The Greyhavens

Sun up on the Nile

Our last day in Juba dawned bright and we both spent our breakfast watching sun up on the Nile. Whilst Clare packed, I went to the hospital to tie up some loose ends. Our journeys to hospital were always amusing adventures, not least because our driver, Mukashfe, would give lifts to complete strangers. He saw this as a service to the people of South Sudan and his way of making a difference. Each day we would pull back the sliding doors of our bus to reveal people from different walks of life. Some days they would be soldiers, other days women carrying sacks of grain. Today I opened the door to reveal a bus full of school children and two policemen. It would be these little acts of kindness, that myself and Clare would miss.

The road on our way to work.

My last morning was spent with some final good byes and gathering email addresses. I sat in the EMW for a while and looked at it’s beds, the patients and the doctors and nurses doing the round. It was my last view of the ward I had come to love. A smile came to my face and my heart overflowed with pride.

My last view of the EMW, female side. The ward is a little like Hans Solo's description of the Millennium Falcon, "She may not look like much but she's got it where it counts." A house officer is at the back (in green) pre-rounding on a patient. Our drugs trolley is in the foreground. We have yet to use it!

After a goodly amount of hand-shaking and the occasional hug, I left the ward and turned left to the outpatients department, heading towards the blood bank. I had one last thing to do…

After three tries, we finally cobbled together 300ml of house red.

At 11 am we arrived back at our hotel, picked up Clare, and began our last journey in Juba, the journey to the airport. The first half was the same route that we took to the hospital. We went past KonyoKonyo market and saw the usual heaving mass of cars, motorcycles and humanity going about their business. We turned left at the T junction and passed a school full of school children playing in the playground. Three hundred metres on, we took the third exit on the roundabout and headed up a small rise.

Juba Teaching Hospital came into view on the left and I gazed at its dusty white brickwork and slightly rusting corrugated iron roofs. We passed the first set of gates and I observed the usual throng of people entering outpatients. We then passed the Emergency Medical Ward. Lastly, we passed the second set of gates and I looked upon a group of people sat talking and laughing by William’s office. That would be our last view of JTH, a hospital that would always be much more than a hospital. JTH was an icon; a symbol that encapsulated peoples hopes and dreams of healthcare for the Republic of South Sudan. It was a hospital that sometimes, I had joked to Clare, seemed to live and breath and have its own personality. It was a hospital, that for four months had held us in our arms and carried our hopes and dreams on its whimsical tide of time. Our fates had been bound to it and it to us. We had developed a strong affinity to the place and in many ways it had become our friend, a familiar face in changing and fickle world. And now our world was changing. We were leaving. We both felt tears in our eyes.

*            *            *

As our airplane journeyed north to Cairo and as the distance widened, our mood changed. Our minds began to accept the finality of our lives in South Sudan. Our wonderful journey in middle earth, with its happiness and disappointment, its laughter and tears, had finally come to an end. It was now up to Rae and Michele, our Harvard replacements who arrived on Monday, to continue this lovely tale. Our future lied to the North and our thoughts moved from reminiscing on times gone by to wondering what the future held. A new chapter in our lives was about to begin.

A view from our airplane from 6 km above. The sun drops below the horizon, splashing a crescent of gold above the evening sky. Below are the cottonwood puffs of cloud and below this is the Sahara

The journey back included a night’s stopover in Cairo. For us, it was our first hot shower and the first time we had been cold in four months (12 degrees). We sat down to a supper of olives, fresh salad, a selection of breads and more cheeeses and meats than we had seen in a long, long time. Each mouthful reminded us of the great things that we have in the UK and we began to talk about our families and friends and what we would do on our return. Slowly our sorrow of leaving was being replaced by a yearning to see the loved ones we left behind.

We finally arrived in Heathrow airport at 1pm on Saturday 14th January 2012 and were greeted by Joanna, Clare’s sister and her boyfriend Melroy. One and a half hours later we arrived in Broxbourne and stared upon a familiar site, Clare’s house. Their standing in the doorway were Clare’s parents, my parent in-laws. We exchanged some long hugs. We drew a deep breath and looked at each other. “Well we’re back,” I said.

*            *            *

Epilogue:

Our four months in Juba were always extremely busy and for those of you that have received less attention than you deserve, we humbly apologise. However, our time was not spent idle and during our stay we trained 112 nurses in malaria, conducted three research pieces (two looking at consumption and one a mortality study), two audits, designed numerous budget proposals, including one for a four bedded level 1 ITU, and completely restructured acute medicine, to name a few things. However, for me, the greatest achievement was changing the attitudes and ethical values of the junior doctors on the EMW. This will usher in a new age of healthcare in South Sudan.

Clare teaching the nurses

Nurses sitting their exams

Our journey also taught us many things about ourselves. In the UK we were first year registrars. When we came here, we were cast straight into the role of Consultants and I was the head of the EMW. I learnt much about leadership and the importance of role modelling; people looked to me for both. As the leader, I felt a strong sense of paternalism towards my team. It is going to be very strange for me to go from the role of a consultant designing policies, budgets, and managing a ward, to being an anonymous registrar in the NHS.

As well as leadership, we also developed novel, problem-solving strategies to patient problems. Many an asthmatic patient was saved with the above four items.

The finished article, an asthma spacer. Ten puffs from this beauty became our first line management in severe asthma. Before it was aminophylline, a drug that has almost disappeared from the UK's asthma management guidelines due to its toxic side effects.

During our stay at JTH we saw a variety of different strategies for improving healthcare. However improvement has to be sustainable. Whilst we accomplished much, if it were not for the continued presence of a rolling rota of Harvard Consultants, standards would slide, hope would fail, and a veil of apathy would again fall on the EMW. Parachuting westerners into Juba for small periods of time to offer sporadic training achieves very little in term of healthcare improvement. There are a complex maze of issues that lead to poor healthcare, of which training is one issue. Thus delivery of training does not equate to healthcare improvement. 

Sustainable change therefore requires:

1)    Addressing all of the barriers to healthcare improvement, not just training

2)    Encouraging sustainability by

a) A continuous presence of healthcare staff that rotate and hand over to each other

or

b) individuals that remain for many years

Similarly, changes in healthcare require the local people to trust you and there is no shortcut; it takes approximately 2-3 months to earn it. Once we had earned the trust and respect of the staff in our departments, we had the support needed to drive forward changes in healthcare.

Lastly, changes in healthcare often require money and our stay in the Rhino Sanctuary proved to be a useful case study. During the early days of the sanctuary, Angie (the owner) had terrible troubles with cattle grazers cutting her electric fences to allow cattle to feed. During one episode she caught the person and threatened to impound the cattle. At this point the cattle owner fell to his knees and wept, wailing “Please madam our cattle are dying of starvation and the only good food is in your sanctuary. What options do we have?” Angie took a very difficult decision. She allowed cattle to mix with rhino’s.  This simple act triggered a miraculous cascade of events. The cattle, no longer malnourished, became healthier, put on weight, and fetched double the price at the cattle market. This put money in the pockets of the people, enabling their children to go to school and allowing commodities to be sold. At a grass roots level, the decision that Angie took on cattle grazing, triggered a cascade of events that led to a big improvement in the local economy and quality of life. Since this, Angie and her family have set up a local school and are looking at creating a primary health care clinic in the town.

Our inspiration, Angie, addressed as "Madam," by the local people who clearly adore here. This photo was taken at the top of the Rhino sanctuary driveway, where someone is putting the finishing touches on a rhino's horn.

One problem that we had in Juba was that it would take a long time for funds to arrive and we had no autonomy over finances. The money for the high care unit is still awaiting clearing from the Ministry of Finance. Staff do not get paid for several months at a time. All of these factors reduce motivation and impair healthcare delivery. It is clear that having an income generating project is a great way to have autonomy over finance and invest in healthcare improvement.

So where do we go from here? There are a few loose ends to tie up in Juba, which can be done remotely. We need to plan for registrar training. We will continue to be involved in the SSMJ and one key goal will be to create e-learning to assist in the development of postgraduate training. Over and above this, we are not entirely sure, although we will definitely be keeping up our ties with Juba Teaching Hospital.

Two things are certain. Firstly, seven years from now, we will become consultants and we will have children. Secondly, the life that myself and Clare have sculpted and moulded together is important. We and our future children will only live it once so we must live it as best we can.  Central to our lives together, is a mutual love of Africa and a strong desire to return. During these next few weeks, we will be re-united with our friends. Over the talking and general mirth, there will be some serious conversations about life plans and rhino-related projects, which will contain the seeds of tales that have yet to come to pass.

On the penultimate day I took this great photo of all the doctors and nurses on our EMW

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5 Responses to The Greyhavens

  1. Lizeth Lelliott says:

    Well done Dave!

  2. Lizeth Lelliott says:

    Well done Clare!

  3. Don Attwood says:

    The well being of many is owed to a few. The fellowship of the ‘consultants’ is over, you have been there and back again and achieved much. Those four months of dedicated service put in will hopefully translate into the equivalent of four years improved growth in the South Sudanese Health Service. So well done and congratulations to you both. All that remains is for the next chapter to be written by the new and inspired medical team that follows on from you.
    Don Attwood

  4. Peter Awang says:

    Thanks for your time in South Sudan!We met occasionally for few minutes but failed to give you better words of APPRECIATION!
    I am back to (Cape Town) South Africa.I have started packing to be home by 2013.We have a lot to do!!!
    Peter Awang
    Surgical Registrar
    Groote Schuur Hospital
    University of Cape Town

  5. Laura says:

    Amazing to hear about JTH 7 years on……I worked as a expat ward Nurse just after the peace agreement was signed in 2005 for 9 months……I wonder if any of the original staff still remain on the emegency ward….is Edriano still the manager…would love to return to see it now.
    Sounds like much has change with increasing medical assistants…..but much also remains the same…..Great blog Dave and Clare…..you may have inspired a return visit!!! Thanks Laura, Nurse Practitioner, Nottingham. Uk

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