Aftermath – cargo cults and treatment failures

It was seven o clock in the morning on the seventh day of the seventh month of ninenteen seventy one. In the cool early hours of the morning thousands of local village people had made the arduous climb through the forest to the summit of Mount Turu in the Sepik District of Papua New Guinea (PNG). At the summit were two concrete triangulation posts which years earlier had been placed there by an American geographical survey team. The villagers were all paid up members of the Peli Association, a cargo cult. They believed that at this auspicious time, they should remove the Americans’ concrete posts and the mountain would open and disgorge for the membership masses of cargo, a term for manufactured western goods, and money. Crops would flourish where they had recently failed, birds of paradise would return in plenty and the members would be rich.
The big man of the area, Mathias Yaliwan was the leader of the Peli Association. Yaliwan had been preaching for many years that Peli members would be rewarded on this date when the mountain would open and be full of cargo. To become a member entailed buying “shares bilong Jesus Christ”. The cult grew to huge proportions and eventually most people in the area joined. Even educated local people, though sceptical bought shares, not wanting to risk missing out. The disappointed members were not refunded their subscriptions and thousands of dollars were unaccounted for. Yaliwan, who was quite possibly a sincere man later became a member of the national parliament.
Of course there were those who realised the impossibility of the prediction. The European expatriates were worried that they would be accused of conspiring with God and Jesus Christ to prevent the local people from getting their cargo so they themselves could profit. This concern proved unnecessary. Some of the Europeans understood that uniquely complex cross cultural dynamics had led to this bizarre situation. However some redneck Australian administrators and businessmen considered the local people to be lazy “bush kanakas” who wanted something for nothing by subscribing to this corrupt organisation rather than working hard.
What was the background to the social aberration of cargo cults? The people of PNG had been more or less isolated from the rest of the world for thousands of years until contact with Europeans started in the late nineteenth and early twentieth century. Then Christian evangelical missionaries started to arrive, but for years made contact with only a tiny minority of the people. Tribal warfare made travel impossible for most people and many had no contact with the outside world except for neighbouring tribes, who were often dangerous enemies, until the mid twentieth century or later. In the 1970’s I met tribes whose first contact with outsiders had been seven years earlier.
After World War one a League of Nations declaration made PNG a protectorate of Britain who delegated the role to Australia. In the first half of the twentieth century most people still lived a stone age traditional village life of subsistence agriculture and hunting. Their homes were built of wood and palm leaves. The men hunted with bows and arrows and spears and used stone axes to chop down trees while the women worked in the vegetable gardens using wooden tools. Neither the wheel nor flights for arrows had been invented.
Gradually a few imported axes, saucepans and the like were acquired from missionaries or bought from trade stores.
Later a Westminster style national government was introduced to govern the country of 700 tribes with 700 languages, most of whom were living literally in the stone age.
In Melanesian societies status was gained through giving and the big men tended to be those who were able to give most. Melanesians believed that their ancestors spoke to them in dreams and could come back to life bringing gifts. Some came to believe that missionaries and other white people were reincarnations of their ancestors.
The missionaries of course taught that the people should believe in the Christian God and thatJesus Christ was the son of God and that traditional pagan icons should be destroyed. Christianity was difficult to reconcile with traditional religions, which consisted of ancestor worship and belief in spirits which had to be placated in order to ensure good harvests and safety from enemies.
Soon after the white people came to live amongst the Papua New Guineans, enormous ships and planes started to arrive disgorging amazing cargo such as radios, cars, refrigerators, beer, and many other things which had never before been seen. These were out of context and the people had no concept of how they could be produced by humans. The goods were destined for the white people and never for the local black people. Some of the local people put two and two together and began to believe that the goods were sent to the white Christians by God and that if they became Christian they too would receive shiploads of cargo. When the goods failed to arrive for the black people, some began to believe this was a conspiracy by the whites. But some local leaders developed large followings when they predicted that the ancestors would send ships and planes with goods for the local people. These beliefs were known as cargo cults.

The superimposition of a twentieth century western culture on a stone age society produced a situation ripe for misunderstandings at an interpersonal level and also at a national level. In his autobiography “Ten thousand years in a lifetime” the then minister for health the late Sir Albert Maori Kiki graphically described the immense personal cultural conflicts and difficulties in his transformation from a child in a stone age village, through missionary school, training in Fiji as a health worker and finally becoming a Westminster style politician and a cabinet minister.
During the three years I spent as a doctor in Papua New Guinea in the 1970’s I often encountered situations in which I had made unconscious assumptions based on my western background only to discover that the people I was relating to had a very different way of viewing the same event.
At the end of a day of hospital clinics and wardrounds, Joseph, a hospital porter who had been friendly with me said he wanted to talk. I invited him for a beer and we sat in my tropical garden under the Frangipani tree, the gentle waves of the South Pacific breaking on the coral reef a few yards away. We chatted in New Guinea pidgin and after a few polite preliminaries he asked me what money really was and where it came from.
“Long wonem yupela Europeans kisim dispela mani na yupela inap baim planti cago na mipela kisim liklik mani tasol?”
How was it that I and other Europeans were able to get plenty of money and buy goods, whilst the New Guineans only got a small amount of money. He wanted me to explain the source of the coins and notes so that he could obtain more for himself.
I tried to explain that money had no intrinsic value but was merely a token paid for services, that my skills as a doctor were rarer and more in demand by the government than his as a porter and so I was paid more money and could obtain more expensive cargo. As I explained I became acutely aware of the limits of my own understanding of economics.
Joseph listened politely and asked questions. After I had explained as clearly as I could he said that this was a very interesting story but now would I give him the true explanation of where the white people got money from. Clearly he believed that the whites had secrets we were unwilling to divulge thus preventing the local people from obtaining wealth. He had no concept of factories producing goods or mints producing coins. Money and goods were given to the white people probably by God or gods and ancestors sending them to the country by ship.

Each morning I would stroll along the breezy point of land projecting into the south pacific and which was the grounds of Wewak Hospital. The basic wood-built hospital was well maintained by the Australian administration and supplies and equipment were adequate. The nursing staff were mostly Papua New Guineans but matron in charge was Australian. The four doctors were, like me, expatriates.
One morning I arrived on the ward to do the rounds. By chance I went into a side room and found a desperately ill old man lying in the bed. I hadn’t been told about this tribesman who spoke no pidgin or any language in common with the hospital staff. I started emergency resuscitation.
When I asked how long he had been in the ward and was told he had been there for about three days and had received no treatment I became rather angry and incredulous. How could it be that a very ill man in hospital was not seen by a doctor for three days and received no treatment? Moreover it seemed that this would have continued had I not entered the room by chance.
The old man died and I tried to discover what had happened. Gradually I understood from Isaac, the charge nurse, that the man was from a tribe which was a traditional enemy of the tribes of most of the nursing staff. There was a feeling that it would be no bad thing if the man were to die. This event was pivotal in my awareness that my own, often unconscious assumptions, did not always hold true in another society.

Today it is recognised that even severe dehydration in children can be safely treated with rehydration by mouth using the correct electrolyte solution. In the 1970’s dehydrated children were treated with an intravenous infusion and there was great emphasis on the correct amount of fluid to avoid under or over hydration. Often the intravenous needles for the infusion would become displaced from the vein and need to be replaced. Every evening in the children’s gastroenteritis ward in Port Moresby we had a ward round to ensure that the night nurses understood the treatment for each child.
One morning I came to the ward and found that the young nurse who had been on duty overnight had placed the displaced needles not into the children’s veins but had run the fluid into the mattresses rather than into the children’s veins.
I was completely puzzled by this apparently strange behaviour. It became clear that the Papua New Guinean nurse had misunderstood me the European doctor. I had emphasised the importance of the level of the fluid in the infusion bottle, assuming that it was obvious the fluid needed to go into the child. Unable to resite the needles correctly into the veins, she was satisfied to get the fluid to the correct mark in the bottle by whatever means. This seems impossible to us with all our assumptions about medical treatment and our background of a western education but it reflects a completely different cultural background.

A middle aged man who had his initial treatment for pulmonary tuberculosis in hospital improved, stopped coughing blood and was stronger. I advised him to go back to his remote village for his eighteen month course of treatment to be completed at the local health aidpost.
A few months later he returned to hospital complaining that he was again coughing blood. X rays confirmed that the disease was producing new cavities in his lungs and sputum microscopy showed that many tubercle bacilli were again present. His treatment card showed that all the right boxes were ticked three times each week indicating to me that he had received all his treatment. My initial thought was that his TB had become resistant to the drugs, a problem which was starting to emerge in the early 1970’s but was rare in the Sepik district of Papua New Guinea.
On further enquiry I discovered that although the man had been to the aidpost three times a week and the aidpost worker had ticked the boxes, no treatment had been given. It seemed that the aidpost had run out of the medicine and the orderly had not been to town to collect more. Later when I discussed it with the aidpost orderly I discovered that he thought the most important thing was to tick the boxes to show that the patient had attended even though the medicine was not given. Maybe there are some lessons for the UK’s health service where important government targets can be met by massaging waiting lists even though no more patients are treated.

Although we westerners do not understand all the causes of diseases we have an underlying assumption that they have a biological or a psychological basis. When I went to Papua New Guinea as a 26 year old doctor I was unprepared for the beliefs about illness held by the people who would be my patients.
All disease was believed to be caused by poisoning or “sanguma” either by angry spirits or by enemies. If it was found that the sanguma was caused by an enemy then revenge would be appropriate especially if the person died of their illness. One night in a village next to the Sepik river, I sat up all night with the village people in the “haus tambaran” or spirit house. A child had died following an illness. The people were gathered in the haus tambaran and the elders and important people were engaged in heated debate, singing, shouting, crying and wailing all night while they tried to determine which spirit or which enemies had been responsible.
Often one could tell the location of a patient’s symptoms by numerous small cuts or scars over the area. The traditional doctor had cut the skin with a sharp stone or a knife to let out the spirits causing the illness. If this did not work the patient would come to the hospital to try western treatment. Sometimes I was very frustrated after my treatment was starting to be effective when the patient would one day disappear. I was told that because they had started to improve they had gone back to the village for the village doctor to complete treatment using their traditional methods.
I believe that the presumption that others are thinking in the same way as oneself, whether within one’s own cultural group or in another, leads to conflict, either interpersonal or on a larger scale. Perhaps awareness of differences in thought processes would avoid some of the horrific problems caused by misunderstanding.