My third week

Last Friday and Saturday two medical students who are completing their elective placement in a nearby hospital visited our Nilphamari hospital for the weekend. We went for several long walks outside the compound to get a closer insight into the local community’s everyday life. We walked through many rice fields (picture 1) and passed through villages where the community gathered to get their picture taken (picture 2). It was a lovely opportunity to exchange experiences and thoughts with other Westerners who are here doing similar things to me.
On Sunday there was a clinic for outpatients to attend, specifically for cerebral palsy (CP) and club foot babies and children. In the morning I worked with the Physiotherapist in the CP clinic, together we assessed the children, the physio would teach parents stretching exercises to do with their child at home (picture 3). I made myself useful by looking the family’s son (picture 4).
In the afternoon I joined the other Physios helping to cast the club foot children (picture 5). Club foot management was preformed according to the Ponseti model. Ponseti developed a method of clubfoot management that is inexpensive and effective for use in developing countries. Long-term follow-up studies show that feet treated by Ponseti management are strong, flexible, and pain free. The treatment takes approximately 6 weeks by completing weekly manipulations of the foot followed by plaster cast applications slowly moving the foot into the correct position. When possible, it is best to start club foot management soon after birth (7 to 10 days). When start¬ed before 9 months of age, most clubfoot deformities can be corrected by using this management. In Bangladesh, there is a distinct lack of awareness in detecting clubfoot babies, therefore, many children’s treatment only start when the parents notice their children do not start walking at the correct age. It is then that they seek treatment; this may be too late for correction of the foot alignment through plaster casting leaving surgery as the only option. Picture 6 shows a 13 day old baby with a cleft palate. The family brought this baby to visit the Doctor in Nilphamari in the hope to get surgery for their childs cleft palate. Luckily the doctor also diagnosed the child with club feet, so the baby received plaster casting at the ideal age and will receive surgery for his cleft palate when he reaches 10 pounds in weight.
On Sunday night I attended the leprosy patients entertainment night. Every Sunday, they meet in the Physio room and take it is turns to sing and tell each other jokes. This encourages the patients to bond with each other, get to know other patients in the hospital and relax and have some light hearted fun.
On Monday I was collected early in the morning and traveled with the Physios to a neighbouring district were another clinic was held for club foot children. We moved tables and chairs outside and carried out the casting in an area under the trees (picture 7). Picture 8 shows me with one of the Physios after our days work.
On Tuesday I observed many surgical procedures carried out by the doctor who was trained by a Surgeon from Switzerland who worked in Nilphamari for 9 years but left earlier this year. I observed club foot surgery, skin graft, below and above knee amputations and thinning of an inflamed nerve using a meshing technique.
On Wednesday and Thursday I worked with both the Physios and Doctor in the wards (picture 9 and 10). This involved assessing the patient’s sensation in both their hands and feet (picture 11) and reviewing the progress of many patients.
On Friday I travelled back to Dhaka to enjoy the weekend. I was sad to leave Nilphamari, during my stay I became very close to many of the staff members and patients. The staff included me into their team with no hesitation; they shared many stories about their families, culture and worries. I feel I have left Nilphamari with many valued friends (picture 12 and 13) who I hope to one day see again.

My second week
On Monday I visited a local leprosy clinic for outpatients. Patients visit twice a month for ulcer treatment, this includes ulcer debridement and 30 minutes soaking their feet in water to soften their skin and provide personal hygiene (picture 1). This ladies profession is begging, it was explained that her ulcer (picture 2) will not heal as she walks over 20km a day, and she will not give this up as it is her only income basis. Customised sandals are manufactured and provided at this clinic (picture3), although recently they have had to change their sandal design due to members of the community identifying a leprosy patient by the sandal they were wearing. This has lead to patients refusing to wear their customised sandal and so a different design has had to be developed. Below are pictures of the previous design (picture 4), and the new design (picture 5).
On Tuesday the physio, orthotist and I assesses this leprosy patient (picture 6). There were two ulcers on the plantar aspect of the left foot, one on the heel and one on the 5th metatarsal head. This patient previously suffered from osteomyelitis after toe amputations on the right foot causing bone loss leaving him with this everted stance, a large ulcer was present on the lateral aspect. We prescribed a customised sandal with a hatti pad (shown later) for the left foot, and a moulded rocker shoe for the right. I then followed the manufacturing process for both the scandal and the moulded shoes. Firstly, we cast the right foot marking the location of the ulcer with a crayon (picture 7). We constructed the positive cast posting the area where the ulcer is present by 1 cm in order to deflect pressure from the affected area. A flannel like material was attached with nails to the positive cast ensuring there were no creases on the plantar aspect of the positive cast (this process took approximately 40 minutes and required a lot of skill, needless to say, I left this part to the experts) (picture 8). Small pieces or cork were then attached with glue to the flannel material and filed until creating a flat base and sides (this was very time consuming taking approximately 1.5 hours). The patient was brought back to check the fit and when the orthotist was happy (picture 9), a cushioning material was applied inside the shoe, leather was stuck to the side, straps were manufactured and a sole was applied giving the final product (picture 10). This entire process took one and a half days.
The scandal for the right foot was manufactured by cutting holes in the base material which the straps could fit through. These are cut individually according to the patient’s foot. Once the orthotist was happy with the fit and location of the straps, he stuck the sole onto the base holding the strapping in place. The hatti pad is then applied to the top of the scandal; the purpose of this pad is to deflect pressure away from the ulcer on the heel and the 5th metatarsal head (picture 11). The patient was then fitted with his scandal and moulded shoe (picture 12).
It is clear that each process takes a lot of skill and are very time consuming. I have found it incredible what can be made from such cheap material and skillful manpower. It is hard to think of easier ways to manufacture these customised scandals or moulded shoes, as the resources and money are simply not available.

I arrived in Dhaka on Monday morning. I was collected and brought to The Leprosy Mission (TLM) guesthouse where I was made to feel very welcome. After a long flight I took the first day to catch up on some much needed sleep and to take the opportunity to settle in to my new surroundings.

Tuesday morning began by visiting a leprosy hospital in Dhaka. This hospital was roughly 1km away, and took 20 minutes to travel due to severe traffic. During the journey, the driver was telling me that Dhaka has a population of approximately 15 million people in a city 15km wide, and the traffic certainly is an indicator of this. I was shown around the hospital starting where the patients are initially assessed and ending at the inpatient ward. Within the ward I saw various clinical features of leprosy; skin lesions, clawing of the hands and plantar ulcers (picture 1,2,3). Many patients are kept in the hospital for ulcer treatment rather than being discharged with advice on self care as if the patients return home they continue work rather than resting and off-loading their feet. This is especially common in men as they are traditionally the main providers in a household, many families are struck with severe poverty therefore asking a man to rest instead of work creates a huge burden for the family.

In the afternoon I visited the slums with a TLM member. She explained that one of their developmental projects involved helping patients and their families deal with the stigma of being diagnosed with Leprosy. Leprosy still has serious social implications in Bangladesh. Many families disown family members if diagnosed. If a child has a parent with leprosy, they are frequently refused education. As clinical features are very noticeable, especially clawing of the fingers and the patches on the skin therefore suffers are easily identified. Due to this, TLM provides education to families to help them accept their family member; they also help to create leprosy support groups in areas of Dhaka. Leprosy patients then have the opportunity to come together to support one another and discuss their feelings among people who understand. Family members are also welcome to join and speak to other families to share their feelings. I attended one of these meetings with a TLM staff member; it was located in one of the poorest slums in Dhaka in a member’s home (picture 4). After the meeting, we walked around the slum visiting different member’s homes. The picture below is a leprosy patient who lives with her 7 children and husband. Due to her disabilities she receives 120 taka a day from the development project. Keeping in mind that 1kg of rice cost approximately 50 taka, this is not a lot of money (picture 5).

On Wednesday I travelled for 8 hours to the Danish Bangladesh Leprosy Mission (DBLM). The following morning I was shown around the hospital, this hospital is the largest of TLM’s leprosy missions with approximately 130 beds. I spent the day between the physiotherapy and orthotist/prosthetic department. I helped evaluate patients and manufacturing prosthesis (6).

I have been in Bangladesh a week and have already had many wonderful, sad and without a doubt life changing experiences. I am learning the culture and adjusting to the life here with the help of many caring TLM members.

The start of my trip to Bangladesh