Philip Wittann - Medical Student from Sydney Medical School, Undertook an Elective In

Philip Wittann - medical student from Sydney Medical School, undertook an Elective in Tonga in 2014-15

In regard to the medical aspects that I have learned on my placement, I would say that I have developed an appreciation and understanding of Dengue fever and the management of the haemorrhagic and shock syndromes associated with the various phases of the illness. Additionally, the high prevalence of non-communicable disease, namely diabetes, in Tonga has been very instructive in understanding the impact of diet and low health literacy on the management of these diseases.

Culturally, I have seen the impressive way in which religion has helped to knit together communities and foster close relationships among the people of Tonga. Conversely, I have also seen the way that scarce resources, which are desperately needed in other areas of the community, are funnelled into large churches and ornamentation. Further, the highly religious atmosphere has coloured the way in which medicine is practiced. While the clinics may showcase posters donated by aid organisations covering a myriad of different contraceptive methods, the clinics themselves tend to carry only condoms and a single option for oral contraception (although tubal ligation is a common practice following repeated caesarean deliveries).

On another cultural note, I have found that there are often cultural practices which go unspoken by the local people and it is often better to ask people directly about things you should be aware of before you get yourself into a new environment or situation.

Now, the challenges I faced in organising my placement were myriad but I’ll just hit the main issues I had to manage. It took a few weeks to get a confirmation message from the nominated supervisor that the date for my arrival was going to be ok. I heard nothing after that and when I arrived at the hospital I found that the supervisor was no longer there and nobody at the hospital had heard anything about my arrival for the elective placement. Fortunately, the secretary for the chief of medicine was fantastic and stepped in to sort things out. In Tonga you can literally go anywhere you want for your elective placement. I chose to visit some of the other island hospitals in addition to spending time in the main hospital in Nuku’alofa.

This next section is more of a practical introduction to Tonga as an elective placement for future students. Organising the elective:  Call people rather than email them. Internet access can be unreliable and there is a low-level of technical skill when it comes to computers and technology. Note that there is often a large delay and limited English language skills when calling so be patient.  If you have any sort of Centrelink payments you will need to notify them that you are leaving the country for your course or they may cease your payments. Contact the designated person in charge of electives at Sydney University to write a letter for this purpose. You will also have to have the electronic elective form signed off by your supervisor and the dean before the letter can be issued. Drop in to a Centrelink office and give them the letter in person. They will tell you that everything can be done online but it is considerably easier to be there in the flesh. It is virtually impossible to contact Centrelink from outside of Australia.  Most of the organisation for placements will be done when you are in Tonga. An introduction is necessary when visiting the islands but if you want to visit another ward or department then all you have to do is walk over there and introduce yourself.  Keep track of the random doctors you meet who seem interested in things and follow them around. Housing:  Tonga has guest houses which are somewhat like a bed-and-breakfast. The ones in Nuku’alofa are pretty good at responding to email but use the phone if you are going to be staying in any of the ones on the other islands.  Guest houses may or may not have hot water. Most of the time you won’t really want hot water so don’t make it a priority item when you are looking for places to stay.  Laundry often costs 10 TOP per load but it comes back to you dry and folded. In Vava’u it ranges from 3.5 to 5.5 TOP per kg of laundry. It is handy to take some washing powder sachets for the occasional hand-wash.  Winnie’s guest house and Dayspring lodge are pretty nice and close to the hospital. Dayspring includes wifi but Winnie’s is nicer and includes breakfast. The website for Toni’s guest house may look like fun but I would recommend against staying there due to the unique personality of the owner.  I stayed in Fifita’s guest house in Ha’apai. It is a fair walk to get to the hospital but the guest house includes breakfast and there is a decent café/restaurant downstairs (Mariner’s café) where you can get a reasonable meal for dinner. When I was in Ha’apai the markets were only selling unripe watermelons so it was very handy to have the café nearby.  In Vava’u I stayed in Port of Refuge Villas. There was a group of us and we split the cost of a nice place which had a great view of the old harbour. The walk to the hospital was lengthy though and Vava’u is hot, humid, and hilly. In retrospect, staying at the Port Wine guest house would have been a better plan because it is much closer to the hospital.

The learning environment:  If you can speak Tongan then you may get a lot out of your placement. If you don’t speak Tongan then things will largely depend on how keen the doctors are to tell you about what is happening. The head of surgery at Vaiola is very knowledgeable but most of the ward round is going to be a mystery to you. In paediatrics, I found that the doctors did more of their work in English and it was much easier to follow what was happening.  Teams tend to do a ward round every day starting after 8:30. Once the ward round is complete, there is relatively little that gets done other than occasionally taking bloods or changing IV lines. Patients are kept in hospital much longer than in Australia due to the risk of sepsis in the community so a lot of the patients are there just for observation.  The surgical team operates on Tuesday and Thursday at Vaiola and there is often a teaching session on a Friday morning. Surgery is a good opportunity for actually doing something because they are quite willing to have you scrub in for procedures, even the occasional caesarean birth.  The tertiary hospitals on the other islands tend to have very few patients. In Ha’apai there were, at most, four patients in the hospital at any one time. Ward rounds go very quickly in these hospitals so your time at the hospital may be very brief. In Vava’u there are often clinics for hypertension, diabetes, and antenatal checks following the ward round. I found that it was a better experience to visit the outpatient clinic in Vava’u because you get to see a lot more variety and this is where most patients will come before they are admitted to the ward and where you may get the chance to throw in a few stitches. Also, if you are keen, the outpatient clinic also starts up again at 7pm and you’ll see more interesting things in the evening than you will during the day.  In Vava’u there is also a weekly visit to one of the village health centres to run a clinic of one sort or another (usually non-communicable diseases). This is a great chance to get out and see the villages. After the formal clinic the team will normally make a few house-calls to visit people who cannot make it to the health centres.  Bring your stethoscope and your torch. Only take electronic versions of study materials if you are intending to do some reading.  Expect that most hospital equipment and supplies may be out of order or out of date. Clothing and things to pack:  Expect to sweat … a lot. Tonga is hot and humid. Vava’u is even hotter and even more humid. You’ll become an expert on locating stray breezes in the hospital. Don’t bring anything that needs ironing or that will become see-through when wet.  Thongs are appropriate footwear in the hospital. You can even wear them into surgery but I would recommend that you bring some light-weight close-toed shoes for safety sake. Don’t bother with your fancy leather shoes that you wear now at your clinical school. Same goes for packing socks (unless you need them for running shoes). If you have them, reef shoes are a good idea for navigating the rocky beaches.  Pack a set of scrubs. The hospital may be able to find some for you if necessary but they are going to be an interesting experience. Once I wore a one-piece jumpsuit and most times I had pants that were big enough for three people (and not even people who were very friendly).  If you are seriously hypothyroid then you might, just might, need a jumper for your trip. Otherwise, don’t bother packing one.  Boys, don’t pack trousers for the hospital. Go to town as soon as you can and get a couple of cheap polyester tupenu (the skirt-like thing that you’ll see doctors wearing in hospital). Black, grey, and dark blue are the colours of choice. Just check that the lower edge is properly stitched and not frayed. Top it off with a casual short-sleeve buttoned shirt and you’ll fit right in. Pack shorts for other times but note that being shirtless is frowned upon. Boys will often swim wearing a t-shirt.  Girls, bare shoulders are frowned upon. Same goes for short skirts and short shorts. Nobody will really say anything about it when you are in public but you’ll get some looks in a professional environment.  Things that are handy: a light beach towel, sunscreen, a wide-brimmed hat, mosquito repellent, a mosquito net, a polarising lens for your camera. An umbrella will be an essential item but you can buy one in Tonga for very cheap at nearly any local shop.

Food and nutrition:  All of the shops close on Sunday so plan ahead.  Most Tongan families will have food growing near their homes. Food, as a concept, is plentiful but the variety is low. If you fancy trying to cook breadfruit then it is polite to ask the owner of the tree before taking one but there is normally a great surplus of breadfruit so the answer will be yes and you may make a friend. You’ll also see the occasional noni (nonu) fruit tree with the white knobbly things hanging from the branches. Noni is supposed to cure everything from gout to HIV but it is the most revolting thing you could imagine (it is also called starvation fruit).  You get fruit and vegetables at markets or on the side of the road. There is a big veggie market in the city centre of Tongatapu but there are others on the main road which runs next to the lagoon. The big market in Tongatapu has two levels and also sells a selection of handicrafts and touristy stuff. Generally, produce is sold in piles, baskets, or bunches. For example, if you see a whole bunch of bananas then you buy the whole bunch and not just one or two from the bunch. The exception seems to be for lettuce, pineapples, avocados, and watermelon where you buy them by singles. Don’t try to get a price for just one item from a pile or basket; they look at you funny and it is so much cheaper to just buy the whole bunch.  Mango season had finished before I got to Tonga in January. Papaya was the hot item when I was there.  Tongatapu has a much wider variety of fruit and vegetables than you will find on the other islands. Ha’apai just had watermelon and Vava’u was somewhere between the two extremes.  Corner stores come in two varieties: ones with a window that you order through and larger ones where you can walk in and there are a few shelves. The small ones have basic things like canned goods, bread, eggs, and things like shampoo and washing powder. Larger shops will have frozen meats and lots of things that you would expect to find in a two-dollar shop in Sydney. The frozen fish is generally the best bargain if you are shopping for meat.  Tongatapu and Vava’u have fish markets at the docks where you can get a decent price for fresh fish. For example, 30 TOP bought a 4kg piece of swordfish.  Expect imported items, like chocolate, mustard, or peanut butter, to be pricey.  It is a very good idea to bring a selection of spices with you. If you cook then you will know what you would want. If you don’t cook then consider pepper, paprika, chilli, a green herb mix, a bbq spice mix, and maybe garlic powder.  Tongatapu has a good selection of restaurants. Friends is a café which caters to the tourist crowd. Escape is a similar type of café but it is air-conditioned.  Ha’apai has the Mariner’s café and restaurants at the resorts but the resorts are generally far away and are often closed for the off-season (January and February).  Vava’u has a more western selection of restaurants due to the expat community. Mango café is open on Sundays and their food is decent. Tropicana café is good for morning coffee and lunch but the prices are a bit steep. Bounty bar is the place to be on Thursday at 7 for quiz night. Bounty bar also does some pretty good food if Lawrence feels like cooking or you can get take-away from the Chinese restaurant if he doesn’t feel like cooking. However, if you want a cheap and tasty lunch then walk down to the market and go into the building that looks like it should be a set of horse stalls. There is a shop at the end of the building next to the vegetable market that does a tasty fish sandwich and it will cost you next to nothing.  Beer can be purchased at most of the larger stores. In Tongatapu there is a shop by the wharf called Davina’s where you can get wine and spirits at a decent price.  If you like instant coffee then you’ll be happy in Tonga. I bought an Aeropress and a hand- grinder and I was happy that I had them with me for the trip.

Getting around:  For the most part, it is the heel-toe express to get from one place to another. Think about how it will help you work off the large quantities of white bread you will be eating.  Nuku’alofa has busses. They are generally labelled for the last stop on the run that they are driving. The hospital bus has Vaiola on it. I think the bus trip is under 2 TOP but I never ended up taking one so I’m not quite sure how it goes. The other islands don’t have any public transport.  Most guest houses will have bicycles for rent. They are pretty pricey though and usually cost between 15 and 20 TOP. I was keen to buy a used bicycle at the Tongatapu flea market but I couldn’t find one. There were a few bikes on offer in Vava’u but I didn’t fancy riding them up and down the hills.  Ask at the larger shopping stores about car rentals. They are generally about 50 TOP per day and this is one of the better ways of seeing things on the weekend.  If you want to do trips to the nearby islands then it depends on where you are. In Nuku’alofa you can just walk to the wharf and catch a ferry for most of the islands. Friends café will book a boat and lunch for you but it will be cheaper if you just pay the ferry driver and buy your lunch when you get to the island. Some of the swankier resort islands will need advance booking but you can do that with a phone call to the resort. In Ha’apai you organise the trips to the islands with a resort on the other island. There are also a couple of tour companies which will do snorkelling trips and stop on some of the other islands. Matt and Jodi at Fins and Flukes do a pretty decent tour. In Vava’u it is a similar deal to Ha’apai where you book the island trips directly with the respective resorts. The Tropicana café in Vava’u is a centre for local information and tour recommendations but I’d recommend talking to Amecia in the art gallery down by the Aquarium café (provided she is in town and not out at the islands).  Many of the resort type places will be run by foreigners. If you are going to be visiting one of the resorts in Ha’apai or Vava’u then you might be able to bargain by offering to pick up some things for the owners in Nuku’alofa which are hard to get in the outer islands.  Travel between the islands is either by air or by ferry. A flight is less than an hour to the other island groups. The ferry will take you more than half a day but is considerably cheaper than the flight. Real Tonga airlines sometimes offers specials on the flight from Vava’u to Nuku’alofa. If you fly, be prepared to be weighed and they can be strict on baggage allowances. The ferry is an interesting experience. It isn’t rough but if you have a sensitive stomach then get yourself some pills. If the weather is good then get to the top deck and get as far forward as you can because the nook at the bow is a decent place to sleep. There is an air-conditioned seating area where movies are played but the thermostat was always set to artic and it was unbearable unless you brought a winter jacket. Otherwise, there is a middle area on the top deck where mostly women and children will be sleeping but this can get a bit crowded. I’d recommend getting a couple cheap mats from a local shop, stacking them up, and staking out an area in the middle. Baggage is 10 TOP extra for the ferry but there isn’t any real issue with weight.

Things to do:  A beach in Tonga is any place where land and ocean come together. For the most part, they are rocky, shallow, and have a reef break a hundred metres off shore so there will be no waves. There are a few sandy spots with deeper water but you’ll have to look them up in your guide books. Ha’apai generally has nicer beaches and they are much easier to reach than on the other islands.  Oholei in Nuku’alofa is a good spot to go for a dinner and show but you’ll have to figure out transportation to get there.  The double-headed palm tree in Nuku’alofa is a must-see. It changed me. It is also on the way to some nice beaches and resort restaurants at the western point of the island.  If you go to the blowholes in Nuku’alofa then make sure you plan to get there at high tide but it is worth a trip.  Toni (from Toni’s guest house) runs a tour of Nuku’alofa which includes a lunch. I haven’t taken the tour but, given the time I spent at Toni’s guest house, I suspect that there are portions of the tour which would be only lightly sprinkled with truth.  If you get an invitation to sit in at a Kava club then go because the singing is often beautiful. However, drinking Kava for the sake of drinking Kava isn’t really worth the time.  Taste of Tonga in Vava’u is a neat place to visit if you are interested in coconut oil, vanilla, and sustainable farming. They are also planning on opening a restaurant soon. While I was visiting, they had a chef staying with them to create their menu from the local produce and the samples were delicious.  If you make friends with the Peace Corps people running around Tongatapu then you might end up with a local guide for a trip to Eua. Either way, plan to spend the entire weekend on the island if you go out there.

Final tips:  Take your shoes off before entering a house.  Always say yes if food is offered but it is ok to take just a small piece.  Dogs are not your friends between dusk and dawn.  You can get a local SIM card from Digicel and using the pay-as-you-go data plan is often the best way to get internet access although the signal comes and goes. There is a big Digicel shop next to the veggie market in Tongatapu.  In the hospital, always ask about opportunities to do things or for information on what is going to be happening throughout the day.  Expect everything to be late.  Pack less when you are leaving Australia. You may want to bring something back and the humidity will make your clothes heavier when you pack to return home.  There are places with book exchanges/swaps so you only need to pack one book for reading.  If somebody suggests an activity or invites you somewhere then always say yes.