A few months ago, I was forwarded an email from the exchange team from Dr Padma Wignesvaran about the Portugal exchange. Now my eyes lit up when I read her name because this was exactly the doctor that I have been trying to track down for my blog. A first5 GP, Padma’s experience in Sierra Leone as part of the VSO/RCGP partnership was often mentioned at the RCGP International Programme Board meetings and I knew she would have to be on my hit list. “You’re not the Padma in Sierra Leone, are you?!”
So, on the back end of this email, she has kindly agreed to be interviewed to explain what she was up to in Makeni and what brought her here.
“I’ve worked in Sierra Leone before Ebola where I did a couple of medical camps and then I volunteered in a clinic in South Africa for a month – so I was slowly building up the time I was working away but I wanted to do something bigger. I realised that these short things are good, you feel like you are helping people in the short term but you’re not doing anything significant or sustainable. I wanted to do something that was longer and this job came up with the RCGP. Its hard to find a role like this that is GP-orientated with the emphasis on community health. This job is both hospital work and community work which was really good so I applied and I got it because I don’t think anyone else did!”
So let’s back up a moment and take a look at Sierra Leone, a former British colony in West Africa which gained independence only in 1961. It was originally the departure point to the Caribbean during the Slave Trade and Freetown gained its name from becoming the city of repatriated slaves. The country has been marred by civil war in the 1990s and then by Ebola only a few years ago and has tragically been struck by landslides in 2017. The residents are no strangers to hardship and strife. The Ebola crisis not only decimated the medical workforce but also highlighted the already fragile healthcare system. Post-crisis reconstruction was badly needed. And this is where the VSO and the RCGP partnership comes in.
“I arrived on the 1st of October (2016) and started work on the 14th of October. In the past year the hospital has changed considerably. It’s running a lot better. We’re seeing a reduction of maternal death rates. When I came, there wasn’t really an obstetric team, there was one surgeon who would do all the general surgery and do obstetrics and he really didn’t have time to do the obstetric side and now we have four doctors who do just obstetrics. They are all from abroad with different projects. It’s improved greatly but again it’s due to external influences. The country itself has to build its own medical workforce”
“A project needs to be improving the workforce and topping up whilst that workforce is being built. I think what the government and other organisations are doing is bringing in other doctors from Africa but also starting training programs for more doctors and physician’s assistants. At the moment they’ve got community health officers (CHOs) in the hospital but they should be out in the community. Now they want to bring in physician assistants because they are easier to train up than doctors so they can take up some more of the basic work that they are doing. Already we have STP’s who are CHO’s who have been taught how to do basic operations – C-sections, appendicectomies, laparotomies, hernia repairs so they are able to come in and do these basic surgeries so we don’t have to rely on doctors to be around because there really aren’t enough doctors in the country. These are the sort of things that have been going on to get more capacity building.
“Some projects are about dealing with problems – and you do need that –to catch up with problems at the moment. Otherwise it will be a few years before things start improving.
So how does the GP fit in?
“Part of my role is working in a hospital and I work in the outpatient clinic. So all the patients who come to the hospital come to the outpatients first, except for the under-five children and maternity, but everyone comes through here so it’s quite like GP in terms of treatment and making a plan. I also run the observation ward, which is a ward a bit like Medical Assessment Unit (MAU) where people go to first when we admit then. When I come in the mornings I get here around 8 or 8:30 and we have our morning briefing and then I do the ward round on observation ward. Since I’ve been here, I’ve done all the wards so I started in paediatrics and ITU and now I’m on observation ward which is where I spend most of this time. Then I go to outpatients. The mornings are quite busy so I see a lot of school children, adults, lactating mothers, Ebola survivors – anyone who comes in I see them. That is the main bulk of the work that I do. Every Friday morning, we do teaching here, so this week I am teaching about asthma, I’ve done teaching on diabetes, hypertension, hepatitis, heart failure, mostly covering NCDs.”
“The other half of my work is in the community although I don’t do as much as I want to. The big part of the project with VSO was to be a mentor to five of the bigger clinics in the area. The furthest one is 2 hours away by car and the closest one is about 20 minutes away. With VSO, it was more about maternity and neonatal health because Sierra Leone has one of the highest maternal mortality rates in the worlds. These clinics usually have a midwife and a CHO as well as some other staff. There should be one of these clinics in each chiefdom in the district .They would be the main clinic with smaller ones in each of the villages around but at the moment there is only five of them.
We do training days where they come to the hospital and we do a day of classroom teaching. Obviously as a GP, my speciality is not obstetrics so I facilitate and get other physicians from the hospitals. We have obstetricians here and paediatricians, I get them to come and give talks. We cover things like obstetric emergencies, what should they do, how they should see someone during the antenatal period, when to refer and things like that. They have already learnt this stuff but it’s just keeping them updated and reminding them so that they practise in a safe way.
We also provided portable USS machines in each of the clinics and staff were trained in how to do a basic obstetric scan. Now for the first time ever, patients are able to get obstetric scans in these clinics.
We’re currently at the evaluation stage where they’re practising and we’re overseeing what they are doing which is great as I’ve learnt how to do obstetric scanning as well. I diagnosed placenta praevia in the community the other day which was quite exciting! I never thought I’d be able to do that! I often go to the community clinics and do clinics with the CHO or midwife. I spend the day with them and we talk about cases and see patients together”
One of the things that I found hard when I worked in low-resource settings is the expendability of life. I can imagine that when there is a lack of resources and an inability to help patients that one almost has to almost disassociate to emotionally deal with this injustice. It’s such a different landscape.
“The younger people – sometimes they come in so ill. There’s only five things we can do blood tests for and we treat what we can and sometimes you never know what’s really wrong with them.”
“The way I see it is you have to do your best with the resources you have. This is what I tell my team. If I know I have done the best I could of done its much easier to get through the day.”
And what other frustrations do you come across?
Things I find frustrating are how late patients present. You think “if only you came to me earlier treatment could of been so much easier”. Patients also see multiple doctors before they come to you and they don’t tell you everything that has happened to them so you don’t know their full history and you don’t know what drugs they’re taking or their friends will give them a drug “try this one” or “try that one”. You can just buy them too. When I go to the market on the weekend there’s a woman with a bag of them and she says “Which one do you want?” They’re not labelled. They’re like sweets and she’s selling them.
Now this is a RCGP and VSO partnership which, in my opinion, is great. A very well-respected organisation, Volunteer Services Overseas (VSO) work to fight poverty through improving education, healthcare and livelihoods. My impression of them is that they are much more about development rather than crisis management.
“With VSO it’s all about passing on your skills. I have knowledge that I am passing onto others and that knowledge will stay with them even after I leave. You hear so many stories about corruption and money and power that its nice to be with an organisation like this where its really about knowledge and skill transfer. It is also about making the country more resilient so that the next time there is a crisis they are better adept to withstand it and deal with it.”
“Also being in Makeni and away from Freetown is great. Its a town in the provinces without the amenities you will find in the capital. I really get to experience what life in Sierra Leone is like. There are vegetables growing in my garden. I have 2 mango trees, which was great when they were in season, and a bunch of the other vegetables growing like sweet potato and sweetcorn. I finally learnt how to cook here so I guess I am learning some new skills too!”
“There are a few people here from Europe so I’ve have made friends with other people in a similar position as me. I also became good friends with the local hospital staff. We often have dinner together at a local restaurants, go and watch football in a local bar or cook for one another. Sometimes there are excursions to the beach or other towns nearby if we have a free weekend.”
Dr Padma Wignesvaran is back in the UK and working in East London planning her next move.
Keep an eye out for the annual recruitment for this role!! Handover is usually in November.