Accessibility Page Navigation
Style sheets must be enabled to view this page as it was intended.
The Royal College of Psychiatrists Improving the lives of people with mental illness

Roast pig

Micronesia blog by Dr Anna Stout

Truly honoured

Micronesia blog by Dr Anna StoutMicronesia is an archipelago of several hundred islands in the Western Pacific, four of which make up the Federated States of Micronesia (FSM). Pohnpei, the largest of the four state islands, is 135 square miles of gleaming rainforest, mist-topped mountains and mysterious mangrove swamp, and where I have been now for three weeks as a volunteer.

The WHO Pacific Islands Mental Health Network was established in 2007, and currently has 19 countries as members, including the FSM. As part of this network, the FSM has established a Substance Abuse and Mental Health (SAMH) council at a national level and in each of the four states.

My placement in the FSM has been arranged by the World Health Organisation in collaboration with FSM’s SAMH project, led by the administrator for the programme, Mr Kerio Walliby. Kerio comes to meet me at the airport on the day of my arrival and almost immediately whisks me off to a World Mental Health Day party at a local restaurant in the bay, where they have roasted a pig in honour of my arrival. Kerio is proving invaluable as a source of much needed information, support and reassurance when I am having one my many blips - those times when I realise for the hundredth time that I know nothing of any relevance and have no idea what to do next. Nevertheless it always seems to work itself out again, one way or another, with Kerio’s calm, good humoured assistance.

"Does a bit of everything”

Each of the four states provides health care to the population via a private hospital, and a state hospital, with outreach health clinics, dispensaries and aid posts in the communities. The state hospital provides emergency and elective treatment, and is staffed by a number of general physicians. I meet Dr Elizabeth Keller, the Director for Health, in my first week here, and also the Secretary for Health at the government buildings in Palikir, the capital of Pohnpei.

There are seven trainees with me for the next three months – four from SAMH programme in Pohnpei and one from each of the other three states – Yap, Chuuk, and Kosrae. They have a range of job titles, including counsellors, outreach workers and community workers, but they say that everyone “does a bit of everything”. There are no psychiatrists on any of the islands, and the patients who need to see a doctor are seen by the general physicians in the State hospital on each island.

Mental Health care in the FSM is entirely community based - there are no inpatient facilities for mental health patients in any of the four states. Patients who are violent or unmanageable are held in the local prison. Pohnpei and Yap State have a “holding unit” – essentially a seclusion room – but these cannot be used unless families are able and willing to stay with their relative 24 hours a day and provide food for them. Given this is usually impossible, the jail is much more frequently used. Patients who are incarcerated in the jail are seen daily by the SAMH workers to be given medication, and once a week by one the doctors from the State Hospital. The decision that the patient is stable enough to go home is taken by the doctor in collaboration with the family, and there is no mental health legislation in any of the states. We plan to go to visit the jail and the clients there as soon as we can.

Micronesia blog - Dr Anna Stout

Tempermental jeep

Micronesia blog - Dr Anna StoutAll the clients of the SAMH programme are cared for in the community by their relatives. The church also plays a large role in supporting families and the mentally ill. Families don’t have the means to bring their relatives to the clinics in the towns and so the SAMH workers go to see them at home, or they might be taken to one of the local dispensaries, or community clinics. So several times a week, and whenever a call comes in for assistance, three trainees and myself pile into the temperamental jeep and bounce off into the jungle. These routine reviews are mostly to administer medication and check on how people are doing – patients are seen on average once a month.

On one of these visits we visit a family with two adult sons, both of whom have a diagnosis of schizophrenia. The father explains in Pohnpeian dialect that the eldest sometimes experiences distortions of his face, with tongue protruding and stiff jaw. When this happens, the parents stop his oral haloperidol for a few days, but then he begins to “act strange” again – angry and running off into the forest and onto the neighbours’ land, chopping at their trees – whereupon they start his tablets again.

We talk to the family about dystonia and the importance of maintaining medication to prevent relapses, and leave a prescription of anticholinergics to try. I am desperate to change his medication to an atypical......but we don’t have any. The only consistent supply is of Fluphenazine and oral Haloperidol, which runs dry from time to time.

Later on, in the jeep, Stencer and Kehn, the two Pohnpei community workers, tell me that there was another, eldest son, who was found murdered in the mangrove a year ago. They think he also had schizophrenia and was attacked and killed in response to his bizarre and aggressive behaviour, although no culprit was ever found.

The active caseload in Pohnpei is approximately 75 with another 100 ”inactive” – this is in a population of about 36,000. Inactive clients are those who are known to have mental health problems but who have refused to engage or take medication. The trainees tell me that frequently it is often the families who refuse, not the patient. Families play such a pivotal role here – no patients are seen without their families consent; it is families who bring their relatives to the hospital or clinic for help; families make decisions about treatment.

“I cannot be happy unless my family is happy”

I am touched by how welcome I have been made since I came. Pohnpeians are warm and generous, and I am trying to accept all of the many invitations that come my way. I am finding that this is a great way to learn as much as I can about the local way of life, and people’s ideas and beliefs about mental health, what works and what is still needed here. I've learnt that the reliance on family and community to support and help one another is the natural way here – that clan is more important than individuality. As someone says to me “I cannot be happy unless my family is happy”.
Micronesia blog by Dr Anna Stout

Suicide is an increasing problem here, with FSM having among the highest rates in the world. But it is also a taboo subject. Local people tell me that the majority of Micronesians believe that talking about suicide will “put the idea into the heads” of others – when I suggest reaching out to young people and educating them about suicide, the trainees tell me that parents would find this unacceptable.

I learn that local belief is that the spirit of a suicide victim will “infect” others and cause them to kill themselves too unless prompt action is taken – e.g. the tree that is used by someone to hang themselves is burnt to the ground. They tell me that “anger suicides” are rife – that young people who are refused some latest gadget by their parents, or who are jilted by a girlfriend or boyfriend, kill themselves as a way of punishing their families.

A man in town I talk to tells me that he thinks the problem is the decline of traditional values, respect for the elders, and that the young people here are “lost” amongst the conflict of local values with Western ideals. I wonder about depression and the role it plays, but the trainees tell me that depression as a concept is new and not widely held here, that people who are suffering from emotional distress or symptoms of depression are taken to the local healer and do not come to mental health. The SAMH clinic seems to only access patients when they become violent or chaotic. It is not a cultural norm here to talk about your feelings, especially not to an outsider like me.


The trainees are enthusiastic, friendly and well equipped with a good sense of pragmatism and humour. They are keen to know more about how to explore psychopathology and how to tell one major disorder from another; and they are quick to come up with ideas as to how we can disseminate what we are doing to others once training is done. They tell me that the biggest challenges they face are to do with resources – human resources, transport to access patients, medications that run out and don’t get restocked.

There is so much for me to learn and to think about. I knew I would be challenged a lot out here, but I am utterly a novice, in so many ways. Three months is no time at all, and we’re already a month in!

Subscribe to this post's comments using RSS


Add a Comment
Login - Members Area

If you don't have an account please Click here to Register

Make a Donation

About this blog

Dr Anna Stout









Dr Anna Stout graduated from Edinburgh Medical School in 2000 and started psychiatric training in London. She was awarded a CCT in May 2010 and spent eight months in her first consultant post before leaving for Micronesia. She has always been interested in working overseas and has a Master's degree in Culture and Health from UCL.