Culturally Appropriate Health Care in Kwaio, Solomon Islands: An Action Research Approach David MacLaren B.App.Sci., M.P.H. A thesis submitted in fulfillment of the requirements of the degree of Doctor of Philosophy School of Public Health Health Group Griffith University December 2006 Abstract The Kwaio people of central Malaita, Solomon Islands who retain the culture and religion of their ancestors, face a stark choice when seeking treatment at Atoifi Adventist Hospital—relinquish fundamental precepts of Kwaio culture and religion by entering the hospital, or remain true to Kwaio beliefs and stay away. Many choose the latter. The result is considerable untreated acute and chronic illness and preventable death. For people who have converted to Christianity Atoifi Adventist Hospital poses fewer cultural barriers and is one of the most respected and best equipped hospitals in Solomon Islands. However, for those who have chosen not to become Christian, the ongoing exclusion they face has resulted in antagonism and mistrust between their community and Atoifi. This thesis describes and analyses the colonial-Christian discourse in which the hospital was established and action taken to achieve a long held desire of many Kwaio people—a facility at Atoifi where health services are attainable without the rejection and desecration of Kwaio culture and religion. Using a Participatory Action Research methodology that challenges the dominant colonial-Christian paradigm, this study seeks to understand the nature of Participatory Action Research through its pursuit of culturally appropriate health services at Atoifi. This thesis outlines how the research process brought together a disparate collection of groups and individuals to analyse the oppressive situation at Atoifi and propose action to establish a culturally appropriate health facility there. It describes how, in the final stages of the participatory planning process for the facility, Atoifi was thrown into crisis when its Australian business manager was murdered on campus. The resultant near collapse of hospital services and the tenuous relationship between the hospital and the local community required the facility be re-conceptualised. A local village health worker, a key collaborator in the research process, who had established a culturally appropriate health post in the mountains fifteen years previously was central to this re-conceptualisation. He coordinated local community action which eventually led to the community funding and constructing the facility at Atoifi. This facility does not require the rejection or desecration of Kwaio culture to access health services at Atoifi. ii The implications of using Participatory Action Research as an anti-colonial methodology and its utility in addressing oppressive situations such at that at Atoifi are discussed in the final section of the thesis. The methodology’s application and ability to facilitate significant personal and social change are embedded in the emancipatory theory established by Paulo Freire. The importance of participative processes which work with people not on or to people is discussed as well as the importance of embracing flexibility and complexity, rather than attempting to control. Reflecting on Freire’s work, the thesis finally analyses how love of people can act as a foundation for commitment to others through dialogue and participation and how, based on this, praxis has the ability to liberate oppressive situations such as those faced by the Kwaio at Atoifi. iii Statement This work has not previously been submitted for a degree or diploma in any university. To the best of my knowledge and belief, the thesis contains no material previously published or written by another person except where due reference is made in the thesis itself. Signed:_______________________________ Date:___________________ iv Table of Contents Abstract.........................................................................................................................ii Statement .....................................................................................................................iv Table of Contents .........................................................................................................v Acknowledgements .....................................................................................................ix List of Acronyms and Abbreviations .......................................................................xii List of Figures and Images.......................................................................................xiv Prologue. A Journey through Time, Place and Space ............................................xv Introduction................................................................................................................xx 1. Health Services within the Solomon Islands Setting and Kwaio Cultural Context..........................................................................................................................1 1.1 Solomon Islands................................................................................................................................1 Geography and Population ...................................................................................................................1 Historical Overview..............................................................................................................................1 Government..........................................................................................................................................3 Religion ................................................................................................................................................4 ‘Ethnic Tension’ and International Intervention...................................................................................6 1.2 Kwaio...............................................................................................................................................12 A Brief Cultural Sketch ......................................................................................................................13 Spiritual Realms .................................................................................................................................16 Abu versus Mola.................................................................................................................................20 Finance and Economy ........................................................................................................................21 Feuding and the Lamo ........................................................................................................................22 Kwaio Today ......................................................................................................................................24 Health and Health Services.................................................................................................................27 1.3 Atoifi Adventist Hospital................................................................................................................30 Background ........................................................................................................................................30 Exclusion from Services—An Ongoing History ................................................................................31 Rhetoric and Contradictory Reality....................................................................................................37 2. Culture, Colonisation, Christianisation—the Experience of East Kwaio.........39 2.1 Atoifi Adventist Hospital in Historical Context ...........................................................................39 2.2 Uru Harbour History .....................................................................................................................41 The Labour Trade...............................................................................................................................41 God and Government come to Uru.....................................................................................................45 Establishment of the Seventh Day Adventist Mission in Uru ............................................................51 Mission Medical Services...................................................................................................................68 v Medical Services on Malaita ..............................................................................................................71 3. Atoifi Adventist Hospital and Kafurumu Clinic—Alternative Responses in Historical Context ......................................................................................................76 3.1 Atoifi Hospital Establishes.............................................................................................................76 Opening and Expansion of Atoifi Adventist Hospital ........................................................................84 The Administration Block and the Tuusitori ......................................................................................91 The 1980s—Consolidation and Confrontation...................................................................................95 The 1990s—Evangelical Zeal and Lost Opportunities.......................................................................98 3.2 Kafurumu Clinic—An Apparent Paradox.................................................................................100