We arrived back in Chuuk a few days ago and have had some extra time to look back and reflect on some of the things we have experienced. If you’ve been reading our blog it is already apparent that the resources on these islands are very thin. But here are a few stories to paint a clearer picture in case you’ve missed the boat:

Story #1 The FSM is endemic with both tuberculosis (TB) and Hansen’s Disease (aka leprosy). On Pohnpei, public health teams manage tuberculosis through DOT (directly observed treatment) teams, as we have mentioned in previous posts. These teams travel to patients’ homes every morning to bring the daily dose of medicine and ensure that the medication is taken properly. This prevents patient non-compliance which in turn prevents reactivation of latent TB and the development of resistant strains, not to mention the prevention of spread to others. This method has worked great; rates of TB have plummeted on the island and not a single case of multi-drug resistant TB has been seen in recent years. After traveling with one of these TB-DOT teams, we decided to travel with one of the leprosy-DOT teams the next day. What we found here is that for leprosy, the directly observed treatment team did not directly observe the treatment- makes sense, right? In this case the DOT team simply drops off a week’s supply of medication and only returns to the patient’s home when the patient runs out of medication. They never actually enforce the treatment. We were puzzled too, so when we asked why the DOT team doesn’t travel every day to ensure leprosy treatment as they do for TB, we were told that there is no funding for DOT for leprosy. They only have funding for DOT for TB. Granted TB and leprosy are different diseases and therefore are treated differently, but the principles are the same; by not enforcing a treatment you risk patient non-compliance, failed treatment, and rapid spread of the disease. This probably explains why locals tell us that leprosy has gotten much worse on the islands in recent years. Public health leaders are forced to choose which disease to target with full resources, while letting others flourish relatively unscathed. Where the public health efforts pay dividends in the treatment and prevention of TB, the same system completely breaks down in the face of leprosy because of lack of funding.

Story #2 While on Pohnpei we had to treat ourselves a few times by going to The Village for dinner. The Village is a very rustic but very nice hotel on the island with a restaurant and bar situated high up on a mountain ridge, overlooking the lagoon. The view is incredible (and it’s actually pictured in an earlier post). The menu is priced fairly but one item, the rack of lamb (serves 2), was priced at $70. Ridiculously priced, yes, but to be fair not unheard of back in the States. Obviously we didn’t order this item (we are poor medical students after all) but we took notice in the price, especially after we observed some surgeries the next morning at the hospital. The first surgery we watched was a laparoscopic cholecystectomy. We were impressed that there was even the capability for laparoscopic surgeries. The equipment may have stopped working a few times, but overall the surgery went very smoothly. We chatted with the surgeon as he closed up the incision and it was then that the cost of such a surgery was revealed… $65!!! We are too early in our training to understand all of the insurance payment and reimbursement rate mumbo-jumbo the surgeons used to justify the ludicrous cost of the surgery, but the fact of the matter remains: surgery to remove one’s gallbladder in Pohnpei is valued at the price a well-off tourist would pay for dinner at a nice restaurant. I don’t know what else to say on this one…

Waiter: "Are we ready to order?"

Restaurant patron #1: “Indubitably. I’ll have the ‘rack of lamb’ priced at $70, please.”

Waiter: “Ah, yes. Delightful. And for you sir?”

Restaurant patron #2: “I’d fancy the $65 laparoscopic cholecystectomy, if you don’t mind.”

Waiter: “Of course. Right away.”

Story #3 Dr. Dorina is a “medical officer” in Chuuk. It’s not what we would call a doctor in the States, but it’s close and it’s the best they have. She isn’t young per se (she is probably in her early-40s) but it turns out she is one of the youngest doctors in all of Chuuk. That’s because almost all of the doctors in Chuuk were trained through a temporary, US grant funded program to train more medical officers for the local islands. The grant was enough to train 10 classes of medical officers, with the last class graduating in 1997. This was Dr. Dorina’s class. Since 1997, there have been essentially no new doctors in Chuuk (unless you count the few non-English and non-Chuukese speaking Chinese doctors; see earlier post). When the health care situation in Chuuk becomes exceptionally dire again, an order for more doctors will be submitted to the United States, and the request will be met with either a grant for another training program, or a rejection. Considering the Compact of Free Association between the United States and the FSM expires in 2023, we can only guess as to what will happen.