Three John A. Burns School of Medicine (JABSOM) first-year medical students embarked on a new and unique clinical learning experience in the island of Pohnpei, where they were exposed to the medical, cultural, and historical and public health issues that are pertinent to this specific region. During July 2011, JABSOM sent first-year students to Micronesia through the medical school's Hawai‘i/Pacific Basin Area Health Education Center (AHEC) and the partnering Guam/Pacific AHEC. This unique opportunity allowed medical students to learn and train in this rural environment.
The history of Pohnpei State and its citizens bears striking similarity to that of Hawai‘i. Centuries of colonization by European and Asian cultures left their marks on the Pohnpeian language and customs, while currently the indigenous population struggles to conform to a Western lifestyle. What has resulted is a significant prevalence of non-communicable diseases such as obesity, diabetes, and hypertension.1
Pohnpei State is one of the four states of the Federated States of Micronesia (FSM), with an estimated population of 34,000 people.1 Similar to many developing countries today, the population of the FSM is relatively young, with 37% of people under 15 years of age and only 3% of individuals 65 years or older. Contrary to what may be expected of a population with these demographics, the average population growth rate has declined from 3% between 1980–1990 and 0.3% between 1994–2000. This decline is primarily attributed to the migration of the indigenous people to the United States due to inadequate health and education systems within the FSM.1
Within this setting, the first-year medical students from JABSOM spent their 2011 summer elective precepting at Pohnpei State Hospital, the Department of Public Health, and the Pohnpei Family Health Clinic. This distinctive opportunity allowed the students to learn valuable medical, public health, social, and cultural lessons as part of their medical training.
Medical Landscape of Pohnpei
Pohnpei's unique medical history, which can be described in 3 general stages, has laid the framework for its current healthcare state. The first stage was marked by the introduction of infectious diseases such as influenza, smallpox, and measles, as foreign ship traffic increased during the nineteenth century. Between 1840 and 1900, the population of Pohnpei decreased by approximately 65%.1
The second stage began with the onset of German occupation, beginning in 1898, until the end of World War II in 1945. The German administration opened the first hospitals in Pohnpei intended for the local populations, started implementing quarantine measures for foreign ship crews and passengers, and introduced regular vaccination practices for diseases such as smallpox.1
The third, stage started in the 1960s, as the number of jobs increased and many Micronesians gained disposable cash income. As a result, diet changed from local produce and seafood to affordable and highly processed foods of the Western world. In addition, Micronesians adapted to a relatively sedentary lifestyle offered by modern conveniences, and abandoned more physically intensive traditional practices like fishing and farming. These lifestyle changes resulted in an increase in the prevalence of non-communicable diseases, such as diabetes and heart disease.1 The increased prevalence of non-communicable disease put a major burden on a healthcare system that lacked preventative education and medical outreach services. Both non-communicable diseases and infectious diseases such as tuberculosis and Hansen's disease cause substantial health concerns for Pohnpei's public health officials.
Today, much of the financial burden of these medical services has been transferred to the State of Hawai‘i. Large numbers of people from the FSM immigrate to Hawai‘i to seek care at hospitals, community health centers, and cancer treatment facilities. Their reason for leaving the FSM is almost unanimous: to seek medical services unavailable in the FSM, and thus improve their quality and length of life.
Under the Compact of Free Association (CoFA), citizens of the FSM, the Republic of Marshall Islands, and the Republic of Palau are allowed to work and reside in the United States. without an immigration visa. However, some arrive in Hawai‘i without the resources and/or education to secure an adequate livelihood. Others are too ill to work, and subsequently end up homeless or in other substandard living conditions.
Current Healthcare Situation in Pohnpei
The JABSOM medical students rotated at Pohnpei State Hospital to learn how the physicians provide health care in this rural environment. Pohnpei State Hospital is an open air, one-story concrete building located at the edge of downtown Kolonia. Each ward consists of a small nurses' station at one end, and two long lines of patient beds at the other. Minimal privacy is attained by drawing curtains around each bed. Most patients prefer to keep them open to allow the humid air to circulate between the fans and open windows. The majority of basic health care is provided by the state with a large percentage of the population receiving care at Pohnpei State Hospital. Private insurance is available but often unaffordable to the general public. Patients with private insurance receive prompt care at private clinics or the competing private hospital. Furthermore, the charge to stay overnight as an inpatient is $10/day. However, for $30/day a patient may have a private air-conditioned room, demonstrating the directly juxtaposed disparity between the poor and the wealthy.
In recent years, there has been a shortage of medically-trained professionals throughout the FSM. One contributing challenge is that there are very limited skills-training programs on the island. In addition, those with the financial luxury to seek higher education elsewhere often do not return home because of the opportunity to earn a much higher salary outside of the FSM. To make up for the shortage of physicians and nurses needed to care for the ailing population, the hospital contracts employees from the Philippines. This has created a new set of challenges, such as language barriers and lack of cultural competency. The transient nature of the medical staff does not allow enough time to master the Pohnpeian language, so most patient interviews are conducted in broken phrases of English and Pohnpeian.
The biggest day-to-day obstacle that the hospital faces is the high cost of health services for a population without the means to pay for them. Physicians rely on developed history and physical exam skills to make a diagnosis because it is extremely costly to maintain diagnostic equipment in the facility. There is no computed tomography, magnetic resonance imaging, or blood bank on the island. Even the simple luxury of electricity is not taken for granted as the island's generators frequently fail throughout the day.
The impact of high medical costs is not limited to diagnostic studies, and often causes restrictions in optimal patient management. For example, in the United States, the standard treatment for chronic obstructive pulmonary disease (COPD) is an inhaled long-acting beta-agonist like salmeterol, which is an expensive drug that is not available in the Pohnpei hospital's pharmacy. Instead, patients with COPD routinely visit the emergency department (ED) to be treated for COPD exacerbations with albuterol, a short-acting beta-agonist, administered via nebulizer, and often end up staying at the hospital for an extended period of time. The diagnosis of COPD in the FSM often means an inevitable rapid decline for the patient, secondary to lack of adequate maintenance therapy. An example of this situation was a gentleman with COPD admitted for dyspnea who remained in the medical ward on oxygen throughout the duration of the medical students' stay (25+ days).
Public Health in Pohnpei
As a part of the Pohnpei medical experience, the medical students spent one week with the Public Health team. During this week, one of the most memorable experiences was spending a day with the Tuberculosis (TB)/Hansen's disease program and accompanying the Direct Observation Treatment Short-course (DOTS) team as they distributed TB medications to patients outside of Kolonia where modern conveniences are rare and most people depend on the land for sustenance. Many of the patients live with large extended families in homes with bare floors and walls, and no electricity. The people were extremely hospitable and generous, offering gifts such as warm mashed taro with coconut milk that they had harvested and cooked from their own crops.
The JABSOM students also worked with Dr. Eliazer Johnson, the director of the TB/Hansen's disease program. Dr. Johnson hopes to eliminate Hansen's disease from FSM by the year 2015. To achieve this goal, he utilizes a geographic information system (GIS) to track and plot TB and Hansen's disease cases on Pohnpei. All TB and Hansen's disease cases are handled on the island, and care is taken to treat the patients promptly and effectively. Dr. Johnson and his team hope to prevent outbreaks of multi-drug resistant TB, as has been reported in Chuuk,1 by identifying and treating active cases of TB early before they have a chance to gain strength and spread. These methods are essential in a culture where large families live closely under one roof.
In addition, the medical students worked at various outpatient clinics hosted by the public health department throughout the week, serving specific patient populations. Prenatal care clinics, diabetes clinics, family planning clinics, and pediatric vaccination clinics attract locals from Kolonia, the state's capitol, as well as outer towns. However, many people living outside of Kolonia do not own cars, so traveling into Kolonia can easily take a few hours. Another means of transportation are local style taxis that pick up multiple passengers along the way similar to a bus system. However, unlike a bus system, there are no schedules or predetermined routes. Streets outside of Kolonia have only one lane per direction, and most are poorly paved. It is an arduous journey for these outer town people to travel to the clinics simply to receive routine medical care.
These clinics are of utmost importance to the people of Pohnpei, especially pregnant women, people with diabetes, and children. Many of the expectant mothers are young and require prenatal antibiotics for treatment of infections such as chlamydia. The patients with diabetes often have difficulty modifying their lifestyles to control their blood glucose and require routine monitoring to prevent dire consequences such as kidney failure and limb amputations. Furthermore, these clinic visits are the only time that patients with diabetes are able to check their blood glucose levels since personal glucose monitors are a luxury. Children have access to vaccinations at these clinics that will prevent contracting and spread of easily preventable diseases. The next steps for these public health initiatives require focus on maintaining adequate drug supplies and making routine outpatient care more readily accessible to those living outside of Kolonia.
Dr. Isaac's Clinic
While in Pohnpei, the medical students were mentored by Dr. Bryan Isaac, a JABSOM graduate. Dr. Isaac exemplifies the definition of a family physician. A master of all trades, Dr. Isaac manages a variety of ailments: infectious disease, chronic conditions (eg, hypertension and diabetes), prenatal care, and minor injuries requiring surgical intervention. To practice medicine efficiently in rural Pohnpei, Dr. Isaac must be self-sufficient: he performs his own lab tests, microscopy, electrocardiograms, and ultrasound. This is vastly different from the hospitals in Honolulu where medical students train with nurses or technicians who perform many of the services mentioned. Due to the unpredictable shipping schedules, Dr. Isaac is often forced to sterilize and reuse items that are typically considered disposable in US medical facilities such as ear speculums and nebulizer mouthpieces. This practice is also common at the Pohnpei State Hospital.
Dr. Isaac places a strong emphasis on preventative medicine and lifestyle modifications. He has had several patients with diabetes successfully wean off their medications through diet and exercise. This is quite a feat since the medical students were told many times that one-third of Pohnpei's population is afflicted with diabetes. Preventative medicine is especially valuable in a place such as the FSM where subspecialty services are accessible only off-island in the Philippines or Hawai‘i.
The medical students witnessed firsthand how difficult it can be for patients in Pohnpei to receive subspecialty services. During their experience with Dr. Isaac, the students encountered a patient who required an arteriovenous (AV) fistula placement in preparation for dialysis treatment. This process was extremely costly to the patient, as it required travel to the Philippines. Even with a successful AV fistula placement, there were only 2 dialysis units at the state hospital, both of which were being at maximum capacity.
In exchange for inpatient admission privileges to Pohnpei State Hospital, Dr. Isaac works as the state hospital emergency department (ED) overnight call physician twice monthly. Unfortunately, many people utilize the ED as an outpatient clinic, especially at night when patients know the cashier's office is closed, to avoid confrontation regarding unpaid medical bills. However, when the medical students joined Dr. Isaac for the first time on an overnight shift, they were in for a lesson that they would never forget.
Two male family members brought an unresponsive man into the ED after he had collapsed onto the floor at home. It had taken the family over 30 minutes to drive the lifeless patient to the hospital. The “ambulance” in Pohnpei is similar to a transportation service, as the drivers do not have medical training, and the transportation time is often too long to provide adequate resuscitation care upon arrival at the hospital.
Dr. Isaac wasted no time as he instructed the medical students to perform CPR and apply a bag-valve mask, and the nurse to retrieve the defibrillator and begin administering shocks. Despite these efforts, the patient could not be revived. The first-year medical students were confronted with the shock of a patient death, much earlier than expected in their medical education. It was a situation far removed from the PBL (Public Based Learning) cases and standardized patients they had been exposed to at JABSOM.
Dr. Isaac's training and expertise truly make him well suited to deal with the variety of conditions that come to his office. He is an eager teacher who encouraged students to participate in physical exams and patient education. He is truly an amazing resource as JABSOM sends future groups of medical students to the FSM for an experience that will surely redefine their definition of rural medicine.
Conclusion
The time spent in Pohnpei allowed the medical students to reflect on why so many Pohnpeians come to Hawai‘i seeking healthcare. While JABSOM students realize early in their training that they will encounter many patients from Micronesia, students are also aware there is a significant workload in front of them, as Hawai‘i's limited resources (financial, personnel, etc.) will not be able to match the demand set forth by the increasing patient load. Many who migrate to Hawai‘i seeking healthcare have not been receiving adequate care in Micronesia, making for more complicated medical cases. Many of these patients are further hindered by lack of financial resources, language barriers, lack of healthcare-seeking knowledge, and the burden of adjusting to a new, often more complicated social environment. On a similar note, healthcare providers in Hawai‘i may find it difficult to treat patients from the Freely Associated States since many of the patients cannot adequately provide their personal medical history, critical in the creation of a successful treatment plan. Cultural notions of health and healthcare-seeking behavior in the FSM may also hinder local physicians from providing the care needed to manage chronic problems such as diabetes and heart disease. Furthermore, many of these patients do not have the financial resources to fill prescriptions and receive the interventions necessary to manage complicated chronic disease.
The experience in Pohnpei introduced the JABSOM students to the political and medical landscapes of Pohnpei, and how these issues relate back to the Micronesian patients that they encounter in Hawai‘i. The students now understand the cultural factors that give rise to stereotypes and are better equipped to provide the care and understanding that will help the Micronesian patient population. Not every individual of Pohnpei can be fit into a specific description of “what it means to be a Pohnpeian.” Also the status of people of Pohnpei cannot be generalized from the medical students' experiences, but this trip offered a chance to learn and experience the local culture and history of Pohnpei, as well as the medical issues that afflict this island state. This experience in Pohnpei has encouraged the medical students to strive to become physicians who are not only competent in the science of medicine, but who are also understanding and considerate of patients' cultures and personal challenges.
Acknowledgements
The authors would like to thank the Hawai‘i/Pacific Basin AHEC and the Guam/Pacific AHEC for providing funding for this educational experience. The authors would also like to thank Kenton Kramer PhD, Bryan Isaac MD, at the Pohnpei Family Health Clinic; John Hedson MBBS, at the Pohnpei State Hospital; Rally Jim MO, and Eliazer Johnson MO, at the Pohnpei State Department of Health Services; and the numerous other health professionals encountered during their journey.
Reference
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