Mental health in the low income Pacific Island Countries – Time for change in paradigms

Abstract

There are 35 countries and territories that make up the Western Pacific region of the World Health Organization (WHO). Of these, the 14 Pacific Island Countries (PIC) can be categorized as low or medium income and developing countries. The populations range between 10,000 and 250,000; their per capita GNP is mostly well below US $4000. Although independent decades ago from the many colonial powers, their progress in economic and health care development has been slow and fragmentary. There are challenging reasons for this. The island countries mostly have dozens of thinly populated islands separated by hundreds of kilometers of ocean. Cook Islands, for instance, has 15 populated Islands totaling about 250 square kilometers of land in 2 million square kilometers of sea and hundreds of kilometers of sea separating the islands. Sea transport between the islands is slow and expensive. Air travel is prohibitively expensive and infrequent. Fish, the only currently exploitable resource is exploited by huge fishing fleets with mother and processing ships from north Asia, which pay nominal fees for the license to fish in the economic zones of the developing countries. The health care systems have innovated local systems to overcome these real problems. Among them has been the fairly good training of registered nurses, nurse practitioners, and systems of contact by telephone, and email in recent times (and radio telephone in past years) to get assistance in diagnosis and treatment for the widely separated small hospitals and clinics. Few are able to afford helicopter evacuations of seriously ill persons and only a few dire emergencies are evacuated through the infrequent commercial flights on small aircraft that serve the outlying areas. The small hospitals in the largest islands have relatively few doctors and even less specialists, many of whom are expatriates as local training of doctors is limited to only 2 established medical schools – one in Fiji and the other in Papua New Guinea for the whole region of 14 developing countries. Most medical students are on scholarships as fees are prohibitive. Perhaps the most serious casualty is the mental health services of these 14 PICs. There are only about 12–15 psychiatrists in the 14 countries for about 8 million people. All of the psychiatrists are in the capital cities of 5 of the 14 countries and at least 6 of the 14 countries do not even have a qualified psychiatric nurse. At least 4 have small mental hospitals that have for the most part been badly run and continue to institutionalize the pervasive stigma of mental illness with locked wards, barbed wire and incarcerated patients.