she had been seeing him for a while but had never thought of a migraine. She later thanked me, and admitted that she really never thinks about medical conditions, that are outside of the behavioral therapy realm.


In the afternoons the nurses or social workers head out into the island in search of patients. Some of them never followed up with their appointments, some of them just get daily home visits to receive a shot. This is something else I thought was pretty amazing. If someone in the states falls through the cracks of the mental health system, they are gone, and more often than not wind up on the streets. In Palau they are making an active effort by basically going door to door and making sure that doesn’t happen. I rode around with a nurse named Georgia who was happy to have me along. She took pride in not only telling me about the patients, but showing me around Palau. I was getting a tour where the tour buses would never go. Off the main road most Palauins live in small rusted shacks that are barely able to support themselves. Georgia having grown up in Palau under such conditions either knew everyone, or was related to everyone. I also learned that everyone generally just knows everyone.


Often we couldn’t find a patient and she would just start asking random strangers, and then it didn’t take long. Georgia was also giving me a bit of a dark history about Palau. The only recent violence they have against tourists happened a few years when a Japanese couple was brutally beaten. She explained that most Palauins especially the older ones really dislike the Japanese. She told me about how Japanese soldiers used to torture and harass the native palauins during WWII. I wonder if all the Japanese honeymooners at Palau Pacific Resort are concerned that people might be spitting in their food?


Georgia also showed me where the one and only brothel was, which was a restaurant as a front. Funny, because Vanessa and I passed by it and thought about eating there once. Georgia said they definitely didn’t serve any food. She told me one of her schizophrenic patients bragged once that he went in there and had sex with a Chinese lady for $5.


On one of our little road trips we went to the Palau Jail to deliver meds to the prisoners. The prison cells weren’t much different than the ward 5 rooms. I guess the guards used to give meds to the prisoners, but of course they weren’t without corruption and soon enough starting selling the drugs or just keeping them for themselves, so the ministry of health cut a deal with the jail to go inside and do it themselves.


Most of the severe schizophrenics in Palau obviously aren’t in the hospital, and the small but courageous efforts of Georgia can’t keep tabs on all of them. What they have come up with is a day program where these people come to the hospital everyday and do yard work and have therapy sessions. The men tend to the grounds, while the women make lunch. They also branch out into the community to do yard work so they make enough income to keep their program afloat. It’s pretty amazing to see a group of mentally ill people coming together and create a self sustaining therapeutic program. Dr. Wally said it has really been helping them.


The final tentacle that the behavioral health department sends into the community is a 24/7 help line. But this isn’t a normal help line. When it first started a lot of the teenagers asked if they could text message in their problems. Dr. Wally has the responsibility of looking through the transcriptions of these txt conversations every month to make sure the social workers are doing an adequate job. She gave me one of the files to read. It was late in the day when she gave this to me, I had already been dismissed, I was hungry and tired, but when she gave this to me I couldn’t put it down. Most of the txt messages clearly came from teenagers, mostly girls asking for advise about everything from depression to boy problems. One in particular read “how d u get a boy to lyke u?” The response from the help line was “just be yourself and it will happen”.


Dr. Wally offered me the invitation to run the help line for a day if I wanted. Unfortunately I ran out of time and never got the chance, but I imagine it would have been a lot of fun. What I found really interesting is that all of the txt messages that came in were serious. Nobody pranked the line, everyone had a real issue, some more serious than others. I told Dr. Wally that I didn’t think it would work in the states because people might not take it serious, she said that people have such limited options here when it comes to reaching out for help that they respect whatever they are given. I also learned that people in Palau due to cultural restrictions never really show any emotion and tend to bottle everything up. With no outlets they eventually fall into some state of misery.


In my last couple of days Dr. Wally was sick, she called me because she knew I was in her office abusing her internet privileges. She asked me to round on the ward 5 patients, write a note, and call her if there was any issues. So for two days I was the only quasi doctor managing the mental health unit. Most of the patients were stable and my plan was either “continue plan”, or “see orders”. I called her once with a list of things I wanted to change, she agreed and that was really all there was to it. Perhaps it was a nice swansong to med school that my last act was holding down an entire ward of crazies, and that I never actually wound up there myself.


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