Travel in the context of COVID-19: Some things to consider…

Travel is hugely important for ADAPT members. The fast-moving nature of the pandemic continues to impact healthcare options globally, as well as travel options for working internationally for global health. Many members will have had their plans for working overseas, or volunteering to support global health projects put on hold and may be wondering if, when and how they can plan for the future.

ADAPT has had recent contact with the WCPT (World Confederation for Physical Therapists) regarding the issue of travel. 

“WCPT would not be able to provide any information on the safety of communities around the globe. We simply don’t have this information and the variability within and between countries as to what is safe is significant. 

As you would be aware in many countries the lived experience and the official government word can vary substantially. In relation to COVID-19 this is changing daily.

The staff and volunteers of WCPT do not anticipate undertaking any travel for the remainder of 2020. 

Humanitarian projects around the globe are being massively impacted by this pandemic. ICRC and HI have removed staff from most of their overseas missions with no sign of when they may return. Therefore I think the likelihood of physiotherapists undertaking LMIC volunteering work in the near future is very remote.”

WCPT CEO May 2020

If you are UK-based and undertake short contracts for a large organisation and are under their responsibility, it is likely they will set their own policy regarding international travel. If you tend to travel for work that that has been independently organised, or indeed hope to continue volunteering overseas it is essential that you are fully informed. This is both for your own safety but also for the communities to which you may be wishing to help. It would be terrible to be unwittingly transmitting the disease to a region of the world that has significantly less prevalence than us in the UK.

If you are working on a long-term project overseas, you will know the reality on the ground and your organisation’s risk assessment, which combined with your personal level of risk, may influence your decision whether or not to return to the UK.

Regardless of which category you fall into, your work and plans will have undoubtedly been affected. Below are some aspects to consider: 

1. Foreign and Commonwealth Office (FCO) Foreign Travel Advice
The FCO has issued an ‘Exceptional Travel Advisory Notice’ in light of COVID-19; “the FCOadvises British nationals against all but essential international travel. Any country or area may restrict travel without noticeIf you live in the UK and are currently travelling abroad, you are strongly advised to return now, where and while there are still commercial routes available. Many airlines are suspending flights and many airports are closing, preventing flights from leaving.

FCO travel advice is developed based on multiple sources including host government agencies and law enforcement. It is important to remember that FCO Foreign Travel Advice directly impacts the ability to secure travel insurance.

2. Flight reliability / availability
As any country or area may restrict travel without notice by, for example closing borders or airports, many commercial flights have found they are unable to operate and options for travel are extremely limited.
 
If you are out in the field and wish to return to the UK, it is advisable to contact the British Embassy or British High Commission within your host country and register for alerts for updates regarding charter flights that may be organised for repatriation of British citizens overseas. These are at individual expense.
 
Due to the uncertain nature of COVID-19 and the impact on the aviation industry, travel options could be unpredictable for some time.

3. Be informed re: host country and the COVID-19 measures in place
 The measures taken by individual countries will be grounded in their own assessments, which may differ from the UK. It is important to stay well-informed to understand your needs, and the needs of your project. Areas to consider include:

  • Is there a mandatory quarantine on arrival?  
  • What domestic or international travel restrictions are in place?
  • Are there any lock down measures in place? Mandatory police checks? temperature checks? documentation requirements?
  • Is it mandatory to wear masks in public?

This information may be detailed on the FCO country specific travel advicepage. However, getting a sense of what is happening on the ground via local partners, or online sources (credible local news agencies, credible social media or via host government websites) may give a more complete picture.

4. Be informed re: UK and COVID-19 measures in place

  • 14-day compulsory quarantine is to be introduced (date yet to be confirmed) for air passengers returning from anywhere outside the UK and Ireland.
  • Current UK government policy is stay alert for England, whist the other UK countries have kept the stay at home message.

For current guidance on what to do if you have coronavirus symptoms see here.

For now, we do not know what the new normal will be. There is a huge amount of uncertainty. In the meantime, there is much we can do through remote support and assistance to our partners and projects in host countries. Whether you’re in the global field or in the UK it would be really useful to know how COVID is impacting your work, or what you are doing to support your colleagues overseas, particularly those in low or middle income countries.

Kate’s time in Kenya

Kate Cottenham

Six thousand seven hundred and sixteen miles, and I felt every single one of them away from home. After months of fundraising, packing and planning my feet were finally planted on the burnt orange, equatorial dust that defines the landscape of Northern Kenya. We had finally landed in Marsabit – a town so remote in Northern Kenya that even the locals didn’t consider themselves as Kenyans.

Earlier this year I had successfully applied to represent physiotherapy in Future Health Africa’s Trauma Team, on this year’s trip to Marsabit District General Hospital, Kenya, with the objective of sharing skills and knowledge with the local teams while providing orthopaedic surgery to trauma patients. Our team was made up of the essential people required to run an orthopaedic theatre and clinic – surgeons, anaesthetist, scrub nurses, ODPs, a radiographer, admin staff, a medical student and two physiotherapists, each carrying a suitcase of equipment. We had joined forces across three South West NHS hospitals- Derriford, Truro and Torbay, with one common goal – to do our bit to help Future Health Africa achieve their vision of “sharing skills, transforming lives”.

After an 8 hour flight from a grey, cloud covered Heathrow, we landed in the dusky Nairobi dawn and were immediately plunged into the infamous Nairobi traffic chaos to make our way across town for the next step of the journey. For those of us not brave enough to endure the endless 12 hour drive to Marsabit, we had opted to take a chartered propeller plane, run by the Christian charity MAF (Mission Aviation Fellowship), to take us to our final destination. MAF run a dedicated service of flying parcels, blood test results, local governors and missionaries to remote areas of Kenya, and our experienced pilot soon put us at ease with his simple words of prayer before starting up the engine. Our two hour internal flight was a spectacular one, covering a range of landscapes from arid desert to verdant rain forest and everything in between until we were circling over the lush green (when the rainy season delivers) national park that surrounds the county of Marsabit. Once the runway was clear of the local goats, we bumped our way over the pot holed tarmac and the propellers slowed in the warm midday sunshine, surrounded by casually inquisitive locals, interested to eye today’s cargo.

For someone who had never travelled to Africa before, these first few hours were slightly overwhelming to say the least. Having grown up in the countryside, there was a strange familiarity to the quiet lack of traffic while stood in the dusty field of the runway, the sound of the birds tweeting and goats bleating, the rolling green hills that surrounded us, and at the same time it was like nothing I had ever experienced before. Already the reality of poverty in Marsabit was evident – the make do and mend shoes on the feet of the observing local children, the bony ribs of the local cattle angularly protruding through their wiry skin and the sight of corrugated houses in the distance was my first glimpse of rural Kenya. As we drove half a mile to our hotel, the feeling of uncertainty about what the week had in store rose in my chest, and while everyone else took the opportunity for a quick travellers nap, mine didn’t quite go to plan.

After lunch we made our way to the hospital for our first ward round of the week and received the warmest of welcomes from the CEO and his team, so eager to tell us about the amazing positive changes they had made to the hospital since last year’s visit. Two new theatres and a dedicated orthopaedic ward were among their proud achievements which they had prepared ahead of our trip, staffed with local health care professionals to join in our team efforts. The welcome seemed to continue at every corner that afternoon and throughout the week, where there was a patient, visitor or staff member from 5 to 85 years old, ready to shake our hands and smile warmly that you were welcome in Marsabit. The only locals who weren’t quite so hospitable were the resident baboons that ran amok along the aluminium roof of the walk -ways around the hospital, making me squeal more than once, much to the entertainment of the patients.

Just as I felt I was getting to grips with the constant lump of unidentified emotion that had taken residence in the back of my throat, I’m not sure anything could have quite prepared me for my first steps onto the general medical wards. Each ward, one male and one female, held around 20 beds, although I’m told that it’s not unusual for each bed to be housing two or more patients – people are used to sharing what little resources they have, even if it is in a hospital setting. The terracotta dust from outside seemed to coat every surface in spite of any efforts to clean the floors, and the derelict bathroom to be shared by the whole ward didn’t see much activity due to the lack of running water.

Arriving from an NHS hospital where infection control, hand hygiene and patient isolation were paramount to stop the spread of bacteria, the lack of clean water was probably one of the most shocking revelations. In a country where the rates of communicable disease are constantly being fought by WHO initiatives to reduce mortality, it seemed a fruitless task when you don’t have the most basic form of cleanliness.

The next day was a whirlwind of organised chaos as our clinic began, and the days continued like this for the rest of the week. By 9 o’clock each morning, a less than orderly queue of not only local patients, but those who had travelled hours by bus, motorbike and on foot, would form outside the consulting rooms waiting to be seen by the “Muzungu” doctors. Due to the geography of Marsabit, our patient group was a cultural melting pot of those from the Ethiopian border to the North, the Somalian border to the East and more Southern areas of Kenya, who all arrived with most of their family in tow. Communication skills were put to the test constantly, sometimes translating through two interpreters to be able to triage for surgery, averaging around 10 minutes for each patient if we were to get through the ever growing queue outside.

Our main objective in clinic was to undertake a brief assessment of each patient to determine if their injury was old trauma, new trauma, arthritis or something not orthopaedic at all. This would then guide whether they needed imaging and ultimately were for surgical or conservative management. This would be a challenge in a familiar patient group where everyone spoke the same language, let alone in three different languages and in a place where the types of common conditions is a very different picture to those encountered in an orthopaedic setting at home. As the trip arrives in Marsabit at the same time each year, some patients had been waiting 12 months or more for our return to have surgery, with very high expectations of our ability to fix things.

It is normal practice in Kenya to travel three or four to a motorbike without helmets or protective clothing which as a result guarantees countless cases of complex orthopaedic injuries and deaths on the roads. As well as road traffic accidents, common mechanisms of injury included accidents at work with machinery due to a lack of health and safety regulation, kicks from restless cattle and gunshot wounds. Just the week before we arrived in Marsabit, there had been a tragic multiple shooting of fourteen people caught up in tribal clashes in the county. The changeable nature of the unforgiving elements in Kenya leading to sudden, long periods of drought can often result in cattle theft and rising tensions between local tribes, which along with the rise of availability of firearms can have tragic consequences. There were also a huge number of mal-union and non- union fractures that had been treated, sometimes very successfully, with twigs and rags from the tribal natural healers; and many cases of osteomyelitis from open wounds that understandably had been unable to withstand infection.

Non-orthopaedic conditions were also a common occurrence in clinic – an ankle swelling that was a symptom of Brucellosis, a shoulder pain that was due to a stroke, and several paediatric patients who were brought to the clinic by their parents for an operation for an undiagnosed neurological condition, who would leave disappointed. This was a heart- breaking part of our role in clinic- because of a lack of outpatient or GP services in the remote surrounding area of Marsabit, often you would be the first clinician to assess a patient or give them any sort of diagnosis. This very often applied to children or infants who had been born with a neurological or congenital condition that was not picked up at birth, and only as developmental markers were missed did the family realise there may be a problem, but with no one to tell them what that was. Disability is dealt with very differently to what we are used to at home- families can’t afford to have high tech wheel chairs and disability aids to help their children, there is limited positive drive for social inclusivity or special schools to support their children with their individual needs. It comes heavily laden with stigma, community exile and unimaginable decisions made by parents in order to maintain social acceptance and normality.

One example which was particularly poignant in the trip was a 9 month old baby girl who was brought to clinic by her mother and grandmother who was translating. She explained the baby had something wrong with her neck as she was unable to lift her head and she wanted “the bone doctors to fix her”. Before I’d even placed my hands on the baby it was clear that she had a neurological condition, with a chest that sounded heavy with secretions, eyes that didn’t track her mother and a very low tone posture. After assessing the baby’s movement, my suspicions were confirmed when she had poor head and trunk control miles away from the babbling, crawling infant you would expect at 9 months, and I realised it was my responsibility to explain this to her mother. Breaking bad news is never easy, but as a musculoskeletal physiotherapist I felt totally out of my depth having to be the person to explain her daughter’s condition to her and that ultimately it wasn’t her neck that was the problem and it couldn’t be fixed. I felt so much sorrow for this poor mother with the knowledge of the long term specialist support and education she deserved and required to be able to look after her baby but with no way to access it. One of the most important conversations of her baby’s life discussed through broken translation with ultimately no solution for her. There was an occupational therapist at the hospital that did provide an outpatient service for passive exercise and a form of sensory play for local children, so I referred her into his care feeling it was a small offering but the only one I had to give.

The sad, interesting and shocking cases continued throughout the week with infected snake bites, osteomyelitis ridden bones and broken hips that had been walked on for months. It was very apparent that in this part of the world, people just get on with things. If you don’t get up and help yourself, go to work, keep looking after your family, there is no one else to do it for you. There’s no government disability allowance, no carers to visit you at home, no free walking aids or community rehab provided. This had a very positive effect post- operatively, in that once the patient was informed that they could go home, they were, more often than not, up and out of bed with little encouragement, packed bags in hand. The sense of community within the hospital was heart -warming. Whole families sat at bed sides listening diligently with furrowed brows to post op instructions, friends travelling for hours to collect new walking aids or providing transport home (albeit on the back of a motorbike).

Our final night in Marsabit was spent in the hotel conference room surrounded by the majority of the hospital staff who had been invited for an evening presentation and dinner before we said our goodbyes. At the entrance to the hotel we were each greeted with handshakes and cheeks pressed together as everyone arrived in their best dress, almost unrecognisable out of their uniforms. The collection of plastic chairs insufficient to cater for all of our guests, extra seats were brought in, pushed against walls, standing room at the back, the quiet chatter of English and Swahili as we sat intermingled with our new friends. The heads of the table each took their turn to give a speech on what the week had meant to them, to the hospital and to the patients. Much was spoken about development, change and learning as well as words of gratitude and friendship. It was so heartening to hear that the feeling of friendship and togetherness was mutual and to our surprise, we had even been brought gifts as a way of thanks. The locals smiled and laughed as we were each fitted with different coloured hijabs and abayas, and even ghutras for the men in our team, our fair skin incongruous beneath the dark patterned fabric. After a familiar dinner of rice, stewed goat and cabbage, we said our final goodbyes, hugs and kisses surrounded by hopeful promises of returning next year before returning to our rooms to reflect on the week.

The continued professional development gained from the trip was invaluable – nowhere else would you have the opportunity to work so closely with specialist teams sharing ideas and discussing patients with the scope to follow the patient from triage to post op understanding each step of the way so well. Working in Marsabit had undoubtedly allowed development of communication skills both inter-professionally and clinician to patient; forced adaptation of physiotherapy skills with the limited resources and broadened knowledge of orthopaedic and non- orthopaedic disease.

As a physiotherapist who ordinarily only sees the very beginning or very end of the orthopaedic surgery pathway, the opportunity to work side by side with a team, with such a wealth of orthopaedic experience to share, from start to finish was insightful. To both listen and contribute to clinical decision making when selecting a patient for surgery, accompany that patient on the way to the operating theatre, observe the operation stood shoulder to shoulder with the surgical team and then assess the patient afterwards on multiple occasions. It supported a depth of knowledge of anatomy and physiology and brought to life the 2D black and white xrays we are familiar with scrutinizing through a computer screen. The approachable nature of the team promoted inquisitiveness and clinical reasoning with encouragement to ask questions and explore shared ideas- something that at home would require a lot of confidence in the alien environment of an operating theatre. There was a feeling of camaraderie built from keeping each other company on a 10 hour flight, eating dinner together every night and sharing stories about uninvited insects in our bedrooms as well as respecting on another’s clinical ideas and suggestions within the hospital.

This trip was however, far more than an interesting addition to your CV, but an experience to enrich you as a human being. To travel to a part of the world that is so incredibly different to home, to see not only the poverty, the disease and the great need for development, but also the amazing welcome we were given, the smiles and the handshakes – all of the things which remind us that we’re all human and this is just another day for the people who live there. We would leave for another year and this would all continue without us only hopefully with some small positive changes supported by our shared learning experience.

We had gone to Marsabit in hope of changing lives, and yet we had all come away feeling as thought it was our lives that had been changed forever.

Working in Madagascar

Claire Mclvor

Physiotherapy in Madagascar

Madagascar is ranked as the ninth poorest country in the world and has a population of 25.5 million people. Most people in Madagascar live in poverty with 78% of the population living on less than US$1.90 per day. For this large population number, there are only 300 Physiotherapists in the whole country. Physiotherapists are trained at the University of Antananarivo, the Capital City in Madagascar, however training is theoretical based and provided by medical physicians with limited to no experience of physiotherapy. From March until May 2019, I travelled to Madagascar to work as a Voluntary Physiotherapist in different hospitals throughout the country. 

Why Madagascar?

I have always had a passion for supporting the development of healthcare services in Low-and Middle-Income Countries (LMIC’s). As a student at the University of Birmingham, I travelled to Tanzania where I completed a one-month placement in a school for disabled children. After graduating, I completed 3.5 years of Band 5 rotations at the Leeds Teaching Hospitals Trust (LTHT), gaining invaluable skills in a wide range of rotations. During this time, I began to make contact and develop links with other therapists who have spent time working in LMIC’s through ADAPT, and Global Rehabilitation. 

Global Rehabilitation are a Charity based within LTHT which aims to support the development of Rehabilitation services in Madagascar. Projects the Charity have supported include; developing a rehabilitation speciality for medical doctors, providing training and supporting an amputee rehab service, and developing the first spinal cord injury rehab centre in Madagascar. The Charity work in collaboration with Malagasy staff to publish papers and research documenting their work, which also helps to incorporate the importance of research into the healthcare system in Madagascar.

After getting in contact with Global Rehabilitation, I then started preparing to travel to and work in Madagascar. I self-funded my work through cake sales, a raffle, and a gofundme page. In March 2019, I took a career break from LTHT and set off for Madagascar!

Healthcare Systems in Madagascar

In the year prior to Madagascar, I spent a lot of time contacting Malagasy physiotherapists, meeting with other healthcare staff who had worked in Madagascar before, and attempting to gain an understanding of what my work would involve. But that’s where my plans stopped. Having never worked or visited the country before, I had no idea of what to expect, both in terms of where I would be living and working. I therefore, did not plan training or an agenda before arrival, as I did not want to make plans based on my assumptions of what the healthcare system would be like.

For the first few weeks I simply observed the physiotherapists and doctors, in an attempt to gain an understanding of how they work. I recorded daily observations, making note of everything from treatment spaces used, type of injuries and patients seen, choice of treatment methods and analysis, and how patients were referred to therapy. I then decided to conduct interviews and questionnaires with all physiotherapists and doctors to gain a more detailed understanding of the physiotherapy service in Madagascar. 

The healthcare system in Madagascar was completely different to anything I had experienced before. Physiotherapy is not an autonomous profession, and physiotherapists actually study nursing initially and then choose physiotherapy as a separate branch of nursing to study. The training to become a physiotherapist is taught by doctors, who teach a ‘recipe’ style approach to treating patients. For example, “if you are treating a patient who has suffered from a stroke, you must treat them by following steps A, B, C.” The fact that each patient is an individual and will present with different symptoms is not taught as part of the Physiotherapy curriculum in Madagascar. Physiotherapists do not write notes and do not clinically reason through treatments. Instead, a doctor prescribes what they would like the physiotherapist to do, and this usually consists of massage as treatment. This is often common practice in many LMIC’s.

I also met with the Ministry of Health in Madagascar, and the University staff who teach Physiotherapy. I conducted interviews with them and explained that I hoped to gather as much information as possible from a wide range of sources in order to support the development of Physiotherapy services in Madagascar in future.

Last but not least, I became involved in an amputee rehab training programme and a spinal cord injury rehab programme during my time in Madagascar. Both projects were delivered with the support of healthcare professionals from the UK in association with the Charity Global Rehabilitation. The spinal cord injury training was delivered to local physiotherapists, nurses, neurosurgeons, and midwives, and was supporting the development of the second Spinal injury rehabilitation centre in Madagascar. My role involved delivering training on functional outcomes post spinal cord injury, positioning to prevent pressure sores, chest management, the assisted cough technique, and how to complete a log roll.

Returning to the UK

Since returning to the UK, I have been writing up the findings of my observations, interviews and questionnaires into a report. This report is currently under peer review for publication. I hope that by publishing a report based on the physiotherapy service in Madagascar, it will support the development of Physiotherapy services in future which are specific to the local population and the healthcare staff in Madagascar.

I have also started two new jobs in Leeds, one working as a Band 6 Physiotherapist at LTHT, supporting the development of a new spinal service, and one working at the University of Leeds as a Research Physiotherapist in Spinal Cord Injuries. I feel that it is my experiences in Madagascar that allowed me to gain these two new roles, and I hope to continue to work in spinal services both in the UK and in LMIC’s for years to come.

If you would like to support the ongoing development of healthcare and rehabilitation in Madagascar, you can donate through Global Rehabilitation’s website: https://www.globalrehabilitation.org/donate

Student placements: the world is your oyster

Kate Mattick

A myriad of career options across clinical, research or managerial settings can be opened up by a career in physiotherapy. This is because, over the last decade, the profession has expanded and developed apace. And, as a taster, student placements can offer valuable and rewarding insights into choosing a career path. They can also be personally enriching.

CSP accreditation of pre-registration courses ensures that students undertake a minimum of 1,000 hours of practice-based learning, giving them an insight into the breadth of the profession. Placements can be found in the UK, or all over the world. So what are the options? And what is the scope of work, preparation and experience needed?  Here’s some expert advice.

Working in a developing country

Physiotherapists and students alike have many reasons for wanting to work abroad. Motives often include a desire to make a difference, skill development and being immersed in new cultures. Opportunities vary from two weeks of volunteering to several years of paid employment, and incorporate a diverse range of projects. There are so many exciting ways to get involved with international work , but it can often feel daunting when it comes to where to start.  

Opportunities abroad may include seeking a student placement as an official elective through your university or a third party, gaining experience during student holidays or working abroad following graduation – as a  volunteer or paid. 

The first port of call in finding a student placement should be your university which may have established links to hospitals and other organisations. Third-party companies can also be used, but more research is needed if you are sourcing placements this way. Ask to be put in touch with previous students for a genuine account of their experience. Also, ensure you choose a specific placement in a well-established site with supervisors used to taking foreign students. 

Work the World and Projects Abroad are well established agencies that can help secure a placement. 

After graduating, keep your university documentation (transcripts and module handbooks). These are often required for future international work. Stay in touch with your personal tutor who could provide a reference.

Once qualified, you are able to practice in most developing countries. If you are volunteering independently it’s your own responsibility to check if any registration, in addition to your Health and Care Professions Council registration, is required. 

Build your skills to strengthen your application and help the effectiveness of international work. Often, getting relevant professional experience first is best. Strong team working, adaptability, problem solving, endless patience and training and language skills are invaluable. 

Research the country where you intend to volunteer and consider culture, customs, climate, security and health. Talk to people who have visited before.

Visit the Students’ Hub for more information and guidance.