humanitarian, often voluntary agencies; may have ... little overseas experience is probably a voluntary .... ambulance was called, and, withsome difficulty, he.
HoIw To Do It Work in a developing country Paul Johnstone
Some health professionals seek the exciting challenge of working for a time in a developing country. Uncertainties about taking this step, however, may have to be addressed. It is important to understand your reasons for wanting to work overseas-it is ill advised, for example, to go abroad just to escape job dissatisfaction in Britain. Skills needed for international aid work nowadays centre on low tech community based programmes, and enabling, facilitating, and managing skills are more important than clinical skills. Further training may be necessary. Careful planning both for the work abroad and for a return to work in Britain is advisable; full health insurance cover, for example, is important. Although working in a developing country is largely unrecognised as an asset to a professional career in Britain, attitudes are slowly changing. A spell overseas can be very relevant to a career plan and the NHS.
Working in a developing country can be an exciting experience, personally rewarding, and in some professional specialties, recognised as a positive career step. There is much interest among doctors, nurses, and managers in this country about humanitarian work abroad, but few take up the challenge. There may be many reasons not to go: personal uncertainty; unknown risks to health and safety; indecision about where to go, who to go with, and what to do; mortgage and family commitments; pension and national insurance; job security on return; lack of support from professional colleagues and NHS employers; and the long term risk and benefits to careers. Still, some people want a new and exciting challenge and decide for a spell abroad. This article addresses some of these uncertainties and is a guide to further information for those thinking about working in a developing country.
International Health Exchange, London WC2E 9NA Paul Johnstone, registrar in public health BMJ 1995;311:113-5
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Why work abroad? A good starting point is to think about your own reasons for working in a developing country. This suggestion was put to doctors, nurses, and other health professionals attending a workshop run by the International Health Exchange, a London based nongovernment organisation. Broadly two types of reason were put forward: altruism, including wanting to help and empower others or share skills; and personal reasons, such as gaining experience of different cultures, personal development (through research), personal career development (clinical skills, knowledge), and adventure and a change. The survey was interesting for what a few participants did not immediately say. Only one person thought that working abroad had any relevance to a career in Britain on return. There were also "negative" reasons, including job dissatisfaction and unfulfilled ambitions. It may be important to think carefully before leaving if negative reasons such as these are important: an overseas experience may provide a respite for a while, but the same problems may exist on return, and readjustment to this country could be even more difficult. People work in a developing country because they are committed and want to, not because they cannot cope here. 8 JuLY 1995
In many circumstances (apart from rapid response relief work), a commitment for at least a year is needed to be useful.
What skills should I have? The skills needed for international aid work have changed. The traditional view of skills and knowledge as a one way transfer from developed to developing countries is now out of date-particularly for long term development. In addition, the need for the high tech skills of Western medicine and nursing learnt in this country have virtually disappeared: a country with a high rate of infant deaths from diarrhoea and dehydration does not need help to build a high tech special care baby unit (box).
Changing skills for international humanitarian aid Traditional needs One way transfer of skills High tech medicine Clinical skills
Current needs Dialogue Low tech community based health programmes Enabling, facilitating, and managing skills
There are two main areas of international humanitarian assistance for which certain clinical and managerial skills are sought: emergency relief after man made or natural disasters, and long term development aid. In addition, a few but a decreasing number of basic medical posts are needed. Within each area, the opportunities and the types of skills needed are diverse. Emergency relief work requires common sense and the ability to make decisions quickly sometimes, combined with good clinical and managerial skills. Food, water, drugs, and hospitals are often urgently required, and large intervention programmes need to be planned and implemented quickly. In contrast, long term development has a much lower profile but is equally challenging and needed. Primary health care features prominently, particularly in the training of community volunteers or workers and support to other community based initiatives. Other areas of programme development-such as community development, management of chronic diseases, developing special disease control programmes, and participating in health sector reforms and new approaches to financing-need common sense with good briefing and on some occasions special training. Finally, there is less scope for basic medical jobs now. Several countries already have a surplus of their own medically trained professionals (there were 2000 unemployed doctors in Pakistan in 1989). Opportunities do exist, howeverfor example, with mission hospitals-and general practice training that included work in casualty departments and obstetrics are important skills for these types ofpost. Initially, if you find yourself with skills not entirely applicable to this type of work, further training is 113
Guide to national and international aid organisations Organisation International agencies * Multilateral aid agencies: WHO and UN agencies, such as United Nations High Commissioner for Refugees (UNHCR), International Labour Organisation (ILO), UN Development Programme (UNDP), UN Food Programme (UNFP), UN Children's Fund (Unicef) * Bilateral government aid, such as Overseas Development Administration (ODA) (UK), Gesellschaft fur Technische Zusammenarbeit (GTZ) (Germany), US Agency for International Development (USAID) * Non-government organisations, such as Save the Children's Fund (SCF), Voluntary Services Overseas (VSO), Medecins Sans Frontieres (MSF), Health Unlimited (HU)
Country-level health organisations * Government health services
* National non-government
organisations * Private health care
* Traditional or lay health care
Remit
Supragovernmental organisation usually with global roles; training advice to government, target setting, or specific roles such as refugee care, food supplies; usually large bureaucracies
Government to govemment aid programmes, usually to assist at government level or to fund other nongovernment organisations; good terms of service for employees Autonomous, usually non-aligned, humanitarian, often voluntary agencies; may have strong ideological basis-for example, missions, family planning, emergency relief; very diverse remits, usually smaller than government programmes; faster to act and innovative; often work independently of local health infrastructure Host countries' own health service; important to work with or for-assistance is more likely to be sustainable; requires cultural sensitivity and diplomacy More diverse, innovative, and responsive and more likely to be aware of locally perceived health needs and how to address them Many developing countries have a large private sector, which provides a wider "mixed economy" of health care; usually few opportunities for expatriate workers Important to work with in community based primary care programmes but requires much greater cultural sensitivity and tact
available. Many aid agencies and the International Health Exchange offer courses in, for example, teacher training, management support, and epidemiology for beginners. Another option is to consider a diploma (such as in tropical medicine and hygiene at one of the schools or universities with departments of tropical medicine). You should aim to complement your existing skills with new skills in order to facilitate and enable developing communities to help themselves. Perhaps the main skills, often learnt during and not before your first experience of work abroad, are patience and the ability to work in complex, changing, and often difficult circumstances with a high degree of self reliance.
Planning and preparations Several mechanisms and opportunities already exist to allow some doctors, nurses, and managers to take a career break and work abroad. For example, several health authorities allow sabbaticals and retainer schemes (and occasionally locum cover). Junior doctors may be able to extend study leave or book hospital posts with gaps for overseas work. In this case, it is advisable not to make a clean break or resign from a career post but to arrange work for your return; it is difficult enough to reacclimatise without the pressure of looking for a job. Doctors in training grades could discuss the implications for their specialist training with their postgraduate dean or college's regional adviser.
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Once you have decided to work in a developing country and the sort of work you might want to do, the next important question is which organisation you should work for. There are a bewildering number of different agencies and organisations with an array of acronyms and remits. The box outlines the main categories of aid agencies and should be viewed as a beginner's guide when applying for posts. The most appropriate agency for a new recruit with little overseas experience is probably a voluntary organisation. If you want to continue in international aid work after a substantial overseas experience a much wider range of jobs becomes available, with nongovernment offices, governments, the United Nations, or the World Health Organisation. Next comes job applications and interviews. A good source of information on jobs and training is the International Health Exchange, which every two months publishes a magazine with jobs and training advertisements as well as articles on international aid. You could also apply directly to the aid agencies to find out more about their work. You should find out if their terms of service and conditions are going to be suitable for you. Many voluntary organisations offer travel and accommodation as part of the package, and a few even offer to pay school fees and give food allowances. With these included, it is surprisingly easy to survive on a voluntary stipend (and even pay a mortgage). It is important to check that the package includes full health insurance with emergency evacuation cover. A few people have run into extremely severe, life threatening situations, which would have been avoided with emergency "med-evac" cover. Terms and conditions offered by aid agencies vary widely, and it is important to find these out before the interview. Before leaving, it is also advisable to ask about briefing and the support provided from central and regional offices of the organisation (particularly for difficult posts and politically unstable countries). Find out what plans have been arranged if there is an emergency such as a coup d'etat or civil or military unrest.
On return Most people do eventually return to Britain, but the culture shock can be traumatic. You'll want to tell everyone about your experiences and no one listens. Euphoria of seeing family and friends quickly gives way to a mild depression (made worse by grey skies). A trip to the supermarket leaves you in shock; bus stop advertisements seem more risque, and you don't understand what your first patients are complaining about. There are several ways to help overcome the worst culture shocks. The agency should arrange a good debriefing. Opportunities should be made to hand over projects, to update the central office, and to talk through some of the difficult tasks with people who know about the country you worked in. If a debriefing has not been arranged then ask for one, and try to visit others who have worked in the same place. Try to plan your next British job before you return, or even before you leave Britain. You may have to return before the end of your contract for interviews.
Attitudes and benefits to a career in the NHS Whereas working in a developing country can be personally rewarding, it is largely unrecognised as an asset to a professional career in the NHS (in contrast with some other European countries). Attitudes are slowly changing, however, and as a result the number of links with trusts, practices, and academic departments in developing countries is increasing. There is a growing recognition of international health and
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aid work in a few royal colleges and faculties-for example, the Royal College of General Practitioners and the Royal College ofNursing. Another recent development is the shift in Britain's health policy towards an NHS led by primary care. Many models of primary health care have evolved in developing countries over the past three decades, and aid agencies may have contributed to these. Britain's health system could benefit from their experiences, and aid workers are well placed to share knowledge. The skills acquired through working overseasmanaging projects, coping in a crisis, and making
difficult decisions in the face of scarce resources (often in harsh and changing conditions)-are all useful in today's NHS. Perhaps now, more than any other time, an international humanitarian aid posting is very relevant to a career plan and the NHS. PJ is funded by the Buckingham Health Board. For further information contact Isobel McConnan, International Health Exchange, 8-10 Dryden Street, London WC2E 9NA. (Accepted 12June 1995)
Ethical Debate Doctors' legal position in treating temporarily incompetent patients Doctors in accident and emergency departments are sometimes presented with patients with potentially life threatening conditions who refuse to consent to treatment. The doctors then face a dilemma: to withhold necessary treatment or to act against a patient's express wishes. Two such cases are presented, and we asked a lawyer, two medical ethicists, a psychiatrist, and an accident and emergency physician to comment on the implications.
Case history: head injury and drunkenness
Stockport Acute Services NHS Trust, Stockport Infirmary, Stockport SKI 3UJ David W Hodgkinson, consultant in accident and emergency medicine Alistair J Gray, consultant in accident and emergency medicine
David W Hodgkinson, AlistairJ Gray
General Psychiatry and Psychotherapy Directorate, University Hospital, Nottingham NG7 2UH Brian Dalal, registrar in liaison psychiatry
Department of Law, University Park, Nottingham NG7 2RD Petra Wilson, lecturer in law Centre for Philosophy and
Health Care, University College of Swansea, Swansea SA2 8PP Zbigniew Szawarski, lecturer
Department of Psychiatry, West Middlesex University Hospital, Middlesex TW7 6AF Tom Sensky, senior lecturer in psychiatry
Department of Neurosurgery, University of Otago, Dunedin, New Zealand Grant Gillett, professor of medical ethics
Emergency Medicine Directorate, Salford Royal JHospitals NHS Trust, Hope Hospital, Salford M6 8HD D W Yates, professor of emergency medicine BMJ71995;311:115-8
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A 46 year old man with a history of chronic heavy alcohol consumption fell down a flight of 20 concrete steps and sustained an injury to the left side of his head, bleeding profusely from a scalp laceration. An ambulance was called, and, with some difficulty, he was persuaded to go to hospital with a friend. On arrival at the hospital he refused to enter the accident and emergency department and became verbally and physically aggressive, but his friend eventually persuaded him to be seen in the department. He initially seemed jovial and cooperative. He smelt strongly of alcohol, was alert and talking, but walked with an unsteady ataxic gait. A doctor assessed him and found him to be alert, uncooperative, and orientated. He had a laceration to the left side of his scalp behind his left ear, and fresh blood was coming from his external auditory canal. His pupils were of equal size and reacted to light, and there were no lateralising neurological signs. A lateral radiograph of his skull confirmed a linear vault fracture of the left parietal bone that extended into the base of the skull. The patient's condition was explained to him, and he was offered admission to hospital. He immediately refused and walked out of the department despite entreaties not to leave. After the case had been discussed with the accident and emergency consultant on call for the day, the police were asked to bring the patient back to the department for further assessment. Several hours later the patient returned in the company of the police but again refused to stay and was both verbally and physically aggressive. His physical condition seemed unchanged, and he left. The patient was brought back again by the police after a short time, and he agreed to be admitted to the ward. At this stage a niece who had been contacted arrived in the department. After spending several minutes with the patient, she stated that this was not his normal behaviour even when drunk. The patient discharged himself from the ward, but some hours later he was readmitted of his own volition. His general condition remained unchanged.
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Authors' comment The main subject for debate is whether this patient was competent to make a reasonable decision regarding the need for admission, observation, and possible further investigations. He had probably ingested alcohol, had sustained a skull fracture in a fall, and had presented with abnormal behaviour. Such a patient is at considerable risk of developing an intracranial haemorrhage or of having sustained cerebral contusions. Should this patient have been held against his will for observation, or sedated until he became compliant, or was he competent to make the decision to discharge himself? He was clearly not suffering from a psychiatric illness that would warrant a compulsory admission order. Should this patient have been physically restrained against his will in the accident and emergency department or on the ward?
Case history: serious drug overdoses Brian Dalal A 30 year old man was found by his father in a drowsy confused state with an empty pack of 100 codydramol tablets (dihydrocodeine tartrate 10 mg, paracetamol 500 mg) by his side. The pack had been dispensed earlier that day. By the time of his arrival in the casualty departinent, about two hours after the overdose, the patient was unconscious with pinpoint pupils and a respiratory rate of 6 breaths/min. His father said that his son had been prescribed codydramol for a longstanding foot injury. He thought that his son had recently split up with a girlfriend, although he was not certain as they tended not to discuss personal affairs. There were no other relatives who might offer a clearer understanding of the reasons for the overdose, and there was no history of psychiatric illness, deliberate self harm, or alcohol misuse. The patient was treated with naloxone (an opiate antagonist), with immediate effect. On waking, he was extremely distressed and refused to disclose why he had taken the overdose. He did not seem to be 115
