To be the First Psychiatrist in the Solomon Islands

THE SOLOMON ISLANDS

The Solomon Islands comprise an archipelago of islands nearly 2000 km off the north-east coast of Australia. The official language is English although Pijin English and local dialects are common.

Twenty years after their independence, the Solomon Islands is still a struggling developing country. In May 2000, an insurrection mounted by the self-proclaimed Malaita Eagle Force stormed the national armoury and took control of the capital. The Prime Minister was put under house arrest and forced to resign. Under duress, a new Prime Minister was elected by the parliament. ¹

As a result, a trend of external migration slowly emerged, especially among the professional populations, including medicine, as the seriousness of the situation confronted the people. ²

SPECIALIST MEDICAL TRAINING IN PAPUA NEW GUINEA

The UPNG offers a Masters in Medicine in the main medical specialities. This is basically a 4 year programme, with examinations at the end of the second and fourth years. A dissertation forms part of the second examination. In the third year, registrars generally come to Australia for supervised training experiences. Australian specialists visit PNG regularly to provide teaching and practical supervision and take part as external examiners in the final examinations.

In psychiatry, the final examination resembles the RANZCP Part 1 examination.

Successful completion of the M.Med. (UPNG) leads to specialist status in that country.

PAUL'S STORY

Psychiatry was a field that had never been even talked about among professionals in the medical fraternity. Talking about it in casual conversation in the form of jokes and so forth was, however, undeniably a common pastime. I completed my intern and resident years at the National Referral Hospital in Honiara, the nation's capital. At first, I was reluctant to take up psychiatry, but the political situation was such that an opportunity to travel outside the Islands and then return was an inviting one made possible through the offer to study psychiatry. Through formal dialogue and proceedings, my intentions were made known to the Ministry of Health and as quickly as the blink of an eye, I had received my posting in 2002 to the National Psychiatric Unit (NPU) on Malaita.

The NPU has 30 beds and is located towards the back of Kilu'ufi General Hospital on Malaita Island. Its construction was made possible through Ausaid. The senior psychiatric nursing offcer generally oversees the running of the unit. There are two other qualified psychiatric nursing offcers along with a few nurse aides, a couple of domestic workers and a driver who comprise the rest of the team.

I felt completely inadequate and scared when I started duties. I could not sleep for concern about patient welfare. As a medical student at the University of the South Pacific in Fiji, I had very little exposure to psychiatry. Now I was in charge of a unit without any supervision from a qualified psychiatrist

–an intimidating experience that I would not wantto revisit. However, the staff at the psychiatric unit with their wealth of experience were very accommodating and supportive.

During my Christmas breaks from the university, when I came home, I would often help out with seeing patients at the mental health outpatient clinic in Honiara. Slowly, more often than not on these occasions, I started receiving referrals from within the general medical health services to see individuals who needed help from the mental health services.

In comparison to Sydney, the medication cupboard was bare. The commonest medication used was chlorpromazine followed by haloperidol and diazepam. There were no psychological therapies as one might consider them in Australia.

With the escalation of lawlessness on one hand and spiralling down of the economy on the other, the government had to suspend certain services. The NPU was struggling to stay open and psychiatric staff were either unpaid or paid irregularly; medication and food supplies were dwindling. There was at times insufficient food to feed the patients.

The scaling down of services by the Ministry of Health unfortunately led to the closing down of the NPU in 2002. The funds to run the NPU were no longer forthcoming and so patients had to be repatriated back into their own communities, almost all without medications. Families and communities now had to deal with some difficult and aggressive behaviours by resorting to physical restraint.

Fortunately, with the external assistance under the Ausaid agreement, the NPU was able to be reopened soon afterwards.

The NPU is accessible from the national capital, Honiara, which is on Guadalcanal Island, either by a 6 hour boat ride on any of the regular boat schedules between Honiara and Auki (provincial capital of Malaita), or via the expensive air route of a 45 minute flight on a twin otter plane. From within Malaita, people accessed the NPU after long and bumpy truck rides on unmaintained coral roads, walking for hours to days in areas inaccessible by roads, or by motorpowered canoes for coastal dwellers. For citizens on other islands, to access the NPU meant travel to Honiara before embarking on another trip to Malaita.

Referrals to the NPU come through the general health services. There is an understanding that respective provincial health services together with the patient's family and relatives are to be responsible for meeting all expenses incurred during the referral while repatriation of patients from the psychiatric unit back to their communities would become the mental health service's obligation. The mental health nurses who have been resiliently running these services over the years would sometimes be forced by circumstances of the situation to perform functions beyond their prescribed duties, such as writing up formal clinical reports to police, prescribing psychotropics to patients and so forth. The psychiatric nursing manpower, however, has been slowly increasing over the years. Currently, there are still no psychiatrists in the country.

The geographical spread of the islands compounded by the lack of adequate general infrastructure and services has made the organization and coordination of mental health services in the Solomon Islands an incredibly difficult undertaking. With about 90% of the population in a rural setting, continuity of care from the NPU to the communities is virtually impossible.

It is in neighbouring PNG that I have gone for my psychiatric training. I was there during 2003 and 2004. Papua New Guinea is the biggest Melanesian country in the South Pacific with a population of 5 545 268. ³ In both PNG and Solomon Islands, there is a rich tradition of attributing illness to supernatural powers. In Port Moresby, the capital, there is a 15 bed psychiatric unit in the Port Moresby General Hospital and a long stay secure unit of 70 beds outside the capital. There are provincial psychiatric units of 1–2 beds at all the provincial general hospitals manned by psychiatric nurses. In contrast to the Solomon Islands, there are seven qualified psychiatrists who are currently practising in PNG.

Under the auspices of the Principal Adviser of Mental Health services in PNG, an innovative and convenient two-way radio programme is running once a week. During the programme, the Principal Adviser, who is a qualified psychiatrist, is linked to almost all the provincial health centres and clinics reachable via two-way radio systems; mental health issues are discussed and general advice given. Certainly, such an innovation could go a long way in the efforts of trying to help bring health services to the remotely situated communities of the geographically scattered Solomon Islands.

The Medical school at the UPNG, in close collaboration with National Mental Health services of PNG, has been involved in training psychiatrists and psychiatric nurses over the years. The Masters in Medicine programme in psychiatry at the Medical school has a close relationship with the NSW Institute of Psychiatry in Sydney. Over the years, through this close relationship, the Institute has helped organize placements at psychiatric institutions in NSW for candidates who are enrolled on the M.Med. Psychiatry programme at the PNG Medical school. Thus far, six candidates have completed this programme.

SYDNEY

Well-developed information record systems, better communication technologies, better tolerated and effective drugs, very specialized and manualized modes of treatments and of course the advanced medical technologies are but some of the aspects of psychiatric health care in Australia that clearly contrast with the mostly under-resourced psychiatric health care systems in the Solomon Islands.

Paul attended the Royal Australian and New Zealand College of Psychiatrists annual conference held in Sydney, 2005 through an arrangement with the NSW Institute of Psychiatry. ‘Not only was I able to meet well respected and highly distinguished professionals in the field of psychiatry, but more so there was the opportunity to share and exchange views on a whole range of issues in and outside of psychiatry. It was certainly another great life changing privilege on this journey in psychiatry for me.’

During the time of Paul's stay in Sydney, he was accommodated at Westmead Hospital. A book allowance, computer access, a weekly structured teaching programme and links with various training experiences were provided. Paul was able to travel to several conferences during his time here and also attend a meeting of the NSW Mental Health Review Tribunal. He travelled to Western NSW to experience the task of delivering psychiatric care to rural and indigenous communities. He undertook a 4 month consultation–liaison attachment at Westmead and was linked to the senior registrar in the area for support and supervision. This was followed by a 4 month child/adoles-cent attachment and 1 month substance abuse term both through Westmead Hospital. Throughout the year, on a weekly basis, he received forensic psychiatry tuition at Long Bay Gaol.

‘What could I take home from Australia?’ This was always the question at the heart of every term and session of supervision with Paul.

CONCLUSION

All the authors believe that it is in the best interest of psychiatry in the Pacific Island Nation-States that these wonderful and essential relationships with Australian psychiatry be fostered and developed in the future.