The site DossierKoninkrijksRelaties reviewed the book ‘Komt een land bij de dokter’ (A country calls on a Doctor), written by general practitioner/street doctor Michelle van Tongerloo (41). She devoted a chapter to her experiences on St. Eustatius, where she worked at the Queen Beatrix Medical Center in 2019-2020.

Working as a doctor in the Netherlands, Van Tongerloo had grown disillusioned with the bureaucracy that hindered her ability to provide the level of care she wished for her patients. On St. Eustatius, she discovered a different way of practicing medicine. ‘I was the doctor, and I truly belonged to my patients—even without my white coat,’ she reflects on her time on the island, which led to a profound and life-changing insight.

From ‘Komt een land bij de dokter’:

So when an acquaintance, a general practitioner himself, came to eat with us and told us about a unique experience on a small, sleepy and tropical island, I impulsively decided to ask for the number of the hospital director. I looked at my husband. ‘Why not’, he said with a shrug. He was also interested in the adventure. “Sorry,” said the hospital director of the Queen Beatrix Medical Center on St. Eustatius, when I called him a few weeks later, “we don’t need doctors right now.” He said he would save my number, ‘just in case’. I thought he wouldn’t call back. But he did six months later.

Sometimes I was pushed into a corner

St. Eustatius turned out to be something different from Rotterdam. Upon arrival, a car was waiting for us in the parking lot of the airport (a red Nissan, key under the mat, left front’, my boss texted me). Looking for our house, my arm became lame from waving at all the people who greeted us.

My children played next to the house with the stray goats, we barbecued that first night under a coconut tree and the car didn’t have to be locked because, well, no one did. When I woke up the next morning, with a cup of Colombian filter coffee in my hand, I saw the sun rise over a misty volcano. I thought I had landed in paradise.

Mistake. Because working on St. Eustatius turned out not to be so easy. The small scale of Statia ( the island of Vlieland is larger), made it impossible to keep a distance from my patients. I also saw our daughter’s teacher, the plumber who had just repaired our washing machine and the man from the bar who I gave my private number after three rum-colas, at my office hours. Within a few days, my number was circulating among the 3,200 inhabitants of the island, and it was being used extensively.

When we got a new hospital director, from the European Netherlands, one of the first things he said was that I had to shield my private number. That was not professional, he thought, I had a work phone, didn’t I? Classic reaction, I thought at the time – but not to do it here.

The inhabitants of St. Eustatius are condemned to each other, on no more than 21 square kilometers. They are often related to each other within the same generation or a few generations back. The mutual involvement is therefore great. When a patient is admitted, there are sometimes dozens of people in front of the hospital within ten minutes. With family who sometimes also work in the hospital, the dividing line between private and professional quickly disappears people also started to interfere with me – sometimes I was literally pushed into a corner because it was too crowded in the room.

It wasn’t just the peer pressure and the blurring of roles that bothered me: Statia also had its own language and culture. Opinions, many opinions, which were often at odds with mine. For example, in the case of a patient who has ‘exhausted treatment’. It is very Dutch to do ‘nothing’ if there is no prospect of a cure. In many other cultures, including St. Eustatius, you do everything you can to prolong life, even if someone is terminal. If I didn’t want to give antibiotics to someone with end-stage cancer and pneumonia, a conflict arose.

Diametrically opposed to the patient

Being a migrant myself in this world I didn’t know turned out to be very different from being a doctor on home soil for people with a migration background. I made one mistake after another. Offered solutions that did not suit the people at all; condemned behavior while it was deeply ingrained in traditions; talked in a direct way that people experienced as offensive. My interpretation, experience and appreciation of a conversation were often diametrically opposed to those of the patient.

Out of insecurity, I clung to European-Dutch communication techniques and protocols. I referred to my guidelines, repeated learned, empathetic sentences. It only increased the misunderstanding. I was the newcomer who was supposed to adapt.

Escape was impossible for both the patient and me: there was no other care institution on the island, you were almost always on duty and if not, my cleaning lady would come by with her family at home for a consultation. Even on weekends, your phone kept ringing. If you didn’t answer your phone, the ambulance just drove into your garden to pick you up (even in the middle of the night, and yes, you can also work in your pajamas, I know now).

An ever-changing insight

I did badly. Felt watched, criticized and never felt free. Wherever I was, whatever I did: if someone tapped me on the shoulder, I had to be willing to talk not only about his troubles but also about complaints from his daughter, aunt, neighbor and outside-wife, without feeling that my opinion mattered.

If I didn’t, I could bet that my name would have a negative impact on the island, because, for a white outsider like me, it turned out to be a real challenge to acquire a place in the local community.

Almost everyone was a descendant of enslaved people, and the relationship with the European Netherlands as a former colony was – to say the least – complex. From the moment you step out of the rickety plane with your factor 50, you are 3,200 – 0 behind. Better do your best. I did and it exhausted me. And here too I lay awake for nights, racking my brain about my position and functioning as a doctor on the island. Why did I find it so difficult to act in a way that was perceived as pleasant by the islanders?

Until my friend Dorette kicked me in the ass. Originally from the island herself, she emigrated to the Netherlands to study medicine. She worked in the Netherlands and Germany, on Sint Maarten and on Sint Eustatius as a gynecologist. ‘You wanted to work here, didn’t you? Then throw away that weird, Dutch nine-to-five mentality,” she said laughing, when I was complaining on her porch in the tropical sun again. You always work a bit here and everyone has an opinion about it. Don’t resist it anymore, it’s the only way this can work.’ It may sound crazy, but it turned out to be a life-changing insight.

It’s all about professional proximity

During my medical studies and later in general practice, I was urged to strictly separate work and private life: your white coat is your shield and is cleaned by someone else at the end of the day. The downside: we hardly know how to create proximity. Statians have no problem with that: white coat or not, I was the doctor and I was theirs. I didn’t have to complain, I had to surrender.

And that, fortunately, eventually worked. How exactly? That’s hard to say, but I think the most important thing is that I didn’t run away. Over time, I came to realize that community engagement did much more for the patient than I could do on my own. Because of that realization, I dared to put aside the checklists, tricks and protocols I had learned. I no longer performed theater pieces in the consulting room. Not: look someone in the eye, ten seconds of silence, a hand on the shoulder and then move on. Don’t screen with ‘that’s how it should be according to protocol’ or ‘that’s just how I learned it’. Well: just be myself. That way people saw that I cared about them. And then we could figure out the solution together.

But to be myself, I had to question myself in addition to the Statians. What are the prejudices I have? How does my origin influence this conversation? What do I want to bring to people? What is my role on this island? To find answers, I no longer sat on my porch complaining after work but looked for Statians. I wanted to understand how they lived and what occupied them, read books about their culture and history.

To finally realize that I was just one person in the larger whole of this island. That brought the peace that was needed to understand my patients. I started to feel the togetherness: exactly this was what I had missed in the Netherlands. Keeping a professional distance, we care and care providers can do that. What we need to learn is to create professional proximity.

The Health Insurance Office (ZVK)

Already in 2021 Doctor van Tongerloo explained that Bureaucracy stands in the way of the proper (patient-oriented) functioning of the Health Insurance Office (ZVK).

Even after her return to the European Netherlands for six months and while working as a street doctor/general practitioner in Rotterdam, she is still approached by Statians who have to share their experience with the ZVK and consult her because they need care. “Sometimes I try to help someone on the island, sometimes I see people in my own practice in the Netherlands who have been persuaded by family and sometimes I see people who have migrated and for whom I can now arrange care here, that I did not succeed in St. Eustatius.” It caused a cry from the heart to post on social media.

Years of waiting

“I still hear many stories of people who have been waiting for months, sometimes years, for normal care: cataract surgery, a new hip to name just a few simple things that seriously invalidate the quality of life. When I worked on St. Eustatius, one thing stuck with me the most: the vulnerability of healthcare. An important player in this is the Health Insurance Office, a part of the Ministry of Health, Welfare and Sport that was placed between the specialist and me as a general practitioner to assess my referrals, probably based on the assumption that I am not doing my job properly.”

“Rejection of applications is often done for bureaucratic reasons. For example, the broadcast of a child with a nasty bone fracture is stopped by a growth plate because someone in Bonaire thinks that I have not uploaded the correct form. It takes me almost two months before someone in Bonaire makes an appointment for a woman with a large tumor in her breast. An emergency operation is canceled without planning a new one – I find out by accident six months ago. A boy who I suspect of an intellectual disability goes to the hospital in Sint Maarten alone because he is not entitled to guidance. Is a child with epilepsy not allowed to go to the specialist because the ZVK believes that a general practitioner should treat it. An official from the ministry asks why I am requesting counseling for a seriously ill man. She saw him get out of a car without difficulty: then he can go to the hospital in Curacao alone, right?”

Complex

According to Van Tongerloo, there is no question of unwillingness. “The role of the Health Insurance Office is complex. Reviewing an endless stream of referrals without a patient in front of you, scheduling appointments on islands where hospitals have all kinds of challenges and don’t forget all the plane tickets, taxi rides and hotel stays that need to be arranged. It results in an endless amount of administration. At one point I gave up on reading and arranging everything.”

“In addition, all applications are uploaded into a portal that contains thousands of references from all three BES islands: I can view them all. Assessments are also done by assistants without a medical background. Are they actually healthcare providers? What about professional secrecy? And that assistant can stop my referral – the treating physician with legal and disciplinary responsibility – because I upload the wrong piece of paper. Who is actually liable if the patient receives care far too late? When I looked at the healthcare law, I read that it is not the Health Insurance Office, but I should get the final verdict on whether and where my patient goes. I was shocked and I don’t know how many people within the Ministry of Health, Welfare and Sport asked for clarification.”

Not important?

“I have bundled all the problems I have encountered in a file and offered them to countless people. Because I still have quite a lot of contact with Statians, I don’t feel that anything will change. Apparently, it is not important enough to put on the front page of the newspaper or to run amok. And I understand that that is the case. How many Dutch people know about the existence of St. Eustatius? The political representation of Statians is not great, I’m afraid. Who can stand up for their interests?”

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