Getting Better

For six years, Stanford students and professors have helped transform health care in a remote Pacific province. No wonder the villagers greet them with songs praising Stanford—in pidgin.

Story and Photography by Uma Sanghvi

Sidebars:
A Primal Place
'You Have to Get Hardened'

HANDS-ON TEACHING: Ann Bui,'00, shows medics-in-training how to administer a blood pressure test in the Papua New Guinea village of Ambunti.

KELLY MURPHY IS STANDING on the banks of the Sepik River, squinting against the glaring summer sun, shaking his head in disbelief. Behind him, the river is a glassy mirror reflecting thatched-roof huts on stilts and, behind them, the jungle swaying slowly in the thick, hot breeze. “There are no patients to be seen here,” shrugs village health aide Anton Namino, timidly, almost apologetically. Murphy, an assistant professor of surgery at Stanford, and his young medical team have just arrived in this village—Tauri, population 535—by dugout canoe from their base downriver in the village of Oum.

OLD MEETS NEW: Immunology and microbiology professor Robert Siegel shares his pictures.

They are the latest Stanford volunteers in a six-year effort to boost health in this province. The campaign has been remarkably successful, but the absence of disease is especially conspicuous here. “Tauri was one of the most unbelievably sick, poor, depressed villages anywhere,” recalls Murphy, who first visited in 1997 to find that almost every child and adult had malaria. Most residents suffered from parasitic worms, dysentery and skin afflictions caused by festering tropical infections. “I’ve never seen a place that looked as bad in my life,” Murphy says. Standing here now, in front of the curious crowd that has gathered to gawk at the Stanford group, he is surprised that in six years Tauri has gone from “a nightmare—to this.” It would seem that Namino has cured them all.

EXAM TIME: The village chief of Oum 2 sits for an eye exam.

Thirty-one-year-old Anton Namino is among the most advanced of the medics who have been trained in basic health care at an annual course taught by Stanford doctors and students here in the remote East Sepik province of Papua New Guinea (PNG). Since the program began in 1996, the Stanford team has seen a striking improvement in the health of villages like Tauri. The small brigade of villager medics—today there are more than 200 in 80 villages—has used the simple but powerful techniques taught in the Stanford course to target the major maladies afflicting this impoverished region—from malaria and dehydration to rampant fungal skin infections.

HOLDING COURT: Luchin Wong, '00, and Miranda Ip, '00, play ball at the Pacific Island Ministries.

IT'S EARLY JUNE NOW, and Murphy and his Stanford PNG Medical Project team set out for the Sepik River Basin four days ago. The 14-member group—two doctors, four medical students and eight undergraduates—rendezvoused in northern Australia to fly together into the highlands of PNG, where a pilot from an international missionary organization picked them up at Mount Hagen. This was the last time they would set foot on tarmac for two weeks. Their 16-seat Twin Otter airplane bounced and hopped from one makeshift airfield to the next, carrying the team above 200 miles of pristine rainforest and into the heart of “the Sepik.” The group disembarked just 80 miles east of the border with Indonesia’s Irian Jaya province and traveled from there by foot and canoe. The journey took mere days, but there was an overwhelming sense of traveling hundreds of years back in time.

HEALTHY BABIES: Infant health has improved dramatically since the medic training program began.

The Stanford team’s arrival in the Sepik each summer is a big deal for the locals. This year, half of its members, including Murphy, set up a base of operations in the village of Oum, which has hosted the Stanford team each year. The villagers greeted them with flower leis, speeches and dancers moving to the sounds of a Yamaha keyboard. Palm fronds and oranges adorned the balcony of the newly built Oum guesthouse, where freshly picked coconuts, heavy with sweet water, sat waiting for the group’s arrival. The other half of the team flew to the village of Nagri, 80 miles upriver. When they landed, they were surrounded by hundreds of villagers who’d painted letters on their bodies reading “Stanford” and “PNG.” They carried ceremonial spears, tossed flowers at the visitors and sang songs in pidgin commemorating the occasion and praising Stanford. The two teams set up village clinics and saw patients for a week before reuniting in the town of Ambunti for the annual, weeklong medic training course.

NEW TO THIS WORLD: A member of the Stanford team last summer was invited to watch traditional childbirth practices, historically off-limits to outsiders.

THE STANFORD-PNG CONNECTION began by happenstance one summer afternoon in 1995 when Stanford dermatologist Peter Lu was introduced to Neal and Martha Kooyers after church. The Kooyerses had developed skin problems after working as missionaries in remote areas of PNG for 30 years. A mutual friend thought Lu might be able to help. “I never charge missionaries, so they figured it would be a cheap visit,” Lu says.

He became fascinated—and dismayed—as the Kooyerses described the impenetrable jungle in the Sepik region, where inhabitants lacked access to the most basic medical care. “There were no physicians in this huge area,” Lu says. “In this country, we have so much medical care. The disparity just didn’t seem fair.”

Lu invited the Kooyerses to speak at a meeting of the Christian Medical Society. Not long afterward, he began planning to make a solo trip to the Sepik. A third-year medical student, Julie Hopkins, heard about the trip and contacted Lu. Hopkins wanted to come along—and she was sure other medical students would like to, too. Lu sent an e-mail to the Stanford med student list. “Forty-five students showed up at the first meeting,” Lu says.

In the summer of 1996, Lu led the first Stanford team to PNG. They knew Sepik was remote—a landscape out of Heart of Darkness—but what they found was more appalling than anything they had imagined. “Kids and adults were dying from malaria or simple infections,” Lu recalls. “Every single person had a tropical skin ulcer. Ninety percent had seven or more open sores all over their body.” The group stayed 12 days. “We could only treat the ones who were about to die,” Lu says.

From there, the group returned to the town of Ambunti, where they devised a one-week course to train volunteers to be village medics. Pacific Island Ministries, a regional organization founded by the Kooyerses in 1971, helped spread the word, and some 30 villages sent representatives to that first course in 1996. Most of the students—the sons of village chiefs and ruling families—hadn’t finished junior high school. The course, taught in the Ambunti school using pidgin translators, focused on treating the major health problems Lu and his team had found on their first visit. Students who scored well on a final exam received basic medicines and supplies to dispense in their villages.

Every summer (except in 2000) a Stanford team returned to run clinics with help from PNG public health authorities, to train medics and to distribute medicine. The program is not cheap. Pharmaceutical companies donate about $100,000 worth of medicine each year, and Stanford Hospital gives medical supplies worth $10,000 to $30,000. Pacific Island Ministries also contributes medicines such as penicillin, anti-malarials and aspirin. The Stanford volunteers pay their own airfare to Australia, while food and transportation to PNG—about $1,000 per volunteer—are picked up by the Christian Medical Society.

PATIENTS, PATIENTS: Stanford students found business brisk on opening day at the new Oum 1 clinic, which will be staffed by advanced medics trained in the Stanford program.

Using these basic supplies and their minimal training, the medics have managed to raise the level of public health in a region that’s home to more than 50,000 people. Neonatal deaths have dropped, and the Stanford team is seeing fewer patients with serious conditions. In some villages, malaria has been all but wiped out. But nowhere are the results more striking than in villages like Tauri, whose medic, Namino, has participated in the Stanford course every year.

WATER, WATER: The clinic serves 20 villages along the Sepik River, some reachable only by canoe.

BY 2 P.M. IN TAURI, a few patients are beginning to trickle in. One man can’t walk to the clinic because of an abscess on his foot, so Murphy and Valerie Do, a human biology major from Jakarta, Indonesia, make a house call. They scale a steep ladder and enter a dark, humid, smoke-filled dwelling. By the light coming through a small window, they examine a large lump on the man’s foot. It needs to be drained. Murphy hands Do a scalpel and talks her through the procedure. If the Stanford sophomore is feeling at all nervous, she’s hiding it well. Do deftly performs her first minor surgery.

PASSING THE TEST: Final exam day in Ambunti where a new cadre of village health workers will be certified.

The rest of the medical team ends up focusing on healthy children, examining them for signs of illness. A line of giggling schoolkids forms, and each steps forward shyly. Many have tinea imbricata, an itchy skin disease caused by a fungus that grows in flowery patterns. Some have scabies, an uncomfortable condition in which mites burrow holes and lay eggs under the skin. No one has anything life-threatening. The crowds of big-bellied children infested with worms and the shrieking malarial babies of a few years before are nowhere to be found. “The well-child checkups were the icing on the cake,” Murphy says later. “We were not needed.”

TIMING IS EVERYTHING: Would-be medics check the schedule of lectures and workshops.

Self-sufficiency, of course, is the goal of the Stanford PNG Medical Project. Lu was determined not to repeat the mistakes of an American doctor who aimed to help residents of a different region of PNG a decade before. The man joined a local clinic, and for two years, the medical condition of the residents improved dramatically. But when he left, the health of the region plummeted. One of the local doctors involved became so disheartened, he left the clinic. The other became depressed and killed himself. “The worst thing you can do,” Lu says, “is change expectations—show people how things could be—and then show them it is impossible.”

BEFORE DAWN ON JUNE 30, under a clear night sky, the Stanford team is leaving Oum for the eight-hour canoe ride to Ambunti and the final part of this year’s trip—the medic training course. The entire village of Oum has assembled on the banks of the Sepik River. As the canoe slips silently into the night, someone calls out, “Lukim yu bihain.” In pidgin it means goodbye.

Two days later, Shannon Peterson stands in front of 130 medic trainees in the Ambunti church, giving a lecture on cell biology. It’s the start of an advanced course being given for the first time this year for returning medics. Peterson, ’00, chooses an analogy that she hopes will make sense to her Christian audience. “DNA is like a set of instructions for life, like the Bible,” she says, pausing while a translator renders her words in pidgin. “DNA tells the cell what to do—everything it needs to know about how to live its life.” The students furrow their brows and crane forward, eager for clues that might demystify the illustration on the board arrayed with words like “mitochondria” and “lysosome.”

Peterson is asking her students, for the first time in their lives, to think of their world in terms of tiny building blocks called cells. “It’s such an unbelievable concept,” she concedes. But it seems to be sinking in. During a question-and-answer session after the lecture, one student asks, “How does the white blood cell know when bacteria enter the body?” Another wonders, “When a man and a woman get married, do they have the same DNA?” Peterson is encouraged. “You could tell they were thinking about it,” she says. “They were really working it through.”

That night, more than 100 students cram into an oppressively humid room for the cell biology workshop. This year, the Stanford team has brought along a microscope. Fourth-year medical student Ward Myers chooses a volunteer—medic John Paul from the village of Yakrawai—and pricks his finger with a needle. The trainees watch as blood is smeared onto a glass slide and slipped beneath the microscope lens. One by one, they line up for their first peek at this mysterious world. Some look up from the microscope without a word, others with a puzzled expression. One lets out a yelp. “I’ll never forget the one medic who looked up and said, ‘So all living things are made out of cells?’” Myers recalls. “You just see the light go on—the ‘aha!’ Some people fundamentally changed the way they looked at the world.”

Other changes come more slowly. Carolyn Chen and Miranda Ip are here to give the most delicate and controversial lecture—on women’s health and pregnancy. Most traditional Sepik views of medicine mesh well with Western ones—both rely on a process of identifying symptoms, making a diagnosis and determining a course of treatment—so village medics simply learn to replace older methods with new ones that they find work better. But when it comes to pregnancy and childbirth, the Sepik people are more resistant to change. Sepik medics continue to report high numbers of newborn deaths and mothers dying in childbirth. In many cases, labor and post-labor complications—retained placenta, maternal hemorrhaging and infections—could be prevented or resolved with the guidance of a trained assistant.

Chen, ’00, and Ip, ’00, know they need to be sensitive giving their lecture on childbirth. Changing childbirth practices is more complicated than training medics to treat malaria or dysentery. In this conservative culture, women’s reproductive lives are shrouded in secrecy. Only female blood relatives who have given birth themselves may attend a woman in labor. Even standard visual aids have the potential to offend. Before the lecture, Chen holds up an anatomical illustration of the birthing process and asks medic John Paul, “Is this picture too graphic?” He shakes his head emphatically. “No,” he says. “This is a matter of life and death. People need to know.”

MARKED MAN: Stanford medical students Ward Myers, left, and Clement Yeh, right, get an assist from PNG trainee Harvey Gitora during their lecture on gastrointestinal and kidney function.

Since the first lecture on women’s health was given three years ago, things have been changing. This year, the advanced medics insisted that men and women be together for the women’s health lecture. More villages are sending female medics to be trained, and some of these women are assisting childbirths back home. For the first time, a member of the Stanford team was invited to witness an entire childbirth this year. Her experience confirmed that women still adhere to traditional childbirth practices that increase the likelihood of complications. Labor, for example, was induced by vigorously kneading the mother’s belly, which can injure the baby or mother by rupturing the uterus or detaching the placenta. The baby was delivered directly onto a dirty bark floor and wasn’t wrapped and warmed for a full half hour.

THE LAST SUPPER: Team members cooked and ate meals usually consisting of ramen noodles or rice.

BACK IN CALIFORNIA, three weeks after the medics’ training course has ended, Lu recounts the story of an old woman who walked for days to the Stanford clinic in Ambunti. She showed up with a tropical ulcer that had ravaged the front of her leg halfway through the bone. “When we cleaned out the wound, flakes of bone fell away—it was so brittle. It was just a matter of time before her bone snapped,” Lu says. The next year, he expected to hear that her leg had broken and that she had died from the infection spreading through her bones and blood. But the woman came back to show him how well the wound had fared. “It was half the size it had been the year before,” he says incredulously. “The bone was nearly healed.”

Lu ascribes this robust immunity to the harsh climate. “The only survivors are the ones with incredible immune systems,” he says. “That’s why a little bit of medication goes a long way.” The PNG program is designed to take advantage of this latent resilience. It focuses on the main health issues and ignores more intractable medical concerns, such as heart disease. The effort to combat malaria is the best example. The Stanford team taught villagers to use mosquito nets, to stay indoors between 10 p.m. and 2 a.m. (to avoid the malaria-carrying female Anopheles mosquito). Medics learned to distinguish malaria and give the proper dose of the limited medicine. The incidence of malaria in Oum, for example, dropped from nearly 100 percent to 5 percent in just three years.

NET WORKING: Anti-malarial medication and mosquito nets were standard issue for second-year medical student Brenda Czaban and her colleagues.

Another cheap but hugely effective strategy: teaching the medics basic hygiene techniques to keep wounds clean has drastically reduced the skin infections that were once routinely deadly.

The team follows the same strategy when deciding what to bring along each summer. Space for clothes and other necessities is sacrificed to make room for hundreds of pounds of stethoscopes, bottles of Tylenol, ACE bandages, cotton balls, surgical instruments and other medical cargo. Murphy estimates that this year’s 14-member team carried more than $250,000 worth of medicines from pharmaceutical companies and medical supplies donated by Stanford Hospital. That represents about $5 per person in this region. In the United States, each person consumes, on average, about $4,400 a year in health care.

HEALTHY DIETS: Fish from the Sepik River provide villagers with their protein, and malnourishment is rare.

The project has been sustained by a web of volunteers from both sides of the Pacific. At its center is Pacific Islands Ministries, the organization founded by the Kooyerses three decades ago to boost education and ensure clean water supplies. Today, PIM is run largely by local leadership; its director is from Oum. It organizes the canoe transportation of the medics—who are volunteers themselves—subsidizes the cost of their textbooks (a pidgin publication called “Daunim Sik Long Ples” (“Treat Illness in the Village”) and distributes and supplements medications and supplies to medics at the end of the course.

The most experienced village medics now teach many of the courses and seminars. Lu suggested the switch in 1999. “They thought I was joking,” he recalls. By all accounts, the seminars that year were the most successful since the program’s founding, Murphy says. “We empowered them to educate and care for their own communities,” he says. “We said, ‘You’re going to fix it. We’ll just show you how to fix it.’”

Increasingly, the medics are on their own. “My immediate presence is no longer as important as it used to be,” says Lu, who couldn’t make the trip to PNG this summer. His absence was noticeable, the more so because of the frequent references to him in the welcoming speeches and songs everywhere the Stanford team went. The new Oum clinic building, which will serve as a regional health care center for 20 villages, sits atop a hill named Mount Peter Lu.

Even as the project reaches self-sufficiency, the University will maintain ties to it. Murphy hopes to send Stanford medical residents to the Sepik for monthlong rotations to continue educating medics and to study diseases like malaria. “Our next task is reproducibility,” Murphy says. “Can we reproduce this in another part of the country? What about another country?”

Perhaps. But the experience of being in the Sepik and connecting with people in the Sepik can’t be reproduced. “I love that I got to explain the solar system to a boy, with just an onion and candle,” Peterson says. “It’s like a place that’s just waking up. It’s amazing to be able to watch them experience these things for the first time.”

A Primal Place

THE UPPER SEPIK remains one of the most remote areas of Papua New Guinea. The absence of roads and other infrastructure has isolated the region for centuries. Although Christian missionaries arrived in the 1950s, most people of the Upper Sepik have had little contact with global culture.

But the enduring image of PNG as the last outpost of “primitive,” Stone Age society obscures the complex truth of its history. Archaeologists identify ancient New Guineans as one of the first peoples to domesticate plants for human consumption. But unlike other early farming societies, they didn’t progress through the technological stages—population expansion, metallurgy, writing, political organization—that transformed other regions of the world. The geography of the island prevented the spread of early agriculture beyond the cool, fertile highlands in the deepest interior of the country.

The same fragmented microenvironments that limited the spread of agriculture also led to the development here of more than 1,000 of the world’s 6,000 languages. The isolated New Guinean rainforests gave rise to unusual species like the cassowary, tree kangaroo and bandicoot. PNG is home to more species of birds of paradise than any other place on earth.

Despite the European “discovery” of PNG 500 years ago, much of New Guinean culture remained unchanged until the 20th century. At different times the Dutch, British, Germans and Australians laid claim to portions of the island. But disease—especially malaria—kept Westerners out of the interior until the 1930s. What they saw astounded them. Mapmakers sent home reports of villagers adorned with cassowary plumes and bird-of-paradise feathers, their noses pierced with bamboo or pig tusk. They told tales of tribes who honored dead relatives by wrapping their bodies in banana leaves before roasting and eating them. Cannibalism and headhunting were, in fact, integral parts of tribal warfare in some regions until the 1960s, when Australian officials made a concerted effort to curb these practices.

Today, the nation of 5 million is in its third decade of independence. In 1975, at the urging of the United Nations, PNG officially broke away from Australia and formed a democracy that has performed well in its infancy. But problems with law and order continue to plague the country. The certainty of the Stanford trip was thrown into question two months before departure when an attempted coup in the capital, Port Moresby, threatened to shut down the airport. Just three weeks before the Stanford team arrived, the Peace Corps announced it would be evacuating volunteers from the country, citing “the difficult security climate in PNG.” Even as the Stanford team ran clinics in Sepik villages this summer, police in Port Moresby were firing on New Guinean university students protesting the privatization of the national bank. Four protesters were killed and 15 wounded.

Poorly developed transportation and communication networks and serious health risks also pose significant challenges for the Stanford project. Between them, project leaders Peter Lu and Kelly Murphy have suffered from scabies, dengue fever, tinea imbricata, serum sickness and giardia from exposure to pathogens in PNG. Past team members have had yaws (a bacterial skin and bone infection) and worms. Without roads, volunteers must travel by foot, canoe and chartered planes, in an area where fuel costs $8 to $12 a gallon. Even in this isolated corner of the globe, the laws of supply and demand apply.

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'You Have to Get Hardened'

OOHS AND AAHS: Ip's experiences left her 'moved, shocked.'

MIRANDA IP JOINED 11 other Stanford students on the trip to Papua New Guinea last summer. Her most enduring memory of the experience: “being sweaty,” she says with a laugh. Ip studied human biology and is applying to medical schools this fall. Meanwhile, the Boston native is working for Americorps in Palo Alto, East Palo Alto and Menlo Park, pairing high school students with community service organizations. Here are excerpts from her PNG journal.

Monday, June 25, 8:24 a.m.
Last night was unbearably humid and hot. I woke up at one point to hear fruit bats—a huge flapping sound, punctuated every once in a while by a thud—the sound of them hitting the wall because their sonar is kind of dumb. At night, the rats come scurrying out, too. Valerie says they are small and brown and cute, but I’d rather not see them.

[later in the day]
The first patient I saw was a 3-month-old baby, severely dehydrated, feverish, covered in infected sores—fungal infections with secondary infections. The mother tried to hand me the baby, who was too weak to even cry, and I turned to Kelly, completely bewildered. The hours of preparation yesterday—the drug lists and disease and symptom chart we so carefully hammered into our brains—completely failed me. After listening to the baby’s heart and lungs, I turned to Kelly, who instantly diagnosed it—ordered Biaxin for the staph infection, oral rehydration and, I think, some mebendazole for his belly full of worms.

Tuesday, June 26
God, it’s only 4:08 a.m. now. The roosters will start crowing soon, and everyone will be awake. Okay, there’s a mosquito in my net right now. I’m going to kill it and get back to this soon. . . .
It’s heartbreaking to see a malaria case you know you can’t treat. It’s a struggle to see those kids with distended bellies—you could give them worm medicine, but they go swimming in the river the next day only to get worms once again. You have to get hardened to it, I guess—that’s what happens to a lot of doctors anyway—but it’s been three days of clinic already, and I can’t stop being annoyed, moved, shocked by the visibly obvious need for health care.

We got cold drinks! We came back around 6 p.m. today from clinic, and inside there was a package sent by the missionaries that included more ramen and other food—potatoes, oil, onions, more Twistees and a cooler of ice cold soda. So exciting. I had a Schweppes passion fruit-flavored one. This is ridiculously good. The food situation, surprisingly, isn’t all that bad. We manage to flavor almost everything with the chicken-flavored msg packets from the ramen and also this garlic-chili hot sauce that in a million years I’d never touch back home.

Friday, June 29, 7:58 a.m.
After the little [farewell] celebration, we went back to the guesthouse, and some of the villagers followed us, hanging around on the porch, watching us do some last-minute packing and arranging. That’s something they like to do a lot: stand outside on the porch and stare at us through the mosquito screens, watch us cook dinner or brush our teeth, like some exotic exhibit at the zoo. Very interesting to be on display.

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