Chaiman's visits to palawan

    I finally visited Palawan again in March 2010.  An account of my visit is below with some new photos in the gallery.      My visit in 2009 was to have been in February but personal factors have led to the postponement of this trip.

        The account of my visit in 2008 is given in the 2008 Annual Report which is below the new 2009 report.   (There are some photographs relating to the 2008 visit in the Gallery)

Report of visit to Palawan

March 2010

             I have just returned from another wonderful trip to see the work of the British Palawan Trust and to see more of the province of Palawan.  I flew via Dubai and was met in Manila by Soc.  The next morning we visited a very active convent where the nuns run schools for all ages.  We were asked to see a number of the nuns with various aches and pains mainly related to their great age.  Then we flew to Puerto Princesa.

            The whole of the Philippines is suffering from a severe drought that is also affecting most of East Asia, and is caused by El Ninõ.  This meant that it was fairly hot, usually over 35° C in the shade at midday but still very humid.   The fields especially the paddies were parched and mainly unproductive.   In addition the inshore fishermen were not catching the usual numbers as the fish had gone to deeper, colder water.   One island that we visited had caught no fish for two months which meant no income at all and little food.   They were understandably rather fed up!

            I stayed as usual in the simple but very pleasant little hotel, Casa Linda.   It has all one wants and is well situated being a short walk from Soc’s house and from the hospital, although I always took a tricycle taxi.   The price of a room has not gone up much although the weak UK pound has caused a slight rise over the last two years.   The staff, who remain the same happy bunch, now recognize me which adds to the pleasure of my stay.

            The week-days are all similar.   I start by arriving at Bahatala at about nine.  Soc is usually there as is the staff.  This includes the Therapists, the Prosthetist, the office girls and the odd job man who makes things and repairs them, things such as seating for children with Cerebral Palsy and also wheelchairs.  There are always a number of new and follow up patients being seen or treated.   We also visit the BPT ward.  This is now in general use, as there are currently two other doctors who treat trauma patients.  Soc usually has three or more of his own patients.  Unfortunately because we no longer have control of the ward it has deteriorated with dirt and loss of the pictures on the walls.

During my stay the ward patients included two fractured tibiae and four fractured femora.  One tibia was mid shaft the other upper involving the tibial plateau.  The shaft fracture was treated by skin traction and then put into a cast.  The upper tibial injury was taken home to be on traction there for about four weeks (see photo at the end).  The femora were at all levels; supra-condylar with extension into the knee, one mid-shaft, one sub-trochanteric and one per-trochanteric.  These were all treated with traction through a Denham pin, the first in 90/90, the second by classical Perkins traction followed by a thigh brace, the upper one in abduction and flexion and the NOF by traction and transfer to her home before early mobilisation.

The out-patients varied from simple closed fractures of the arm to more difficult cases.  The arm fractures were most often in children.  Distal radius, fore-arm bones and supra-condylar fractures made up the majority.  There was a case of tibial osteomyelitis in a teenage boy requiring sequestrectomy.    I was asked to see two cases of pseudo-winging of the scapular producing muscular pain and both caused by mild mid-thoracic scoliosis in young women.   There were two cases of fractured clavicle plus a fracture of the glenoid neck.  One had minimal displacement but the other had an upper brachial plexus lesion with a Horner’s syndrome.   All the fractures are treated without any internal fixation. 

We saw one case of carpal tunnel syndrome and one bilateral ulnar palsy from elbow pressure whilst in hospital.    A young man presented with osteoarthritis of the hip secondary to either an impacted subcapital fracture or possibly a slipped epiphysis.  There were the usual number of babies (Soc seems to have dealt with the older untreated club feet) coming for change of plaster using the Ponsetti method, and also patients with the puzzlingly common constriction band syndrome.  There are usually a small number of elderly patients who appear to have “burnt out” or quiescent Rheumatoid but I have never felt any evidence of synovitis.

I am sure that I have left out many patients but I do know that any visitor would see a vast and wide variety of both orthopaedic and other specialty pathology.  It is often a test of one’s retention of basic medical school training!

Two days were spent in Bahay Sanay our purpose built Training Centre.   The programme was to teach doctors from the, often remote, Rural Health Units.  Some are recently qualified and are sent to the more remote parts on a Government scheme.   They were shown how to apply bandages and slings, how to set up upper and lower limb skin traction and how to apply POP back-slabs.   They were very enthusiastic and keen to go back and try out their new skills.   On their return they started sending photos by text taken on their mobile phones for advice about management.

Some of the most interesting days are spent visiting patients in their homes.   We went south principally to measure a number of patients, paraplegics, amputees and cerebral palsy children for wheelchairs.  We now get the wheel chairs from a factory set up in the Philippines by Handicap International.   These chairs are of a very high standard and are able to cope with the local conditions.  The rough ground and the humidity wears out less well made chairs very quickly.

            We made three visits to the north of Puerto Princesa to follow up patients.   These included a young woman confined to a wheelchair because of Polio with major social problems.  Another was an 89 year old spinster who farmed in a very remote part of the country.  Four months earlier she had fallen (pushed by a bad spirit she said) and fractured the mid-shaft of her femur.    She came to hospital which must have been a difficult and painful journey in a bus where she was treated with traction followed by a thigh brace.   She was delightful and because I was the first white man to visit her we had to go upstairs for a cup of coffee.

            The trips to the outlying barangays (villages) are not always pure work.  Once we stayed on a small island on a reef, CocoLoco.   Quiet and remote with the most marvellous coral and fish just a meter or two down.  Another time we stayed in a new very comfortable resort (the local name for hotels with the rooms in individual huts or buildings) on a beach near the St Paul’s Park, a World Heritage site.    The sea water is always as warm as a bath and crystal clear, the beaches white coral sand and almost empty.

            I spent a great deal of time in discussion with Soc and Cecile.   The Bahatala building in the hospital grounds is beginning to show its age and we need to start making plans to replace it.   This will take time and, of course, money and will be outlined in a future News Letters.

            I would like to thank all the people who made my visit so enjoyable, Soc & Cecile, the Staff of Bahatala and the many friends in Palawan especially Oscar and Susan.

Louis Deliss

PALAWAN NEWS

Special Appeal Edition

 An Introduction to the British Palawan Trust

The British Palawan Trust was set up and registered as a charity in June 1990.   The primary aim of the charity is to improve the medical care of the peoples of Palawan with special emphasis on orthopaedics and trauma.

The main driving force and organiser of the concept was, and still is Dr. Jose Antonio Socrates M.D., F.R.C.S.Ed.   'Soc' as everyone calls him, trained in medicine in The Philippines and has worked in the USA and Great Britain.    His surgical training was mainly in the UK and he worked as an Orthopaedic trainee in The Ipswich Hospital.    He started work for the British Palawan Trust in Palawan during the spring of 1992.  He has built up an Orthopaedic Unit in the government hospital in Puerto Princesa the capital city of Palawan.   In addition he travels to outlying towns and villages.   It has therefore become possible for the inhabitants of Palawan to receive their treatment for such conditions as fractures, bone infections, polio and congenital defects on the island and not rely on herbalists and "bonesetters” or fly to Manila at their own expense, as they did before The British Palawan Trust orthopaedic unit was set up.

Mrs Cecile Socrates is also very much involved.  She gained a degree in Community Based Rehabilitation in Developing Countries.  The result is the evolution of a rehabilitation service network based near the hospital but extending to many outlying areas.  In addition she is the Chief Executive in Palawan and does all the administration with the help of a secretary and a bookkeeper in the cramped office above the clinic.

The British Palawan Trust is registered in the UK. There is a Board of Trustees who are or were Consultant Orthopaedic Surgeons at the Ipswich Hospital.   The charity has close links with The Charities Aid Foundation.

The administration of the Trust is all fairly simple.  In the UK it is run by the chairman from the registered office and from his home. The donations come mainly from British doctors and are collected in Ipswich.   The result is that all the money donated can be used directly for the expenses of patient treatment and for Dr. and Mrs. Socrates' living expenses. NewsLetters are sent to donors in the UK from Palawan on a regular basis.

The work increases each year as the Orthopaedic and Rehabilitation Units develop and reach remoter parts of the island. The current annual costs of running all the charity’s work is about £50,000 and without continuing donations the indigent people of Palawan would not have the specialist Orthopaedic care or the Community Based Rehabilitation network that have been developed.

Palawan

Palawan is the third largest of the islands of the Philippine archipelago.    It is in the southwest of the country only a few degrees north of the equator and therefore tropical.  It is nearer to Borneo than to the Philippine capital of Manila.  The countryside is mainly mountainous tropical rain forest with about 30% of the land in the coastal plains available for cultivation.   The main crops are rice and coconuts but the chief industry is fishing as Palawan provides much of the fish eaten in the Philippines. There are about 750,000 inhabitants the majority of whom live in the coastal towns and villages.

The medical needs of the population are provided by Private Practitioners and also a government Health Service although this has very few specialist medical or surgical services.  It is this specialist orthopaedic and trauma service plus rehabilitation facilities and the training of doctors and nurses that are now provided through the British Palawan Trust.

The activities of Bahatala

The work in Palawan can be divided up into various parts.

1.      Rehabilitation.

a.        Physiotherapy in Bahatala.

b.      Community Based Rehabilitation through our local workers.

c.       Manufacture of Orthotics and Prostheses.

d.      Manufacture and maintenance of wheelchairs

e.       Manufacture of Aids to Daily Living for the disabled and injured.

2.      Trauma & Orthopaedics.

a.       Treatment of fractures and soft tissue injuries.

b.      Treatment for congenital deformities such as club foot.

c.       Care of degenerative conditions.

3.      Training.  We have a separate purpose built Training Centre.  (See photos in Gallery and details in 2006 Annual Report below)  Here we train doctors, nurses and village health workers the principals of Appropriate Orthopaedics. (See Soc’s book for details.  This is available from the Trust)

 In order to perform all these services we acquired the use of an old building in the grounds of the Provincial Hospital.   This was named Bahatala from the Tagalog phrase Bahay Hawak Tayo Lakad or “House to Hold to Stand to Walk”.   It not only serves as a clinic area but also houses the Physiotherapy, the two workshops and the office.  The building itself is getting old and is now too small for our unit.  In addition the long term plan of the Hospital administrators is to build a new theatre block on the site, which is already surrounded by builders’ rubble from the first new hospital block.

We have found an ideal plot of land near to our Training Centre and not far from the Hospital.   It has no building on it which is good as we can put up one to our own design to fulfil our needs.    If we can have our own land and building it frees us from “political” interference and most importantly ensures our long term future.   We would also have enough space compared to the present cramped surroundings making it much nicer and more efficient for staff and patients.

This is where you come in. 

We need money to build the new clinic and to fund training.  

This is of course in addition to our regular income that is used for patient treatment.  We are appealing to individuals and companies in the Philippines and worldwide. 

For further information and to discuss how you or your company can help with these projects please contact me.

Louis Deliss. Chairman

e-mail.  palawanTrustuk@aol.com or louisjdeliss@aol.com

The 2009 News Letters should have reached you by now showing the success of the Ponsetti method that Soc learned at the conference in Finland a few years ago.   If you do not have a copy please let me know and I will put your name on our mailing list.

Soc has gave an invited lecture to the ARTOF (Association for the Rational Treatment of Fractures) meeting during the EFORT (the European Federation of national Associations of Orthopaedics & Trauma) meeting in Vienna. 

Please remember that costs are always rising and we are looking for new supporters.   Please tell your friends and let us know the address of anyone who would like to be on the mailing list.

Notice to all donors

1. Thank you to all our loyal donors.  I am well aware that many of you make donations on a regular basis often more than once a year for which we are extremely grateful.  I apologise that I do not acknowledge all the donations but I feel that this is really a waste of our resources,  If you do require a receipt let me know.

2. The work in Palawan is still increasing.  Not only do Soc and Cecile have to care for an increasing number of patients but the new training centre (Bahay Sanay) creates even more work - and of course needs even more money.

3. The latest Annual Report is now available.

4. We are about to send out a News Letter to doctors who are not on our Mailing List.   Please encourage others to support us and let me have the names and addresses of any colleagues who might be interested in our work.  Addresses on the Contacts page.

5. It would help me enormously if donors who have previously signed a Gift Aid Form could let me know when they sent donations.

Louis Deliss

ARCHIVES

Below are some articles that have appeared in these pages over the years.

They may be of interest to new supporters.

2008 Outstanding Award in Community Empowerment/Service

SOC IS GIVEN SPECIAL AWARD

by THE UNIVERSITY of the PHILIPPINES ALUMINI ASSOCIATION

GARI M. TIONGCO (Chair, UPAA Search & Awards Committee and President, U.P. Alumni Association) wrote to Soc.

Congratulations!  The UPAA Board of Directors has confirmed your award as 2008 UPAA Outstanding Awardee in Community Empowerment/Service.  We are proud to note that you have used your education from the University of the Philippines as a springboard to your total development in your profession.  We recognize your achievements in your particular field, and your leadership in projects which contribute to the welfare of Filipinos and to the larger society.

This is a great honour for Soc.  He and Cecile attended the meeting in Manila during the celebrations.  This year is the 100th anniversary of the founding of the University making the award to Soc very special. 

There are some photos of the event in the Gallery.

Sasakawa Health Prize

I am delighted to report that in Mayoc attended the World Health Organisation (WHO) Sixtieth World Health Assembly at the Palais des Nations in Geneva. He was there to receive the Sasakawa Health Prize for 2007.   The prize is given for outstanding innovative work in healthcare development.  this is a wonderful achievement and recognition of Soc's work in developing appropriate Orthopaedic and Rehabilitation in Palawan that is applicable in many parts of the world.

Photos of the award ceremony can be seen in the Gallery.

Further details can be found on the following links.

http://www.who.int/gb/ebwha/pdf_files/EB120/B120_DIV3-en.pdf  See notes on page 4.

http://www.nippon-foundation.or.jp/eng/brief_dtl/20070528HealthPrize.html

http://information-hub.ofw-connect.com/OFW_Articles/?q=Palawan_Doctor_to_receive_WHO_Award

Photos on  http://www.who.int/mediacentre/multimedia/2007/wha60/en/index2.html

Report of visit to Palawan August 2007

My annual visit to the Philippines started with two days in Manila.  Soc had arranged meetings with various, hopefully, influential people.   These were both in government and at the University of the Philippines.    Some would be helpful with Soc’s medical activities and some for his geological work as he still advises the Provincial Government on geology.   I was also scheduled to give a talk to the Orthopaedic Department of the Philippine General Hospital.   The PGH is the main hospital and medical school in Manila.   It was interesting to be shown around by the Chief Resident (SpR).   I lectured on Appropriate Orthopaedics as I see it, concentration on the need to question the excessive use of internal fixation.   The senior Consultants agreed but the juniors had more difficulty!

Then we flew to Palawan.   There are not many changes but a steady increase in the signs of affluence.   There are more cars and tricycle taxis on the road and more smart shops and restaurants as well as many new buildings.  The other measure is the tripling of scheduled flights from Manila.   I stayed as usual in a fairly simple wooden hotel near the centre where they are extremely welcoming.

Soc and Cecile were also most welcoming but got me down to work straight away.   Off we went to the Bahatala building to meet the staff including Angela a Canadian VSO Physio.   Then we went to see patients both in the clinic and in the ward.   There are the usual large numbers of Club Feet, many Constriction Bands, skeletal trauma and infection.    The first patient in the ward had a nice cold abscess with muscle wasting and osteoporosis making the diagnosis of Tb easy.   There were also the large numbers of forearm fractures in children and some in adults.   These fractures vary from fresh to a few weeks old, some even hoping for correction years later.  The fresh ones are treated by either manipulation under haematoma block or a few days on skin traction, often at home, before casting.    Fractured "NOF" are as usual not treated surgically and do very well, as do the femoral shaft fractures.   The sub-capital fractures often do not come in but are given a few days rest and then mobilised with sticks or crutches. The per-trochanteric are mobilised the same way after 1-3 weeks on traction.   Femoral fractures are treated by traction, skeletal in adults, on a Perkins’s bed for 4-6 weeks and then put in a thigh brace and mobilised.

We had a trip out as always.   This was to follow up some patients and to see new ones.   We went to Taytay which is the old Spanish capital of Palawan north of Puerto Princesa.   It was particularly nice to see “Lee” (see under “gallery” on the web site) who was at school and came running across in normal trainers.  We also saw new patients that had been “found” by Aimee, the local CBR worked attached to Bahatala.   These varied from simple trauma to complex difficult cases some probably infective and the usual congenital problems and CP.   Whilst there I unfortunate caught the local ‘flu and found a fever in temperatures of 95+ quite difficult.  But at least it was not Malaria!

The last week of my visit coincided with a two day course for doctors.  They came from most of the municipalities of Palawan to learn some Orthopaedics.   They are often the only doctor for many miles and have to be “multi-skilled”, performing Caesareans and treating the two common diseases of childhood, gastroenteritis and Malaria, but must be ready for anything including trauma.    I was able to present Soc with the Eyre Brooke Medal awarded by World Orthopaedic Concern International at the opening ceremony.  I then gave opening and closing talks, Soc did the most and short talks were given by the VSO Physio and by Cecile.   Everyone seemed very keen and to enjoy themselves.   The meeting was held on the BPT Training Centre (Bahay Sanay.   This building is in constant use for meetings and training courses.  It is definitely showing its worth.

I spent much time with Soc and Cecile talking about future developments and inevitably about finance.   The exchange rate has fallen a bit after the spectacular climb from 43 peso to the pound to 110.  It has now settled at about 90.   This means that the inflation proofing effect of the exchange rate has stopped and slightly reversed.   In addition the costs inevitable increase and the Training Centre will have revenue consequences.   Below is a table I will put into the 2007 Annual Report.  It shows the additional funding that Cecile skilfully and successfully arranges.  The small but increasing local contribution is very reassuring for our long term sustainability.   All the funds in Palawan go through the NGO we set up, Bahatala Inc.  There are in addition some other local donations for the supply of wheelchairs.

             I hope that we will be able to increase our income by completing the revision of our mailing list.   This has already gone up by about 15% but we need to increase further to cover increased costs.  Please consider us when making charity donations and pass on the news about our work to your colleagues

Chairman British Palawan Trust

www.britishpalawantrust.org.uk

2 September 2007

Report of 2006 visit by Trust Chairman

My annual visit in 2006 took place over Easter.  Being there over this devoutly observed religious holiday is a mixed blessing.  The whole island is in holiday mood with small shrines in each street and the Stations of the Cross at Calvary, a hill on the outskirts of Puerto Princesa which is part pilgrimage and part fiesta.  On the other hand the work stops and it is really to see the work being done that I visit, although the enjoyable holiday is another good reason.   I was greeted by Soc and Cecile at the airport and after dumping my things at the hotel it was straight to work.  

I saw very many patients with both traumatic and orthopaedic problems.   I spent time in the Bahatala building and with the staff we employ.   I even saw some new patients on my own when Soc was off doing other things.  It all brings home the excessive reliance on high technology that is the fashion in the west! 

I was also able to spend a great deal of time talking to Soc and Cecile.  Sometimes I talked to them both at other times I was able to talk to them separately.  The result was that I learned much and began to understand what the real problems had been over the last year.   It is now, I am pleased to report, all irrelevant as Soc is now reinstated with full admitting rights in the hospital.   The week after I left he had two operating lists and has had more since.   He is also once again using the BPT ward that we built as an extension of the hospital.   However one must remember that the majority of his patients do not require in-patient care

The new training centre, now called Bahay Sanay the Tagalog for Training (and exercise) House, is a really wonderful facility.   We must be very grateful to the Bishop of Palawan for most generously giving us the land.   The building, funded by an oil company, is in the grounds of a seminary close to the Bishops Palace.   This means that it is totally free from “political” interference.     The centre will be use for training courses.   The first is on 6^th & 7^th June and aimed at the School Nurses.  It will also be used for training village health workers.   At the opening I invited the Palawan Medical Association to use it for their meetings and I hope they will take up the offer.  I have suggested to Soc that training sessions for local doctors should start as soon as possible.

The cost of building the new training centre was all met by an oil company but there will be an ongoing cost for courses, upkeep and electricity.   In addition the number of patients increases each year.   Cecile has been very successful in obtaining additional funds from partner charities such as CBM (Christoffel Blindenmission), Stitchting Lilliane Fonds and others but the British Palawan Trust will have to find more money.  To this end I have been working with Soc on the mailing lists and NewsLetters.  I will also try to find companies to give donations and look to others to do the same. 

In summary the work of the Trust is still needed and appreciated by the Palaweños.  The numbers of patients and of the disabled who benefit is enormous and growing please keep supporting us. 

WOC International Eyre-Brook Medal Award

Soc received this letter from Mr K Tuson F.R.C.S. in 2005.

Dear Dr Socrates,

I am delighted to be able to tell you that I was able to announce to the International Committee of World Orthopaedic Concern that your nomination by WOC UK for the receipt of the Arthur Eyre-Brook Medal has been approved. As you know, the Arthur Eyre-Brook Medal is named after one of the founders of World Orthopaedic Concern and designed to recognise the efforts and input of surgeons like yourself who spent many years working in areas of great need. Many congratulations. I hope that Dr Rajasekaran, who is visiting the Philippines shortly, will be able to make contact with you to present you with this medal.

P.P.S.  I presented the Medal to Soc at the opening ceremony of the Doctors Training Course in August 2007.  I had been asked to do this by WOC.  The Medal now hangs in a frame with the certificate in the Bahatala staff room.  LD.