JO CHANDLER | The Australian
IT WAS MIDNIGHT and Barry Kirby had been at the wheel for almost seven hours, nudging his 4WD 200km down a goat-track of bog, fog and yawning ravines in some of Papua New Guinea's most inhospitable back country, when he experienced his epiphany.
Later, friends would gently suggest he was overthinking a garden-variety midlife crisis. He was a prime candidate - 40, a loner, a searcher; a carpenter by trade and adventurer by nature, nearing the end of a defining four-year posting in a lost corner of PNG.
"People would talk about 'change of life' and other stupid things," says Kirby, ever the plain-spoken Australian tradie. "But I kept getting these messages."
That night on the road in 1990 he was hauling building materials back to the village of Menyamya, where he'd lived for the past four years, when his headlights fell on what looked like a hessian sack.
Language doesn't necessarily translate from one valley to the next in PNG, but Kirby learnt that the woman had been cast out as a witch. She had two dead husbands. She also had chronic diarrhoea and, on later reflection, very likely HIV-AIDS.
Kirby asked the villagers to help him bundle her into the passenger seat. The smell was beyond bad. "She was sitting there and I'm driving along - I couldn't talk her language, she couldn't talk mine," Kirby recalls. "She had lovely white teeth, I remember." She huddled deep in the folds of her bark malo.
At the health centre Kirby looked for the doctor, but he was away. So he put the woman to bed, fetched some water and tracked down someone who promised to watch over her. "I went back to see her in the morning and she was dead," Kirby says. "You walk away and you think, 'F..k. That's preventable. She died because no one went to see her and put a line in'."
He made a decision that night - or rather, he yielded to a mad, nagging notion he'd been slapping away like a bothersome fly throughout his time in Menyamya, where he'd too often witnessed the grief from PNG's understaffed and failing health network. "I sort of gave up fighting this feeling, just gave in."
Barry Kirby, a Northern Rivers farm boy who had never been much of a student, would become a doctor.
On a good day, Dr Barry Kirby wakes to benign conditions on Milne Bay, beyond the easternmost tip of mainland PNG. In flat water he can coax 33 knots from the outboard of his borrowed banana boat as he commutes the luminous avenues between palm-fringed Pacific islands.
It looks for all the world like paradise, but he knows better. He will be met by gatherings of heavily pregnant women waiting in the shade of tumbledown health clinics, fanning themselves with copies of their Buk Bilong Ol Meri, the precious record of their antenatal visits.
On the best days he might deliver a baby into the arms of a healthy mother. After a difficult labour, he's as exultant as she is exhausted. On the worst days he treks up to a village hidden in the jungle to find the sister, mother or husband of a woman who has died in childbirth, and will add her story to his overflowing archive of similar sorrows.
His crossings into this hidden landscape, where all that separates birth and death is luck, obsess and distress him. It's why he's making a special trip to Normanby Island, one of the larger rocks in the archipelago where he conducts his medical rounds. There's another story waiting for him to collect before the forest swallows it up and the lessons are lost.
With the boat moored in a shallow cove, we wade over the litter of bleached and broken coral to unload supplies of drugs and equipment for the clinic. Dr Barry is in foreman mode. He has the tradesman's swagger of capability as he strides around the health centre at Sehulea station. For the moment his hard won doctoring credentials are less useful than his old tools.
He's trying to fix the plumbing, because there's no water coming down from the tanks up on the hill and the single solar-powered light in the delivery room is on the blink. Water is the priority.
The nurses are well accustomed to birthing babies by lamplight, but as the ordinarily unflappable resident midwife Sister Dorcas John laments, they can do nothing without a clean water supply. Two women who have made the journey to the clinic from their villages several hours' walk away wait patiently on the veranda, though it provides little relief from the midday heat.
Kirby strips off his sweaty clothes, washes in a shallow dish of precious water and emerges from Sister Dorcas' little house in crisp collared shirt and shorts, transformation completed by the stethoscope draped around his neck. The doctor is in.
His first patient, Clara, is ripe to bursting and a week overdue, assuming her dates are right. He stretches a tape measure over the mountain of her belly, drops his head and listens intently to the baby's heartbeat. He closes his eyes and gently travels his hands. The baby's head is still floating high, not engaged as it should be by now for imminent delivery.
It's her second baby, but there's no record of whether the first was also late, or even when it was born. "How many Christmas' since the first baby?" he asks. Two.
"Is your husband here?" Yes, he's around. Kirby tells Clara she must stay close to the clinic, not go home to her village. If the baby hasn't budged by morning she'll ride back with us in the boat to Alotau, four hours away on the mainland, where he'll admit her to the provincial hospital.
Next patient is Malika. She's not due for a couple of weeks but her tiny frame staggers under an even more spectacular belly. Kirby goes through his routine again, feeling for clues. "Is there a lot of kicking, lots of movement?" She nods vigorously. This time around "it's gotta be twins", Kirby concludes, but without an ultrasound he can't be 100 per cent sure.
His questions trip more alarms. Malika's husband has a history of violence towards her and has left her for another woman. She's marooned in his village, so she won't have much, if any, help when her time comes. He tells her to send word to summon her mother from her garden in the island's interior.
Malika will certainly be coming back with us to Alotau and she will need a guardian to look after her at the hospital. The boat's beginning to look a little crowded on the return trip.
If all goes to plan, Kirby won't be relying on the weary outboard to service his far-flung country practice much longer. He's finalising a deal to buy a seaplane, which he will pilot himself once he has finished updating his licence - the relic of another previous life.
Milne Bay is about to get its own "flying doctor", specialising in on-call emergency obstetrics retrievals, a first for PNG. The seaplane rescue service is the centrepiece of an ambitious, largely self-funded experiment trialling strategies that have emerged from Kirby's own research - his painstaking collection and analysis of the stories of dead women - and which he hopes will claw back the death toll of PNG's escalating maternal health emergency.
"There are moments," he reflects later, nursing a beer on the deck of the Alotau boatshed he calls home, "when I've got my head up a perineum, stitching it up, and I look back and think, 'How the hell did I get here?'"
Young Barry Kirby never much enjoyed city life or schoolrooms, and pined for weekends out on the family farm. He scraped through St Laurence's in Brisbane, a middle-rung Catholic boys' college, then got a job as a trainee accountant on the seventh floor of the BP building in Sydney ("how boring was that").
He lasted less than 12 months before following his father Frank's footsteps and getting an apprenticeship, finding satisfaction in craftsmanship and freedom in the unfettered life of a journeyman carpenter.
He was also taking his father's lead when he signed up for the job in PNG. Frank Kirby had served with an Australian artillery unit that fought an ugly campaign to dislodge the Japanese from Shaggy Ridge, near Madang. He rarely spoke of the war, but many times he told his son of the warmth of the people of PNG and the wild splendour of its landscape.
Kirby discovered these for himself when, after his building business in Alice Springs went bust, he took the job in Menyamya to build a high school and student boarding house with Australian aid money.
He immersed himself in a community where men decorated themselves with cassowary bones, women wore grass skirts, and bows and arrows were carried in earnest. The history books recount many blood-curdling tales of white men's encounters with the local Kukukuku tribe - infamously fierce warriors. "Magnificent people - once you get to know them," Kirby says.
By 1990, the school project was almost complete and Kirby was mulling over whether to accept an offer to stick around or return to Australia when he found the dying woman in his headlights and his destiny became clear.
It took him 12 years and the sale of all he possessed to pay his way through medicine - the long way, via the University of Technology Sydney, Griffith University and the University of PNG. He was 52 and had $50 to his name when he emerged as a rural obstetrics specialist.
It was during his final phase of training at Alotau Hospital in 2002, working 24/7 on local wages of $250 a week, that a plan started to form. After a further three years' preparation for exams, Kirby qualified for Australian registration and started to pick up locum work in the bush and lucrative short contracts overseas, stashing away his earnings and pursuing his last academic requirement for rural obstetrics practice - a research project digging deep into some of the casualties of PNG's maternal mortality crisis.
Women die during or soon after childbirth at a rate of 733 per 100,000 births in PNG - a rate that has doubled in a recent decade. (In Australia, the figure is about eight, unless you are Aboriginal, when it is about 21.)
Analysis of World Bank and PNG Demographic Health Survey data puts the lifetime risk of dying from pregnancy in PNG at one in 28, compared to one in 10,000 in Australia, says Professor Glen Mola, head of obstetrics and gynaecology at the University of PNG. Mostly, mothers bleed to death for want of basic medical attention. Kirby's research told how, where and who, honouring the casualties with identity.
I came across Kirby's work in 2010 while researching news stories on the woeful fallout of PNG's collapsing health system. Mola had forwarded the investigation his then postgraduate student had compiled tracking the deaths of 31 mothers in Milne Bay province.
The report was intriguing - and not just for the surprising provenance of its author. It contained an excruciating litany of case studies, true tales animating the well-worn statistics.
Take the story of Lispa, Case #26, and the valiant efforts of her husband Isaac to save her. Isaac raced over a mountain to borrow a dinghy and beg fuel to ferry Lispa to help after the umbilical cord broke while delivering their fifth child.
"Placenta is too hard for me to push out," she told Isaac's sister. She was bleeding badly by the time they reached the remote aid post - only to find the health worker had no drugs or equipment. She suckled her baby until she died.
Kirby's tone showed little regard for the conventions of the dispassionate, distanced, disembodied academic voice. He put himself squarely in the picture, explaining the travails of access across wild seas and jungle, realities that would have to be tackled if health services were ever to improve. He prefaced the report with a dedication to "the brave Milne Bay women who have given up their lives for the sake of giving life".
Of PNG's 200,000-plus births a year, more than 120,000 are unsupervised. As Professor Mola tells it, these women deliver in the bush or their villages "on a dirt floor, with no skilled attendants, no equipment, no capacity to get somewhere if something happens, and many die".
Despite years of talk and promises, little has happened to improve a health system that one former PNG health minister described as "bloody useless". With Kirby gearing up to trial his crazy brave ideas at half a dozen remote island sites, I wrote him a note, eventually wangling an invitation to come and see what he was doing.
We ride into Alotau in the doctor's battered Land Cruiser, half a million miles on the clock, avoiding dogs and chickens, pigs and potholes, and women carting babies, food and wood. He crunches the gears as we crawl up the winding avenues. His routine is to ride his bike up here most mornings; at 62, there's a lot to do before he gets "too decrepit".
We pass simple, tidy shacks draped with long lines of flapping laundry, frangipanis sprinkled with pale blossom and broad African tulip trees, boughs blazing with crimson spikes. We slow at a vantage point above the turquoise bowl of the bay. The sea and sunshine have nurtured happier and gentler cultures around this idyllic coast than some of the more punishing landscapes of the interior.
Nonetheless life is hard in Milne Bay. Cash is scarce since copra (dried coconut flesh) prices crashed and depleted stocks forced the closure of the lucrative beche-de-mer (sea slug) harvest. Women bear the brunt of it. At local markets they might earn just 10 cents for a hand of bananas or a pawpaw.
One of the things women told Kirby, when he surveyed them about why many didn't come into the health centres, was that they couldn't afford the 5-10 kina ($2.25-$4.50) fees. So he's lobbying provincial authorities to scrap the charge and in the meantime subsidising it for mothers at his trial sites.
They also told him they were embarrassed they had no clean clothes for their newborns and no soap to wash them with. Hence the busy enterprise we find when Kirby pulls up at his boatshed. Four local helpers are loading dozens of plastic baby baths filled with tiny singlets and plastic pants, nappies and towels, talc and baby oil, mosquito nets and bright loincloths. Midwives distribute these "baby bundles", worth about 60 kina ($27) each, as a reward to women who come in from their villages - sometimes many hours' walk away - to deliver their babies at the health centres.
It's proving a powerful lure. In the six months they've been offered at his sites, supervised deliveries have risen sharply and deaths have fallen away. More than 600 bundles have gone out. Sehulea health centre used to average 60 to 70 supervised births a year, but there have been more than 90 in the six months since the bundles have been distributed.
Other initiatives include extra staff training, drug supplies, equipment and a bonus for health workers - 20 kina ($9) for every baby above the previous year's average. The incentives payment is based on a successful program in Cambodia that Mola was keen to see trialled in PNG.
(He's supported it with funding through "Send Hope Not Flowers", an initiative of Australian obstetricians who encourage their patients to ask for donations in lieu of congratulatory bouquets.)
In a context where health workers are overburdened and unsupported, some are also notoriously cranky and rough with their patients. The "baby bonus" encourages them to refine their bedside manner.
The next phase will be a radio network to the far flung aid posts and the seaplane rescues. Kirby has founded a fledgling charity to run it, tentatively called The Hands of Rescue Foundation. His role model is another maverick medico, the late Fred Hollows.
Kirby cheerfully admits he's fixated. There's room for little else in his life. He was married once, to the first girl he ever asked on a date, but it didn't last long. Other romances, and the opportunity for children of his own, were sacrificed first to Menyamya and later to pursuit of his medical degree, which absorbed most of his time and all his money and passion.
"Once you have the knowledge, how can you walk away? You've witnessed it. You have to do something about it. You won't be happy with yourself unless you do."
He doesn't subscribe to much of the Catholic orthodoxy of his upbringing but the baggage is harder to shake. Kirby was raised in a household where faith and social justice were central to identity and conscience, and the search for meaning - vocationally and spiritually - remains a powerful motivator.
Along with, perhaps, a dash of redemption. "I've got some skeletons in my closet," he declares. "Some of them I don't want to say anything about. I've been an arsehole at times. No risk about that." That conversation is closed.
We trek up into Normanby Island's lush hinterland, following the vague contours of a jungle path past clusters of huts and cooking fires. Kirby sets a cracking pace; I'm trailing, drenched in sweat.
The last time he was on Normanby, about three months back, Kirby was interviewing the families of two women who had died in childbirth when the meeting was interrupted with news that there had just been another death, not far up the track. He found Catherine Pindo with "the most peaceful look on her face," Kirby recalls. "Almost beatific." With her clan gathering and wailing, this was no time to ask questions.
We've come back to find out why she died. She was 23. Her sister Marita is waiting at the abandoned hut where Kirby last saw Catherine laid out on the floor. Marita is nursing Catherine's sleeping son, John Bosco, named for the 19th century Italian priest who founded the Salesian order. The missionaries did their work thoroughly in these parts. We sit in the shade of a hut decorated with icons of the Virgin Mary to talk to Marita and a cousin, Flora, who was also present when Catherine died.
Kirby settles with his notepad and pen, launching into his practised posthumous ritual, a kind of verbal autopsy. Did Catherine go to school? Yes, to grade nine. Was this her first baby? Yes. Her husband, Ronald, was he a good husband? Yes. Did he beat her? No, never. Did he take her to the health clinic for checkups? Yes. Who helped the baby come out? Our mother.
Questions and answers go back and forth in Tok-Pisin and Tok-Ples (local language) and English. There are 82 of them on Kirby's standard checklist.
Flora describes Catherine's last moments. The labour was long, a day and a night, but she had seemed well the morning after her son finally arrived. Then she went down to the river to toilet, and when she returned she said she was dizzy and hot. She lay down and there was froth at her nose and mouth.
"She said, 'Mummy, you tell Marita to feed the baby'," Flora says. "She said, 'I'm going to leave you'. And then she said thank you to the Lord. And then she died." For long moments the doctor's pen is still and his head is bowed over his notebook. The only sound is the wavelike cicada chorus echoing through the forest. Kirby composes himself, coughs and finds his voice.
It's not clear why Catherine died. What Kirby learns is that, three days before it happened, she had been to Sehulea and attended a clinic. The nurse urged her to stay close by because the baby was due, but someone - it's not clear if it was Catherine or Ronald - insisted they needed to go home to collect a few things, four hours' hard walk away. It's a familiar story.
"Catherine walked back to her village and went into labour on the Saturday. She died on Sunday. She was already at term," he tells the nurses at Sehulea when he gathers them together for a meeting that night.
"We are professionals. We know a walk like that could bring on the labour. We need to be strong. We need to say to mothers, 'No, you can't go, for yourself and your baby you must stay here. Let the husband go, if he must'."
In the morning we board the banana boat in the already sweltering dawn. Clara won't be coming - her baby has dropped into position. She will be safe in Sister Dorcas' hands. Kirby puts a cannula into Malika's arm, in case her babies attempt to come out early during the trip and he needs to quickly insert a drip.
The motor roars and we power into the blue, heading back to the mainland, carrying Catherine's story, Malika and her mother, and the next generation of Milne Bay women - twin girls - who will be safely delivered in Alotau Hospital a few days later.
For more information and to donate: www.sendhope.org