Alison & her mission in Myanmar to celebrate International Midwives' Day

Alison Crabtree

To mark International Midwives Day, Doctors of the World UK is highlighting the valuable work our international midwives do around the globe. We want to highlight the fabulous work of one them who is just back from Myanmar (otherwise known as Burma).  Alison Crabtree, originally from Yorkshire, is a midwife and also trained as a nurse.  She went to work in the Pyapon township of the Irrwaddy Delta region earlier this year.  It was an area that suffered major destruction when Cyclone Nargis hit the region in May 2008.

Alison has spent most of her working life in the Bradford area, as a multi cultural area it was an ideal background for working overseas.  However, she’s no stranger to midwifery abroad having taken a career break to work with 3 other non-governmental organisations in Afghanistan, Ghana and Angola before this mission with Doctors of the World.

Job title: Maternal and child health advisor
Duration of mission: 3 months from the 8th January until the 10th April 2012

Alison explains why the mission was so important:
“Access to good quality primary health care is very limited for the population in the rural areas of Pyapon Township -  84% of the total population of the area live there (approximately 127, 000 people). They really lack trained health professionals, health facilities and added to this there are geographic constraints.  All of this means overall there’s limited access to the public primary health care system. Local people tend to resort to unofficial healers and traditional birth attendants however, there are many risks.  Many of these so-called health gurus work unsupervised and often provide poor quality care.

Group lessons on maternity care

The health system in Myanmar is centralised and severely underfunded. In 2009, the total expenditures on health represented only 2% of GDP( ). In addition, the health resources are not fairly distributed with most of the funding going on secondary healthcare, leaving the primary health sector under-resourced. The high maternal and infant mortality rate, 2.55 and 59.7 respectively per 1000 live births which demonstrates the seriousness of the situation. (In the UK the figures are 0.12 and 4.5 respectively.)

My work was part of the current community health project being implemented by Doctors of the World to improve the health status of the rural population.  The project is supporting 137 rural villages in the central, south-east and south Pyapon Township over a 2 year period. In fact the project aims to serve a rural population of approximately 127, 000 people.  Doctors of the World’s mission supports a network of community health workers, auxiliary midwives and, village health committees. It aims to improve health knowledge among the rural population.

I was working with the field team of national staff.  The team consisted of 8 nurses 3 nurses / midwives and 9 community facilitators.  The nurses / midwives role provide supervision to the Ministry of Health volunteers, community health workers and auxiliary midwives.  The rural population are fairly dependant on all of them.

I found what they need most medically are qualified nurses, midwives and doctors!  I signed up to do this mission because I enjoy this type of work, it is always challenging. I feel that I have something to offer in the way of education that is useful to the population.

The thing I learnt most is that one should never take for granted all the advantages we have with regard to health and education, housing, water and electricity.  It is only by experiencing day-to-day life in a situation when you have none of these luxuries do you really appreciate what you have back home.

I think volunteering is a personal thing and this sort of work would not suit everyone. You have to be able to adapt personally and professionally.  Personally, on this mission I learnt an appreciation of people who have lived under a restrictive regime."

If you are interested in volunteering overseas with us then have a look for more information.

Doctors of the World help survivors of last year's tsunami cope with their grief and rebuild their lives in Japan

Class activites

It is the 1st anniversary since Japan was hit with one of the most powerful earthquakes in history, together with a tsunami, the disaster set off a nuclear explosion.  The destruction caused over 15,000 deaths and thousands became missing or injured. 125,000 households were damaged or destroyed.   

In the aftermath of the tsunami the Doctors of the World Japan team mobilised and chose Otsuchi as a project since it was one of the three most affected places that were accessible (other locations badly affected were part of an exclusion zone due to the risk of radiation ). Otsuchi was one of worst-hit towns due to its location in a narrow valley.  90% of its buildings had been destroyed by water and fire, and 1,400 people out of a population of 16,000 were dead or missing. Up to 5,500 homeless people were taking refuge in 44 collective shelters, including one that was housing over 1,000 people.

Doctors of the World Japan project in Otsuchi that was designed to address the mental health needs of the victims and relieve the psychological suffering caused by the disaster such as suicidal tendencies, anxiety and loneliness. It also aimed to ensure continuity of care for people who were temporarily unable to receive their treatment due to the destruction of the hospital, roads and transport. The programme offered medical and psychiatric consultations, as well as relief in the form of massages,  therapy through talking and relaxation techniques.

Dr Morikawa is a volunteer in Otsuchi.  BBC World Service Outlook programme spoke to him to find out more about the project.  In his interview he explained the issues victims were coming to terms with:

Therapeutic massages

“Classes have been put on to combat insomnia by talking through problems. The Japanese have a strong hesitancy to talk about emotional problems, this is why we gave non medical names to the classes, it was the only way people would attend. Most Japanese people try to solve problems on their own and especially more so in this region. The problem is when the problems become too overwhelming and lead to suicidal feelings. I think I managed to save three people who told me personally that they would not be alive had they not had this place to come to.

People come to the 'problem sleeping' classes, because they can’t get help elsewhere. One person only told me after ten months of attendance what was on their mind, that they held a lot of guilt, because they let go of their wife’s hand, but no-one could help him with his grief. These feelings have been left with a lot of people of all ages.  One young girl explained how she had to let go of her grandmother’s hand. People who have gone through this feel like they’re the only survivors and have a lot of grief and guilt. I offer advice and methods to deal with such emotions.

A consultation with one of Doctors of the World's health professionals.

The approaches we offer are 3-4 months of talking therapy, where we mainly listen, give support to those who survived and help relieve them of their guilt and help them understand that they had no other choice.

I am motivated to help rebuild the community and make Japan a better place. I feel like I can make a difference by helping people to talk through their emotions and help them feel more hopeful about the future."

To listen to the BBC interview in full click here.

© Photos by Eric Rechsteiner

National Student Volunteering Week; featuring Project:London volunteer Claire Ferrero

It’s National Student Volunteer Week from 20 – 26th February 2012. To highlight the wonderful work of our student volunteers we are sharing the experiences of one of our medical students, Claire Ferraro, who worked as a Support Worker at our Project:London clinic while she studied at the London School of Hygiene & Tropical Medicine. She also appeared in the student BMA news.

She says it was an ideal opportunity to practice her communication skills and have contact with patients: “The service users are often so desperately in need of help as a Support Worker you are easily able to see the positive impact of your work. It’s a real "get-away" from academic studies and quite often a harsh reminder of the difficulties some people face on a day-to-day basis. Whilst working/studying in the NHS, it's sometimes easy to forget that there are still people who miss out on our excellent healthcare.”

Volunteering gave Claire practical skills: “I became really confident at communicating effectively with service users via translators, either in person or on the phone, which should be invaluable in my foundation job in east London. In addition, I quickly learnt to be assertive on the phone with GP secretaries and practice managers whilst advocating for GP registration for service users. The clinic relies on working effectively in a team with other support workers, the nurse and/or doctor and communicating back to the office. I had first hand experience of giving explanations, recording accurate information, coping with distressed relatives, being empathic and this was always in the context of language and cultural barriers.”

“Project:London is a really friendly and rewarding place to volunteer. There is nothing better than being able to tell someone you've successfully found them a permanent GP. The overwhelming gratitude and relief at being able to access healthcare when they need it emphasises how much they were in need of help in the first place.” 

If you would like to become involved with Project:London or any other volunteer opportunities for Doctors of the World, read more.

Dr Paquita de Zulueta fights for those on the margins of society

Dr Paquita de Zulueta

Paquita de Zulueta has been volunteering at Project:London as a doctor for over two years. She’s helped many vulnerable people who are unable to register with a GP. When she’s not volunteering she works as a locum doctor. She has been a GP for 26 years. 

Paquita is passionate about Project: London and supports Doctors of the World UK’s work in this area. Paquita feels an affinity with immigrants and asylum seekers having lived abroad and met many people from different cultures and backgrounds while she was growing up. Paquita has worked with many asylum seekers in different areas of London during her time as a GP.  


She says she enjoys the challenge that comes from working at Project:London and the feeling that her work makes a big difference.

Here Paquita’s documents her experiences at the clinic which featured in the BMJ in October 2011 in an article entitled: ‘Asylum seekers and undocumented migrants must retain access to primary care’.

"They come singly, or in huddled clusters, subdued, their eyes downcast, their shoulders stooped. They tell us tales of loss, of devastation, of living in the penumbra, always fearful of exposing themselves to bureaucratic scrutiny. They sleep, if lucky, on the sofas of friends or in hostels, otherwise in doorways, on park benches, in churches and bus stations. They are like Dante’s lost souls, shadows wafting in limbo, neither in heaven or hell, but in a cold and lifeless purgatory, a place the world refuses to acknowledge. They tell me their stories, their faces etched with suffering, their eyes reflecting dull despondency or despair. And yet, as I bear witness, I am humbled by their grace, dignity, and endurance.  Somehow they manage to look clean, orderly and well presented. The tell-tale sign may just be the tightly clutched plastic bag. That bag may hold all their possessions, including documents such as a dog-eared letter, years old, from the Home Office blandly reporting information regarding the status of their asylum appeal. Many of them have not sought medical help for several years despite serious medical problems - some brought on by the lives they lead or the trauma they have experienced.

A support worker assists a service user at the clinic

The stories are varied and at times harrowing. A woman flees her village and elopes with a man she has fallen in love with. But he brings her to the UK in order to sell her to other men, not to marry her. He steals her passport, drugs her, and forces her into sexual slavery. Now she is pregnant and too sad to care, yet she cares enough to refuse abortion. A couple have been refused asylum. Local gangs threatened his life and they cannot go back home. The pregnant wife is in the third trimester. A depressed young woman fled the house where she had been enslaved since she was 14 and is forced to sell her body to get some food. A teenager with severe post-traumatic stress disorder has difficulties controlling his anger and is at risk of harming himself or others (he has already made a serious suicide attempt). A woman in her forties has rheumatic heart disease and is breathless with heart failure. These individuals are all in clinical need yet have been unable to access primary healthcare in the UK. Despite pleas to my colleagues to take them on, and even when they undertake to do so, they still turn them away when they arrive on their doorstep. Secondary care, including antenatal care, may be available, but carries the threat of unpayable fees. Do healthcare professionals expect women to deliver their babies in the street? In fact, some women we see have delivered at home without any clinical supervision. What do they think happens to those who are suffering from severe mental health disorders and chronic untreated diseases? Have they at least considered the risks to public health? The litany of misery continues and I take note of the small acts of unkindness and indifference meted out by my peers. But there are shining exceptions, and some GPs do manage to overcome bureaucratic barriers and register patients irrespective of their residential status. 

Paquita seeing a patient in the clinic

I am a general practitioner and work, when time permits, as a clinical volunteer at Project:London, a health advocacy programme set up by Doctors of the World UK in the East End of London. Here I treat those who cannot access primary care. These include those accepted or refused by the asylum system and undocumented migrants. The BMA reminds doctors that there is no requirement to determine someone’s immigration status to access primary care services. The GMC’s Good Medical Practice requires that doctors do not discriminate unfairly, but provide care and treatment to meet the clinical needs of all patients. The Royal College of General Practitioners (RCGP) endorses this:  “Based on the principle that General Practitioners have a duty of care to all people seeking healthcare, the RCGP believes that GPs should not be expected to police access to healthcare and turn people away when they are at their most vulnerable.

When people evince a lack of compassion and callousness, they use various tricks to preserve their self-esteem. One of these is to comply with bureaucratic diktats and elide responsibility for the consequences of ones actions. Another is to dehumanise individuals and view them as dangerous and unworthy of normal human decency. In mitigation, I recognise that some Primary Care Trusts send officious and misleading guidance. Receptionists and practice managers are exhorted to reject individuals who do not present a range of documents such as utility bills and passports – not easy if you are homeless or someone else holds your passport. These impositions carry no valid legal or ethical authority, but some may believe they do.

A Support worker sees a service user

What does the future hold? Finances are tight. Consortia may be more draconian. The government seeks to expand its existing restrictions to free secondary care and include primary care. This does not augur well for the vulnerable and dispossessed in need of humane clinical care – particularly as compassion appears to be a dwindling resource in modern medicine. "

This article was originally published 18/10/11 on the BMJ blog at http://www.bmj.com/content/343/bmj.d6637

Listen to Professor Chris Bulstrode and Dr Oda Mukkuaka discussing Haiti on BBC Radio Oxford and BBC Radio 4

Doctors of the World's Professor Chris Bulstrode, and Haitian surgeon Dr Oda Mukkuaka worked alongside each other in Haiti after the devastating earthquake that struck in January 2011.  Doctors of the World invited the surgeon over to the UK to help train him in surgical techniques, so that he in turn can help his colleagues back home.   The two explain their work with Doctors of the World's emergency mission and discuss how things are now in Haiti in these interviews.  Listen here to BBC Radio Oxford's interview and here to the Radio 4 interview.