July 8th – July 9th Final Days in Samoa

On Wednesday I celebrated my birthday in style: by filling 533 prescriptions for 252 patients! Media exposure of our clinic over the past two days has really gotten the population excited about what we are doing here. Thursday was our last day of clinic and we were only open from 0800 until 1300. The local news station, however, told the public that we would be there all day. There was nearly a riot when we closed registration. A few hundred people were crowding the registration desk in the building's entryway. Another 20 or 30 people were loitering around the back door of the pharmacy, looking for a way to enter the building. The police had to be called in to disperse the crowd and thankfully the situation resolved without incident. While the situation could have ended badly and I do feel bad about having to turn people away, I hope it serves as an eye opener for the local healthcare system. I hope they are driven to improve their system and restore the public's faith in their abilities. I also hope that the public stands up voices their concerns. Our presence in Apia has exposed the public's desire for quality healthcare. Let Pacific Partnership 09 serve as the catalyst that transforms the healthcare system of Samoa.

Tomorrow we set sail for Tonga. I'll leave Samoa with fond memories that will last a lifetime. I've learned so much here, done and seen things that I couldn't have imagined just a few short weeks ago. We may not have transformed their healthcare system, but we have sown the seeds. If I'm lucky enough to return to Samoa in the future, I'm confident that I will witness the fruits of our labors.

July 7th Apia, Samoa

On the second day of clinic, we changed our hours from 0800 – 1600 to 1200 – 2000 to accommodate the work crowd. Business was good: 230 patients and 442 prescriptions, but I'm starting to notice a trend in the type of conditions we are treating. In Sataua, we were serving an immediate need. The people on the island of Savaii have very limited access to healthcare and the conditions we treated reflected that. We saw several conditions or disease states that were the result inadequate healthcare. I wrote earlier about the patient with elephantiasis. This condition can be completely avoided if the filariasis is treated early. We also saw a lady that had a large cyst on her upper leg that prevented her from sitting properly and dramatically decreased her quality of life. The examples go on and on, but if it was not for our clinic many of the patients on Savaii would still be suffering.

In Apia, healthcare is much more accessible. The city's main hospital is in the center of town and care for Samoan citizens is nearly free. Samoans need only pay a $5 tala administration fee to obtain their medical record. The actual care is free. As a result, the conditions we saw in Apia were much more acute. Gone were the progressive complications of long neglected diseases; replaced with simple cold symptoms or muscle aches and pains. On the whole, this is a good thing. Such basic conditions reflect a fairly healthy society, but we are missing a golden opportunity.

Each day we saw more and more patients. When asked why they waited in such long lines to be seen by us instead of going to the hospital, the nearly unanimous answer was that the quality of care we were providing was far superior to the local hospital. This is the opportunity we are missing. We are setup in a community center. All the local translators and helpers are volunteers with no medical background. Instead of treating simple conditions that the local doctors are already capable of treating, we should have been working alongside the local healthcare providers. Had the local medical community been represented at our clinic two things would have happened. First, we could have had a tremendous exchange of knowledge. There were several tropical skin conditions that our physicians had never before seen. The local physicians would certainly know better how to identify and treat these diseases. Furthermore, we could have taught them more advanced treatment procedures and diagnostic techniques. Secondly, the peoples' faith in their local healthcare system would be strengthened had they seen their physicians and nurses working, as equals, alongside our team. We could have helped them identify why the public views their health system as inferior and helped them improve. By treating only short term conditions in total isolation from the local health system, we have set ourselves up to achieve only short term goals. The people in Apia clearly need our help, but a more lasting contribution would be to help them improve their health system thus rendering our services unnecessary.

July 5th – July 6th Clinic in the Capital

Returning to Apia, I was pleased to see that the Byrd was pier
side. This would make it much easier to get on and off the ship. We got back on board with just enough time to shower and grab some food before we left again to set up clinic in Apia. The site chosen for the clinic was a large community center near the center of town. The main part of the building was a massive open room with a stage in one corner and a kitchen in another. With Apia being the capital as well as the most populated city in Samoa, we were expecting to see larger numbers than what we encountered in Sataua. However, I was still shocked to see just how many chairs had been set up in the waiting areas. It was a sea of plastic. Hundreds of chairs…we were going to be busy.

The building's kitchen opened up to the main room through a series of windows that could slide to one side to allow for the serving of food. It seemed the natural choice for the pharmacy location with one exception: It was overrun with ants and cockroaches. A call went out to the Navy's preventative medicine team and they responded with a backpack sprayer of permethrin. I have to admit, I was a bit skeptical at first. After all, permethrin is what we use on little kids to kill lice. I expected to return the next day to find a room full of angry cockroaches, alive and ready to fight. Thankfully these bugs capitulated to the chemicals and I returned the next day to find massive cockroach casualties.

With the roach problem behind me, my focus returned to how to deal this onslaught of patients that had been predicted. In Sataua, John Nett and I were alone and making it up as we went along. Here in Apia, we had help from a Navy pharmacy tech and series of lessons learned from our experience in Sataua. Before long we had the pharmacy organized and a workflow established. We saw 180 patients the first day and filled 270 prescriptions. We were busy, but it was smooth sailing all day. Never did I feel rushed or overwhelmed.

July 5th Update on Savaii

We've packed up our gear and sent it ahead to the Samoan capital of Apia on Upolu. We have a bit of down time now as we wait for the ferry to Upolu, so I've had time to tally our pharmacy numbers. In 3 days the pharmacy saw 368 patients and dispensed 689 prescriptions!

July 2nd – July 4th Sataua Clinic

We opened the clinic at 0800 and it became immediately apparent that we have some rather large holes in our formulary. We're missing some key antibiotics, we have almost no GI meds, and our selection of antifungals is painfully limited. But on the plus side, we do have enough 100 count bottles of pseudoephedrine to start several meth labs and enough bisacodyl to keep the entire island on the porcelain for several days. Joking aside, I find that I rather enjoy these oddities. It gives me the opportunity to work directly with the physicians and challenges me to find creative alternatives for therapy.

Most of our patients speak very little English, but it's clear they are grateful for our help. The lines, in every part of the clinic, are long, but I have yet to hear one person complain or see anyone get upset. In the pharmacy, we are hand writing all of our prescription labels on small stickers or plastic bags. This takes time, but the people here are nothing but understanding. If it wasn't for the 90% humidity and the lack of internet access I might just open a pharmacy here.

Our medical clinic is busy, but dental and optometry are at capacity. Access to healthcare is limited on Savaii, but it is still possible to get care. The hospital is staffed by nurses and a doctor visits the hospital once a week. The same is not true for dental and eye care. These services are virtually nonexistent on the island and travel to Apia, the capital city, is too expensive for much of the population.

As the days progress, the clinic gets more and more interesting. We had a patient with a severe abscess requiring IV cefazolin. Under normal conditions, this would be prepared in a sterile environment. Under our conditions, it was prepared on an old weathered desk sterilized with Purell. Later we had a patient with elephantiasis resulting from lymphatic filariasis. He had been suffering from the condition for over three years. The origin of the name, elephantiasis, was clear. His legs were massive, at least 8 inches in diameter at the ankle. And his skin had become thick with callus and hyperpigmented. It was an amazing sight; one that evoked both fascination and sympathy.

July 1st Hitting the ground running.

0030 Climb Jacob's ladder to board the USNS Byrd.

0100 Finish check-in and receive room assignment

0115 Scare roommate as I burst in carrying a backpack and large duffel bag

0130 Receive a quick ships tour

0200 To bed (or cot as it were)

0500 My roommate is up…so I am as well

Our team musters in the helo hanger at 0630. We have five providers on our team: a general physician, a pediatrician, an optometrist and two dentists. All told, there are 12 of us on this mission. We are going to a hospital in Sataua, Samoa on the island of Savaii, where we will establish a clinic.

The scenery on the helo ride in is amazing. Savaii has but one road. It circles the island near the shore. The islands center is mountainous and bathed in shades of green that I've never before seen. We are only a few hundred feet above the jungle, but it is so thick that individual trees cannot be distinguished; they simply blend together as if one giant organism.

We land at a small air strip where some vans were waiting and drive to the clinic site. The hospital is on a beautiful piece on land; a small peninsula with a bay on each side. The hospital itself…not so beautiful. It is an open air building consisting of several small rooms all joined by covered walkways. The facility is old. Several windows are cracked or missing all together. The paint is peeling and what little equipment they have has been neglected. It is immediately apparent that we have a huge opportunity to really help these people.

Within hours, we've transformed the facility. It now has two dental bays, two medical exam rooms, a surgical suite, and optometry room, and a pharmacy. I have only worked in a handful of pharmacies in my time, but unless there is a Walgreen's on top of Mount Everest, I'm pretty sure the pharmacy we setup in Sataua has the best view of any pharmacy in the world.

From behind the pharmacy counter (built out of a series of old lecture podiums) I look east, over a bay filled with crystal blue water. Waves break over lines of coral exposed by the low tide. On the far shore are coconut palms swaying gently in the wind. There are no other buildings in sight, just nature…it's absolutely beautiful.

As I take in the view, fatigue takes hold. I'd been running on adrenaline for hours now. The meager three hours of sleep I've achieved in the past 24 hours are finally catching up to me. I'm exhausted, but excited for tomorrow and the opening of our clinic.