Podiatrist Overseas

A Career Series in Podiatry –  Alison Clark-Morris

Experiences of Leprosy in India are brought into focus by Alison Clark-Morris’ as an overseas volunteer podiatrist. If you think of The Good Karma Hospital, think again! Alison certainly was not on a film set. The scenes shown in this article bring the reality of the disease, a bacterial infection that is still present in communities, wrecking lives.

Alison qualified in 1987 from Sussex School of Podiatry. The NHS beckoned and she worked at the Royal Berkshire Hospital in the acute sector managing diabetic patients.  Alison had home commitments and a family as she was undertaking the experience at a time when her career was established in the UK.

Her background in diabetic foot disease was an important plus but her story offers more detail about her impressions of India and her people. Her brother and his wife are involved with Hope Worldwide UK and have links with the other projects which involved India, Nepal, and parts of Africa.  So, that is how she found out about the ‘Village of Hope’. She made contact directly with the project coordinator to see if they would like a podiatrist to come and visit and work in the bandaging unit and whether she would be useful to them. The response was positive.

“My sister-in-law visited the Village in March before I went, which was in December 2017.  She took some photographs of the bandaging unit just so that I could see what resources they had and what’s sort of things I needed to take with me. My friend, Marian, accompanied me on my first visit went in December 2017 and it’s grown from there.”

Much of the work with leprosy is dealing with ulcers that fail to heal, managing wounds, offloading the pressure that patients cannot feel. As the foot breaks down with this cruel and indiscriminate disease which is not endemic in the UK, podiatrists and surgeons work to remove the diseased bone, loose toes, and even trim feet back to allow better healing.=

Alison has been to India four times so far, the first year she went with a friend, who had nursing experience and who worked for a charity. With a good understanding of project managing and how charities work and get funding, Alison realised the range of problems and operational complexities that had to be overcome.  On her second trip, she was joined by Lloyd, her husband, and built on the experience from the year before. They made links with the local Leprosy Mission Hospital, but with only a short time visiting the country it was easy to lose these connections.

By her fourth time, she went out for three instead of the usual two weeks. This visit included a colleague and her oldest daughter who had just finished her engineering degree. Reflecting on why she chose to manage this disease, officially called Hansen’s disease – an infection that attacks the nerves.

“I’ve always been interested in leprosy. Not that I’m very religious, but Bible stories have inspired me. I felt quite a lot of sympathy for that group of people who were ostracised by their communities. At that point, I didn’t know that they had foot ulceration. But learning about it at college I just thought, that’s something I would really want to be able to do and help that community practically.  I’ve always kept my eye open for opportunities, but never really been able to give up more than two- or three weeks time out of my working life because of various other constraints really, a bit family or financial.”

Arriving in Delhi

As she walked through the disembarkation hall she was struck by the noise and the dust.  Alison only ever goes during the winter period, so the heat’s never been an issue. So, the first time she went, she flew out on Boxing Day and returned in January in order to take advantage of the cheap flights. Her last visit was in March as COVID-19 was starting to come to the fore. Apart from the dust, she found pollution a big issue, together with the noise and the smells and the rubbish. She repeats her memory of ‘the litter!’ Of course, other smells are more typical with the aromatic waft of spices. She used Airbnb for an apartment.

Her descriptions are vivid. To travel around she used Uber and Tuk Tuks – a motorized rickshaw. She had no idea what her accommodation was going to be like although she had checked out the photographs beforehand; “I remember driving to it and thinking, Oh, please, God. Don’t let it be here.  The roads got narrower and narrower, and dirtier and dirtier. There was more wiring all over the place, and I thought we can’t possibly be living here. But that’s where we were living. But then when we opened the door of the apartment, it was good. It needed a good clean. We spent the first day cleaning it, but once we made it home, it was fine. And it was quite a good location for getting to and from the village. I have found somewhere better since then.”

The people and barriers

The language was a concern especially with work as she had to try to convey information to her patients. Visual prompts were required all the time. People were ill-educated, unable to read or write. They had to be taught not to put effluent waste in the drinking water and how to be clean and tidy. It is better as the grandchildren are getting an education now, and the Hope Worldwide project is working well, and “the community is becoming more affluent, and I can see that every year I go. There are maybe more motorbikes. It’s a bit cleaner, more mobile phones, that kind of thing.”

neurotrophic ulcer as a result of lack of sensation

During her last visit, she used a lot of MedihoneyTM brought from the UK on wounds because of the inherent antibacterial and antimicrobial properties which help with the bacterial load in ulcers. People with leprosy still walk on their wounds and we keep the honey in place with a gauze dressing. She started to see improvements in wounds and was able to issue low-cost shoes designed to offload the pressure. During Covid, the bandaging unit was closed but they left lots of honey behind. Twice weekly bandage distribution was carried out and patients queued up to receive these so that they could dress their wounds at home.

adapted shoes help this man with a form of club foot

Skills building

While universities provide all graduates with a range of skills, it is not until employment begins that you know just how much or little you need to develop. We are all young once, and we believe we can fix the world, or so the saying goes. That drive, confidence and enthusiasm are what allow us to progress and add knowledge that turns into a skill. Handling a sharp knife is second nature to every podiatrist. First, do no harm to patients, secondly do not harm yourself. Third, use the knife in such a way that it achieves your aim. The podiatrist first learns to remove skin and tissue without causing bleeding, however, in the diabetic and those suffering from the neuropathic ulcer, the material is dead and attracts microorganisms. This must be removed. Alison was influenced by a mentor, an important person we should all seek. Someone who has the knowledge, an abundance of skills, patience and understands your need. We find a mentor and make changes in our life. Later we become mentors.

“Neil Baker was a wealth of information, and I used to work in the diabetes centre, Royal South Hants Hospital with him and used to help out the wound clinic there. And then I moved up to Reading. I was out in the community for a while, but by that stage, we were prioritising people with diabetes. And then I moved from the community into the hospital base, so most of my NHS work has been working with foot ulceration and diabetes.”

Today Alison covers a wider range of practice, but working with her husband, Lloyd, she uses his skills for the musculoskeletal side. Diabetes is a metabolic disorder, and wound healing arises because of a metabolic abnormality. Alison adds,

“Stuck in a static wound phase there’s defective chemotaxis or there’s impaired growth factor production or impaired angiogenesis. So those proliferative and inflammatory phases are interrupted and so you get that chronic wound with raised blood sugars, there’s a higher risk of infection, reinfection, and antibiotic resistance. With a leprosy wound, it’s simpler in that Leprosy is caused by a bacterial infection rather than a metabolic disease.”

Alison points out from the medical point of view unless patients have a combination of diabetes and leprosy, the latter condition is easier to manage. The podiatrist will minimise the bacteria, reduced the pressure loaded onto the foot and ensure any material tissue that no longer has a blood supply is surgically removed, usually without anaesthetic. Working as part of a medical team was both satisfying but had its frustrations because doctors from the Leprosy Mission Hospital could provide laboratory and pharmacy support but liaison between them and the Bandaging Units was limited.

How easy was it to manage patients and their problems?

Alison pointed out it’s just very difficult to get the patients to rest, but if you could get them into good shoes and made to measure insoles then improvement is notable. Another important part of work is establishing preventative care.

“We were doing a lot more preventative care than we were on our wound care because they would come with a wound on one foot, and we were insisting that they showed us the other foot. Pre-cleansing was important before we commenced working to remove dead tissue with a scalpel.”

Alison helping locals adapt to foot problems

Teaching the locals was important and those called bandagers responded well and could be taught how to use scalpel techniques once podiatrists had left.  As she points out “some of the stuff was verging on surgical,” meaning going deeper than the surface layer of the skin.

It is not just the skin that deteriorates in leprosy but joints. Deformity arises because of the loss of nerve sensation. Muscle power alters so the foot drops down at the ankle making walking difficult. Braces could be used to redirect pressure, but financial constraints acted as a barrier, but the technology was there if the money was. Many patients were seen sitting cross-legged, men playing cards and women cooking or washing. This meant they developed wounds on the side of their ankle bone. Alison’s caseload was biased toward men by 3:1 and based on her observation and experience. The impact on men where they are the breadwinners provides some idea of the potential impact on the socio-economic stability of parts of Indian society.

Close communities as much as anything alongside poor hygiene is an aim of the World Health Organisation. The WHO has reduced the incidence of new cases worldwide and have launched a global leprosy strategy in 2016. The aim is to accelerate towards a leprosy free world. Liaising with governments and government partnerships and funding remain critical and then sponsoring a programme from the UK, Australia, and the USA. Early diagnosis and prompt treatment reduce the spread of the disease and the development of deformity. The process does not just stop there as education to stop discrimination, to promote the integration of those patients into society so they’re not ostracised, and are able to earn money as part of normal members of society is really a multi-phase aim of the programme Alison explains.

India is responsible for about 60% of the new cases with plenty of work and opportunity in India and Nepal. There are around 159 different countries where new cases are reported and so the Indian continent is not alone. Poor diet, poor hygiene, and lower castes are at greater risk from leprosy. Medieval images of people wearing sacks over their faces or hoods to minimise the visual are seen more in women than the men in India. Women often lose their noses and try and hide their noses with their hands but their hands are probably worse than their noses because they often lost their fingers.

Perhaps there is little humour to be found in such a profound condition but Alison recalls using  Snapchat photography. In the case of one woman, Alison tells me, “I put a filter on my phone which gave her glasses, and it gave her nose. And she was absolutely thrilled. She just couldn’t stop looking at it. Women are more conscious than the men.”

specialised bikes arrive with celebrations

It is easy to see that those who volunteer don’t just apply their medical skills alone. Raising money is another important role and when Alison, a colleague and a friend tried to raise money for tricycles to help mobility, the expectation of supplying 10-15 bikes was surpassed and they were able to buy 57.  They gave out all 57 tricycles to the community on World Leprosy Day.

“We had a stage and we had dancing, it was beautiful and colourful. Two double amputees were helped onto their tricycles and wheeled away. Such stories have changed people’s lives in a simple way that they are now able to go out and do the shopping and contribute to the family. Even if they could go shopping, they couldn’t carry the shopping because their hands didn’t work. For example, one man now takes his child to school because he can sit his child next to him and take him to school on his tricycle.”

 Once the bikes are available a little box can be attached to the back which allows items to be carried in the box. Each bike is manufactured in India, and they arrived the night before Leprosy Day, as flat packs on two lorries.  Once assembled at the village they were ready on the morning of Leprosy Day. One patient’s prosthetic fitted poorly so that he kept getting a wound on his stump. The tricycle allowed the stump to heal, and he was able to get around on the tricycle

 Alison recalls breaking the strap on the flimsy sandals provided by the hospital as she was fitting them back on some tiny feet. So, she found some children’s pink sandals, which the patient was very pleased with. The following year she brought back a purple pair. “Each year we bring her a new pair of shoes, and she’s very pleased with those. I just think they’re very grateful. They’re a very open community.”

 Alison has managed to find funding for podiatrists and foot care assistants and says if podiatrists, or even podiatry students, are interested in getting involved, help with funding your trip may be possible.

Some of the key aims of a podiatrist

  • Educate ALL as best you can, given the language barrier
  • Remove non-viable (dead tissue)
  • Manage infection
  • Enhance the closure of the wound
  • Check both feet to aid the prevention of escalating problems
  • Integrate back into the community

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Thanks for reading ‘Experiences of Leprosy in India’ by David R Tollafield following an interview with Alison

Published by Busypencilcase Communications. Est. 2015 for ConsultingFootPain