Greetings from Kiribati!

Or, as one might say it here, Kam na mauri ni Kabane!

I have been here on Tarawa, the teeny tiny atoll that constitutes the capital of the Republic of Kiribati (pop. 100,000-ish), for almost two months now and have been terribly remiss in posting to this blog. My excuse is that I was busy learning as much as I could, as fast as I could, about this country and its health system, so that I could actually be of use to the Ministry of Health during my brief stay. I have so loved reading what each of you post-ers has had to say about your placements, though, and now want to offer at least a few thoughts on the not-very-well-known part of the world where I have been living.

In short, as I have (maybe unsuccessfully) tried to depict in the photos above (of exactly the same view, but at different tides/times of day) Kiribati can be either "the BEST!" or "the WORST!" depending how you look at it.

Here in Tarawa, you may at all times be within 100 meters of what I reckon is the most beautifully-aqua lagoon in the world, but you are also, no doubt, aware that this gorgeous body of water lays claim to the highest concentrations of E-coli in the world (understandably, given the limited access to water and sanitation with which most of the population struggles).

The temperature may never rise above 86 F or fall below 79 F, but combined with the humidity and salty sea air, one soon learns, this means that the smallest and most insignificant cut you ever had will turn into a festering, infected wound with high sepsis potential if not attended to immediately and consistently for the next month (difficult in a place where band-aids or similar products are unavailable)… your shoes will grow mold… and any and all electronic devices will develop a series of unexplained malfunctions of varying severity and annoying-ness.

A camping trip to a nearby island may take you to the most idyllic beach, with straight-out-of-finding-nemo-quality snorkeling, and the most generous picnickers with whom to share a lunch of coconuts and fresh fish, but it may also entail a night spent fearing for your life while gale-force winds blow your tent over (think splintering poles and wet nylon plastered to your face) and down the beach with you in it, torrential rains all the while filling it with just enough water to thoroughly soak everything you own… and you might at first be thankful that at least the wind also blew the mosquitoes away…for a minute.

Perhaps more importantly, a visit to the doctor might be quick and free, and (if you’re lucky and you have sought health care early and for a relatively common and easy-to-treat condition) result in prescriptions for exactly what you need at no charge. Whatever it is you need, though, might be out of stock at the one-and-only pharmacy and not be expected back in until the next ship comes... in a month.

Thanks to the hospitality of many i-Kiribati and some wonderful new friends, I’ve been able to maintain an outlook of the "BEST!” variety in almost every area of my Kiribati life, and I have learned a ton from my experiences inside and outside the Ministry of Health.

The majority of my working life thus far has revolved around research into how pain treatment and palliative care are provided in Kiribati, how delivery of these services could be improved, and what a national policy to support increased access might look like. This research has given me an excuse to visit a range of health centers, clinics and hospitals in the capital and on more remote outer islands, and to speak at length with a wide range of health care providers and administrators. I have been able to explore issues of drug supply and distribution in a fantastically complicated and remote setting (Kiribati is made up of 32 different islands spread over 3.5 million kilometers of the pacific ocean); issues of education and training of health care providers in a country with no medical schools; the transition in health care delivery strategies and public health priorities demanded here, as in many developing countries, by a growing burden of non-communicable diseases (NCDs); and, finally, health care seeking behavior, particularly among women, who, as in many other places, tend to prioritize the needs—health and otherwise—of their children and other family members above their own.

One of the most memorable and eye-opening experiences I have had in Kiribati took place on a small boat in rough seas off the coast of Abaiang, one of the atolls just north of the capital, Tarawa. I was on my way, with the Abaiang Medical Assistant (thanks to a recent E.U.-funded program, each of the outer islands has a health center staffed by a Medical Assistant, who, as a nurse who’s been given a bit of additional training and salary, essentially runs the entire health system of the island—from disease surveillance and vaccination programs to health promotion/NCD prevention/anti-smoking campaigns; from emergency medicine to food safety and palliative care—on his or her own and in communication with doctors at the main hospital primarily through CB radio) from the main island to one of the even smaller and more remote is-lets that is also part of his catchment area. Huge waves broke over the bow as he drove, soaking everything in the boat that wasn’t very securely wrapped and fastened inside a waterproof tarp, and salt-ily splashing into our eyes so often I was unsure how he could continue to steer the boat. There was only one seat, so I was using one of the tarp-wrapped bundles to cushion the impact of wave after wave of into-the-wind, tailbone crushing, impossible-to-predict-the-exact-direction-or-intensity-of blows to the hull.

After something like two hours of this, it occurred to me that we were taking this boat because it was the best one available—much more comfortable, everyone said, than the canoes that were once the only means of travel between islands. A couple of other things also occurred to me: 1) If I were suffering from appendicitis, or even a tooth-ache, this trip might just qualify as torture. It might also be my only hope of getting to a hospital. Under such circumstances, unless I was in very dire straights, I most likely wouldn’t choose to see a doctor unless he came to me. 2) This is the trip the Medical Assistant has to take at the drop of a hat, every time a shipment of vaccines comes in—not to mention any time a patient on the islet needs any kind of specialized care or medication—sometimes with little notice. The fact that the Medical Assistant does not, himself, own a boat and must borrow one for every trip, just adds to his burden. 3) This might amount to what one would call a difficult link in the cold chain supply system.

It is not so much that I didn’t previously know about a whole range of difficulties in reaching remote populations—here and everywhere else—with health care. It just hadn’t ever been made so totally, absolutely, and (literally) painfully clear to me how some of those difficulties manifest themselves.

Of course, consistent with the theme of Kiribati’s being simultaneously “the BEST!” and “the WORST!” we were also at that very moment, driving into the most vibrant sunset I’ve ever witnessed, reflected off of the deepest-blue ocean I’ve ever seen, and headed towards the palm-tree-studded silhouette of that quintessential paradise island I once thought only existed in travel brochures.