The premise of the NHS ‘equal access for equal medical need’ is a distant reality in developing countries. The World Health Organisation estimates that 70% of people in developing countries don’t have access to basic health services.
Like many doctors I have always wanted to work for an Non-Governmental Organisation (NGO) and help to provide medical care to people who need it most. Those of us who have looked into it have found that larger organisations like Medicines Sans Frontier require a minimum six-month commitment which can never normally fit in with our training or annual leave. Thus, many doctors never get a chance to scratch that itch.
But there is another way. I have just returned from a ten day visit to Sierra Leone. A small charity called the Better Lives Foundation runs three medical camps a year, in a small purpose built hospital 88 miles from Freetown in Yonibana.
Sierra Leone is one of the poorest African countries in terms of infrastructure; devastated by a ten year civil war that finished in 2002, there is virtually no clean water and electricity is scarce. The life expectancy is shockingly short at just 42 years and over 80% of medical care is provided by outside agencies.
I was going to take part in the Hernia camp and the goal was to perform thirty hernia operations in ten days with a team of doctors and nurses whom I met at Heathrow airport. None of our team - the anesthetist, the consultant general surgeon, the specialist registrar, the theatre sister, or myself had ever been to Sierra Leone before and no one knew what to expect, except that there was a declared cholera outbreak and it was the end of rainy season.
On arrival at the camp it was straight to work. We had to turn a couple of dusty disorganized rooms into an operating theatre, a pre-op assessment area and a post-op ward. It was clear this was going to be a team effort. The camp wasn’t due to open until our second day but there was a queue when we arrived and after a long clinic looking at unbelievably large hernias we filled up our operating list. The need was obvious. Most of our patients were manual laborers with years of heavy lifting behind them and the lack of preventative surgery contributed to the high prevalence of hernias, often untreated from birth.
Over the next few days we began operating and were struggling to get through our planned lists with the expected delays of an unfamiliar environment. Nevertheless patients kept turning up and it was evident that the demand for operations exceeded the number we were able to perform. We started to question our initial approach. Should we have booked patients on a first come first serve basis? The issue being that some people had to walk for days to attend camp and word had only reached distance villages after we started.
Would we have been better off booking smaller hernias and getting through more operations? We had started by prioritizing patients with large hernias whom we perceived to be in the greatest need of surgical intervention. But these operations were more complex, requiring longer operating times and with greater risk of complication. Then there were the patients who had attended previous camps with their medical notebooks documenting the hope of an operation if they returned this year. Should we have prioritised these patients?
We considered setting up another operating table in theatre and running two operations at once. But that wasn’t a practical solution and we had to face up to the difficult reality. We had to turn patients away, despite overwhelming medical need with it’s accompanying patient desperation. It was heartbreaking and against the instinct of a doctor, especially without a robust justification as to why one patient would be operated on over another.
In contrast to these frustrations, I found the way our team approached equipment shortages, time constraints and organisational challenges to be truly inspirational. None of us felt that we should compromise our UK standards just because we were in a developing country. We needed to operate as we would at home or not operate at all, and with this as our goal we found a way around each of our problems. We ran out of sterile drapes and thought we would need to cancel operations but improvised using patient gowns as sterile fields with make-shift holes cut into them. We developed a post-op scrotal support system made out of crepe bandages that we found more efficient than the expensive alternatives used in the UK. We rewired the diathermy machine into a health and safety hazard but fully functional piece of kit to prevent intraoperative bleeding. We conducted a group consent session to save precious operating time. And when the generator gave up one evening we used our head torches as operating lights and we treated an acute asthma attack using a polystyrene cup as spacer device instead of a nebulizer.
These innovations and many others provided a great sense of satisfaction. Outside the constraints of a large organization, in situations of overwhelming need, with limited resources, doctors are forced to be pragmatic to enable the show to go on. It is under these conditions that a doctor flourishes. Finding life saving solutions to problems and watching them implemented to enhance the life of another is central to why doctors choose the career they do. Nevertheless it is a feeling, perhaps, that we aren’t able to replicate in our day to day jobs where medical care is rightly protocol driven, innovations are less immediate and change is difficult to bring about. The normal response of a surgeon operating in suboptimal conditions is to go red in the face and get extremely frustrated with the system. In Sierra Leone suboptimal is the norm and finding innovative solutions is a necessity to the provision of safe medical care.
The difficulties our team shared over those ten days brought us together and created a strong team spirit, with a great sense of comradeship, equality and creativity that disregarded the fact we were all newly acquainted and was something I have rarely experience in my training as a doctor.
I don’t know if we prioritised the right patients. I dread to think of the fact that some of them will experience complications that we are no longer able to treat and I feel sorry for those patients we had to turn away. Thankfully, as a people, they graciously face hardship and show an appreciation which is unrivalled by patients in the UK. I would recommend the experience to anyone. There are multiple organizations that need doctors and other support staff to donate manageable amounts of there time to help provide a small amount of relief for the people who are less fortunate than ourselves. If I was you I’d sign up now.
Better Lives Foundation – Three 10 day camps a year with a need for medics, surgeons, dentists, anesthetists and general volunteers.
Operation Hernia – One 12 day camp a year with need for surgeons anesthetics and general volunteers.
United Planet – Multiple sites. Recruiting volunteers from a wide range of professions 2 weeks to 2 years.
Volunteers Overcoming Poverty – actively recruiting healthcare professionals in 2012 to a range of projects.
