Echo in Africa 2015 – from Truro to Tafelberg – A Personal Journey by Sam Freegard

I don’t do marathons. I’ve never enjoyed running. Fortunately, when it came to fundraising for Echo in Africa (EiA) this year, I had an alternative plan.

image5

As I sat listening to Guy Lloyd present the EiA project to the 2014 BSE Annual Conference in Birmingham it occurred to me, “Why not me, next year?” I was planning to retire from general practice at the end of June followingmy 60th birthday. I had never set foot on the African continent. What better way to mark these professional and personal milestones?

As a GP with a special interest in adult cardiology, I run a community echo service from my practice in St Ives, Cornwall. I have BSE accreditation in ‘Community Echocardiography’ and personally perform, report and, where appropriate, give clinical guidance on just under 500 scans annually. The service was established in 2007 together with a sonographer colleague, Verity Curnow of ‘Echogenicity’, and is delivered from 12 sites (both in community hospitals and selected GP practices) across the county. Prior to this, a ‘direct access’ echo service for GPs was only available in secondary care at our local district general hospital (Treliske) in Truro. For some patients this could involve a round trip of some 70 miles and, almost unbelievably now, a waiting list then of up to eighteen months! My echo ‘patch’ covers West Penwith – the furthest southwest reach of the county – and, on occasions, has involved taking my Vivid-i machine over to the Isles of Scilly by helicopter.

After ‘collaring’ Guy Lloyd and Dawn Appleby at the 2014 conference, I kept an eye on the BSE website to request, and subsequently receive, my ‘Volunteer Information Pack and Application Form’ at the start of the year. By the end of February I was signed up for a two week placement from 27 July – 8 August. Names of other EiA volunteers began to filter through by email over the ensuing weeks and months. I failed to join the EiA Facebook community (I’m naturally diffident about using social media) but, as the departure date approached, there was some email connection amongst the volunteers as we began to choose the ‘extracurricular’ excursions we wanted – which sub

sequently proved to be a rich and enjoyable mix of Stellenbosch (‘Fairview’ and ‘Spice Route’) vineyards with wine tastings, Waterfront restaurants, a trip to Cape Point and the Kaap de Goede Hoop, an overnight stay and safari on the Aquila game reserve image1(including sightings of ‘the big five’) and, inevitably, conquering
Table Mountain. Moreover, my two-week attachment gave me weekends in the middle and end for catching up with a GP friend in Scarborough on the Cape, as well as visiting the Kirstenbosch Botanical gardens, climbing the Lion’s Head (2,200 feet) and – poignantly – on my last day, a crossing to Robben Island.

My flights were arranged simply, making use of the recommended, and very helpful, Ian Allan Travel team. Importantly, I had ordered my EiA ‘hoodie’ (£22). All that was left for my
preparations was the question of fundraising… I wanted to raise at least £1000 to cover my flight costs and, preferably, a little more to contribute to the overall project. This year, due to the success of the first year and, following increased industry sponsorship of the EiA project, the earlier requirement to contribute £200 to the costs was later rescinded and reimbursed.

For at least fifteen years now, together with two GP friends, one an accomplished pianist and the other a fine soprano, I have performed in the Cornish trio of ‘Medical Maelstrom’. About 6-8 times each year we are invitNew Picture2ed to perform shows to support a variety of fundraising events, mostly in Cornwall. Ours is a rather outmoded but, it appears, intensely popular form of entertainment that draws on the charm and skills of Fascinating Aida, Stillgoe and Skellern, Ronnie Barker, Victoria Wood, Kit and the Widow and several others. My contribution is mainly that of monologues and verbal nonsense interspersed with some songs: my colleagues provide the ‘quality’ musical items. Much of our material has a slight medical slant. We usually perform to audiences of around 100-200 and the venues range from village halls and small theatres, to churches and grand Cornish houses. At a guess, over all the years we have been functioning, we must have raised somewhere between £100-150,000 for local charities. More importantly it’s fun – especially the rehearsals.

So, that was it. To mark my retirement, a fundraising concert in St Ives. Why not capitalise on the goodwill of my colleagues and patients? Almost next door to our surgery there is a theatre – a converted Weslyan Methodist Chapel – which houses the ‘KidzRUs’ youth theatre company. For over 20 years successive waves of prodigious youth acting talent from within the community has been nurtured and developed by Philip Barnett, a local hairdresser and amateur dramatics enthusiast. For the loan of the theatre for one night (and help with staging and ticketing) it was agreed that any profits would be shared. It seemed an appropriate joint venture: the ages of the children involved with the theatre in St Ives are very similar to those of the children I would be helping to screen for rheumatic heart disease in Cape Town. Would we get enough, or any, punters to come along? And so, two days after my retirement, on 2nd July, on a sweltering summer’s evening and to a sell-out audience of just over 300 in St Ives, Medical Maelstrom raised a little over £3000.

Not long after, sporting my newly acquired ‘Senior Railcard’, I trundled by train from Truro to Heathrow. Dawn Appleby was there, waiting at terminal 5 with trolley, heavily laden with several large holdalls full of donated children’s clothing and shoes. It seemed I was first to arrive. Gradually the faces behind those now familiar, emailed names joined us. Among our throng was our President, Rick Steeds, whose wilder excesses over the next week were to be contained by the presence of his son, Art (or was it the other way round?). And there was some wry amusement among Cape Town arrivalthe assembled team when that other BSE dignitary, treasurer Vish Sharma, was noted to be travelling business class – there being, of course, no connection whatsoever with his personal comfort requirements and his official BSE role, but he took some ‘stick’ nonetheless! It was great to have them both with us and their presence undoubtedly lent a certain gravitas to our reception at the other end, as did that of Guy Lloyd and Mark Monaghan who, for the second year running, both came out to support EiA.  And so we each relieved Dawn of a holdall, bid her farewell, and, ignoring the ‘Have you packed your luggage personally?’ and ‘Has anyone handed you any luggage to take for them?’ booking-desk questions, we slipped through security and onwards. We were soon to become an effective and cohesive sonographic outfit, one that – entirely coincidentally and
unbeknownst to us – would come to share a love of Cape craft beers and wines.

A film or two later, after the eleven hour overnight flight and feeling unexpectedly fresh and free of jet lag (due to the marginal longitudinal difference of our destination), we approached
Cape Town just as the sunrise gave the Tafelberg (Table Mountain) a welcoming, pink glow on a glorious, cloudless morning. After collecting personal luggage – and nearly forgetting Dawn’s holdalls – we were greeted by the ever cheerful Clarence “too blessed to be
stressed” Prince, one of Heidi Whites’s “P2P Shuttle & Tours” minibus drivers who looked after us magnificently for the duration of our stay. Heidi’s transport service was at our disposal for the duration of our stay and was terrific. We were whisked off to Tygerberg Hospital and the very adequate student accommodation in Mankadan Lodge, part of the University of Stellenbosch. Admittedly, there were some minor teething troubles accessing
the rooms but these were soon forgotten.

An excellent distance learning module (with a reassuring summative assessment option) on Rheumatic Heart Disease devised by our hosts (Professor Anton Doubell, Dr Philip Herbst and Dr Alfonso Pecoraro) at the  Tygerberg Academic Hospital Cardiac Department, as well as a concise scanning protocol (based on the BSE minimum dataset but with some important highlighted additions for closer scrutiny of mitral and aortic valves) had prepared me reasonably well – I revised the learning module again shortly before leaving and took printed copies of both documents out with me. The subtleties of the early signs of rheumatic heart disease were certainly a revelation to me.

The ‘Sunheart’ echo suite in the cardiac department at Tygerberg has been designed specifically for the EiA project with its 10 scanning bays and a teaching suite. There, the slightly nervous, but cheerful and invariably polite scholars, mostly aged between 12 to 18 years, transported in cohorts of twenty or so from the township schools of Ravensmead and Khayelitsha, congregate and learn more about the project. I, too, was a little apprehensive. Was20150730_113740 I going to be up-to-scratch with my echo skills? Would I be as efficient at scanning as my new colleagues? Would I miss subtle signs of rheumatic valvular disease? I was at least familiar with the Vivid-i machines. We were quickly put at ease by the warm welcome from Anton, Philip and Alfonso – our hosts – with their support  team of Adelaide, Edward and Maryke. After a brief introduction at 08.30hrs on Monday morning, the first cohort of children filed in and so we donned our ‘Echo in Africa’ tunics, rolled up our sleeves and pitched in!

Part of the EiA project is about assessing the hand-held ‘Vscan’ as a suitable tool for wider dissemination of the screening programme in more remote areas of the Cape Province. During every screening scan we each performed, Philip or Alfonso (and sometimes Guy or Mark) would come around and effectively ‘check our findings’ with the Vscan device (with its very impressive 2D imaging) and we would be able to discuss the cases and hone our new skills with the required ‘additional views’ of the mitral and aortic valves. Although disciplined, it was all informal and friendly, and our hosts proved eminently approachable and helpful.

I think we all were humbled by the children. For starters, they are all bilingual (Afrikaans & English speaking). And it never ceased to amaze me how, from their impoverished, mud splattered and littered, ramshackle, corrugated tin homesteads (‘informal settlements’) around the suburbs Weekone4of Cape Town, these lovely kids could emerge so immaculately uniformed, bright-eyed and
aspirational – in fact, inspirational. During my fortnight, they made a huge impression on me. Amahle who wanted to be gynaecologist; Mosa, an actress; Elani, a social worker; Mpho, an IT consultant; Nkosi, whose sixteenth birthday it was, who wanted to join the South African Navy (like his father, based in Simonstown) and whose birthday treat later that day was to visit his eighteen-year-old brother who had recently been imprisoned for murder. All the children seemed so certain about what they wanted to achieve beyond school.

Sometimes, during a lull in the flow of schoolchildren through the department, we might be shown fascinating (and positively alarming) echocardiographic case studies: florid HIVassociated
cardiac lymphoma, Loeffler’s eosinophilic myocarditis, penetrating stab wounds to the heart that somehow had defied instant death…. all part of a normal weekend on-call ‘take’ it seemed.

Dr Philip Herbst presented the project and some ‘headline’ findings to the October BSE Annual Conference in Birmingham. During the last week of EiA 2015, the ‘2000 screened’ landmark was crossed – and this coincided with ‘Rheumatic Heart Disease week’ in South Africa. So far, ‘definite’ cases of rheumatic heart disease have been found in 1% of the screened population, with another 3% in a ‘borderline’ category (World Heart Federation criteria). A further 1% of screened schoolchildren had other, non-rheumatic, heart conditions. The positive cases will be followed up in the cardiac department at Tygerberg Hospital and those considered to fulfil the criteria for rheumatic heart disease will be offered prophylaxis
against recurrent acute rheumatic fever with monthly Penicillin injections – probably until aged at least 35 years. The screening project is to run for another three years. Thoughts about whether and how to extend the project towards providing a comprehensive Cape-wide screening service are gaining momentum.

So, what were the highlights of EiA for me? Numerous: a first foray onto the great African continent and a resolve to return; involvement in an interesting and worthwhile collaborative humanitarian project; better acquaintance with the mitral valve apparatus; an opportunity to scan alongside highly competent and delightful companions; a greater feeling of ‘belonging’ to the BSE community back home; instant oversight of my echosonographic studies (something of a novelty to me as a single-handed provider working alone in the community); relief to be using a familiar echo machine – the Vivid-i; the humbling experience of the informal settlement; some inspirational township schoolchildren full of hope and aspiration; unfamiliar cuisine of crocodile, impala and springbok; quaffing local wines; spectacular scenery; watching the Pumas beat the Springboks at rugby on South African territory; 500 and more photographs to savour; personal reflection on the horror and hardships of Robben island and an introduction to (I am embarrassed to admit, a name previously unknown to me) the former inmate, Robert Sobukwe. I have since read a lengthy and acclaimed biography of his remarkable life.

Perhaps most striking of all the memories of my South African adventure was that of visiting a township. Cape Town, one of the most multicultural cities in the world, and the economic and cultural hub of the Western Cape, like many large cities in the ‘developing’ (and, for that matter, even in the ‘developed’) world is embraced by acres of ‘informal settlements’ around much of its landward Freedom Farmperiphery. With their origins in the apartheid era, many of the townships are illegal settlements, traditionally overcrowded
with poor sanitation and public services, low levels of education and all the associated health problems that such conditions promote. Hence the basis of the EiA project, focusing as it does on one specific medical condition – rheumatic heart disease.

And so it was with the (relatively small – housing a little over 600 families) Freedom Farm township, nestled on the northern boundary of Cape Town’s airport. Heidi Whites, the proprietor of our P2P minibus shuttle, has for some years (and through her local church) been instrumental in the Freedom Farm feeding project – AKA ‘3FP’. Most weeks, she provides the children with a hot meal as well as sponsoring other events, including Christmas parties. Each week’s cohort of EiA delegates accompany Heidi to the
Freedom Farm township to distribute donated children’s clothing and shoes – hence Dawn Appleby’s pack of holdalls at Heathrow – often supplemented by individual gifts of drawing books and crayons, sweets and footballs…. The irresistible joy on the faces of those grubby, impoverished, grinning urchins who clustered around in their scores, and then rapidly enveloped, the P2P minibus did much to assuage our European awkwardness, embarrassment
and, yes, frankly, guilt. We continued to tussle with, aFreedom Farm 6nd mull over, those emotions in the coming days. I often find myself returning to those images captured on my mobile: hauntingly beautiful children – the heartbeat of Africa.

Extraordinarily, my first echo study on returning home to Cornwall is that of an 82-year-old woman (who I scan annually) with advanced (‘barn-door’), calcific mitral and aortic rheumatic heart disease – so it is good to rehearse my sharpened knowledge of the Wilkins and commissural calcium scores…. And yes, there have been a couple more Medical Maelstrom gigs. As I maintain, it beats running marathons and I’d love to go back to Tygerberg.

written by Sam Freegard – Volunteer 2015