My Time in Sierra Leone
After FY2 I went to work in a rural hospital in Sierra Leone for 6 months with the Kambia Appeal. The country is now peaceful and well into the recovery stage of development following a brutal civil war that destroyed all areas of society over the course of a decade. The hospital is relatively well supplied with drugs from UNICEF (free to children and mum’s) but no running water or electricity and local staff included a surgeon, 2 community health officers and a few trained nurse/midwives but the majority of staff have had little formal training.
My role (along with 1-4 other volunteers) was multifactorial with the overall aim of improving the standard of health care long term. This was very flexible and I decided to focus on the paediatric ward, which was also the feeding centre for the district as well as the untrained medical staff. We held lessons 2 afternoons a week to teach basic nursing skills over 4 months, whilst writing the curriculum and learning aids for the second module. We would also reinforce training trips that came out for 1 week intensive district wide teaching with UK consultants. The rest of the time would be spent either on the wards, working along side the volunteer nurses seeing emergencies-sadly common and serious, doing teaching ward rounds, discussing and implementing protocols with local staff (e.g. dehydration, blood transfusions, parent education) or attempting to reinforce local management to sort out some of the many difficulties systemic to the hospital. Towards the end we were able to implement a first aid course for the police officers who also played the role of paramedic in that area. The Kambia appeal gave such a wonderful opportunity to implement things that were so desperately needed and asked for by the local staff using the limited resources effectively, even if it sometimes it took blood, sweat and tears to take small steps further, the impact was worth it.
We lived wit ha local family in the compound of an one of the few colonial houses still standing as it had been occupied by the rebels, eating with them and spending weekends around the town fully submersed in the culture including the market, dancing devils and stunning countryside. There was also the occasional trips for some fabulous fresh fish on deserted golden beaches or camping in the bush with the nomadic cattle herders.
There were of course huge challenges, frustrations and success stories. I would be happy to discuss this furtherwith anyone who was interested. firstname.lastname@example.org.
The Kambia Appeal
The Severn Deanery School of O&G seems to have forged a very strong link with Mbarara Hospital, for which they to be congratulated. If, however, any of you are interested in working and teaching in a less developed and more challenging environment perhaps you might consider volunteering to spend some time in Sierra Leone with the Kambia Appeal. This is a Cheltenham based charity who have been working in Kambia District to try and improve the healthcare of women and children for over 20 years. We are currently in receipt of three major grants and are looking for a relatively experienced and robust obstetrician and gynaecology trainee (or post CCT and, ideally, paired with a like minded and skilled anaesthetist) to spend 6 months at our base in Kambia, sometime in the next couple of years or before the funding runs out. An orientation course, flights, transport, accommodation and food would be provided, and you would be staying on the base with a group of similar volunteers.
If you have any interest in this whatsoever then please contact Mr David M Holmes, Consultant Urogynaecologist and look at the website and view the attached Link which gives much more information and puts into film the incredible experience this programme offers.
Teaching in The Sudan
In July 2011, whilst in my final year of training, I was granted a week study leave to travel to Sudan to take part in a World Health Organisation and Royal College of Psychiatry affiliated project to provide postgraduate psychiatry teaching to Sudanese junior and family doctors. The teaching was delivered at the medical school in Wad Medani, 150km south of the capital Khartoum. Sudan has no undergraduate psychiatric training, and approximately 50 psychiatrists cover a population of 55 million. Sudan has a strong network of traditional or faith healers who are often the first port of call for people experiencing mental distress. Typically faith healers may have no formal training but provide valuable support and hope to families and patients who are unable or unwilling to access orthodox psychiatric assessment and assistance.
Two teachers and one Sudanese facilitator took a group of approximately thirty five doctors. Teaching was based on the WHO's Mental Health Gap Action Programme (mhGAP) curriculum. This represents a guide to core subjects needed to address psychiatric development in developing countries. The methods of teaching were left to the teachers to develop.
We provided group, role play and didactic teaching methods as well as visiting local psychiatric police facilities and psychiatric outpatient clinics. The teaching was well received and the students, as a group showed an improvement in their knowledge and confidence via pre and post course assessment.
It was a valuable experience, both developing my skills and confidence in developing and delivering teaching materials in unfamiliar environments and to experience the culture and warmth of the Sudanese people and their vibrant and beautiful country.
Dr Tom Cant, June 2012
Simon Clausen and Lizzy Clausen worked in Upper Nile State, South Sudan after they completed their GP training in 2009 on the Bristol VTS.
We had both taken opportunities to travel and work abroad where possible during our medical training, but needed to wait for the right time before we could commit to working overseas for a longer period. As a couple in the same medical specialty and at the same stage of training, the right time came for us in the Autumn of 2009, when we had just qualified as GPs. Between us we had worked in the USA, China, Bangladesh, Sri Lanka and Uganda, but Africa was the continent that drew us both back.
During our GP ST3 year, we decided to work with Medair. Medair is a humanitarian Non-Governmental Organisation (NGO) whose staff are motivated by their Christian faith to provide emergency relief and rehabilitation to some of the most vulnerable communities in the world. Medair‘s sectors of expertise are primary health care and nutrition; water, sanitation, and hygiene; and shelter and infrastructure. After an intensive one-week training and selection course in Switzerland, we were offered posts in South Sudan. We would be involved in running a primary healthcare project in Melut County, Upper Nile State, which is in the north eastern part of South Sudan, near the border with Sudan. We would both be working on one-year voluntary contracts.
In 2009 before independence, Sudan was the largest country on the African continent, and the 10th largest in the world. A 2009 census estimated the population of the whole of Sudan at 39 million people, with the Southern Sudan population between 7-9 million. There are approximately 500 ethnicities that speak over 400 different languages and dialects. The Comprehensive Peace Agreement (CPA) was signed in Sudan in 2005, but prior to that there had been over 40 years of civil war. This had a huge impact on the provision of health services in the country. Sudan has some of the worst indicators for health in the world. One in nine children die under five years of age and 32 percent of children under five years of age are underweight for age . South Sudan also has one of the highest maternal mortality rates in the world. Disturbingly, a 15 year-old-girl has a higher chance of dying in childbirth than completing secondary school.
We were informed before we signed our contracts with Medair that we would not be doing much hands-on clinical work. Our jobs would involve managing the primary health care clinics, supervising and training staff, and working closely with the local County Health Department to support them in improving the health services in their county. This was reassuring in some ways, as we weren’t too experienced in diagnosing and managing patients with dracunculiasis, visceral leishmaniasis and onchocerciasis(!), but we knew we would have the opportunity to develop lots of new skills. We were prepared to learn more about management, human resources, finance and IT systems, as well as the ways that NGOs and the health infrastructure in South Sudan worked. We would also need to cope with the obvious differences in climate, living conditions, and working very closely in multicultural international teams. We were prepared for an adventure!
We were based in Melut town, the main town in Melut County. One of the first things that struck us when we arrived was how under-developed the area was. Most of the community lived in mud huts, drank water directly from the Nile and open defecation was a common sight. The clinics were set up to function at a basic level, and at a level that was sustainable. Employed staff were paid in correlation with Government salary scales and drugs and treatments were issued in accordance with the then-Government of Southern Sudan Guidelines.
Simon’s role was managing the primary health care centre in Melut town and the six primary health care units spread throughout the surrounding county. These covered a population of approximately 50,000 people. The nearest health unit was about 40 minutes road-travel away from Melut town, and the farthest about three hours away. Simon travelled by 4x4 vehicle or by boat on the River Nile, depending upon the terrain and weather. The health units in the villages were run by young community health workers (CHWs) who had received nine months’ ‘health training’ and then worked in a similar way to GPs in the UK. The CHWs made up the majority of the health workforce in Melut County, as there is a shortage of higher-level trained health workers (e.g., nurses and doctors) in South Sudan. The major parts of Simon’s job was educating and supervising the work of these CHWs.
Simon also spent a lot of time managing the malnutrition feeding programme, extended programme of immunisation and reproductive/maternal healthcare. This involved a lot of teaching, logistics and liaising with many external agencies (e.g., WFP, UNICEF and UNFPA). Simon also organised the monthly distribution of staff salaries, ordered the necessary drugs from Nairobi every three months, and worked closely with the Sudanese health workers within the Medair team, encouraging them to develop and improve their teaching and self-management skills.
One of Lizzy’s main roles was to work with the County Health Department who eventually would be in charge of running the health services in Melut County. They needed to develop the skills required to run all the health services, order drugs, manage and employ staff, supervise the clinics and report on all the required areas (e.g. disease surveillance, immunisations, morbidity and mortality data, etc.) to the Government of South Sudan Ministry of Health. Lizzy met with them regularly and supported them in building up their skills in these areas.
Lizzy also managed the TB program, which was very challenging. The TB unit covered a huge population and patients often travelled for hundreds of miles to receive treatment. Patients needed to take treatment for six to eight months as in-patients. It could be very difficult to encourage patients to stay to complete treatment as they began to feel better, especially if they had families to care and provide for (see http://www.bmj.com/content/339/bmj.b4248/reply#bmj_el_227720). If patients defaulted from the program, trying to find them and persuade them to come back to finish their treatment was very challenging, but it was very an important aspect of our efforts to stop the development and spread of multi-drug-resistant TB.
Lizzy was also the Team Leader for the health project, which involved managing the team’s day-to day-activities, booking flights and cargo, monitoring our spending for the project and lots of HR and staff management that was all very new!
We had to be flexible with our work because sometimes unexpected opportunities came along. For example, a few months into the project we heard that a team of ophthalmic surgeons were soon coming to a nearby town for two weeks to perform simple eye operations, such as the removal of cataracts, which were alarmingly common. We advertised this in our health clinics then we examined the eyes of about 150 patients who were blind or partially sighted to see if there was a chance they could be treated surgically. We spent an entire morning getting these patients and their care-givers onto boats to go to the surgeons, a three-hour boat ride away. It was a stressful experience trying to get 75 partially sighted patients and their care-givers onto two big metal barges, but a great feeling when we finally waved them off! We learned afterwards that more than 50 patients whom we had sent received corrective surgery.
We carried out two research projects as part of our work. For these projects we both received RCGP International Travel Scholarships, including the Katharina Von Kuenssberg Award.
One of the biggest challenges we faced was the pace of work – we learned to measure achievements in weeks and months rather than days. The language barrier was difficult at times, especially when trying to work directly with communities. Problems with security sometimes meant our plans had to be changed at the last minute. The climate often made work difficult; it was hard to work in temperatures constantly over 40 degrees, and when the rains came we were not able to reach some of our clinics at all for months due to flooding. Possibly the most difficult challenge was to consistently strike the balance between providing a good service to patients but one that was sustainable, and could be continued by the local community when the project ended.
We have now returned to Bristol and are working in general practice. Rarely a day goes by without us thinking about our team members and the local people who became our friends and are continuing to work in the clinics to provide basic healthcare. It was a huge privilege to be in Sudan and immerse ourselves in the culture, especially just before the people voted to separate into two countries. We are very grateful for the experiences we have shared and the skills we have learned, and hope that the health system in the new country of South Sudan will continue to grow peacefully.
MRI Fellowship, Sunnybrook Health Sciences Centre, Toronto
This is a cardiovascular imaging research fellowship based at the Sunnybrook Health Sciences Centre. There is a 50% clinical commitment to cardiothoracic imaging. There are opportunities to learn cardiac CT and MRI as well as subspeciality training in thoracic radiology. I certainly got a lot better at cardiothoracic imaging after this fellowship.
The supervisor of the fellowship is Dr. Alan Moody, Chair of the UoT Dept of Medical Imaging.
Interventional Fellowship, University of Alberta, Edmonton
This fellowship is an undiscovered gem! I think it is one of the best general interventional radiology fellowship program in the Canada. There is a bias towards interventional oncology and biliary work. The only weakness of the program is a lack of exposure to aortic stent grafting, which is performed by the vascular surgeons. The staff are approachable and are genuinely interested in teaching. The IR facilities in Edmonton are some of the best in the country. The fellowship salary in Alberta is the highest (and the tax lowest) in the country (so there is not much of a pay cut for a UK SpR!). Many staff radiologists are UK trained and are therefore familiar with the British system. There is also plenty of support for those who would like to sit for the Canadian board exams.
Reasonably priced (and good) accommodation can be found within walking distance of the main hospital. Edmonton is a decent sized city with direct flights to the UK. The Canadian rockies is around 4 hours by car and world class sporting facilities are available. The major downside to Edmonton is the cold, with winter temperatures of down to -50C. However, it’s almost always sunny in winter and I personally prefer the weather in Edmonton to many other places in Canada.
The fellowship director is Dr. Dermot McNally.
K.T. Tan MD MRCP FRCR FRCPC
Clinical Assistant Professor, University of Saskatchewan