‘Fit for purpose’ – donation and innovation

Are you one of those people? I’m certainly not, but I shared a flat for 4 years with two people who definitely are. You know of whom I speak, the kind of people who quietly take note of an offhand comment mentioning your favourite childhood movie, and months later present you with the limited edition DVD for your birthday. Another friend observed my geekish interest in neuroscience and my love of music making, and thoughtfully gave me a copy of Daniel Levitin’s fascinating book Your brain on music. A gift certificate to spend a day learning to drive a steam train would probably not top the internet search engine suggestions of gifts ‘for her, aged 20s-30s’, but this enjoyable experience courtesy of another friend resulted in the local Steam Museum offering me a position as volunteer train driver. Apparently I have a ‘feel for steam’. I might put that on my CV. In other words, some people seem adept at perfectly matching a gift to what that particular person ACTUALLY wants or needs.

If you are not one of these eerily insightful and thoughtful individuals, it can be much harder to get gifts right, as the survey of 2,000 people for classified ads site Gumtree.com testifies. They found that the UK spent £2.4 billion on unwanted Christmas present in 2011. Only 2% of these gifts are thrown out, and a third end up gathering dust in storage because we feel too bad getting rid of them. (1)

Charitable donations can be similarly tricky. Generosity and good intention are the vital starting point, but by no means the whole story. In 6 months travelling around hospitals in Madagascar, I lost track of the number of pieces of fancy but non-functioning equipment gathering dust in corners. Many were donations, gratefully received but quickly becoming useless in the context to which they had been donated. The WHO once estimated that in lower income countries, up to 80% of equipment in hospitals is donated. This means that local maintenance contracts or supplies are unusual, and assessments show that almost 40% of donated equipment is out of service. (2,3)

One memorably day in the operating room, our scrubs drenched through with sweat in the 35 degree heat, we asked about the air conditioning unit in the corner. It had been donated last year, but stopped working just 3 days later. With no biomedical technician for miles, no one was able to fix it, and it had lain dormant ever since.

Visiting a sick baby on oxygen therapy, we were pleasantly surprised to see the first neonatal resuscitation station we had come across, until we were told it hadn’t been functional for over five years.

A modern and sophisticated ventilator in another hospital also was not being used, as the intermittent and poor quality power supply in the hospital had totally fried the complex circuitry, and no replacement parts were available.

Square peg, round hole

As an anaesthetist in the NHS, I often take for granted the incredible machines that we use daily to deliver a modern miracle of medicine. It is quite astonishing that it is possible for someone to remove one of your internal organs while you are safely kept unconscious with a carefully balanced kind of ‘temporary medical coma’ – general anaesthesia, all the while your vital organ systems are constantly monitored and supported to keep you safe.  The anaesthetic machines and monitoring equipment produced in recent years utilise increasingly sophisticated computer processing, and are reliant on infrastructure such as tightly regulated pressurised pipeline gas and uninterrupted electricity supplies. Just a few years ago, ‘A survey conducted among anaesthetists in every African country that has a national society of anaesthesia found only five teaching hospitals in the entire continent that claimed to have good quality supplies of both electricity and oxygen. (2)’ The modern machines mass-produced for our high-tech context are therefore virtually useless and prohibitively expensive in the many parts of the world.

It is no surprise then, that

in 2008, two thirds of the world’s population purchased just 4% by value of the global output of anaesthesia machines. The remaining 96% of mainstream production cannot even be used in most of the places where those 4.5 billion people live. (3)

The equipment developed, used, sold, or donated in resource-rich settings is essentially ‘not fit for purpose’ in the challenging environment of many hospitals around the world, and can even cause waste of valuable resources. This is why organisations like the WHO and AAGBI produce guidelines for anyone seeking to give medical donations.


For exactly these sorts of reasons, I was delighted to join a teaching session run by the Medical Capacity Building team from Mercy Ships with members of the anaesthetic team in Hopital Be, Tamatave. UK anaesthetist Steve Alcorn is seen in the picture below, explaining how to use the elegantly simple ‘Glostavent’ anaesthetic machine in the newly refurbished operating room where the team practice running through essential pre-use checks. Just like the Lifebox pulse oximeters our team donated nationwide, the ‘Glostavent’ and the ‘Universal Anaesthesia Machine’ are examples of innovations in equipment technology driven specifically by the needs of underserved populations delivering healthcare with limited resources. The machines are specifically designed to be affordable, durable, and suitable for use in harsh and unpredictable working environments. There is a backup power supply if electricity cuts, and oxygen is extracted directly from the air by the oxygen concentrator.

We have all probably given something to someone else (for the lack of a better more inspired idea!) on the basis that it is what we ourselves would want. Thankfully, in many situations, such a gesture of magnanimity will be appreciated and gratefully received. It’s just as well that with personal relationships it often truly is ‘the thought that counts’!

However in practical matters solutions for provision of global health care, it’s a challenge to find ways to truly understand the needs of a different context instead of just inappropriately transplanting solutions from our own.

‘People trained to do research are concentrated in higher-income regions. The UN Educational, Scientific, and Cultural Organization (UNESCO) estimates that only 13% of the world’s scientists are located in Africa, Latin America, and the Middle East.The highest volume of surgical research is not done in, or by, the countries with greatest clinical need.’ – Global Surgery 2030: Lancet Commission.

This is part of the reason why international collaboration and innovation in this area is essential. Innovation in technology and other areas not only provides increased access to more comprehensive and safe health services for those who desperately need it, but the lessons learned from puzzling out how to provide excellent services when resources are limited may well prove valuable to all of us facing rising health care demands and financial constraint.

I have to admit though, you may still receive novelty socks, bad jumpers, and generic chocolates as Christmas presents. I myself will gratefully receive all of the above.

If you are interested in donating to tried and tested innovative technology being supplied to lower income countries, check out the links below. Thanks for reading!

  • Lifebox: Oxygen monitors developed for distribution to every operating room in the world.
  • Safe Anaesthesia Worldwide: Charity supporting provision of anaesthetic equipment including appropriate anaesthesia machines worldwide, committed to also providing appropriate training and technical support.
  • Great short video on this topic below produced by Tropical Health Education Trust (THET)


(1)Gumtree survey report: http://www.thisismoney.co.uk/money/news/article-2078516/Britons-spent-2-4bn-unwanted-Christmas-presents-year.html#ixzz44TTX3Ogz
(2) Perry L, Malkin R. Effectiveness of medical equipment donations to improve health systems: how much medical equipment is broken in the developing world? Med Biol Eng Comput 2011; 49: 719–22.
(3)Global surgery rapid response, Mike Dobson http://www.globalsurgery.info/engage/direct-comments/
(4)Paul M Fenton Formerly Professor and Head Dept of Anaesthesia College of Medicine Malawi, Africa 1986-2001. Writing in World Anaesthesia News 3 March 2010.

A Malagasy Doctor’s thoughts

I have had the enormous privilege of living, working, and travelling with two incredible Malagasy doctors over the last 6 months delivering training to hospital teams throughout Madagascar. Dr Hasina Rakotoarison recently shared her reflections on this experience, she graciously agreed to let me share it here! Over to you Hasina…

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Hasina loves her beautiful country and is passionate about bringing hope and healing through healthcare to those in need.

‘I had never heard of the Checklist until my Supervisor at the Hospital proposed it as an interesting topic for my thesis to finish my medical degree. I chose to study this area because I was very interested in patient safety, and the Checklist was little known in Madagascar but had astonishing benefits for the safety of the patient having surgery. I always had in mind that I want to become a surgeon, so I planned to apply the checklist to my own work, but I never imagined that I could have an opportunity to share the benefits of the checklist with other teams around the country.  For me, this project with Mercy Ships is very exciting because it has made a dream of mine come true; to share what I have learned and spread the message to surgical teams in every region.

During the last 17 training courses, I have discovered that many other people are also very passionate about increasing the security of patients undergoing surgery, but they don’t have many opportunities to discuss this together and find practical solutions. Even though I am Malagasy myself, I did not realise the challenges some of these teams face in their everyday working lives. For example, some teams in remote regions are very isolated, the health care needs of their population can be very great, and the hard-working hospital staff manage in difficult conditions.

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Hasina talks a team through adapting their own Checklist for the operating room

This training course has given me an opportunity to encourage those who share the vision to increase the quality of care for patients, and work together with them to make that vision a reality in their local hospital.

I have also seen how a tool like the Checklist can transform the atmosphere in teams, improving communication and working relationships. Even our training team didn’t recognise the significance when some hospital teams said that the secret of their success was ‘love’. This is something I have learned from them when I read the feedback forms! Because even such a simple word like ‘”LOVE” I didn’t understand until much later when I came to realise how right they were in saying you have to “Love each other”. The Checklist is not just a simple tool, it can change the whole hospital. The Checklist brings love with it and can change everything at a place where it is implemented well. We have noticed that where teams support each other and communicate well, you can FEEL the difference in the working atmosphere if they have love in their team.

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The Checklist can reinforce relationships in the operating room by helping teams work TOGETHER for the good of the patient

The hospital teams I have met on this project demonstrate by their actions the true meaning of ‘love’ described in book of Corinthians:

‘Love never gives up, never loses faith, is always hopeful, and endures through every circumstance.’ 1 Cor 13:7

In the future, I wish to remember those people from the places I have visited where there is great need, and would love to have the opportunity to revisit them to assist in providing healthcare and bringing ‘hope and healing’.

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Hasina volunteers as a patient for a simulted operation. One day she hopes to come back as the surgeon!

All you need is…

How do you measure success?

What we see largely depends on what we look for, as Sir John Lubbock once noted, so this question was on my mind over the past fortnight as we have been going back to visit those hospital teams we worked with 3 to 4 months ago at the beginning of this Mercy Ships field service in Madagascar.  We spent hours listening as 9 teams from different ends of the country told us about their experience of attempting to change working habits to integrate a completely new system into their every day practice.


Theatre team from Diego tell their stories

It has been an enormous privilege to hear stories from every site about the positive impact the training has had by introducing the Surgical Safety Checklist and vital monitoring equipment, with many places giving specific stories of lives that have been saved as a result.


One particularly small team said the habit of pausing together at critical stages of an operation to do the Checklist ‘feels like having an extra team member’ especially in emergencies, reassuring them they don’t miss something critical when under pressure.


The interactive ‘checklist’ board on out MAF light board on the MAF light aircraft. I resisted the urge to press the shiny buttons. They don’t let you sit up front again if you do that kind of thing.

Another team spoke passionately about how the safety of their patient has truly become the focus of all they do, how they experience a shared sense of responsibility for safety from every member in the team. Those who previously would never have spoken up feel free to raise questions or concerns, they notice greater efficiency in preparing and managing their resources because they communicate better… in short totally inspiring stuff!

Our department in the Mercy Ships team is concerned with ‘Medical Capacity Building’, so I was struck when I came across this answer to the question of how you measure your successes…..

‘Your success will be the degree to which you build up others who work with you. While building others, you build up yourself.’- James Casey

This answer to ‘what’ success means certainly resonated with me in this project which is all about empowering medical teams across Madagascar to work together to deliver high quality safe surgical care. I have also been reflecting on the ‘how’ you make this happen!

In some places, we were struck by how particular teams seemed to take this whole process in their stride! Not satisfied with what and how, we put the next obvious question to these guys; why have you found this so easy when some places find a change like this such a challenge? What is the secret of your team’s success? Any quick and easy top tips?!

The answer we got might surprise you, but after the 4th or 5th time we heard the same thing, it stopped surprising me.

‘You have to love one another.’

Love? Really?! Isn’t that a bit fluffy? Not really. English is one of those languages that seems rather limited by having just the one word to mean so many different things!

I love my Mum and I love chips.

Apparently Malagasy is the same! When you ask these guys exactly what they mean by ‘loving your team’, you can see why it has helped them succeed where some struggle. These are the sort of things they say:

Sharing information, mutual respect: Instead of everyone just looking to their own interests and getting on with their own specific role, they now consider how to work together towards a shared goal. Anaesthetists, surgeons, nurses, and support staff all share if they are aware of any potential difficulties or complications, so that everyone is ready to help in case of problems. Every member of the team has a voice and is included.

Shared responsibility and open communication. One surgeon commented that previously, if someone questioned or ‘checked’ what you had done, it could be perceived as criticism or bullying, whereas now they all realise the checklist helps them avoid making serious errors. It is not personal, but for the good of the patient and the better working of the whole team.

Again and again, ‘supporting each other’.


Dr Delbert (centre) says the secret of his team’s notable amicable atmosphere is their shared philosophy to ‘treat every patient like you would a member of your own family’


What makes people flourish? Lessons for life and teams

Professor Robert Waldinger is director of the Harvard Study of Adult Development, which is possibly the longest running study of it’s kind tracking the health, work, and home lives of over 700 men since 1938, and now studies their wives and over 2,000 children.

In his TED talk on the results of this extraordinary study, Professor  Waldinger reports that in a recent survey of ‘Millennials’ (kids of the 80’s, 90’s, 00’s) over 80% stated that a major life goal for them was to get rich. More than 50% aimed to become famous. So what have the Harvard group concluded from all the tens of thousands of pages of information gathered over 7 decades about what keeps people healthy and happy?

Well, the lessons aren’t about wealth or fame or working harder and harder. The clearest message that we get from this 75-year study is this: Good relationships keep us happier and healthier.’

Not riches, not renown, but relationship. Waldinger goes on to emphasis it is not the quantity, but the quality of relationship that matters, that you can ‘really count on the other person in times of need’.

In fact, in Tamatave this week there was a leadership course for staff from the local hospital and the ship, starting with this same insight.

 Là, ou il y a de l’amour, il y a de la vie – Where there is love, there is life.

It is easy to pay lip service in organisations to encouraging processes which improve safety and encourage improvement, such as ‘whistle-blowing’, or ‘reflective practice’ in which you can share and learn from mistakes or near misses. We all make mistakes all the time, to err is human after all! Another great TED talk by Dr Brian Goldman on mistakes in medicine can be found here. In reality, revealing our mistakes can be terrifying, especially when the stakes are high and perfectionism is endemic in our working cultures. It is easy to see why fear fostered by a culture of ‘blame and shame’ leads us to deny or cover up mistakes at every opportunity instead of growing and learning from them. It makes all the difference in the world when you know the people around you are ‘for’ you.

There is no fear in love. But perfect love drives out fear, because fear has to do with punishment. 1 John 4:18

In essence, in asking people to speak about the situations that prove their human fallibility, we are asking them to make themselves vulnerable. Someone who has researched extensively on this topic and how it impacts not only personal but also profession relationships is Dr Brené Brown. Her insights are striking in mapping out the exact opposites of the behaviours the hospital teams at the beginning of this post mentioned:

‘Shame, blame, disrespect, betrayal, and the withholding of affection damage the roots from which love grows. Love can only survive these injuries if they are acknowledged, healed and rare’. ~ Brené Brown

The first hospital I worked at as an anaesthetic trainee held departmental meetings where our consultants would regularly share their most recent experience of a mistake or near miss so that we could all reflect and learn together. Whether they knew it or not, this was perhaps one of the most loving things they could do as leaders in the hospital and has set a memorable example to me ever since.

Valuing and supporting our fantastic fallible human healthcare workers:

Sadly, in situations where resources are stretched, it is sometimes easier, cheaper, and more convenient to blame individuals than to address underlying systemic problems like inadequate staffing or resources. Once again I find myself writing as protests and industrial action are planned in the NHS back home. If you ever have (or ever hope to have) access to a safe and free public health service in the UK, I would urge you to take a few minutes to watch this video produced by my friend Salwa, which summarises why tens of thousands of junior doctors have been compelled to take industrial action for the first time in decades. As Salwa says in this video, ‘I will not stop going on about this.’

Despite estimates by the Royal College of Physicians that we need 40,000 EXTRA junior doctors (double the current number) to staff the NHS safely, recruitment and retention is in crisis. Rather than funding the recruitment of the extra recommended staff, a new contract for junior doctors that has been repeatedly condemned as unsafe and unfair threatens to stretch remaining staff even more thinly, and make increasing mistakes inevitable. Sadly, scapegoating and even litigation rather than improvements increased resources and support are becoming common responses to the situations these working conditions helps create.

According to an American study from thousands of interviews, when you ask managers why they think their employees have left, 89% of them said it was for more money. If you ask the departed employees? 88% said they left for reasons OTHER than money, most often for reasons such as ‘not feeling trusted or valued’.*

If we want to see health services that are built on healthy team dynamics, striving for excellence not driven by fear, then please speak to health care workers you know, or those you see protesting this week about how these proposed changes will affect our ability to provide these things to the public. After all, we’re only human!
* quote from Leigh Branham, The 7 Hidden Reasons Employees Leave: How to Recognize the Subtle Signs and Act before It’s Too Late (New York: AMACOM, 2005), 24.

Stories of Safer Surgery Saving Lives

Happy New Year! It’s has been a great start to 2016 for our Medical Capacity Building team here in Madagascar. We have now introduced the WHO Surgical Safety Checklist at 16 hospitals across the country, so we were very excited to start re-visiting some of these teams 3-4 months on for follow up, alongside continuing to run courses.

We approached our first follow up visits with a mixture of excitement and trepidation. George Bernard Shaw famously commented that the single biggest problem in communication is the illusion it has taken place! It’s no small thing to ask for a change in daily practice from an entire team, using a Checklist together during surgery is a completely unfamiliar process to most of those we have trained. We hoped that the new Lifebox pulse oximeters we donated would be used routinely not only during surgery, but in the recovery areas after surgery too. What’s more, just before Christmas one of the courses required us to communicate in English, French, Malagasy and Chinese! Would the teams still be doing the Checklist 3-4 months on? Will the Lifeboxes be helping? We were not sure what we would find…

“Every act of communication is an act of tremendous courage in which we give ourselves over to two parallel possibilities: the possibility of planting into another mind a seed sprouted in ours and watching it blossom into a breathtaking flower of mutual understanding; and the possibility of being wholly misunderstood.” Maria Popova

Following up:
We kicked off with visiting our friends in Sambava and Antalaha, two of the first hospitals to implement the Checklist in October last year. Thanks to the Lifebox pulse oximeter donations, Antalaha have been able to safely open a second operating room, and are now able to help many more patients.  On this follow-up visit we also were able to supply them with equipment to monitor blood pressure and some child-sized anesthesia equipment to continue to improve the safety of the surgeries offered.

In Sambava their main challenge came from the fact that many of their theatre team were Chinese, and didn’t speak French or Malagasy! At the follow up we were able to work with a Chinese doctor who spoke French. Using the WHO materials published in Chinese, we added a Chinese translation alongside the Sambava team’s French locally adapted checklist so that the whole team can now do the checks together!

Both teams also reported better communication and atmosphere in theatre with inclusion of the whole team, and increased confidence in the safety of their processes. Both also told stories of how the checklist had helped them to avoid making serious errors, such as patients getting mixed up in emergencies and the wrong patient getting the wrong surgery.

Chinese doctor and opthalmologist

Translating the adapted checklist into Chinese. We also worked with the Opthalmologist (far right) to develop a specifically adapted checklist for use in the eye operating room. 

Lifeboxes: Truly boxes that save lives!
During follow up phone calls this week we heard stories from two different hospitals about very unwell patients who made it through major surgery, but had suddenly and unexpectedly deteriorated after their operations. Both teams reported that at the time, there was no other obvious warning that things had changed, it was the alarm from the Lifeboxes which alerted them to the sudden life-threatening plummeting oxygen levels, this gave the team the vital seconds they needed to react and resuscitate these patients in time to save their lives. These stories are so encouraging, as my manager Krissy Close said ‘lives have already been protected and operating room teams transformed. Nurses feel empowered, surgeons feel protected, and patients are better cared for… this is what it’s all about!’

Toplit theatre

Checklist, Lifeboxes, and surgical instruments and swab counting put into practice in theatre

Courses continue
Back in teaching mode, our team of 3 continued on to Manakara where we held the largest teaching session so far, 28 people!  We had fantastic support from the regional Minister of Health, who attended both the opening and closing ceremonies, and the hospital personnel were very enthusiastic. Farafangana also were very receptive, and during the course we were able to join the team in theatre for 3 real cases. This has proved hugely beneficial, as we have seen the Checklist being confidently used and the Lifeboxes introduced into the theatre and recovery before we leave the hospital. It has also been fascinating for me to spend time teaching and discussing in theatre with the nurse anaesthetists, (there are very few doctor anaesthetists here) who do an incredible job with great flexibility and resourcefulness in situations where materials, medications and equipment can be hard to come by. For example, Ketamine is a medication which has recently narrowly escaped changes to international regulations that would affect it’s availability. At home people may have heard of Ketamine as a drug of abuse, but in most hospitals here, it is an essential part of anaesthesia provision. See the World Federation of Societies of Anesthesiologists (WFSA) ‘Ketamine is medicine’ campaign for more.

Tomorrow at mid day we head off for 2 weeks of follow up visits, during which we will re-visit 5 different hospital teams around the country, and later in February Checklist courses will continue. I’m sure we will have more stories to tell!

Team photo

Some of the team from Farafangana with Dr Nandi and Dr Hasina



Not more beautifully than truly…

‘It’s summer time and I am in my singlet, shorts and thongs, Oh! Jingle bells, jingle bells, Christmas time is beaut……’

Errr, nope, I didn’t know this version either! But I admit I enjoyed it. It’s 32 degrees here in Taomasina, where the Australian members of crew led us in an …’alternative’ rendition of jingle bells at our carols by candlelight. On the dock. Burning stuff on a ship is apparently frowned upon.


My favourite entry from the Ship’s Gingerbread House making competition

But thats not the only thing about December that’s been different this year. I do miss dressing up warm, the twinkling London lights, mulled wine with friends. I very much DON’T miss the relentless commercialism that seems to start some time in mid-September at home. The incessant barrage of advertising of stuff, ‘Black Friday’ sales, Christmas sales, January sales…  The Brits spend more money on Christmas presents than any other nation in Europe, and are more likely to get into debt by doing so according to a study last year.

I recently re-read Charles Dicken’s classic ‘A Christmas Carol’. It seems to me that the real transformation in the story of Scrooge is not that of penny-pinching miser converted to open-walleted extravagance, now a commendable consumer par excellence buying ALL the stuff and boosting the economy! Rather the beginning of the story depicts a self-absorbed materialist, who you might say knows the cost of everything and the value of nothing (Oscar Wilde). By the end of the story, he has been transformed into someone who cherishes community, values people over things, and relishes giving over getting.

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I’m trying to speak more French but still don’t get the subjunctive!

There is no doubt that a well-chosen gift can be a wonderful way to express our appreciation of someone. My personal favourite I think was the ‘mandolinden’, a mandolin made from Linden wood from my family one Christmas! But I have been reflecting on a different kind of generosity this Christmas. Not in gifts of things, but in people who have given something impossible to stick a price on; themselves. Their attention and time. Like the team at one hospital in Madagascar where we delivered training. They all turned up at our hotel in a minibus the night before we left town so that they could take us out for BBQ and karaoke! They had just finished up a long day treating 10 trauma patients brought in following a terrible road accident, but somehow they found the energy after work to reach out in hospitality to their visitors in town.

Or one of the nurses on board who invested so much time and energy to encourage and support me on my return to the ship, even though she was working long shifts and would herself be leaving for home in Holland in just a matter of days.


Seits (Holland) and Lina (Sweden), amazing nurses and generous friends!

Immeasurable worth

So how do you decide how much particular people are worth? How do you decide who makes the Christmas card list? How do we decide which displaced people deserve to be allowed into our country?  None of us has unlimited time, money, or emotional energy, so it seems understandable that we ‘budget’ these things- after all they will only stretch so far!

If someone is very obviously important, interesting, fun, useful to know, or good looking, the decision to give them our full attention is easy! If they are none of the above, we may find ourselves ‘dialling out’ especially when we are tired or busy. But a consequence of this line of thinking is that it can encourage us even subconsciously to view other people like ‘commodities’ whose worth (just like all those other ‘things’ we get pre-occupied by at this time of year) is weighed by their appeal or usefulness to me. Somewhere along the line, I have made a valuation.

I am challenged when I remember the truth, that every person we come across had immeasurable worth.

Our team shares an office with the wonderful ‘screening’ team who travel the length and breadth of this enormous country to find patients we can help through surgery. One of the team has a note above the desk quoting Dr Paul Farmer, who already got a mention in my last post! (Quotation seem to be coming in twos on this blog.)

Paul Farmer

But there is another reason I am thinking about the value of people this Christmas. I am always struck when I read the words of the man often referred to as the ‘English Hippocrates’ or the ‘Father of English Medicine’ Thomas Sydenham. All the way back in 1668 he wrote these words….

It becomes every man who purposes to give himself to the care of others, seriously to consider the four following things; First, that he must one day give an account to the Supreme Judge of all the lives entrusted to his care. Secondly, that all his skill, and knowledge, and energy as they have been given to him by God, so they should be exercised for his glory, and the good of mankind, and not for mere gain and ambition. Thirdly, and not more beautifully than truly, let him reflect that he has undertaken the care of no mean creature, for, in order that he may estimate the value, the greatness of the human race, the only begotten Son of God became himself a man, and thus enobled it with his divine dignity, and far more than this, died to redeem it. And fourthly, that the doctor being himself mortal man, should be diligent and tender in relieving his suffering patients, inasmuch as he himself must one day be a like sufferer.’ Sydenham T. Medical Observations Concerning the History and Cure of Acute Diseases, 1668

I love the fact that the motto of the Royal College of Anaesthetists is “Divinum Sedare Dolorem” – “It is divine to alleviate pain.” Jokes about physicians having a ‘God complex’ aside, this is one of the reasons I love being an anaesthetist. When you see hurt, pain, brokenness, it feels natural to us to want to put that right, that it should be put right.

The events of Christmas, as Thomas Sydenham reminds us, describe a God who sees a broken world of broken people, and is filled with compassion. Not just sympathy or judgement from afar, but compassion leading to extraordinary action. It’s a mind-blowing thought… In Jesus, God himself was born into poverty and social rejection, fleeing his country as a refugee to escape a terrible genocide. Which might not sound a festive thought, unless you read to the end of the story! That despite all our faults and failures, you and I are so immeasurably valuable that Jesus was willing to give the greatest gift of all, his very life. No half measures.  And because of him, everything broken can be made new.

‘The people walking in darkness have seen a great light; on those living in the land of deep darkness a light has dawned’ Isaiah 9:2

So Merry Christmas and a happy new year!

PS, a Christmas thank you message from the UK crew on board Africa Mercy can be seen here: if you want to help bring health and wholeness to some more people like those in the video for the new year, a generous donor is matching all donations for December!

Don’t know what you got ’til it’s….

We just got back from Hell-ville! Which is just as hot, but much more pleasant than the name might suggest.

Hellville is in fact a port town on the beautiful Island of Nosy Be where we just finished the last leg of a 3 week trip, running training with operating room teams in 3 different hospitals in the north west region of Madagascar. The team have become accustomed to long dusty road trips, but this particular journey culminated with a 45 minute bumpy speedboat transfer over the open ocean, which was rather ‘exciting’ for those in our team who can’t swim!

View from hospital

View from meeting room, Hellville, Nosy Be. Not bad.

Thankfulness for stuff starting with F.

We arrived back to Antananarivo on Thursday, with impeccable timing as it turns out. It was the evening of Thanksgiving, and Kathy, our host at the Mercy Ships team house is American, extremely hospitable, and a fantastic cook.

So with an assembled group of people passing through from America, Australia, Madagascar, South Africa and the UK we took the opportunity to benefit from Kathy’s culinary genius and remember the things we have to be thankful for. The first things that came to mind probably wouldn’t surprise you:

  • Firstly, Food (of course, given the setting. Especially pumpkin pie.)
  • Friends.
  • Family. And another particularly astounding F…
  • Free healthcare. 

More specifically, free, safe, accessible healthcare. One of the incredible privileges of my life has been to work as a doctor in the UK National Health Service, where care is free at the point of need. Anyone coming to the hospital looking for help will get the best treatment my colleagues and I can give. How much the patient can (or can’t) pay doesn’t even come into it. In a global context, this is truly an extraordinary and rare privilege.

By contrast, 5 billion people in the world do not have adequate access to safe anaesthesia and surgery. They may live many miles away with limited transport.  The cost of hospitalisation can prove financially ruinous, and even if you manage to reach a hospital, there may not be the medication, equipment, or expertise available to safely treat you.

So one of the things I have become extremely thankful for is living and working on a part of this map which is comparatively speaking, ‘peachy’.

Access to surgery Jpeg

This is a map from the Lancet Commission on Global Surgery published this year(1). It shows the proportion of people in each country worldwide who do not have access to safe, affordable surgery as defined by international standards. The reasons for these geographical disparities are obviously multifaceted and complex, but many people are working hard to see quality and access to services strengthened in those dark red areas.

Isn’t surgery just too expensive?

Surgical services are sometimes perceived as an expensive specialist service, which can only be expected by the privileged few in resource poor settings. Surely providing surgery is just too difficult and costly when money is short?
Far from it! Recent publication ‘Essential Surgery'(3) is part of a comprehensive review and analysis of the most effective (and cost-effective) approaches to global health, produced by the World Bank.

“[This publication] dispels the myth that surgery is too expensive by showing that many essential surgical services rank amongst the most cost-effective of all heath interventions” – Dr Paul Farmer

So where to start? How can you improve the safety of surgical services? Another key conclusion from ‘Essential Surgery’ is that implementing the WHO surgical safety checklist (a simple system for team communication) is affordable, feasible and has been shown to improve safety and quality. This tool simply requires a brief pause to ask some critical questions as a team: firstly before starting anaesthesia, secondly before the knife is put to skin, and finally before the patient leaves the operating room. Simple! Yet remarkably….

 “Using the checklist is the best way to reduce surgical errors and improve patient safety.”
– Dr. Margaret Chan, Director-General of WHO

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Dr Hasina (centre, blue scrubs) Dr Nandi (far right) with Nosy Be team

This is why we are so excited to be working with the Minister of Health for Madagascar to implement the checklist in all regionals of Madagascar. It is also why Dr Nandi and Dr Hasina (the two extraordinary Malagasy doctors on our team) are so passionate about the opportunity that implementing the WHO Checklist in every region gives for improving healthcare services across Madagascar.

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Dr Nandi volunteers as a patient for simulations using the checklist!

How does using a checklist make surgery safer?

A fascinating question! For a full, entertaining and educational answer, I’d recommend Atul Gawande’s best-selling book ‘The Checklist Manifesto’. But specifically, here are two examples of what we do in our training.

Reduced Infections:
According to the WHO, rates of care-associated infected can be up to 20 times higher in developing countries(3). The WHO Checklist we are introducing across Madagascar includes checks to ensure antibiotics are given in a timely fashion, that equipment is properly sterilised, and that no swabs or surgical instruments are accidentally left inside the patient by using rigorous counting techniques. Research consistently shows using the checklist is associated with 50% reduction in post-operative infection and 25% reduction in the need for re-intervention.

Detecting and treating low oxygen levels:
7 in 10 operating rooms in sub-saharan Africa have no pulseoximeter available to monitor oxygen levels during surgery. Without this essential equipment, anaesthesia becomes an intrinsically unsafe process. Consequently, death rates during surgery are between 100 to 1000 times higher in some developing countries than in the developing world (4). We train theatre staff in pulseoximetry use, teach on how to manage falling oxygen levels, and provide Lifebox pulse oximeters for every operating theatre.

‘If anaesthesia providers can correctly interpret the information displayed by an oximeter and respond effectively to treat the cause of hypoxia and prevent it from worsening, many patients who might otherwise die during anaesthesia and surgery will be saved.’ – Global pulseoximetry project

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The team using Lifebox pulse-oximeters and documenting surgical counting during a simulated case in the operating room.

Don’t know what you’ve got til it’s….

This might all seem a million miles away from you, especially if you are lucky enough to live in the ‘peachy’ parts of that map.

As I mentioned at the start, November is a month for Thanksgiving. November is also the month for Remembrance Day. I don’t remember life before the NHS, but if you have a few minutes to listen to someone who DOES, 91 year old World War II veteran Harry Leslie Smith’s eloquent and passionate speech in the video at the end of this post moved me to tears when I watched it in 2013. (Disclaimer. It happens it was recorded at a Labour party event, but this is non-party political!)

As well as a debt of gratitude for the enormous cost with which Harry and his colleagues won the freedom I now enjoy, he powerfully reminds us of something else he fears my generation will forget.

‘Poverty and no health care were the norm for the Britain of my youth. That injustice galvanized my generation to become, after the Second World War, the tide that raised all boats.’

After a ‘long hard Great Depression, and a savage and brutal war’, Harry’s generation supported the creation of the NHS. Now, he says his greatest fear is that my generation will allow it to fall by the wayside. I share his concern. At home this month, an overwhelming 98% of junior doctors voted in support of the first all-out industrial action in 40 years in response to the government’s threat to impose contracts for NHS workers which are unfair, unsafe, and have made 7/10 junior doctors consider leaving the NHS. This, despite the fact that the think-tank Nuffield Trust has said that 47,700 more nurses and 26,500 more doctors are needed to match the average for similar countries. This extra staff would cost the NHS another £5bn a year. According to the Organisation for Economic Co-operation and Development (OECD) report of 30 developed countries, while access to care is good in the NHS, the quality of care is suffering after 6 years of under-funding.(5)

Britain has the world’s 5th largest economy. 

72% of Britons think the NHS should continue to provide all drugs and treatment at any cost.
Yet only 38% are willing to pay more tax for it.(6).

Wherever you live and work, the question of how we continue to improve affordability, accessibility, and quality of healthcare is one that none of us can afford to ignore. I hope the events at home in the coming weeks will unite the British public around their NHS and it’s incredible staff.

Because too often, we don’t know what we’ve got til it’s gone.


Aneurin Bevan, Minister for Health who established the NHS

(1) Lancet Commision on global surgery executive summary


(2) http://dcp-3.org/volume/34/foreword

(3)WHO Safe Surgery Saves Lives. 10 facts on patient safety. Retrieved 14 Nov 2012

(4) Global pulseoximetry project  www.who.int/…/1st_pulse_oximetry_meeting_backgr…

(5) http://www.oecd.org/health/health-at-a-glance-19991312.htm

(6) Economist ‘Physician, heal thyself’  http://www.economist.com/news/britain/21676793-jeremy-hunts-battle-junior-doctors-exposes-awkward-truth-britons-do-not-love

I would (drive) 1000 miles…

 Last week the ‘Checklist Team’ reached a milestone. In fact, we reached the 1000th! We have now officially bumped, rattled, snoozed and trundled our way over one thousand miles of road in Madagascar during our mission to introduce the World Health Organisation’s ‘Surgical Safety Checklist’ to every one of the 20 regional referral hospitals in the country. In fact, including flights, I have now covered well over 14,000km on this project since I left London. 

As you can tell from the picture above, public transport designed to accommodate the average Malagasy person is not designed for the optimal comfort of someone of my proportions! However at the end of every road, we have found a reward that makes every mile worthwhile; like seeing the team above use their new pulse-oximeters for the first time to monitor the oxygen levels and heart rate of a very sick patient following a bad road traffic accident. Due to the injuries involved, the anesthetic was tricky and the operation was complex, but the team was able to use the teaching they received during that week to improve their teamwork and communication, incorporating new safety checks and using new monitoring equipment to keep their patient safe.

One hospital told us that although there are many great public health interventions in their area (for example vaccination programs and malaria prevention), this was the first time anyone had come to do training like ours specifically for their operating department. That is a big motivator for our team, as many people don’t realize that a lack of access to safe surgical services  is one of the most important, yet frequently overlooked issues in global public health. In fact this was the topic of a recent New York Times op-editorial piece by Mark Shrime (who also works with Mercy Ships) and John Meara.

One other course attendant wrote ‘This course has brought our team closer together, the training has newly reinforced the cohesion in our team.’

 These hospital teams often act as referral centers for very large populations, approximately 2 million in the case of last week. So the opportunity to work together to build up surgical services through delivering team training and essential equipment makes every bump in the road, every early morning completely worth it.

Trainees become trainers: an anaesthetist teaches his whole theatre team what he has learned in Lifebox training

The team behind the team:

Even with all this to encourage us, being constantly on the road is challenging at times, like earlier this week when the alarm went off at 2.30am to catch our flight. At that time, it can feel like a mini triumph of hand-eye co-ordination and manual dexterity simply not to poke yourself in the eye with your toothbrush! In the flurry of activity I sometimes loose track of what day of the week it is …(ok, this is not entirely new for me!)… Instead it’s day 1/day 2/day 3 of the course or a ‘travel day’! A project like this would be impossible without the amazing extended team back at the ship, and with the support of our friends and family. 

So this last week, I have been particularly grateful for a mystery envelope which I received several weeks ago before we hit the road. It was from a group of girls I met in the first few days on the hospital ship the ‘Africa Mercy’ in Tamatave, where they have since been working. This was what was inside….. 

For the record, ‘when youre hungry’ came in very useful during a 12hr road trip, ‘ when you are bored’ kept the team entertained through the 3rd power cut of the day


Envelopes of encouragement

It may seem a small gesture, but I was totally taken aback by the thoughtfulness of this act. I had only known these girls for a few weeks, they had only recently met each other, and came from multiple different countries  but they got together and spent an entire evening of their precious off-duty time to consider how they could encourage and support me. None of them receive a salary for working on board, in fact as volunteers they pay to work here! (Mercy Ships is a charity operating a fleet of hospital ships in developing nations since 1978).  Yet even with their free time they chose to be generous and think of how to encourage someone else. 

As someone who often fails to get round to even pairing my own socks (much to the despair of my extremely tidy and organized ex-flatmate) I find this humbling. It seems like a pretty good demonstration of what can happen when a group of people ‘desiring to follow the model of Jesus, seek to: 

– love God

– love and serve others

– be people of integrity

– be people of excellence in all we say and do.’  (Mercy Ships core values). 

It also pretty much fits a description of what following this ‘model of Jesus’ should look like, written 2 thousand years ago in a letter to the early church; 

Don’t push your way to the front; don’t sweet-talk your way to the top. Put yourself aside, and help others get ahead. Don’t be obsessed with getting your own advantage. Forget yourselves long enough to lend a helping hand.”‭‭ Philippians‬ ‭2:1-4‬ ‭(Message translation).


Yep! Some of them are ever so slightly nuts….


Farewell dinner


It seems our culture gets pretty preoccupied with ‘getting ahead’. After all, whether the issue is time, money, energy, jobs, houses… there never seems to be enough to go round, so you better look out for number one, after all, it’s a jungle out there right?! It seems totally nuts to ‘put yourself to the side and help others get ahead’. 

But it’s encouraging to remember that something as small as writing a quick note to a colleague or spending a few minutes to come alongside someone else in their task can have a bigger impact than you would ever imagine. I’m sure it didn’t seem like a big deal to my friends to scribble a quick note, but through those little envelopes of encouragement, they have become part of making this project happen. Especially the envelope that had the chocolate in it. That one fueled a whole teaching session!

Of course, in Aesop’s fable of the Lion and the Mouse, the Lion eventually gets the unexpected rewards of his kindness returned to him in  a ‘what goes around comes around’ kind of way. But even though it doesn’t always work out like that….

Every man must decide whether he will walk in the light of creative altruism or in the darkness of destructive selfishness.‘ – Martin Luther King Jnr

I quoted Martin Luther King Jnr in my last post, and I’ll let him have the last word again! If what he said is true, it would seem that doing what is good for someone else, can actually turn out to be what is good for us too. So here’s to creative altruism!

Surgical Safety and Lessons in Leadership

“A leader is a dealer in hope.” This is a description of leadership I have heard attributed to the French leader and naval commander, Napolean Bonaparte. But for me it loudly resonates with the vision of those leading a very different kind of ship across oceans – the crew aboard the hospital ship ‘Africa Mercy’ seek to fulfil the vision of Mercy Ships to bring ‘Hope and Healing’.

Most obviously this vision is manifestly demonstrated in the lives of hundreds of patients who are receiving free and life-changing surgery on the ship. However, it is not only the patients who need hope, but also those who are working day by day to provide care for them, often in challenging circumstances. Our department of Medical Capacity Building has the privilege of coming alongside the health care workers in this beautiful country to work together towards better building healthcare.  

Hope for change

You may recognize the feeling; you and your team are already working hard, personnel and resources are stretched thin. Even just managing can feel like a big challenge, never mind expecting improvements in performance. This is one exciting thing about the WHO surgical safety checklist. Without the need for extra staff or lots of expensive new equipment, this simple communication tool can help surgical staff to improve their teamwork and safety awareness, and research consistently shows astonishing benefits to patient outcome after surgery. But introducing changes to day to say practice can be difficult at the best of times! You need leaders who are willing to step up and be ‘dealers of hope’.

Since the last post from our team introducing the WHO surgical Safety Checklist throughout Madagascar, we have visited another 4 hospitals in our tour of 20 regions! Below is a summary of what we have been up to, and some observations of what leadership looks like as demonstrated by these diverse teams from around the country.

‘The challenge of leadership is to be strong, but not rude; be kind but not weak; be bold, but not bully; be thoughtful, but not lazy; be humble, but not timid; be proud, but not arrogant, have humor, but without folly.” – Jim Rohn. 

Antsiranana AKA ‘Diego Suarez’ – professorial participation

Diego Suarez lies at the far northern tip of Madagascar, where we were warmly welcomed by the hospital team in this very hot (but mercifully breezy!) port city. We have been hugely encouraged to see the energy and example of those in clinical leadership roles in these hospitals, supporting their teams in implementing a new system. At Diego Suarez, 2 Professors from the surgical team attended every single training session, enthusiastically immersing themselves in discussions, demonstrations and scenarios and engaging their whole team in the process.  Everywhere we go, staff mention the benefit they see that using the WHO surgical safety checklist has on their team spirit, level of communication, and awareness of patient safety. The vision and example of senior leaders like these in Madagascar is crucial to the training becoming a lasting part of the working culture in their teams. “Culture does not change because we desire it to change. Culture changes when the organisation is transformed; the culture reflects the realities of people working together every day’ – Frances Hesselbein. 

Professor of obstetrics and gynecology adapting the checklist with the team

Sambava and Antalaha – share, support and serve

After returning briefly to Antananarivo to pick up supplies, we caught another plane up to the north east, to the Regional Referral hospital in Sambava where were also joined by staff from the nearby district hospital in Antalaha. It was fantastic to see these two very busy teams collaborating, sharing ideas, and using the WHO checklist in real emergency cases in the theatre before we left Sambava. By the time we reached Antalaha on Saturday to run through the final day of teaching with the rest of their team, those who had been at the training in Sambava were  already teaching their own colleagues about what they had learned! These teams are often hard-pressed, and expressed the importance of giving time to their relationships with each other. One of the surgeons described how they often take time at the end of the working day to eat together and support one another, before seeing everyone home after work. “We have to rely on each other and support each other here.” 


The director at Antalaha explains the benefits of the WHO surgical safety checklist to his team


2 anaesthetic nurses using their new lifebox pulseoximeter in theatres


Miarinarivo – leadership at every level

A few hours drive outside the capital city, we met the team from Miarinarivo in the Itasy district. Of course it is not only professors or those in management roles who can impact a team with strong leadership! The training includes all theatre staff including surgeons, anaesthetic staff, scrub nurses, technicians, the whole team. During a particularly challenging clinical scenario simulation in the operating theatre, one midwife was exemplary in leading the team clearly through the elements of the checklist. After the teaching sessions, the anaesthetic nurse gave a dynamic and detailed 10 minute summary of the teaching on Lifebox (the medical equipment that allows monitoring of oxygen levels and heart rate during surgery – an essential part of the WHO Checklist) to the rest of the theatre staff. As he remarked during the teaching…

‘There is always something more to learn, you never know 100% of everything! So we should always be learning.’

Of course, he is right. I am enjoying learning from these incredible people. Our hope is that each of those who have been part of this training (now at the 7th site this week) will share what they have learned, face the challenges of introducing new practice, little by little changing things for the better and leading the way in being dealers of hope

‘We must accept finite disappointment, but never lose infinite hope.’ – Martin Luther King Jnr.

Potholes, pulseoximeters and pyramids

The Ambatondrazaka Anaesthesia Team get hands on with the new pulse-oximeters

The Ambatondrazaka Team get hands on with the new pulse-oximeters

The journey to our second of 20 hospitals in Madagascar turned out to be quite an adventure! The long and winding road that leads to Ambatondrazaka is an 827km round trip from the Africa Mercy in Taomasina, and gets some pretty heavy use from large trucks carrying timber, rice, and other goods. So many thanks to our team co-ordinator Ali who negotiated 12 hours of road like the one below to get us to our destination! When the rain stopped however the view was truly beautiful.

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On our arrival we were joined by a local translator named Leah, who often works with the local Peace Corps. The team at Ambatondrazaka are very busy, serving as a regional referral centre and trauma unit for a very large region, so it was fantastic to have 24 people from their team join us over the 3 days to develop their own local version of the WHO Checklist for use in their operating theatres.

Simulation sessions in the operating room allowed all the members of the team to get used to using this safety checklist tool, and many commented in the course feedback how they enjoyed seeing the effect of using this system on team spirit, encouraging open and effective communication, helping to keep the patient safe by dealing with potential problems before they arise.

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It was my privilege to deliver a teaching session on monitoring and managing oxygen levels during surgery in my slowly improving French, with help from Leah to translate into Malagasy! As Bear Grylls loves to remind us in his survival programs, you can only survive around 3 minutes without oxygen, so the new Lifebox pulse-oximeters we brought with us enable the team to detect and manage falling oxygen levels much earlier during the dangerous time during and immediately after surgery when problems with oxygen delivery are frequent and potentially fatal. These units really are little ‘boxes of life!’

The anaesthetic team including a doctor and 3 anaesthetic nurse practitioners immediately put the teaching to use in the afternoon with managing a simulated hypoxic episode in the middle of surgery using the treatment algorithm for falling oxygen levels.

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As with all the hospitals we are delivering training in, we plan to follow up in a few months and see how this team is doing, so it is very exciting to see the passion and commitment of these Malagasy colleagues to develop their teams and give the best possible care to their patients.

After a short break on the ship, the Checklist team will head out to our next hospital for our biggest course yet, I won’t be back to the Ship before December so will get used to living out of a suitcase for the next 2 months!

I almost forgot the pyramids… Rice is a several-times-a-day feature of the gastronomic experience here, but this presentation in Ambatondrazaka was a spectacular first!2015-09-23 19.54.59

Update from week 1 on the road

From left to right, Emily Bruno (Harvard, USA), Dr Hasina (Madagascar) Ali Herbert (GBR) Dr Nandy (Madagascar) Me!

From left to right, Emily Bruno (Harvard, USA), Dr Hasina (Madagascar) Ali Herbert (GBR) Dr Nandy (Madagascar) Me!

We are back on the ship this weekend after a very exciting week on the road with our WHO Checklist team! The team shown above (and also joined by Consultant Anaesthetist and program leader Michelle White) all bundled into a jeep and headed north up the coast to Fenerive Est. This is the first of the 20 regional referral hospitals we will be visiting during this field service, coming alongside the surgical teams in each city and working together to improve patient safety throughout the country.

Fenerive Est, a few hours drive north from the Africa Mercy in Taomasina

Fenerive Est, a few hours drive north from the Africa Mercy in Taomasina

We were joined by surgeons, anaesthetists, and members of the whole theatre team for the 3 day course during which time the hospital team worked energetically to adapt the World Health Organisation’s ‘Surgical Safety Checklist’ for use in their own environment. This simple but effective tool has been shown to cut operating room deaths and serious complications by nearly a half! The Fenerive Est team were so enthusiastic that by the second morning they were already using their own version of the checklist for the emergency cases which needed to be done that day.

Our course coordinator Ali Herbert ran a very popular training session on surgical instruments and swab counting – another essential step in the WHO checklist to avoid the complications caused by swabs being accidentally left inside a patient and causing infection. We also had the privilege of delivering 2 new pulse oximeters to the hospital with training for the anaesthetic staff through our partnership with ‘Lifebox’, a charity committed to making sure every operating room across the word has this critical piece of equipment to monitor blood oxygen levels during and after surgery.


Running simulation scenarios in theatre: Ali overseeing the pre-operative counting

Getting hands on with the new pulse oximeters: one of the nurse anaesthetists

Getting hands on with the new pulse oximeters: one of the nurse anaesthetists

Tomorrow morning we will be heading out for a 400km drive to our second regional hospital, I better get packing!