Damien is a humanitarian doctor and author of the book ‘Bandaid for a Broken Leg’. Read about one of his missions with Medecins Sans Frontieres, then explore more Personal Stories.
GHG: Tell us about your experience with Medecins Sans Frontieres in Angola.
Medecins Sans Frontieres had a hospital in an isolated corner of the country serving a rural population of 20,000 or so. It was four years after their civil war ended, and despite the time passed the people were extremely poor, with no infrastructure at all in the region. Roads and rural areas were still heavily land-mined, but it was otherwise a safe place to live and work. There were four expats – myself, a midwife, a coordinator and a logistician (with the latter two being non-medical). We supervised about forty clinical Angolan staff, who were basically-trained health workers.
My job description was broad, but the reality of the job was even broader, with a lot of the work being non-clinical (and this is true of many medical positions in the field). We had 80 beds and an outpatients department. Mornings began with a formal, several-hour ward round which we used for teaching. This started in the small ‘ICU’ (no electricity, no ventilators, and no oxygen: just used as an intensive observation ward for markedly sick patients). Then moved onto the paediatric ward, the adults ward, the isolation ward, and the malnutrition ward. The midwife looked after the maternity and labour wards.
GHG: How did you get support for this very challenging job?
I had no medical colleagues in town to confer with, and no prospect of evacuating or transferring patients – it’s a sobering responsibility at times, and one could never have enough clinical experience to be truly competent in such a setting. I could consult with specialists via email, though.
That said, probably 75% of patients had easily treatable conditions: diarrhoea with dehydration, chest infections, malaria and malnutrition made up the majority of cases (and soon become as routine as seeing someone with asthma or chest pain back home). A smaller percentage had more severe conditions, and yet others had things that we clearly could do nothing for: cancers in adults, babies with congenital disorders, etc. But that was a minority.
The truly difficult things to deal with were obstetric emergencies, and I would advise doing plenty of obstetrics and paediatrics before going overseas! We also had a small OT, and one of the health workers could do certain life saving procedures – Caesarean where mother’s life was threatened, limb amputation, etc – with us giving only ketamine. Impressive guy – he’d picked up the skills working with the Red Cross during the war for a year (but wasn’t a doctor).
Non-clinical tasks were a large part, particularly teaching. There’s no point coming, doing things your ‘Western way’ in a whirlwind, and then leaving nothing. Teaching was a big priority! Other responsibilities included organising staff rosters, ordering drugs (which take 3 months to come from Europe and need to be anticipated), looking after HR issues, etc.
It is a humbling, eye opening experience. To see how fellow humans live, struggle, and often thrive under such circumstances gives you a perspective on life that I’d suggest could not be gained many other ways. You really do get to help, and the benefits of your work are tangible, real, and much appreciated.
GHG: What were some of the biggest challenges?
Where to begin! Realising the limitations of your abilities as a doctor; you’re dealing with an immensely complex, huge problem (the issue of lack of access to healthcare and resources, lack of equality, etc), one patient at a time with limited drugs and resources. For me it involved a re-adjustment of my goals and expectations to something more ‘realistic’. Being the only doctor and having to confidently make clinical decision with few investigations is difficult; they’re not the diseases you see back home. Living with three other people, stuck in a compound, with no prospect of social variety or a weekend away (or not being on call, for that matter!) is an interesting experience. Your team mates are often the make or break factor.
Leaving is heartbreaking. Coming home is hugely difficult – working in a resource-drenched ICU just two weeks after having had to tell a thirty year old woman with breast cancer that a pain killer and metoclopramide is the best you can do for her, is a confusing experience. The ‘gap’ is a misnomer – its a chasm.
GHG: What is some advice you would give others interested in humanitarian assistance?
Keep your skills broad – do obstetrics, paediatrics, emergency medicine, surgical rotations. HMO3/4 years are good times to go if you’ve had general rotations; being an advanced urology or cardiology trainee is not going to give you a lot of extra skills, and you’ll probably have forgotten your paeds and ED stuff by then. People often say they can’t intubate, so can’t go: Who are you going to intubate over there?! People don’t die of ischaemic heart disease and COAD and complications of T2DM (yet – in most poor contexts). They die mostly of easily treatable or preventable infections.
Tropical Medicine training is invaluable – I did a 10 week course in Peru, and think that 90% of the work I did overseas involved things that I specifically learned during my course. Tropical Med courses that I know of (usually 2-4 months) are in London, Liverpool, Lima (Peru – the Gorgas course), Amsterdam, and now Bangkok.
MPH? The theory is interesting, and applicable to managerial/project planning roles. For being in a clinical role, I think that clinical skills are the more urgent need – tropical med, and varied post-grad rotations. Don’t feel compelled to finish one before heading overseas.
Work in Indigenous Health in Australia. You really don’t have to go far from home to deal with malnutrition, and other diseases not usually seen in Western countries. The significance of the health problems can’t be underestimated, and the social issues are devastatingly confronting. The needs are massive.
Regarding who to work for: if you have a partner, MSF won’t take usually let them go with you. This is a big issue for many people. Working independently negates this problem, however you have no idea what resources you will have available to you. An established organisation such as MSF usually means a minimum level of resources (e.g. drugs, text books, protocols, medical advice) available to you, and your costs are covered.
Don’t keep putting it off is the main thing. People say they’ll wait until they’re a consultant… you’ll have a mortgage and kids by then, and its no easier to put your career on hold for a while. Get in there early, and get experience! You can still go back again later, and drag the hubby and kids along.
Dr Damien Brown has completed multiple missions with Medecins Sans Frontieres, in places such as South Sudan, Mozambique, and on the Thai-Burma border. He is now back in Australia and has recently seen the publication of his first book “Bandaid for Broken Leg: Being a Doctor with no Borders (and other ways to stay single)”.