Fieldset
Non-Communicable Diseases: A short assignment in Lebanon

UK doctor Mike Tomson returns to Médecins Sans Frontières / Doctors Without Borders (MSF) to help refugees and vulnerable people in Lebanon... 

A nurse attends to a patient in Lebanon

Looking back I should not have been surprised that it was a very intense few weeks of work. 

When I was working with MSF in Jordan last year I was part of a non-communicable diseases project focussing on diseases that can't be transmitted from person to person, like diabetes, asthma, heart disease and hypertension.

While I was there I had been lucky to meet two visiting senior colleagues involved in running the non-communicable disease (NCD) programme based in two projects in Lebanon. They later asked me if I could do an assignment in their programme to look at ways to help them develop their work. 

I’d replied that I was interested, but that I really needed more time at home. 

Home

I’m clear that unlike some of my colleagues I’m not planning a long-term career working abroad. I want to develop my role here in UK in my local community and through this support refugees or marginalised communities in other ways. 

Going on assignment with MSF freezes the development of new projects at home. Plus it makes it more likely friends will drop out of contact as “Mike’s always off doing interesting stuff abroad now!”  

Short, intense projects can be exhausting

I’m also very aware of what a challenge it is for my family when I have been away.  The routine chores of normal living go on, all the paperwork and organisation and fixing broken things still have to be done, and I’m not there to support any of this. 

So after discussion at home, I replied to the team that I’d only be able to do two to three weeks in Lebanon. I largely expected that this would mean that the idea was off and they’d recruit somebody else who could offer a more normal six to nine months…

Lebanon

I was asked to go on the shortened assignment. The terms of reference were pretty broad and certainly could have occupied me for many months… “to support the project in reviewing and planning strategically the non-communicable disease activities in both projects … provide recommendations on programmatic aspects of non-communicable disease care ...  etc.” 

Looking back at the end of the assignment and after completing a short (20 page!) report of ideas I can understand why I have returned and wanted a break; short intense projects can be exhausting.
I got a fair amount of knowledge about the Lebanon projects (or at least the non-communicable disease side!) before leaving. 

My fears (as they have been throughout my career) were that I was an imposter, though I knew I had suitable skills. 

Médecins Sans Frontières has been providing a non-communicable disease treatment programme in Lebanon since 2012. The programme aims to meet the needs of Syrian refugees, vulnerable Lebanese patients, and others who don’t have access to treatment or cannot afford the high cost of medical consultations, examinations, and treatment. 

Throughout its clinics in Beirut, the Bekaa valley and the north of Lebanon, MSF is supporting today around 14,000 non-communicable disease patients – the largest number of such patients for MSF worldwide. 

An unexpected problem

Before I began this short posting I had some worries; this was in many ways a consultancy role, as I was going to review and suggest, rather than to implement things. 

Consultancy is for those who have lots of experience; I’ve had lots of experience in the NHS, in management and change, as well as in medical education, but I am not able to claim that I’ve extensive experience in international settings. 

My brain was concentrating primarily on questions about how things could be done differently

So my fears (as they have been throughout my career) were that I was an imposter, though I actually knew I had suitable skills. 

The reality was that I was stumped on the first day in Lebanon by something much more mundane…  I was given a Swiss laptop…  I couldn’t find the “Y” or the “@” … and suddenly the advantages of 10-finger typing faded into chaos. 

I’m not sure if it was random luck or a deliberate joke but the password I was given featured four symbols which were not where I’d expect to find them on a UK keyboard.  Luckily I’d brought my own laptop … so except for finding files on shared systems I’ll admit that I strategically decided that learning Swiss keyboard layout was not a priority from me for now.
 

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Swiss laptop
The cryptic keyboard of the Swiss laptop

The job meant that after some briefing and preparation time in Beirut I was out in the projects visiting clinics. 

During my short assignment in Lebanon, I had the opportunity to visit six of MSF’s clinics providing the non-communicable disease programme in the Bekaa, and the north of the country, where the highest concentration of Syrian refugees are living in deplorable conditions. 

These clinics also provide (depending on the location and so the needs of the population) mental health, and maternity or paediatric support.  

The big questions…

My brain was concentrating primarily on questions about how things could be done differently, how could we be more efficient and effective whilst also keeping connections and treating patients as people? 

Were we getting the balance right between who the nurses saw and managed and who the doctors saw? 

How much could education resolve questions and challenges that we identified?

Were the questions about diet really issues of lack of knowledge or questions about confidence in managing insulin-dependent diabetics? 

As a doctor though I was also fascinated by the types of challenges that the clinics faced and want to share some examples, especially as these are issues that would not happen in the same was in a Western world setting.

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Consultation room at one of the MSF Lebanon projects

The challenges

A mother brought in her four-month-old who looked unusual (paediatricians would say he was “dysmorphic” and by this stage in other settings a chromosomal test might have been done to look at what genetic issues were present) and was not feeding well. 

The team had already picked up that he had been born failing to produce enough thyroxine (an essential hormone) but had to use fractions of adult tablets to supply it, whilst also explaining that normal development might be unlikely… and that feeding might remain difficult.

A 17-year-old woman came who had insulin-dependent (“type 1”) diabetes. She had very poor control and the team were concerned about what would be the consequences of this. 

What had seemed like a question of adjusting her dose became a problem about understanding how to survive and become more healthy in a marginal life...

Talking with this patient revealed that the real challenge was that she had to be working out in the fields during all daylight. Taking her insulin was something that she knowingly missed: if she had taken her insulin and worked too hard in the fields, her blood sugar could drop, and she could not afford sweets which could bring her sugars up again. What had seemed like a question of adjusting medical doses became a problem about understanding how to survive and become more healthy in a marginal life. 

In all settings managing anticoagulation (medicines that prevent blood clots) is challenging. Either too much or too little is dangerous for the patient. 

Managing this when we had a delay in getting the results of tests, and with a frail older person who was being cared for by (and so being moved between) the different members of his family was complex. 
This patient was seeing several different doctors which made it even harder. How could our doctor balance making a decision which he was happy was safe with the family’s already planned movements? How possible was collaborative care when most care in Lebanon is by individual specialist clinics? Could we make decisions based on results phoned to us from Beirut?  Could we change any of our systems to make things better in the future? 

It was a privilege to work with the local doctors and the international workers in the projects and to try to think about things which would help improve the care we can offer to patients with non-communicable diseases in our Lebanon projects. 

Often the themes are similar to those I am used to in the NHS, and common to all Quality Improvement work. 

The power of data

In the West there is often excess data, as the computerised systems that are used make this relatively easily accumulated.

It is much harder to measure, for example, how many different patients people in each role have seen when you have a paper appointment system, common in less developed settings. 

But if you don’t have the data on what you are doing, changing what you do may help, but you will never know how much.

Quality is not improved if the data or the targets take over common sense

(You may also suffer from assuming that your changes will improve things because you believe in them. The data may tell you otherwise). 

So, as well as lots of detailed feedback, one of the themes of the work was that we need to have data, so that we can tell if changes make things better, or not! 

(Of course you need to have data which is relevant. Quality is not improved if the data or the targets take over common sense. My experience of the UK health system's four-hour-wait target for accident and emergency departments is an example of this. It resulted in people not being allowed out of ambulances and into the hospital: a great example of measurements and targets causing harm.) 

Looking back, I’m aware of many similarities with the non-communicable disease work that I was involved with in Jordan, but also aware that then I was a member of a project based team with all the support and community, both national and international, that this brings. 

This time because of the brevity and travelling to all the clinics, I was working with one (fantastic) colleague who supported my work enormously, but I did miss the familiarity of a team you worked and ate with every day.