Things I’ve learned as a doctor in Mali
In August 2016, after two years working in Bristol and Yeovil, I left the NHS and took a job with Critical Care International in southern Mali, providing UK-quality healthcare – emergency, primary and occupational – to all the workers employed at a British-owned mine.
Over the last year, I’ve seen a lot and figured out how to work successfully in my role, I think. The following, in no particular order, represent the most important things I’ve learned.
It’s the subtle differences that take you by surprise
In west Africa, it’s never the big, obvious culture differences I seem to notice, it’s the little things. The poverty is pervasive, the language foreign and the weather delightful, but I think I was subconsciously prepared for that. However, it’s the subtle differences in values and communication that never cease to take me by surprise.
Each Wednesday afternoon we invite all the healthcare workers who practise in the surrounding villages to our clinic for a teaching session. Normally about 10-15 attend, a mixture of nurses, pharmacists, midwives, and student nurses.
A few months ago, I had just begun explaining the basics of tuberculosis when I was interrupted by a wafting, guttural burp emanating from the front row. Its owner was Aminata, one of the matrons (not a trained midwife but she’s been delivering babies for over 30 years).
No one really seemed to notice the burp except Dr Ndane, a Cameroonian doctor and my colleague for the past year, who burst out laughing having seen my look of surprise.
Almost on cue, every five minutes she’d drop another, look up surprised at why I’d momentarily stopped talking, and then continue taking notes. I’m still not sure whether it was meant as a not-so-subtle jab at my teaching or whether she was merely having a gassy day.
South Africans can be interesting as well. The processing plant – the bit that takes in rock and pumps out gold – was designed and constructed by a South African company and I’ve therefore spent a lot of time living and working with them. Many have spent most of their lives working all over Africa and there’s no one better to spend an evening chatting with.
However, despite being bilingual, they seem to prefer speaking Afrikaans. Many times, I’ve been chatting with a group of them, in English, and then without warning the conversation switches to Afrikaans, spelling the end of my involvement. Maybe I should add Afrikaans to my list of languages to learn…after French and Bambara (the native Malian language).
Trust your colleagues
Before I left the UK I’d never treated someone for malaria, in fact I’d never even seen a case first-hand. Considering that on some days the clinic will now diagnose 15 cases, I have been on a rather steep learning curve.
Luckily, I’ve been working alongside Dr Ndane, who has seen thousands of cases over his career. We’ve grown to trust each other, acknowledge when one of us has more experience than the other and work closely to ensure we share our knowledge for the best of the patient.
Getting on with your team is always important, but here where you’re working together for weeks and living next door to each other, it’s critical.
Appreciate what you have
By the time I left the NHS I was thoroughly disillusioned with many aspects of UK practice: the bureaucracy, the repetitive paperwork, the day-long inductions and the straitjacket in which I seemed to work most days. However, as soon as I left the NHS bubble, I realised how naïve I had been. Much of what I had questioned, the incident forms, the pages of guidelines, the hours of inductions, began to make sense. In fact, I began to replicate most of it in the clinic.
It is only when you step away that you appreciate the NHS sits on a mountain of accumulated knowledge from all the doctors, nurses and allied health professions, and patients, who have come before.
In contrast, many of the Malian doctors and nurses I’ve worked with have no concept of guidelines or referencing doses. Many times, I’ve noticed an odd sounding dose being prescribed and enquired, normally to be told that someone they worked with a few years ago gave that particular dose. Often these doses were wildly inaccurate, especially when children were involved, but to look in a book, or on an app, was seen as a glaring sign of weakness…doctors should remember everything.
The culture in the mine clinic has changed dramatically since I’ve shown the importance of accurate dosing and where to check doses. We also invited the local nurses to the clinic and helped them download the MSF medical guidelines app so they are able to check doses themselves.
Look after your own mental and physical health
I’m sat writing this outside my room having flown into Mali 48 hours ago, since then Dr Cracknell and myself handed over and now he’s on his way back to the UK. This afternoon we had to stitch up someone who cut his hand open while cutting onions, we saw three people with malaria, one of the nurses taught eight workers first aid for an hour and another one ran the occupational health clinic with Dr Didier.
Like any job in medicine it can get very busy and there can be a lot of pressure. Added to that, tonight I’m on call overnight, as I will be every night for the next seven weeks. I realised soon after starting that, if one isn’t to lose the plot, you’ve got to look after yourself. Regular periods of downtime and enjoying yourself are important.
Each evening after work I go running, or read and drink tea as the sunsets. Later, I’ll have dinner with one of the other expatriates on-site and then maybe watch a film. Ensuring good mental health is critical, although there are some physical considerations as well, trying not to get malaria and become a patient yourself, for example!
Health and safety is crucial
The week I first arrived in Mali, they started pouring the first concrete for the foundations of the mine, since then they’ve erected thousands of tonnes of steel, miles of cabling and piping and taken the delivery of eight shipping containers of cyanide. A lot could go wrong.
Over the last decades the rate of industrial accidents and deaths have dropped dramatically due to increased regulation, training and standardised procedures, which is rigorously enforced by senior management. Most people employed on the project are from surrounding villages and have grown up without much concept of health and safety, so education is crucial. While we have seen accidents on site, most commonly traumatic amputations, the culture of safety has meant more serious accidents are very rare.
The story when people are not at work is very different. One gentleman was on his way home on his scooter when it snapped in half. He was thrown onto the ground face first and sustained serious injuries to his face and upper lip. Helmets are a rare sight in Mali. Spending time in the community, you can’t help but notice the lack of awareness regarding safety: welding without a mask, children walking around open fires and glass and other sharps littering the floor.
We’ve used our Wednesday teaching sessions to deliver education to the local healthcare workers, knowing that they’ll pass on the information. For World Malaria Day, the mine organised a teaching session for a selection of senior figures from the community. We taught them what malaria is, how to help prevent it and when to seek treatment.
Use the existing infrastructure
A couple of months ago at a medical conference someone asked what I did. I explained where I worked and suggested there may positions available in the future. 'I’d think twice about working for a gold mine,' he said dismissively before strolling off. I’m not exactly sure of his reasoning but these opinions are not uncommon.
I shall attempt to explain why this is short-sighted. Consider an NGO who are concerned about childhood malnutrition in southern Mali, and want to do something about it. They design a project to measure and weigh all the children in a certain area and start treatment for those who are malnourished…simple.
To do this, they need to organise a team, fly them to Mali and then drive them to the project location. Then they need to ensure everyone has somewhere to live, food to eat, water to drink and toilet facilities. They may even need electricity and internet. Boring logistics aside, they’ll need to meet all the relevant stakeholders, the village chiefs, the nurses and many others, and get their support. Only then can they begin the project.
All in all, this will cost thousands, maybe tens of thousands of pounds. However, if we were to deliver such a project, it would cost a fraction of the price, as we’re able to piggy back off the infrastructure already in place, courtesy of the mine. Earlier this year we worked alongside the mining company, Hummingbird Resources, to deliver such a project.
We weighed and measured over 1,000 children and instituted treatment for all those exhibiting signs of malnutrition. It cost £400.
In the next instalment, Dr Cracknell will explore how he delivered the project.