New Blog

I've just started publishing a new blog concerning my time in Juba 2009.

Please refer to http://onedoc.blogspot.com for further details...

James

There and back again

It will be strange working in a hospital without goats roaming free...

It is 8.10 pm in Addis Ababa Airport and we are waiting for our flight to England which leaves at 00.25 am. In twelve hours time, we will land in London Heathrow and this whole tale will seem like a dream. Already our old lives in Juba seem to be shrinking into the shadows as we dwell in the limbo that is Addis. It is now time to write the epilogue of this most glorious little adventure.

Some of our EMW nurses with new uniforms plus Sister Anna

On Friday myself and James did the last clinical work we would do in JTH. Rather fittingly it ended when one of our nurses alerted me to a sick patient who was really sick - they had to go urgently for an operation for necrotising pancreatitis. The rest of the day was spent doing a formal handover to the folk at JTH. They will have a busy life ahead of them instituting triage, setting up structured medical teaching, continuing nurses training and continuing with the restructuring of the acute care services. However, from working with these people I have faith that they will do it- they are wise beyond their years and hard-working.

Part of Dario's House. It was a beautiful summer's evening

That evening the Hospital Director, Dario, invited us to his house along with all of our friends in JTH to say goodbye to us. About 30 people were present and Dario’s family laid on a fine feast with wine in the aftermath. Although Dario lived in Juba city, it felt more like we were in a close-knit village. There were about 25 people living in 6 tookalls (the huts they live in) within a fenced compound, all of whom were Dario’s relatives. The courtyard was everyone’s “lounge” with tables and seats outside. They all take their meals together, chat together and the kids play together. It was a really lovely, friendly set up, which made for a relaxing experience. A perfect end for us, marred only by the rancidity of having to say goodbye to all of our close friends. James summarised the event quite poetically, “I am glad saying goodbye has been so hard. It is a sign that we have made some strong, true friendships. It's a price worth paying.”

Hanging out with some of the JTH crew at Dario's

The next round of goodbyes came when we had to bid a fond farewell to the Comboni’s. Valentino gave us a big hug and they all said that we would be welcome back any time.

As I sit here in the internet cafe in Addis, I cannot help but reflect on the times I have had with these people and all the smiling and hand-shaking that went with them. The trust and friendship that we had traversed our cultures and brought us closer.

We had some awesome conversations that I would never have in the UK. The most memorable one had to be with the Ward Sister of the Emergency Medical Ward, Anna, when I jokingly told her she had the memory of a goldfish:

“What is a goldfish?”
“It is a small orange fish that we keep in a tank.”
“Do you eat them?”
“No!” I laughed
“Well what do you do?”
“We watch them swimming.”
“Why?”
“Because it’s what we do. It’s fun.”
“How can this be fun?”

I realised how stupid the whole thing must have seemed to her and when I thought about it, it is. It’s little things like this that make you chuckle.

Oddly enough, it is being here with these people, immersing yourself in their way of life that makes you realise some of the imperfections in our own society. Allow me to elaborate.
I spoke to Martin, the Obs and Gynae Consultant about English Society. “Do you speak to strangers when you wait at a bus stop, Martin?” “All the time.” He answered.“At home,” I continued, “We do not speak to strangers. If I was to speak to a stranger, the first thing that would go through their mind is ‘What does he want?’”

James and I have often talked with the Comboni’s and we find it interesting that we started out as Westerners thinking that African society was not as good as Western Society. Many people want to “help” Africa by making it more Westernised. Although in some respects this is good, is it all good? Probably not when you consider that 25% of the British population have been registered as depressed at some point in their lives.

I believe that all of us, whether we be African or English, have profited emotionally and spiritually from this experience. For us, we have developed a new found humility and respect for Southern Sudanese values and their way of life. These guys know what they want and they will achieve their goals irrespective of the St Mary’s Juba Link, NOT because of it. However, they really appreciate the helping hand.

Anna and Magdy often said that they were guilty of not thinking ahead and this is true. I often used to say to them that the only thing I would want to export from my culture was a sense of planning ahead - here people wait until something runs out before they replenish stock, which causes a truck load of chaos. I think this has been exported, our drugs cupboards have never run out of supplies.

However, there is something that I am going to import from these people - their humility and gratitude for the good things (such as oxygen that flows out of the walls of hospitals, drinking water from a tap etc.), their kindness and hospitality to strangers, and their sense of family and community. Our anonymous and fragmented society, hopelessly lost in the relentless worship of consumerism, would do well to learn from them.

Dave and James

PS: We both got back safely to the UK. It's going to be tough for us both I think to readjust. If you've enjoyed following our journey then do comment on the blog or email us. We'd appreciate it.

Performance = (Knowledge x Motivation) / Obstacles

“Look to the east, on the morning of the fifth day” Gandalf said to Aragorn. Aragorn was to go on and assist commanding the defence of Helm’s Deep whilst Gandalf went off in search of Eomer’s army to relieve the defenders from the evil armies of Isengard. This ended the battle of Helm’s Deep but the battle for Middle Earth was far from over.

One of the Nurses expressing her thanks for the training

Today the armies of Isengard, represented in Juba as the evil forces of apathy, hopelessness and low self esteem were delivered a long overdue, crushing blow. We have often talked about the plight of the nurses, the down-trodden profession of Southern Sudan. Their self-esteem is low, morale is non-existent and their pay amounts to £50 a month, which is hopelessly inadequate to feed a family of 6 or 7. The only way out for these people is promotion and this comes from training and good patient care. As a result their thirst for knowledge is insatiable.

Dr Dario adressing the audience.
With him is Jo who was covering the event for the news

You will also recall that we have helped develop the New Medical Emergency Ward, staffed by nurses that we had trained and had volunteered to work in the ward. It’s much busier than all the other wards, and they weren’t expecting anything in return. On November the 13th the ward opened. We had well trained nurses. We had the life-saving medicines and equipment. The question was “could they deliver good patient care?”

Dr Yatta, Director General for Curative Services, MOH/GOSS

To answer this question, we compared the mortality levels in July with the levels since our ward opened and the results are, quite simply, breath-taking. The mortality reduction was immediate and absolute. Although the number of admissions had actually increased since the wet season, we measured a 40% reduction in 24 hour mortality and a relative reduction of 18% in overall medical mortality (For the medical folk amongst you absolute difference is 1% hence our NNT is 100). We had shown that these nurses had delivered staggering patient care and had training. The stage was now set for the grand finale - the empowering of the nursing profession - in short a massive reward.


We asked the senior medical and nursing staff in JTH about the best way, culturally, to employ these nurses as an example to motivate and empower others. The glorious thing about the people here is they know exactly what gets their people excited. A few high level meetings were held, a modicum of strings were pulled, and the results, you see below:



Nurses (and indeed everyone) here love ceremonies. So the JTH staff held a ceremony for the 120 nurses who graduated in the courses we had ran over our stay here. Present at the ceremony were two key players in the Ministry of Health, Janet Michael (Director General of Midwifery and Nursing) and Dr Yatta Lugor (Director General of Curative Services - i.e. secondary care).

There was lots of singing and dancing as well which was thoroughly enjoyable

During the ceremony, the Medical Emergency Ward received modern, new, blue uniforms to replace the old 1950’s white uniforms that they usually sport. But life just kept getting sweeter. Following a personal recommendation from our Hospital Director, Janet and Yatta vowed to promote all of the Emergency Medical Ward nurses.

Janet Micheal, Director General for Nursing and Midwifery, MOH GOSS

“I want to send one clear message to all my nurses.” Janet said. “There is only one way to get more money and that is through promotion. This comes from training and through good patient care.” She had empowered the nursing profession by offering them hope and a way out of poverty. Furthermore, the uniforms that our Emergency Medical Ward nurses wear will serve as a constant testimony to all nurses that if you work hard, there will always be a reward. This is some powerful motivation, which is vital in the long term strategy for capacity building. And who better to build Southern Sudan’s capacity than it’s own people?


At the end of the ceremony, we were surprised and very touched when we received three sets of presents from three parties, the Juba Core Team, the Ward Sisters and the nurses on the Medical Emergency Ward, who had all clubbed together.


The greatest present, however, was a wooden plaque in the shape of Sudan that read:

"The entire community of JTH will always remember you and miss you. Thank you for the services you offered in Juba Teaching Hospital. We wish you all the best in your profession and your service to God's people."

It is gifts such as these that are the most generous and greatest gifts of all because these are the gifts that people have given up their time to make. In a land where days off are still a luxury, the time and efforted invested in hand-crafting this is, quite simply, priceless. and we were rendered speechless (and a little tearful, I may add) with gratitude. We know the people here very well and even after four months, they will still surprise and amaze us.

Tomorrow we are going to Dario's house for our leaving party. He has promised to slaughter us a goat...

...the next time we write will be from Addis on our way home.

D & J

Endings

I’m sorry we haven’t written much for a few days; life is tremendously busy for us at the moment. A well written story has a strong beginning, middle and end, and we feel it’s important to arrange a good strong ‘ending’ to our work here, which has been occupying a lot of our thoughts and activities for the past couple of weeks.

Dave teaching our nurses the finer points of the glucometer

The Emergency Medical Ward continues to be a success – the doctors and nurses are very happy with it. In a world of evidence based medicine and clinical governance, we need more than anecdotal evidence however, and we’ve been involved in both clinical audit and research into mortality rates and distribution to prove its efficacy. The results from both are very encouraging and we’re arranging a final big presentation for the hospital and the Ministry of Health to present the results. This will also be combined with a big public reward ceremony in JTH for the nurses we’ve trained to acknowledge and commend them for their dedication and hard work. They are the real heroes and it’s largely been the nursing staff (with a little training and guidance from us) that are responsible for the improvements. Nursing here has traditionally been a profession which is rather downtrodden, and so it’s important to actively continue to take steps to change that culture.

Louis' family and house

Louis & Dario: two key players in JTH. (Dario's our boss)

One of the greatest privileges we had during our time in Juba has been the opportunity to get to know and forge real friendships with the Southern Sudanese doctors and nurses we’ve been working with. They really don’t see us as outsiders anymore. The folks here are always very polite to foreigners, especially ‘kawajas’ (white people) but beneath this there are some very definite suspicions of their motives. (And in some cases rightly so...)

Louis and Baby Danga. A proud father.

William, the hospital administrator. William's a huge Sudanese man who has a handshake that could break your wrist, but a big heart.
He also has 4 wives and 21 children!

On Sunday afternoon we were invited to Dr Louis’ (Paediatric Registrar) house to eat with him and meet his family. It was wonderful to share in his hospitality. We had a great time actually. I think we would both agree that it was far better to eat there in his home than a pizza in an air-conditioned restaurant full of kawajas. Dave and I have also recently been enjoying our after-work beers in an African ‘local’ pub rather than the posher hotels for the similar reasons. For one thing, it’s cheaper(!) and for another, what’s the point of coming to Africa and spending as much of your free time as possible trying recreate the western world you’ve just left? Peer support and relaxation is important in often demanding circumstances, but I think it’s also easy to get too sucked into that world.

Some of the key players in Comboni.

We’ve learnt a lot of this philosophy from (other than Bruce Parry) the examples we see in the Comboni Missionaries we live with. We have the utmost respect for their unrelenting identification with and love of the people here. They didn’t even leave Sudan during the civil war. “Well the Sudanese people can’t leave for safety so why should we? It wouldn’t be right!” Brother Valentino once told me in the context of a story about how their village was being shelled. Incredible.

Jubalicious...

The UN, Statistics, and School Children

Hi there.

We can hardly believe that we’ve only got a couple of weeks left in Juba. I think we both have very mixed feelings about this. There’s a tension of not wanting to leave the people and the work we’re doing, but also missing home. It’ll be good to be back with family and friends for Christmas, but on the downside we haven’t had a day below 30 degrees* C for the past 4 months so we’re anticipating absolutely freezing back in the home-land.

*(can't do superscript in blogger)

It's pure coincidence I appear to be wearing the school uniform...

Yesterday we had the hilarious experience of being mobbed (in a nice way) by a group of school children on our walk into work. It was too good a photo opportunity to miss, which of course excited them further, so I’m sure their teacher wasn’t too pleased that morning. It’s funny how even at this stage amongst all the bad stuff we see this place can still surprise you completely out of the blue and bring a smile to your face.

Right – down to business. The Emergency Medical Ward is continuing to go very well. The nursing staff are just great (great fun and also great at nursing) which makes it a real pleasure to work on. The morning team of nurses actually volountarily stayed for a couple of hours after their shift this afternoon (for no extra money) because we'd had a busy morning with some sick patients and they wanted to make sure as much of their work was wrapped up as possible so the afternoon team didn't get lumped with it. I've never seen that in the UK. Also the junior doctors are unanimously in favour of the system, and the consultants are also very impressed. Sustainability is the name of the game at this stage, and we’re making good in-roads into this as well.

These visitors had banners which we never had. Oh well.

There's been a delegation of consultant surgeons, anaesthetists and nurses come over from Saudi Arabia here for the past week working and teaching in the hospital. It's been quite an insightful experience actually watching 'Juba newbies' come in and do similar things to what our link is doing. By all accounts they've been doing a good job.

We’re keeping a very close eye on mortality rates in the department, and at this juncture they are looking quite good. I think one of the things we feared was that we could cut down 24 hour mortality on our ward, but it would all shift to day 2 when they were transferred. However, this is just not happening at all, which vindicates our repeated emphasis that early recognition and intervention really does have a better overall outcome.

Ward shot. Notice the Oxygen concentrator we have full time now. Very important.

Patients are still dying on our ward of course (and we’re keeping a detailed log of who and why) but the key thing for us as doctors is that we know in good conscience that they probably would have died in a UK hospital. This is mainly down to the late presentation issue, which is somewhat outside of our influence. In other words, we’re (and by’ we’ I mean the whole team on the ward) are doing everything possible for them. Mortality in the department of medicine is hovering around 4% at present, from over 5% in July. This may not seem much, but it means that the new ward system is saving 1 life every 100 admissions, which is roughly every 4 days. (ie. the number needed to treat is 100 for those statistically minded.) It’s still early days but I know that anecdotally I’ve seen the nursing staff save the life of patients who would have otherwise died. It would be the icing on the cake (in a world of evidence based medicine) to demonstrate it formally, but we’ll see.

John Holmes shaking hands with Dr Magdi, the lead Consultant Physician in emergency medicine.

The UN arranged a flying visit by John Holmes, one of their top officials this afternoon who was looking into the state of healthcare in the Southern Sudan. He was only here for a day I think which was why he couldn’t get out into the rural areas where things are much more dire, so he came to the hospital here instead. The Jubans of course were only too delighted to proudly show the whole entourage round which included (unexpectedly I may add) a trip to our new emergency ward. Luckily it was tidy... The Minister of Health came visiting the other day (see photo in an earlier post) and was generally pleased with the clinical care, but thought that the place was looking a bit dirty and wanted more bed sheets etc. So we’ve been working on making the place look a bit prettier recently (blue sheets for the male bay and pink for the female no less!) which was convenient for this visit. Apparently he said to Dario afterwards that "Juba Teaching Hospital is one of the best hospitals in the developing world I've seen." High praise indeed.

Gratuitous cute photo from one of my favourite wards.
It's getting into mango season now as you can see.

OK, that will do for now.

Jem-ez & Daff-eed

For the people we leave behind

Hello everyone. I have been spending much time talking about our endeavours in JTH. It is true to say that the work of the St Mary’s Juba Link has had a huge impact in JTH. However, none of this work would be possible were it not for the kind efforts of our friends back in the UK. So for the friends and family members we leave behind, this blog post is for you.

The St Mary’s Core Team have been working hard on the Isle to set up the St Mary’s Juba Link Bikeathon. The event took place last week and below is a glorious photo of the UK’s only Southern Sudanese Consultant on his bike:

Dr Hakim, Consultant and Medical Adviser to the St Mary's Juba Link

Continuing the biking theme in London, one of my good friends Richard (Edward Wilson Kattan has decided to “grab life by the bars” by growing his very own handlebar moustache for the entire month of November (aka Movember). This is Richard with his clean shaven baby face on November 1st:

Clean-shaven Richard

And this is Richard 3 weeks into his glorious facial hair growing extravanganza:

Richard "Hell's Angel" Kattan

Our blog will continue to update you of Richard's facial hair growing antics. Curently he has raised over £300 for the St Mary's Juba Link by ritualistically humiliating himself for one month. So if you feel like donating some money to this man for our benefit then please visit:

http://www.justgiving.com/richardkattansmovembermission

Dan (left) and Tom (right) taking a rest before cycling up another rancidly steep slope

Back in September some other good friends of mine, Sophie Quarterman, Dan Westlake and Tom Kenyan, decided to cycle the South Downs Way. for the St Mary's Juba Link They cycled solidly for two days covering 75 miles on the lumbering slopes. "Doing this was the hardest thing I have ever done for charity," Sophie said. "There were 20 miles of slopes that were too steep to cycle up and too steep to cycle down."

Sophie and Tom relaxing after the South Down's Way

A special mention should also go to Dan “The Man” Westlake who managed to do this herculean distance on a BMX!

Some of the beaut views on the South Downs Way. Dan's BMX is in the foreground

We would also like to thank everyone for their countless emails of encouragement and words of advice and support. In the days when smiling is difficult, a small email can make a huge difference.

So to my friends who have been supporting our efforts, I extend my thanks. Access to healthcare is the most basic of human rights and in a land recovering from 40 years of civil war, in a land where only 25% of the population have access to healthcare, the need to train healthcare professionals has never been more immediate and dire. Your kind words and novel approaches to fund-raising make us smile, keep us motivated, and will ultimately transform the healthcare given at JTH.

See you all soon,

David

Life

In a UK hospital, when a young patient dies, it is a huge deal. The general public do not realise how hard hospital staff fight to keep their patients alive. Sometimes, despite our best efforts, the illness claims our patients life. We then have to tell the patients relatives the bad news and they leave, crying. However, for the hospital staff that lose the battle, it is also devastating- a sombre air descends on the whole department as each person inwardly reflects on what happened and how unfair life can seem.

In the Southern Sudan life is cheap. Young patients die on our wards with an uncomfortable regularity and the staff seem detached and apathetic to it all. I am not surprised - after a war spanning three generations, where over 2 million people died and horrific atrocities were committed, hope remains a distant dream.

However, on Saturday, something special happened on our Emergency Ward. I was summoned by the nurses to assess a patient who was obviously very sick and we turned his bed into a high dependency bed. He received monitoring, suction, and oxygen. There were lines and tubes coming out from all parts of his body. I summoned my seniors. For two hours, myself, another SHO, a Consultant and two nurses fought desperately for the life of this 21 year old man. However, despite our best efforts, we were losing the battle.

One by one, his organs were shutting down. His kidneys were the first to go. His digestive system was next- we passed an tube into his stomach and blood was aspirated. Whilst trying to solve these problems, we noted the electrical readout to his heart was changing, a worrying sign that there was inflammation of the heart. His blood pressure then plummeted and his heart slowed. I looked at my Consultant and he shook his head. The family, who had been present throughout this, knew that there was nothing that could be done.

H.E The Minister of Health came on a visit to the ward last week

Our 21 year old patient died at 3.05 pm. I looked around at the nurses faces and in their eyes I beheld something that I had not seen since I started at JTH - they were devastated that a life had been lost. “Well done everybody.” I said. “We all did our very best. There is nothing further that we could have done. He would not have lived even if he was in the UK.”

In our ward, life has become precious.

David