On Boxing Day 2004, a 9.1 earthquake struck off the west of coast of Sumatra triggering tsunamis along the coasts of 14 Indian Ocean countries killing an estimated 230,000 people. We read and donated much to the relief aid in the hardest hit nations of Indonesia, Sri Lanka and Thailand but little was heard of the fate of those in African nations.

In Somalia the tsunami killed 298 people and displaced an estimated 5000.

WA orthopaedic surgeon Dr Graham Forward was like most of us until a phone call from a doctor at the Bosaso Hospital in northern Somalia asked him directly for help.

“A friend had told this doctor about me. We spoke and in February, 2005, I put a team together, went on the radio and a lot of money came in to equip the team and buy relief equipment,” Graham said.

Transparency and accountability

But as in all things, Graham was meticulous – if he was going to do something, it was going to be done right. He formed Australian Doctors For Africa (ADFA), a registered charity that would account for and audit these aid activities. It has a board chaired by John Bond and a clinical governance committee chaired by Prof Shirley Bowen (Dean of the Notre Dame Medical School) and assisted by consultant anaesthetist Dr Rob Storer.

“ADFA has proved to be a very good vehicle. It appeals to a lot of Australian surgeons, nurses and doctors as an organisation with which to volunteer their time to Africa,” he said.

Over the intervening 12 years, ADFA has become professional and practical in its approach to providing medical and surgical services to four Indian Ocean countries – Ethiopia, Somaliland, Madagascar and Comoros Islands – all of which struggle with political dysfunction to lesser or greater degrees.

Planning reduces security risks for ADFA volunteers and Graham states simply: “We would not go into a risky environment.”

Help from the ground, up

“We have good relationships with various government departments and foreign ministries in these countries mostly by doing a good job in a measured way. People are able to meet us and see what we’re doing. We are a bottom-up organisation, which is why it is sustainable,” Graham said.

“We start off by just going and operating and pretty soon that morphs into a relationship with the local doctors and then it develops into a training relationship. Once you have a trained surgeon, they need a good facility to operate in so we help develop the infrastructure – build or renovate operating theatres, fix sewerage and water supply. We provide nursing staff to teach the nurses so that patients can recover and rehabilitate.”

“We try to take a holistic approach to take situations from dysfunctional to independently functioning. Some good work gets done. The people are resilient and appreciate the contribution we’re making and are keen to help themselves.”

“We only go by invitation and we go to give a hand, not to take over. We have a charter and those are the first two items. It’s a mantra that has stood us in very good stead.”

Seeds bearing fruit

In 2015/16, ADFA sent 13 teams of doctors, nurses, technicians in its core specialties (a list which has grown from the early days of just orthopaedics to include gastroenterology, urology, paediatrics and anaesthetics to hospitals in the four nations within its scope. Dr Digby Cullen and Prof Barry Marshall are among the major gastroenterology contributors. They have recently been awarded the Chevalier of Madagascar from the President of Madagascar in October 2016.  Most volunteers come from WA but there are also doctors and nurses from the eastern states and ADFA collaborates with the international orthopaedic charity AO Alliance on some projects.

Among the WA doctor participants over this reporting period were Dr Tony Jeffries, Dr Sarah Kurian, Dr Zoe Wake, Dr Digby Cullen, Dr Kate Stannage, Dr Mike Wren, Dr Sue Chapman, Dr Colin Whitewood, Dr Li-On Lam, Dr Rob Genat, Dr Anna Negus, Dr Doug Kingwell, Prof David Wood, Dr Emily Forward, Dr Nick Kontorinis, Dr Rashmi Patel, Dr Samuel Duff and Dr Donald Horwath. Nurse teams included Ms Ann Mitchell, Ms Anne Coyne, Ms Josiane Sabouriaut, Ms Beth McGrechen, Ms Judy Thompson, Ms Stephanie McDonald, Ms Cheryl Genat, Ms Catherine Poole, Ms Kim Mackley and Ms Lucy Harris. Graham said he usually undertook two clinical trips a year but in the last financial year he made three with a fourth to a GI conference ADFA organised in Madagascar last June for local doctors to extend their knowledge and networks.

According to ADFA’s 2015/16 annual report, donated time and medical equipment amounted to $918,600 or over half of both its ‘expenditure’ and income.

Graham said ADFA doesn’t actively recruit volunteers. Teams are filled by word of mouth and a lot of hard work by a phalanx of behind-the-scenes volunteers such as board member and operational manager Christine Tasker. An administration officer was appointed in 2014 – ADFA’s first employee – when the organisation grew beyond the capacity of part-time volunteers.

Adjusting to culture shock

“These trips are not for everybody. On the first trip, you are bewildered; on the second trip, you’re building trust; by the third trip you are getting somewhere. We want volunteers to return because that’s where you get the best benefit for everyone.”

Graham says ADFA is clear on its strategic priorities, what he describes as a Development Staircase: Service Provision, Infrastructure Development, Training and Teaching and Advanced Development. It wants its limited resources to have the greatest impact.

In several hospitals in Somaliland and Ethiopia, the staircase has progressed to the training level and ADFA, in the shape of Graham and WA colleagues, is putting some serious muscle to the task alongside doctors from the Swiss-based AO Alliance. Taking on a course for first year orthopaedic trainees at the Black Lion Hospital in Addis Ababa has had a spin-off training course for orthopaedic nurses (run by Ann Mitchell). And ADFA offers scholarships for promising young doctors. Surgical teams in these developing sites are invariably a mixture of local and ADFA doctors.

There is always room on board for more volunteer trainers and teachers.

Skills training needed

“Academic teaching is very strong in all these countries but the practical training and post-graduate training is not. In Ethiopia they graduate really smart doctors but they don’t have stethoscopes.”

Graham was to head off with colleagues Michael Wren and Hari Goonatillake shortly after this interview to teach first-year orthopaedic trainees a skills laboratory.

“This is such a powerful thing. If these 48 first year trainees are taught good habits and techniques from the start it will serve their community for a lifetime,” he said.

The final step on the ADFA staircase is advanced development, which is in its infancy, but the organisation has begun a screening program for talipes in babies and young children; the international GI conference brought new evidence-based research to these shores; and container loads of medical equipment continue to arrive with the help of ADFA board member and shipping expert Graeme Wilson.

Equipment keeps rolling

“We just sent our 50th container – last year about $1.2m worth of equipment was donated and shipped,” Graham said.

“We are grateful to the medical fraternity for generously donating quality equipment and contributing their services. But when it comes to funds, the way we have always worked is to take on a project that fits our strategic plan and then worry about where the money comes from!”

“We have a ‘13 hospitals project’ – we’ve done four so far. They are now running autonomously with mentorship and leadership and we’re about to move onto our fifth. When we’ve gone through those 13 hospitals, we will find another 13. There’s no shortage of need.”

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