Issue 10 Volume 2
Peer reviewed article
This article discusses healthcare needs and provision in the third world nation of Vanuatu. The major focus of the article is on how healthcare needs have been affected in the aftermath of Tropical Cyclone Pam, a category 5 storm that devastated the country this year on March 13th. The article discusses developments in healthcare in Vanuatu leading up to this natural disaster as well as the immediate response to it and expected healthcare requirements.
Australia – the lucky country. Few of us genuinely appreciate just how true this well-known saying is. We have political stability, an effective welfare program, a trustworthy judicial system and education available to all. We can also lay claim to one of best healthcare systems in the world. Our life expectancy is the 8th highest worldwide and we have 1 doctor per 312 people. Even in our most remote areas there is the option of transfer to a tertiary facility, with care that is equal to the best provided anywhere in the world. While there are obviously aspects to work on, we are, on the whole, incredibly privileged.
Our geographic location, however, includes many less privileged countries where healthcare is, at best, rudimentary. One of these countries recently gained significant, if fleeting, publicity in the aftermath of Tropical Cyclone Pam. An archipelago nation of more than 80 islands 2000km from Australia’s eastern coast, Vanuatu is home to around 270,000 people. I was fortunate enough to call Vanuatu home for 6 months as a volunteer on one of the outer islands and also spent several weeks as a medical student in the capital’s Port Vila Hospital. Vanuatu and Australia were different in many ways, but as a medical student, the differences in healthcare funding and provisions were the most striking. While Vanuatu is one of our closest neighbours, its healthcare system could scarcely be more distant.
Prior to the devastation caused by Cyclone Pam, healthcare in Vanuatu was able to support the rudimentary needs of the country. Vanuatu’s 270,000 citizens were serviced by 4 regional hospitals and 2 main referral hospitals. There were only 49 doctors in the country, equaling less than 1 doctor per 5,000 people and fewer than 350 nurses practicing in the whole country in 2012. Life expectancy was ranked 101st globally and healthcare expenditures were just $167 (international dollars) per person per year (compared to $4068 per person per year in Australia).
Healthcare services in Vanuatu are centred almost exclusively in the two largest cities; Port Vila and Luganville. Almost all of the country’s health professionals are located in one of these two centres. Smaller health centres and dispensaries are scattered throughout the country, with most staffed by one or two nurses or volunteers with limited training who cater to around 1,000 people. Tertiary services are non-existent, and patients must be referred to Australia or New Zealand for any advanced treatment. Another significant complicating factor in Vanuatu’s healthcare system is the country’s ‘double burden of disease’. The incidence of non-communicable diseases has increased significantly as diets and lifestyles have changed throughout the country (particularly in urban areas) but communicable diseases still contribute significantly to morbidity and mortality in both urban and rural areas. The main causes of death in 2010 were closely divided between non-communicable (ischaemic heart disease, diabetes and stroke), and communicable and nutritional causes (including diarrhoeal diseases, tuberculosis, pneumonias and malnutrition).
All statistics aside, the reality of practicing medicine in such a resource-poor environment cannot be understood until it has been experienced. Vanuatu’s most advanced imaging modalities are X-ray and ultrasound which are available only in the two major hospitals, and many blood tests have to be sent to Australia for analysis. Once a diagnosis has been made it is not uncommon for crucial medications to be unavailable. Patients who require complex surgeries must be flown to Australia or New Zealand to receive care. As very few locals can afford such arrangements, funding often comes from the Vanuatu government and/or private donors. Unfortunately, the available funds are insufficient and only a small proportion of those in need can access such treatments. In the few short weeks that I spent in the Vila Central Hospital, I saw several patients die from diseases that are preventable and/or treatable in Australia. I also saw diseases that have been all but eradicated from Australia and other western countries, including rheumatic fever, malaria, and tuberculosis. While this may sound like a difficult environment in which to practice medicine, the smaller hospitals and dispensaries have even fewer resources.
In spite of these difficulties, health outcomes in Vanuatu have steadily improved over the last 25 years. A government driven program for improving health and increasing numbers of medical professionals in the country has been the main force behind these changes.[4,8] Morbidity and mortality from communicable diseases have decreased yearly since the 1980’s as vaccinations and clean water have become more widely available. Immunisation rates have increased, resulting in a significant decrease in childhood mortality rates and improvements in antenatal and perinatal care have caused similar decreases in maternal and infant mortality. Unfortunately, these tentative advances are now in grave danger of being lost.
On the 13th of March 2015 Tropical Cyclone Pam, a category 5 storm, tore through Vanuatu, wreaking havoc as it went and leaving devastation in its wake. It is estimated that 90% of the population of Vanuatu’s capital, Port Vila, became homeless overnight. Some reports stated that around 70% of outer island inhabitants were left in a similar situation. Electricity was lost in those few urban places that had it, clean water sources were contaminated and vital crops were flattened. The country’s main hospital, Vila Central Hospital, was evacuated and some of its wards are still closed today. A large proportion of medical supplies including medications, vaccinations, and basic equipment were also damaged or lost in the storm. These losses in conjunction with structural damages to healthcare facilities add up to over US $7 million. This has left Vanuatu’s medical professionals almost entirely reliant on international aid to provide even the rudimentary level of care that they had achieved prior to Cyclone Pam, let alone meet the additional demands which have emerged in its aftermath.
As Vanuatu rebuilds after Cyclone Pam, the burden of disease is expected to shift dramatically. The significant advances in the fight against nutritional and communicable diseases in recent years will be largely lost. The contamination of water supplies, when combined with overcrowding in emergency shelters, will create an ideal environment for the spread of many infectious diseases that Vanuatu has only recently started to control.[10,11] The destruction of crucial water tanks has drastically limited access to safe water supplies, with damage to an estimated 90% of tanks and sanitation facilities in affected areas. This has already led to an increase in the prevalence of diarrhoeal diseases, which is expected to continue for
the foreseeable future. The widespread destruction of Vanuatu’s crops will have both immediate and long-term effects on public health.  Malnutrition and vitamin deficiencies are conditions that were only recently controlled
and the sudden loss of almost all agriculture in the affected areas is likely to result in a mass resurgence of such diseases as are commonly seen in post-disaster settings.[7,10] In addition, Vanuatu’s immunisation rates for diseases such as diphtheria, typhoid, and hepatitis A are much lower than those enjoyed in Australia, meaning that healthcare workers will have an even greater task than otherwise anticipated.
In the years leading up to Cyclone Pam, the Vanuatu Ministry of Health had worked with significant success to eradicate mosquito breeding sites, drastically reducing the number of malaria cases. The utter destruction wrought by the cyclone will undo most, if not all, of the hard work on this project by creating an ideal environment for mosquitos to multiply. This, in turn, will likely result in a significant increase in the incidence of malaria and dengue fever, as was recorded after a similarly devastating earthquake and tsunami struck Vanuatu in the early 2000’s. 
All of these challenges come at a time when the government of Vanuatu is least able to manage them. Damage estimates alone, based on similar disasters in other Pacific nations, run between US $248 million to $316 million.[10,12] This is money that Vanuatu simply does not have, and while significant international aid has been forthcoming, with Australia, as the biggest donor, pledging $50 million, current totals and ongoing projections indicate that the total aid provided to Vanuatu will likely fall short of that which is required. The population’s immediate concerns are focused on food and shelter, and even within the health sector the focus is on rebuilding what was damaged by the cyclone. This means that no real provision or funding has been allocated to long-term disease prevention at this time. Economic concerns are compounded by the fact that Vanuatu’s two main industries, agriculture and tourism, have been the most severely affected by the cyclone. In some cases, the damage caused to Vanuatu’s agriculture can be rectified quickly but some crops, including kava – one of Vanuatu’s biggest export crops, take several years to grow to maturity. Many resorts and tourist attractions are still closed in Port Vila and the island of Tanna (one of Vanuatu’s biggest tourism areas and also one of the worst affected by Cyclone Pam), and it will be many years before the income provided by tourism matches pre-cyclone levels.
The Ni-Vanuatu are a resilient people who have made significant advances economically, medically, and politically over the last few decades, but they are still reliant on international aid. Their healthcare, while greatly improved, remains at a much lower standard than that of developed countries like Australia.[5,6] Cyclone Pam has destroyed much of the infrastructure of this beautiful country and, in the space of
a few hours, managed to undo years of work achieved by the people of Vanuatu. In the coming years, healthcare needs will change dramatically, and Vanuatu’s reliance on international aid has suddenly and drastically increased.[10,11] Unfortunately, as is often the case in international disasters, the extensive news coverage of the crisis lasted only a couple of weeks. While that period brought with it an inspiring influx of aid from many countries, decreased news coverage has led to a waning in international awareness and foreign aid.
The plight of many of Vanuatu’s 270,000 citizens remains dire. It will take the country years, if not decades, to completely recover from Cyclone Pam. Infrastructure, tourism, agriculture and healthcare have all been set back significantly, and international support in the form of economic aid is vital to the rebuilding effort.[10,11] This will involve thousands of people, millions of dollars and many years to complete. Because of the financial situation in Vanuatu it will need to be an international effort involving governments, volunteer organisations and, perhaps most importantly, the support of tourists returning to this still beautiful country to support the economy. Vanuatu still has much to offer, with its stunning beaches, tropical rainforests, and beautiful oceans but most importantly, its unique and rich culture and the unfaltering positivity and generosity of its people.
Emma is a final year medical student at Monash University. She has a keen interest in global health and has been lucky enough to travel to Vanuatu several different times, including a med- ical elective in her 3rd year in the Vila Central Hospital. Emma was prompted to write this after Tropical Cyclone Pam devastated Vanuatu in March this year to raise awareness of the health- care situation of one of Australia’s closest nations.
Conflict of interest declaration
I declare that I have no conflict of interest regarding the contents of this article.
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