Australia, New Zealand, and New Guinea are the most familiar countries of the South Pacific, but a large number of smaller islands are scattered throughout Oceania, less well known and with far less health services. A comprehensive western-style system of medical care with full specialist services exists only in Australia and New Zealand, but over the years, otolaryngologists and audiologists have provided their services voluntarily to other countries in the region.
Otolaryngologists from Brisbane, Australia, helped develop a training program in Port Moresby, the capital of Papua New Guinea, which is the eastern half of New Guinea. Lack of equipment remains a problem. The Australian government in 1995, via its aid agency AusAID, contracted the Royal Australasian College of Surgeons (RACS) to provide services to a number of specialities, including otolaryngology and head and neck surgery to 10 small island nations in the Pacific Island Projects (PIP). These 10 nations have a large population, ranging from Fiji with nearly a million people to Tuvalu with about 10,000 people. The Republic of Nauru, with a population of less than 10,000 also joined the program, with a population of Melanesian, Polynesian, and Micronesian people.
PIP continues to provide visiting consultative and operating services to the people of these island nations on an annual or sometimes biannual basis. Recently, the project has been taken over administratively by the Fiji School of Medicine, although logistically it will continue to be run by RACS. ENT visits to Timor-Leste (East Timor) began 10 years ago, a few years after it declared independence from Portugal, a period marked by protracted civil disturbance and fighting that resulted in a loss of nearly a third of the population. The population is generally young and lacks expertise in all areas, including medicine.
RACS established the Australian Timor-Leste Program of Assistance for Specialist Services (ATLASS), which included otolaryngology, head and neck surgery, and audiology visits. Visits to Timor-Leste have been more frequent but shorter, typically four one-week visits, mainly focused on the capital Dili and the eastern provincial capital of Baucau.
Management and Philosophy
All RACS team members are unpaid volunteers but receive air travel and living expenses. Teams consist of one or more otolaryngologists, an anesthesiologist, one or more nurses, and usually an audiologist. Visits last between one and two weeks. Countries receive visits only at the request of their health authorities, and ENT services are consistently in the top three surgical areas requested. Training and skills transfer is regarded as fundamentally important. Papua New Guinea now has several otolaryngologists, and the Solomon Islands will have one next year. An East Timor doctor is training in Indonesia to be an ENT.
We believe that the backbone of the country's program must be the ENT nurse who carries out simple treatments, notably ear toilets, audiograms, screenings for the school-age population, and hearing aid fittings. The ENT nurse also triages patients for the specialist team. This has been an outstanding success in the Solomon Islands and Vanuatu with active nurse practitioners for more than 15 years. A nurse is currently training in audiometry in the Solomon Islands through an Australian program because there are no audiologists in the region. Some members, ENTs and audiologists, carry out a regular training program for ENT nurses in Vanuatu, which also welcomes nurses from other countries. Currently, we are trying to establish a similar program in East Timor, which is only just getting off the ground.
Teaching the Deaf and Hearing Aids
Hearing aids and rehabilitation have often been provided informally by organizations such as the American Red Cross, but teaching services and other provisions are still lacking. Australian audiologists have become interested in providing outreach services and several individuals are committed to the programs, accompanying most teams and often doing recurring visits. Hearing aid provision is difficult. Donor aids are typically used, but maintenance is problematic.
Two Australian audiologists in East Timor surveyed children in two widely separated areas, and found deafness at 17 percent and 18 percent, which has grave implications for education. The primary problem in all these countries, which may be typical in developing countries around the world, is ear disease, especially chronic suppurative otitis media. Apart from the mortality and morbidity considerations, it has a significant effect on the population's educational prospects. We have been mainly focusing on this, although other aspects of otolaryngology and head and neck surgery are also included.
PIP in its present form is coming to an end but will hopefully persist to provide help where needed until these countries can establish their own services. This is beginning in some countries, but in the smaller countries will probably take years, if they are created at all. The program is due to finish in Timor-Leste within two years, with the aim of the country becoming medically independent. It is difficult to see how this can be achieved in that time. We hope to have our ENT nurses on the ground by then.
ENT service and teaching provided by otolaryngologists in Vietnam and Cambodia has been going on for some years now, but these visits do not receive government or RACS funding. Sporadic visits to other countries have occurred, including one visit to Nusa Tengah Timur on the island of Flores, Republic of Indonesia, some years ago.
The author wishes to acknowledge the Australian Government Aid Agency, AusAID, which has funded most of the projects mentioned in this article; the Rotary Club of Balwyn in Melbourne, Australia, which has funded half of the visits to Timor-Leste; and all the otolaryngologists, nurses, audiologists, and other medical colleagues who have generously given their time to these projects.
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