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Tonga

Written by Cath Langusch, 2002

Vaiola Hospital, Nuku'alofa, Tonga

Located in the South Pacific Ocean, directly on the International Dateline and approximately 800km south-east of Fiji, the Kingdom of Tonga was nicknamed “The Friendly Isles” by Captain Cook in the 1770’s. The Kingdom comprises around 170 islands, with only 40 of these inhabited by the nation’s population of around 100,000. Tonga is a traditional monarchy with a rich cultural heritage, and is fiercely proud of the fact that it is the only South Pacific nation to have never been colonised by outsiders. In this country, we found laid-back, friendly people; idyllic beaches; and a fascinating, hands-on medical experience. In December 2002, Cath Langusch ventured to Tonga for the MSAP. Please read her report below:

TONGATAPU Hospital Experience

Vaiola Hospital is situated about 2km south of Tonga’s capital city, Nuku’alofa, and, with around 200 beds, is by far the country’s largest hospital. After arriving to “check-in” with our supervisor, Dr Palu, we chose which department of the hospital we were interested in working in. We nominated Paediatrics, but also ended up doing some General Surgery, as well as a week of General Medicine. Obstetrics and Gynaecology is also on offer and is always busy.

We arrived shortly before Christmas, and the Paediatrics ward was the most colourfully decorated part of the hospital, complete with tinsel and a nativity scene. We were warmly welcomed by Mele, the head nurse, as well as Toa, the consultant Paediatrician, and Lisiate the registrar. We participated in ward rounds, general ward duties, outpatient clinics (mostly following-up children who had been recently discharged from hospital), and were often left in charge of conducting the day’s newborn baby checks. We also had the opportunity to help with the WHO (World Health Organization) project of introducing rubella immunisation to Tonga. In the 6 months or so before we arrived, Tonga had been experiencing a major rubella epidemic – with none of the population ever having been immunised, thousands upon thousands of people fell ill to the German measles, and a particularly high number suffered meningo-encephalitic complications (1 in 42 as compared to 1 in 1000 in usually). The WHO had embarked on a mass immunization campaign, and had immunised around 70,000 people in 3 months – an amazing feat by anyone’s standards. Lisa and I lent a hand in the statistical collation after this – which involving trawling through the hospital’s records of presentations to emergency to count the number of “measles” or “rubella” diagnoses. It was incredible to watch the rate drop from 70-90 cases of measles per week in August, to only 10-15 cases per week by late November.

There were usually around 10 children on the Paediatrics ward, many of whom suffering from gastroenteritis, which could be extremely severe - most often because they presented late and very dehydrated. While we were there, a number of infants died from severe gastroenteritis. Other conditions we witnessed included meningitis, epilepsy, asthma and burns injuries (due to the ubiquitous firecrackers at that time of year). We also saw a 9 month old baby who presented with failure to thrive and significant global developmental delay, as well as being hypotonic, sleepy, and having a large tongue and hairy, dry skin. We suspected hypothyroidism, rarely allowed to progress to this point in Australia because of the newborn screening program, but unfortunately this could not be confirmed because Thyroid Function Tests cannot be preformed in Tonga. It was tragic to see this suspected cretinism, now irreversible, but so easily treatable if it had been detected earlier.

I also spent some time in the operating theatres at Vaiola Hospital, as well as attending surgical outpatient clinics. Tonga has an interesting mix of health problems, with a combination of both developing world diseases, such as tropical infections, as well as developed world conditions, most notably, ischaemic heart disease and Type 2 diabetes. The latter contributed many cases to our theatre lists – with a large number of diabetes- related ulcers, debridements and amputations. Other interesting surgical cases included a 17 year old boy who had cut the sole of his foot on a bottle whilst chasing a pig (and had actually presented 2 weeks later with postural hypotension due to blood loss!) and many cases of severed wrist tendons from halving coconuts with large machetes. I also assisted in Caesarean sections, appendicectomies and internal fixation of fractures. One major difficulty was not having access to an X-ray machine intraoperatively – one poor 11 year old boy (who had fallen from a coconut tree and fractured his radius and ulna) had to return to theatre three times to have closed reduction and application of plaster cast under general anaesthesia – because the position of the bones could not be assessed whilst he was still in the theatre.

The management of cancer in Tonga is quite different to Australia, and usually involved, firstly, difficulty in localising the cancer (as there are no colonoscopes nor CT scanners in Tonga, far less any nuclear medicine scanning techniques), and then not being able to offer much in the way of treatment, other than surgical techniques (mastectomies, anterior resections and so on). There are no chemotherapeutic nor radiotherapeutic options in Tonga, and usually the patient is not even told they have cancer unless they are wealthy and may be able to afford to fly to New Zealand for treatment. There’s a saying that they don’t tell the patient that they are dying, but rather tell the family to start fattening the pig (in preparation for the funeral feast).

Lisa and I also spent one week attached to the general Medical team at Vaiola Hospital – we saw a lot of diabetes, ischaemic heart disease and chronic airflow limitation, but also many cases that are not so familiar to Australian hospitals, including rheumatic fever, rheumatic heart disease, tuberculosis and filariasis. Attachment to this team was much like being a medical student in Australia – attending ward rounds and clinics, and helping with cannulae and venipuncture.

Out and About

We stayed at Winnie’s Guesthouse when we were on the main island, which was very close to hospital, but a bit like staying with your grandmother! It’s not as cheap as many of the other places in Nuku’alofa ($20 Tongan per night for medical students, but includes breakfast) but very clean and convenient to the hospital.

There are many things to do and see around the island of Tongatapu, including: the island of Pangaimotu (10 minutes boat ride from the main harbour – a good way to spend Sunday swimming, drinking and relaxing); the spectacular blowholes on the southwest coast; ancient monuments such as the Ha’amonga ‘a Maui trilithon and the Royal Tombs; and the secluded Keleti Beach. We also greatly enjoyed, and thoroughly recommend, the tuna sashimi at the Waterfront Hotel, the karaoke at the Billfish Bar, taking in a round of golf at Tonga’s only golf course and seeing a game of rugby at Teufaiva Stadium!

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