Dr. David Mills in November 2016 about the Kompiam Hospital and how MAF supports their work in remote areas. Photo copyright MAF PNG
A Case Study:
Dr David Mills and the Kompiam District Hospital
by David Gilchrist
Just 5 degrees south of the equator rise the high mountains of the Kompiam District, Papua New Guinea. Here the summers linger and the winters don’t intrude too much.
This is where Dr David Mills lives and works. Rising to another Kompiam morning will mean facing a day that will be typically wet and overcast. It is that way year-round.
Somewhere beyond his front door, in the montane forest, lush and green and layered with orchids, ferns and vines, the bizarre calls of a Bird of Paradise echo through a mountainous landscape that rises up nearly 4000 metres or so above sea level.
Life in Kompiam District, for David Mills, is to live and work in a wilderness that provides shelter to Engans, a tribal group that even other PNG highlanders call “mountain people.”
David Mills’ journey to Kompiam took six years after he completed his medical training at Flinders University, graduating in 1994. It was a journey that was more than a trek of around 3000 km from the quiet, manicured, squared away, civic planned, streets, sidewalks and shops of Adelaide and the modernist, clean and crisp architecture of Flinders University.
It was a career trek to live with a people that had survived in isolation, largely unaware of the world beyond their mountains, until 1934 when European gold miners arrived. Theirs are lives with a cadence the dates back centuries in a province that is possibly the least modernised of any province in Papua New Guinea.
Before David Mills arrived in PNG, he completed his internship at Flinders then his career saw him and his wife Karina move to Australia’s Northern Territory where he competed a year of obstetrics and anaesthesia before entering 4 years on the rural pathway .
A stint in Katherine saw him complete his post graduate degree in rural general practice. A 6-week rotation as a student in PNG eventually led to his full time return to Kompiam in 2000, serving a population of somewhere between 40,000-60,000. David is employed as the Kompiam District Hospital Medical Superintendent.
Over the last two decades, he was the only doctor from 2000-2004 and has had short stints on his own in the intervening years. However, he now works with another doctor serving the community.
When he took on the role it meant having to build up the Kompiam District Hospital from a very challenging start. His initial task was to transform a hospital that consisted of two buildings, no laboratory, no x-ray facility, and no operating theatre, kerosene lighting, and no phone communication into a working district hospital.
Two decades later and David says, “It’s expanding – we have got about 55 beds, a laboratory, a couple of operating theatres and x-ray facilities. We have an international school for our staff and are slowly building up our housing capacity. All that’s been 20 years of fairly solid work and still going on.” That work also includes building roads and bridges to make the hospital more accessible.
“We now have a situation where a lot of those things are reasonably bedded down and now we are starting to take off in terms of expanding our clinical footprint.”
Mountain of morbidity
When he started Dr Mills saw within the community a degree of illhealth that amounted to “a mountain of morbidity.” And, having chipped away at it, that mountain is largely still there. Yet, he has learned how to not allow the enormity of the medical challenge to overwhelm him.
Dr Mills said that the key to working in areas like Kompiam means, “you have got to have a glass half full mentality.”
“You have got to have a glass half full mentality.”
He said, if working in that area meant “always staring at the enormous amount of unmet need, people suffering because they never get any help and there is no prospect of them getting any help, and the ones that are getting helped are not getting helped to the level that you would want, you just couldn’t stay – you’d go home.”
Instead, David Mills takes a far more positive approach. “Before I came here, there was nothing, everyone was getting nothing and suffering and I’ve made significant improvement. Each year we are doing a bit better and we’re seeing more people that are getting a better standard of care.”
His approach to his work means doing his best for each individual that presents for care while maintaining an overall strategic perspective to make the decisions that will progress and continue to improve the entire service.
Training key to success
Training, Dr Mills said, is one of the most useful keys to success. “When doctors know that they are getting trained well and at a high standard then doctors and nurses will come a long way – they’ll put up with a lot in order to get good training. That is something that you can leverage,” he said.
That understanding led David Mills to play a key role establishing PNG’s first training program for rural doctors – the Masters of Medicine (Rural), in collaboration with the University of PNG.
That programme wasn’t a natural fit for Papua New Guinea as medical training typically had little emphasis on rural medicine. David Mills explained that in establishing the Masters of Medicine Programme in 2008 a survey of medical students revealed that no student was interested in rural medicine as a career. “It just wasn’t on their horizon, because it’s never been there in the culture of medical training. Training has all been geared towards specialist medical training,” Dr Mills said.
His approach to the PNG Masters programme was to present generalist training as a worthy alternative to specialist training.
“There is an unspoken, subliminal message out there that somehow generalism is not as demanding as specialism.
“There is an unspoken, subliminal message out there that somehow generalism is not as demanding as specialism. Those of us that are generalists know that’s nonsense,” David said. For that reason, David was determined to build a masters’ programme that is as demanding and rigorous as any specialist training.
“The reason people choose careers can often be quite buried in these sorts of human aspiration things that are not that complicated. People want to be recognised and they don’t want to be minimised. A surgeon has higher status just because they have a masters or specialist level qualification – that’s significant. I have always felt that it was a mistake to make generalist programmes less in terms of their ultimate qualifications compared to surgeons or some of these other qualifications,” David said.
David felt that a two-year diploma would not meet the aspirational needs of PNG doctors. He was determined to make the Masters of Medicine (Rural) at PNG University recognise the fact that rural medicine in PNG needs to accommodate many skills including surgery and anaesthesia. That’s because, David said, “You can’t refer in many cases in PNG, so you have to have an enormous number of strings to your bow. And you’ve got to be able to do them reasonably competently.”
“So, in that sense, our guys feel like they are multi-specialists. They have to be carrying an enormous amount of knowledge and clinical courage in various situations to be able to function.”
For that reason, the University of PNG course is six-year post-graduate training rather than the four-year programmes typical of other specialist courses. “Instead of making it easier we thought no – we want to make it harder – so that people at the end of it really feel like they’ve attained something that’s quite elite.”
“Those wheels have taken a while to get going, but it is definitely happening. There is no question that there’s a movement afoot now in PNG.
David Mills’ approach seems to be working as the programme enrolments are growing and the Masters programme is finding traction amongst aspiring young doctors in PNG.
“Those wheels have taken a while to get going, but it is definitely happening. There is no question that there’s a movement afoot now in PNG,” he said.
Moreover, David believes that the PNG government has also responded to the changing emphasis that places more imphasis on rural and remote primary healthcare. That's because the PNG government now fund district hospitals and encourage generalist training.
Using the level of health funding grants as an indicator, David Mills is correct. The national health function grant allocated to provincial governments through the national budget is for primary health facilities to improve the availability of specified priority services. There have been gradual, but nonetheless substantial, increases in national budget allocations for health function grant since 2009 from the national governmentv, due to the reformed intergovernmental financial arrangements for service delivery. The health function grant almost doubled from K14.5 million in 2008 to K28.4 million in 2009, with incremental increases to K112.5 million by 2016, althoug it has remained at similar levels in recent years.
Overall, the result is that trainee numbers for the Masters course are growing also. David Mills said that because of the impact of funding and the increasing interest in the Masters programme, in terms of overcoming that mountain of morbidity, “we have some hope that we are going to get there, but it’s still very early in the journey.”
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