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The Victoria-Vanuatu Physician Project (ViVa) was a Canadian non-governmental non-profit organization of physicians and their families from Victoria, British Columbia, Canada that for 24 years supplied a medical doctor to the 35,000 people on the island of Tanna, Vanuatu. ViVa started in 1990 and finished in 2015 during which time 42 different Canadian physicians and their families provided uninterrupted health care services to the people of Tanna. ViVa was remarkable for its small size, local origin and longevity as an international development organization.

Mission
ViVa [was] committed to participating with the people of southern Vanuatu in improving their health by:
 * improving the quality of hospital facilities
 * working towards self-sufficiency
 * facilitating local health initiatives
 * encouraging different innovative approaches to health care delivery
 * ensuring ViVa actions and policies [were] consistent with local customs and [were] informed by consultation with local groups

History
In 1990, Canadian University Service Overseas (now CUSO International) as part of their development mission, decided to facilitate professional and cultural connections between Canada and other Pacific Rim countries. A CUSO International representative approached the James Bay Community Project, an urban health and social services cooperative in Victoria, Canada, with the idea to create a formal linkage with Vanuatu, the newly independent South Pacific nation formerly known as The New Hebrides.

After meetings held with interested citizens in both Victoria and Vanuatu, it was decided that the project would start first with placing much-needed medical doctors in Vanuatu. The island nation did not have a medical school and had a shortage of skilled medical professionals. It was thought that a Canadian doctor could provide medical services, supervise and train local nurses and staff, and help manage the hospital and rural health care services.

Victoria at that time had about 200 physicians. A call for volunteers to work for 1-year or 2-year terms in Vanuatu went unanswered. CUSO International, which was offering to subsidize the travel costs and provide a small living allowance, did not ordinarily sponsor overseas terms for less than 2 years. After some deliberation and consultation with the Victoria Medical Society and the Vanuatu Ministry of Health, it was decided that a 6-month term could be offered and would be more appealing. This time the call for volunteers was successful.

In 1991, a formal memorandum of understanding was signed between the Victoria Doctors Association, later renamed the Victoria-Vanuatu Physician Project (also Society or Association) or ViVa for short, and the Government of the Republic of Vanuatu. The job description was for 6-month postings as Medical Superintendent of TAFEA province, stationed at Lenakel Hospital on the island of Tanna. Housing and a living allowance would be provided.

CUSO International’s initial 3-year funding was vital to getting the ViVa project started, but it ended its financial support in 1994. CUSO assisted the ViVa organization in establishing itself as a Canadian non-profit society with registered charity status. A new MOU was signed with the Government of Vanuatu. ViVa then started regular fundraising to support the travel costs of physician families and the maintenance and replacement of the ViVa truck.

ViVa Doctor role and accomplishments
Tanna is a volcanic island in the southern part of Vanuatu. At the time, with a population of about 35,000, it was the most populous of the five islands in TAFEA province and one of the most populous of the 80 islands in the country. Lenakel, the largest town, was the location of the 40-bed hospital and doctor. There were at least five local languages spoken on Tanna in the 1990’s and early 2000s. Most people also spoke at least one of the three official languages of Vanuatu which were English, French and Bislama (a form of pidgin English). Tanna is one of the most fertile islands in Vanuatu and produced kava, coffee, and many fruits and vegetables. Tourism was also gaining economic importance. Tourists were (and still are) attracted to the volcano, traditional culture, and beach resorts.

In the early 1990s, crowded smoky living conditions, few sources of clean running water, a high birth rate, low vaccination rate, and poor access to maternity and medical care contributed to prevalent health conditions such as malaria, tuberculosis, chronic lung disease, soft tissue abscesses, typhoid fever, and other infections not often seen in Canada, as well as a relatively high infant and maternal mortality rate. The role of the ViVa doctor was to reside at Lenakel Hospital and consult on outpatients referred by the nurse practitioners, supervise care of hospital inpatients, provide minor surgery and emergency Caesarian sections, assist the midwives with complicated deliveries, teach regular in-service educational rounds, and also ensure that care was being delivered in the nine rural health outposts.

In its teaching role, the ViVa doctor mentored occasional visiting international medical students. The ViVa project also had a memorandum of agreement with the University of British Columbia Post-Graduate Medical Program to host and supervise Family Practice Residents in elective global health training.

Challenges to delivering care on Tanna included the high heat and humidity, volcanic ash, tropical storms, some intermittent medicine and oxygen shortages, equipment malfunction, and power and water outages. Outweighing this, however, were the goodwill, friendliness, and gratitude shown by the local health care staff, their families, the patients and the whole Tanna community to the ViVa Doctor and his or her family. Creative problem solving was used to overcome or mitigate most of the infrastructure and administrative weaknesses in the health care system. ViVa families were welcomed and bade farewell with a traditional “salusalu” (hello-goodbye) ceremony every 6 months. Several doctors and students wrote about their experiences in blogs and/or journals or were interviewed by others after returning to Canada.

An additional ViVa accomplishment on Tanna was the establishment of a "green card" program for management of non-communicable chronic diseases. Asthma, chronic lung disease, diabetes and hypertension were prevalent in the older population. Similar to the "blue card" program where all parents were given a blue-colored card at their child's birth and which was used to record well-baby visits and vaccinations, the adult green card was used to record active medications, blood pressure and blood sugar measurements at regular outpatient visits. This was a significant benefit and achievement in an environment where only the hospital had medical records.

Another accomplishment was the elimination of malaria on Tanna. This was mostly due to the multi-pronged effort of The Global Fund to Fight AIDS Tuberculosis and Malaria, Australian Aid, and the Government of Vanuatu. Resources were put on the ground to detect malaria, treat it early, and prevent the spread with mosquito nets and sprays. ViVa Doctors did play an important role as acknowledged by Sir Richard Feachem, founding Executive Director of the Global Fund who met with ViVa Doctors in Vanuatu in 2009 and 2010 during planning meetings. Upon the closing of the ViVa project in 2018 Sir Feachem stated in an email to ViVa, "I am sure your work on Tanna contributed to the elimination of malaria in Tafea Province. Hopefully this achievement can now be extended to other provinces of Vanuatu.”

Finally, the most important accomplishment of the ViVa Project is probably best summed up in the words of the late Vanuatu President Iolu Abil. In November 2012 on the occasion of a visit by the Canadian High Commissioner (Michael Small), he said the following in a public speech:

''“I wish to note in particular a special arrangement currently in place, whereby experienced Canadian medical doctors are being recruited on a 6-months rotational basis, to serve our main hospital for the Southern province of Tafea. I wish to further note that such service touches the very core of our people’s lives and has a long-term positive impact on the over-all welfare of our people, for which we are truly grateful.”''

Sustainability model
It is notable that this small organization managed to provide continuous physician coverage for the Vanuatu island of Tanna for 24 years. ViVa was probably successful for many reasons but largely due to the enthusiasm of those doctors and families who served on Tanna, their efforts to respect the local culture, and the positive experiences they had. The ViVa organization was totally voluntary, with no paid administration. Funds raised were spent on the doctors’ travel to and from Vanuatu, maintenance and repair of the doctor’s truck and house at Lenakel Hospital, and some medical equipment. The following factors were also important in sustaining this project for so long:


 * An organizational structure that required each applicant to attend monthly ViVa meetings in Victoria for at least two years before their Vanuatu term, to serve as Secretary for 6 months before going, and to serve as President for 6 months after returning from Vanuatu
 * Effort to consistently recruit applicants from the greater Victoria area, rather than from elsewhere in Canada, so that this local organizational structure could be maintained.
 * Ensuring that each applicant had a spouse or adult partner who could provide necessary domestic support on Tanna.
 * Local training in Bislama language and customs, domestic living advice, and clinical case studies provided by returning ViVa doctors to those applicants waiting to go to Tanna.
 * Specialist training donated by Victoria physicians in TB diagnosis, infectious disease, vasectomy, Caesarian section and gynecological surgery, and ultrasound interpretation.
 * Assistance from the Government of Vanuatu with visas, medical licensure, and salary (local scale) payment for a new Doctor every 6 months.
 * A minimum 7-day crossover period every 6 months that allowed the incoming doctor and family to live and work with the outgoing doctor and family.
 * A comprehensive field manual written by ViVa Doctors for their colleagues
 * Support and assistance from the dedicated Vanuatu nurses, midwives, hospital administrators and maintenance staff
 * Repair and maintenance of the Tanna Doctor’s House and Lenakel Hospital by volunteer members of the TAFEA Committee, Rotary Club of Port Macquarie, New South Wales (District 9650), part of the Rotary Australia World Community Service
 * Annual fundraising in Victoria that included medical conferences, charity golf tournaments, dinner lectures and silent auctions. For many years organization of this event was assisted by a pharmaceutical company donating time and expenses.
 * Good will and financial generosity of the Victoria medical community, their patients, and the public, reinforced by word of mouth and regular publicity generated by ViVa at medical gatherings and in the media

End of the ViVa Project
The ViVa Project wound down in 2015 for two reasons. Firstly, part of the ViVa mission was to enable the country to work towards self-sufficiency. This appeared imminent in 2015 with many graduated native Vanuatu medical students returning from training in Cuba and China who would soon be available for placement around the country. Secondly, ViVa encountered increasing difficulty recruiting Canadian physicians due to a shortage of Victoria general practitioners with the requisite skills, interest and capacity to commit to a 6-month term. Some physicians from elsewhere in Canada were able to fill spots but this made it difficult to sustain the local organizational structure.

In August 2014, ViVa gave written notice to the Government of Vanuatu that it could no longer sustain its mandate. The last ViVa Doctor served until the end of January, 2015. A final “salu-salu” ceremony was held at Lenakel Hospital, Tanna, on the 2nd of February, 2015, with hospital staff, Government of Vanuatu representatives, local chiefs, and five former ViVa Doctors, in attendance. Many speakers expressed their gratitude to ViVa. Uncertain about future physician coverage, a group of Island chiefs submitted a letter to the Government of Vanuatu pleading for the Canadian doctors to continue their services. In response to this, the Government representatives introduced the new Vanuatu replacement physician and reassured everyone that the Ministry of Health would continue to provide a doctor for the Island. Sixty “kastam” dancers from the Tanna village of Yakel performed a dance. A small plaque was presented to ViVa and “the people of Canada” in appreciation of 24 years of service.

Cyclone Pam
On 13th March, 2015, only six weeks after the last ViVa doctor left Vanuatu, the country was hit by an extremely powerful Category 5 hurricane called Cyclone Pam. The island of Tanna was devastated. Fortunately, very few lives were lost but most homes and the hospital were damaged or destroyed. The ViVa organization quickly leveraged its contacts within the community of Victoria and elsewhere and raised $CAN 150,000 for rebuilding. Over the next 3 years, ViVa worked, from a distance, with the Rotary Club of Port Macquarie (District 9650), New South Wales, and the Vanuatu National Disaster Management Office to use this money to renovate and repair the Lenakel Hospital and staff housing. Funds were exhausted and repairs completed in 2018.