Medical practice on Tristan da Cunha--the remotest island community in the world

Midway between Africa and South America, on the edge of the 'roaring 40s' (37°S 12°W) is an archipelago of five tiny volcanic islands. Tristan, a British Overseas Territory, is the largest--seven miles across and rising 7,000 feet above sea level. There is no airport, no air access except for an occasional ship's helicopter and no sheltered anchorage. The nearest port is over 1,700 miles away--a week or more by ship and the tiny harbour requires constant repair due to the impact of the relentless South Atlantic. Ship-to-shore travel is hazardous as passengers (and medevacs) are transferred sitting in a box hoisted by crane to a raft or rigid inflatable boat. Tristan has traditionally had a resident 'ships surgeon' or 'island doctor'; although these terms may not have changed, the training and experience to fill these roles have. The island needs a general physician with experience of primary care or a general practitioner with experience of secondary care. Additional training is required in surgical and gynaecological emergencies. The two authors between them had appropriate experience in general medicine, general practice, resuscitation and critical care and to be able to worry together is a better prospect than worrying alone--so a joint appointment for six months seemed sensible and was found to be effective.