As part of the Migrant Health Series, I interviewed Dr Kiran Cheedella about his work in the refugee camps in Greece at the height of the refugee crisis in 2015.
Kiran and I did our Diploma in Tropical Medicine and Hygiene together eight years ago and formed a friendship that would span his adventures in South Africa, Nepal, Greece, and now Germany. What I love about Kiran is his attitude – every challenge is a cloud with a silver lining and he attracts positivity. He currently lives in Germany, having finished GP training three years ago, whilst still maintaining his UK license. He is someone who makes general practice work for him and is probably one of the handful that inspired me to follow this career in primary care. Sierra Leone via the RCGP/VSO partnership is next on the cards. Kiran probably won’t know this but he propped me up a few years ago when I became really disillusioned with international development work and when working with vulnerable populations in the UK. In a situation where, as medics, our impact is limited without core changes in the political and economic system, he has always been the one to remind me of the good one person can do and showing kindness in someone else’s darkness is enough.
So, as a dedicated primary care physician and advocate for reducing social inequalities, I wasn’t surprised when he told me that he was off to Greece to work with refugees in 2015.
“I got involved working with young refugees when I was at medical school with the Red Cross, basically befriending unaccompanied minors, who have made the journey to the UK by themselves, who are alone without their family. I guess you see that there is something positive that you can do to help and that you can contribute significantly. That was something that I wanted to do. I also volunteered in a social community centre and hanging out and cooking with young asylum seekers and using it as an opportunity to interview them for my dissertation [for my International Health BSc] about access to healthcare for failed asylum seekers. And then I’ve always been interested in or been one for social equality – there’s such a massive health inequalities. Seeing people who are too scared to go to a doctor just triggered something and I wanted to see if there was something I could do about it. And as I got more qualified there were more things that I could do like go work with Doctors Of The World (DOTW) refugee camps and things like that.”
“I’ve done about six different camps [in total]. The first time, I was at Idomeni (Greece) which was basically a transit area where people were coming in and out. They were trying to get through the border with Macedonia but eventually, because the border was blocked, by default, it became a camp. I was there for about three months in 2015.”
Who could forget the furore of media coverage of the “refugee crisis” in 2015 following the photo of the body of three-year-old Alan Kurdi washed up on the beach? Suddenly, there were placards of “refugees welcome” popping up everywhere and memes all over the internet. Kiran had been working in a Doctors of the World (DOTW) London clinic for a few months at that point and, through them, was invited to Greece “That was in the crisis in 2015 and that was probably the most dramatic, most high intensity work. They weren’t sure what was already there. It was about going there and seeing what we can do and trying to set up a clinic. So I went and what they had so far was a gazebo, just like four posts, and a hospital bed and a couple of tables because we were still waiting for our tents to arrive. We were trying to imagine what scenarios we would have. We all jumped in a car and went to a medical shop and it was like kids in a sweet store – like three doctors in a big shop of medical equipment and we were so excited we bought everything we could. We got lots of sterile packs as well, minor surgical equipment, we got a couple of things in case of emergency deliveries just in case. So that was quite exciting because we got to build up our own tent and clinic so it was quite nice to see that develop.”
“So it was about doing rapid assessment and treatments and referrals if needed if they were really sick people to the other side of the border to the hospital there. There were lots of foot wounds, general wounds, viral infections, coughs, colds, bit of hypothermia. People were getting off the boats soaking wet and then on the bus for 12 hours to come to Idomeni. So it was a lot of first aid, very basic primary health care and, during the whole three months, we were developing the clinic.”
It sounded like local residents were really pitching in too. “We managed to get a couple of tents lent to us by boy scouts. I didn’t even know that the scouts existed into adulthood but these Greek guys turned up in their scout uniforms and tents and pitched a couple of big tents for us. It was one of the most bizarre experiences of the whole thing – I really wasn’t expecting it.”
“And then we had two tents for a little while but again it was very basic. We could just about fit a bed in there and our medicines and it was cold, really cold and sometimes we didn’t have any light so we had to use head torches. So it was pretty rustic. A lot of the time people were just really cold coming to the tents so we would provide blankets and offering hugs. It was a lot of primary health care but also some psychological stuff as well – to give people a little hope or support. We would have a queue outside of this small tent of maximum ten or 15 people. The tents arrived quite late, maybe after a month or so, so quite high-tech tents, which we could have lighting. We had a couple of air heaters which was really good, and a generator. We had a bed and some screens for privacy and some tables.”
“So we were deciding what we wanted in our pharmacy. A Swiss doctor, who was an internal medic so he was used to hospital medicine, was there a week before me so he was already compiling a list of what should be in it. But then me, as a primary care physician, I thought we didn’t need things like digoxin and atropine so I tried to stock up on primary care type medicines and just a few things on standby for emergencies. It was really exciting to develop that, to really think about what kind of medicines you’ll need to treat people in this setting, and also to develop a pharmacy, do stock counts, how to order the medicines, how to logistically store it and how are you going to bring it in and out of the camp, how to have it secure if we are going to have it on the camp. It was a really great experience.”
“We had a field co-ordinator and then we had two to three doctors at a time – foreign doctors. The constant staff was really the Greek field co-ordinator, expat doctors and one nurse and one Greek doctor and one Greek nurse and there were two Greek social workers who were constantly there and some administration staff who would take the patients name and Date Of Birth. Then there were a couple of other interpreters but they could only interpret from Arabic into Greek.We had one interpreter who could interpret from Arabic to English.” Many of these humanitarian missions need people who can put the infrastructure together so that the skills offered by medical volunteers can be best utilised. Incredibly importantly and it might sound silly to point it out but they need to plug into the local need. “The Seven Sins of Humanitarian Medicine” is a real favourite paper of mine and lists all the pitfalls of a well-intentioned field mission in a well-thought out way. Admittedly, it’s for surgeons and it was published in the ‘World Journal of Surgery’ but these ‘sins’ stay relevant across the board.
“The whole project was run in co-ordination with DOTW Greece who have a huge standing in Greece. They are very popular. With the Greek [financial] crisis, lots of people couldn’t afford healthcare anymore and couldn’t access medicines so MDM [Medecins du Monde – confusingly the other name for DOTW] set up polyclinics. So it was an integrated effort between MDM Greece, Swiss and UK. So the Greeks were always involved and in charge of the co-ordination which is really important as it’s their healthcare system. We needed them also, amongst other things, to navigate the referral system and negotiate with police and border control because we couldn’t speak Greek so it was really necessary.”
How about co-operating with other Non-Governmental Organisation (NGO) teams? When you have so many people wanting to help, how do you co-ordinate to make sure you’re giving the most effective help? “So there were about five or six medical actors in a relatively small space. Medecins Sans Frontieres (MSF) were probably the biggest actor there. They’re very good, very fast. They already had cabins when we were working out of a tent. They had interpreters who could speak seven different languages and they had all medicines and they had everything already. They had an amazing logistics teams. They were putting up massive tents where the refugees were given some shelter before they were moving on past the border and they were providing various things such as towels and support packs – first aid packs with toilet roll and toothbrushes and things like that. So they were doing a lot of the groundwork. There were a lot of ad hoc nameless organisations too- people just wandering around with a stethescope and some paracetamol. It was pretty random. And that was the same case with the aid that was given. There were random people coming with tea and people dumping loads of clothes somewhere. It was a big mess basically.”
Linking in with local NGO’s is essential in order to co-ordinate efforts both for efficiency and also improving the patient pathway. It’s important that we let go of the ego and remember that no one is more humanitarian than another. “So apparently they [the other NGO’s] didn’t take us so seriously and didn’t want to work with us but it was a bit stupid because we were all there [at the camp] at the same time or there was no one there. So one of our field co-ordinators said we need to be there at night-time because there was no one there covering night. So we started coming in at night time. So MSF were like ‘maybe we should be there at night time’ and then Red Cross were like ‘maybe we should be there too.’ So then we got together. Our field co-ordinator did a good job and negotiated that we should be having meetings which I was involved in and we sorted out a rota – an eight-hour rota so we split it between the main four NGO’s so that we were there eight hours at a time. MDM, MSF, Red Cross and a Greek NGO.”
So what advice would you give to anyone who is compelled to work in the field in the name of migrant health? “You should go with an oganisation, a well-known organisation and ask how are they co-ordinating with the general process and the other NGO’s in the relief process. Are they just going because they think they are going to do a good thing? Have they fundraised a whole bunch of money at home and going there to take loads of photos of them helping and setting up a table with some cheese cobs on there and handing them out or are they there with an organisation with aims and goals and a plan of what they want to achieve and how they are going to achieve it? Have they have been given access as well? Are they working with the Greek or local government? I think that’s important. Sometimes, often you presume that this is already there with big organisations such as MSF or MDM and Red Cross so I think it probably doesn’t apply with them but I would think that of the smaller organisations that are often advertising for help and volunteers. I would just be wary of how they have integrated and how they have communicated their response.” Although these organisations may be just as legitimate as the international NGO’s, it’s always worth questioning this. When judging the applications for the RCGP International Travel Scholarships, this is certainly one thing that I look for personally. Have they been invited and how are they plugged into local resources? Otherwise, as soon as that organisation or person leaves, there is nothing but a mess left behind – the consequences of “voluntourism”.
Our conversation naturally flows to why GPs are excellent at this kind of work. Kiran had already mentioned it in the stock take for the pharmacy. “This is really primary care. There may be a handful of sick people but they’re generally fit people who have traveled in really horrible circumstances. They’ve passed the test. They’ve done the worst part of the journey on the boat and it was survival of the fittest. I met some incredible people. For example, a man with diabetes who was blind and completely by himself. He had diabetes and renal failure, having attacks of angina and he somehow made it all the way. Although I wanted to refer him to hospital, he wanted to carry on the journey and get to Germany or wherever he wanted to get to.”
“The great thing that we’ve got, especially training as UK GPs, is that we are able to treat all patients including children and women. In Germany , for example, [where Kiran is working as a GP at the moment] unless you’re a GP who works out in the sticks, any child goes straight to a paediatrician and women, even breast examinations, go to a gynaecologist. And in Germany, if you want to have your skin checked, or a mole checked, you would go directly to a dermatologist. So our training is really good in the UK – so wide-reaching. And we’re used to treating people to quite an advanced stage before referring them to hospital. So we’re really good at managing uncertainty compared to a lot of other GPs. So that brings a lot. Also, the UK is known for its evidence-based medicine. So for example, for setting up the pharmacy, we can say you can use that medicine rather than this medicine. These two medicines do the same or this medicine doesn’t have much evidence behind it and it’s really expensive. So there’s loads of things that you can do as a GP, especially if you’ve just qualified because you’ve just had a lot of hospital experience which you tend to lose as the years go on.”
I’ve really enjoyed this interview as I don’t think I’ve ever spoken to Kiran so in depth about his experience despite being friends for years. “I think it makes you more humble – puts things into perspective. As a GP, we’re very very nosy people – we like to get involved and know how they are living and know why they are the way they are, what really drives them to feeling so low or anxious and you’re in this unique position where you’re allowed to be nosy and really ask questions and get an insight into other people’s lives. Being a GP but in all these different settings broadens your horizons massively because you are in a unique position to see what peoples lives are like, not just from reading the paper and all these headlines on ‘poor refugees’ ‘poor migrants’ and look at all the sh*t that they are going through. You really need to have the one-on-one opportunity to listen and if you listen well that can be really therapeutic at the same time.” I think, for Kiran, GP really suits him because of his compassion towards others. “It gives you a unique chance to really be there for people when times are really really hard. Maybe often it’s not medicine that you’re giving but the social and psychological support. It’s like reassurance because everyone is so super anxious that they get really anxious about even having a sore throat for half an hour. But the whole situation just heightens people’s anxiety about everything. You can really do a lot for people as a GP and that can impact someone for the rest of their day, or maybe weeks, or maybe months or life..”
So any final words of advice? “I would say, if this is something that you want to do, just do it, just go out and do it. Go and contact people like DOTW or MSF or Red Cross, look at their criteria, send them application forms and if they don’t quite fit, see what you need to fit and then get involved. Sometimes it can be a bit difficult because there are a lot of people who want to get involved. One way is, you need to be qualified GP, but start off on volunteering like Project London (DOTW) clinic to get an insight or get some experience with refugees or migrants or undocumented migrants. From there, they can help you get involved with overseas refugee work after that. There’s plenty of things that you can do.”
Kiran is a F5 GP, currently working in the UK and Germany. He has done two missions to Greece after qualifying as a GP as well as work in Nepal. He will be off to Sierra Leone later this year for the RCGP/VSO partnership.