Life As An Ortho Surgeon: A Chat With The Gambia's First Orthopaedic Surgeon
As part of my one-year blogiversary, I had the opportunity to interview one of my biggest inspirations in Orthopaedic Surgery, Dr. Kebba Marenah, about his career in Ortho and Trauma but most specifically about his return to the Gambia.
The Gambia-born and UK-trained Dr Marenah leads the way in Orthopaedics and Trauma Surgery in his hometown. He is the first fully trained consultant in the specialty. He is the Head of Surgery at the Edward Francis Small Teaching Hospital, Gambia. Dr. Marenah is a Fellow of the Royal College of Surgeons of England and holds a Post Graduate Diploma in Musculoskeletal Sciences. He is the Country Lead for the AO Alliance Trauma country initiative and has been very instrumental in organising courses in fracture care in the Gambia.
I met Dr. Marenah in 2018 through one of my mentors (both pictured on the left). What struck me the most about our conversation that day was his dedication to improving Ortho and Trauma care in the Gambia. He told me something that stuck with me. He said that the UK can replace his job post in a heart beat, but the Gambia can not. His services and expertise are more needed at home. That, for me, is the reason why we do what we do. To make sure that everyone has access to surgical care regardless of where they are in the globe. Not many doctors get training in state-of-the-art institutions and go back home. It takes discipline, selflessness, commitment, passion, drive, love, and determination to change lives to make a decision like the one Dr Marenah made. It is absolutely awe-inspiring! In our little Q and A session, he shared his journey in Orthopaedics so far, some of his highs and lows, his passion for training young doctors and his vision for the future of ortho and trauma care in the Gambia.
Marcella: Thank you so much Dr Marenah for joining me today. I know you're very busy and I am really grateful. So let's get started on why you choose medicine as a career? Did you always know you wanted to be a doctor?
Kebba: I'm not even sure, to be honest. When I was younger, I wanted to be a mechanic, an engineer. That's the kind of thing I like to do.. using my brain to solve problems and solving issues with my hands. Both my parents are in healthcare. My mum was a nurse, and my dad is a doctor. And somewhere along the line, it kind of found its way, I'm not sure how. I did science subjects in school.. biology, chemistry, the usual things. I think something clicked. One theory was that my sister (I only have one sister, and we are very competitive) did electronic engineering. So I said, well, my sister has done engineer; I will not do the same thing. So I found a different area, and I fell into medicine.
Marcella: Why Orthopaedics? What inspired you to choose Ortho?
Kebba: So I think it goes back to what I wanted to do before. Ortho is the engineering of medicine. Orthopaedics is like being a mechanic in medicine where you get to use your hand and mind to fix things, make things, and improve things. I always knew I wanted to be a surgeon, but orthopaedics was the only logical thing. I wanted something technical. Ortho gives me all of that, plus it makes a big difference in our part of the world. I always knew I was going to come home, and I wanted to do something that I felt would make a difference. At the time I started doing orthopaedics, there was no Ortho Surgeon in the Gambia. When I graduated, I was the first. Now we're two, soon to be three. At the time, it was (still is) very useful, because three ortho surgeons for a population of 2.1 million is still far too little.
Marcella: You've basically answered the next question I was going to ask about when you decided to move back to the Gambia. Did you always know you wanted to go back home, or was there a particular instance that you decided to return home?
Kebba: I think it may be a family thing. My parents both did their training in England and then came back home. My sister went to school in England and came home, so it was always something in our setting. We were brought up to love our country and serve our country. So it was always something that I wanted to do, and I felt I needed to do. So it was never a question for me. It was always to do my medical school, do my training, get to the highest level possible and then bring those skills back home to serve my country, my people.
Marcella: That's really good, though. Because many people go and they don't come back... for many, many different reasons. So it's vital to have people who want to go back home. For me, that's one of the things that stuck with me the most when I met you. You were so determined to come back home and change, and I mentioned this earlier in the introduction. I found it so inspiring coming from a similar country with similar needs. What would you say is the most rewarding part of being home?
Kebba: Ah! There are two sides to it. I think one of the fears I had (knowing my people) was being appreciated. And you know we don't do what we do for the recognition, but it makes a big difference to be appreciated because it's hard, it is very hard, I'm sure you know. The work we do, the conditions we work under, but still have to make people better and improve their lives. And if you're not appreciated for doing it, it can be even more challenging. So I think that appreciation helps push me. When I see that people appreciate what I do and that I'm actually making a difference, it helps push me through the hard times; times where you think, is this worth the stress, the aging, and everything? That goes a long way because you feel well, I am appreciated. And often people tell me that before you, this couldn't be done or we had to go abroad. But now, all that can be done through hard work, so that's probably what the best part is.
Marcella: I guess that must be very satisfying- knowing that you make such a massive difference in these people's lives is really rewarding. A little while ago, you were on BBC Focus on Africa about the first knee replacement surgery in The Gambia. It was fascinating to hear you talk about that. How does that make you feel? Does it give you some hope that things are moving in the right direction? Because I know that the Gambia is similar to Sierra Leone, sometimes clinical work can seem like an extreme sport. So did the possibility and success of a knee replacement surgery in the Gambia give you some hope for the future?
Kebba: I think I still feel like I have to push. I have to be the driving force for any change I want to happen, but what that knee replacement surgery did was two things. One was that it got the confidence of people. In the past, I mean, you know, even if it could be done here, they would say I'm not gonna let it be done here, or I'm not gonna let a Gambian do it. I will instead go abroad and have it done. The person who had the operation possibly could have afforded to go overseas to do it. Still, the fact that they had faith to stay and do it here, for me, was a positive change. Because it means a lot of other people will want to stay and have things done. So things are moving from that point of view because they now have faith in the system and trust the system to want to have surgeries done here. And the other part, to be honest, I wasn't expecting the reaction that I got. Because you know me, and I do post many things on social media anyway just to try and get this confidence from people. And again, for me, this was just one of the things I was posting, not expecting that it would go viral and get the recognition that it did. But again, out of that came a lot of that appreciation; when people see and commend your work. For me, it was a small thing in a way because it was one out of maybe 150 or 200 knee replacements that I've done. But for the country, it was the first-ever, and it never happened before. Most people felt like it was something that they never imagined would happen. So then I realized that it was really a big deal. It made me realise how much of a big deal some of these things actually are- some of the things I may be taking for granted because I'm used to doing them in other places.
Marcella: I think it is a big deal. Very many congratulations again on that! We don't do knee replacement surgeries in Sierra Leone, so it would be a big deal if we did one now. We're all so proud that you did that. You're leading the way. I know you have done quite a lot in the last three years, but what are you most proud of? What accomplishments are you most proud of?
Kebba: When you're in the situation, you often think about how things are going, and you feel frustrated. Because the pace of change feels so slow every day, fighting against the system and pushing to get things done. And I have always had to remind myself that sometimes you have to take yourself out of the situation, take stock and look back. And recently, I was looking at a plan that I'd made before I came home. I used to come home for two weeks and see the department because they barely had an Orthopaedic department, which was to serve the whole country. So I came up with plans, and it was interesting that I looked at them a few days ago. I realized that I have achieved most of the things that I felt were immediate priorities and things that needed to change; I have managed to change. But like I said, day to day, you'll just keep thinking that nothing is changing, nothing is moving, you're just frustrated, and you don't see the small changes. It's like when you're living with someone, and they grow up, or they grey, you don't realize how much until you spend time away from them, and when you see them again, you're like, Oh my God. But if you're with them every day, you don't realize that it's happening, and that's how it feels. So sometimes, you just have to take a step back and look. And we've come a long way, I think. To successfully establish an Orthopaedic department, a functional department has to be one of our successes. But the main thing for me is really making it sustainable. With the AO Alliance partnership that we have, we have one trainee currently being sponsored in Russia. This year, we have one who's going to Malawi, and we have funding for another one to go to Malawi next year. So in five years, roughly, there will be four of me. So from zero to five in five years, I think it has to be one of my most outstanding achievements. It's not just for me. Of course, the residents have to do the work. I think quite often people worry about competition and other things that we shouldn't be worried about. For me, having other people who can do it as well as me or even better than me is the best thing I can leave this country with. I came with a plan. I had a five to seven-year plan. And I want to be able to say in seven years that I have brought Orthopaedics to this level, to the point where it can sustain itself. The people I have trained can start training the next set of Ortho surgeons. Then, I can concentrate on at least trying to specialize more in a particular area in Orthopedics and be the go-to person for that area, but for now, I have to do everything.
Marcella: It's essential to train more people. Because you can be there alone for five years, or ten or fifteen years but doing it all by yourself is not sustainable. A new generation of well-trained doctors is the best legacy you can leave behind. Also, I totally agree with you on the power of reflections. Things can get really frustrating in our settings, so it's really important to go back and look at all those little steps and all the changes they've accounted for. That's extremely important. What are some of the biggest challenges that you face every day? What do you find most challenging in your work and everyday experiences?
Kebba: I think one is attitudes. I have been fortunate in some way to have a very good team, or at least been able to put a good team together. Just take today, for example. I finished work after 6pm. They all stayed without me having to ask them to stay. Whereas the majority of people pack their bags at 2 o'clock and go home. And that's a tough concept for me as a healthcare worker, especially in how I work- you work until the work is done. And I think there are various reasons for these attitudes- the pay is not very good, the conditions are not good, so people don't put their all into it. But I am the kind of person who puts my everything into whatever I'm doing. So I find it problematic that others are not doing the same. I think we are alright in my little tiny area of Orthopaedics, but the rest of the hospital makes it so frustrating. You know you get calls to say that there are no gowns because laundry didn't do it or was not sterilized. Or there are no gloves, or sutures, or water (happens very often). All those systemic issues are the most frustrating because you try so much to change the path that you can change, and the paths that you can't change are the ones that are frustrating because they hold you back. But there's only so much power you have to change everybody's mentality or change the whole system and how the system works. Those things will take a much longer time, and you just have to keep your sanity while they are slowly changing. I'm pragmatic though, I think I wouldn't be so frustrated if I saw that things were changing slowly because then I'd say, okay, you know there's a way out. In five years, it wouldn't be like this. When you look round and feel like it hasn't changed in three, four years, then you start to worry whether it's ever going to change.
Marcella: That's true, though. Because of the lack of systems, things can look really frustrating and challenging. Still, we have to keep pushing, hoping that somehow we can influence some change. What breakthroughs would you like to see in patient or surgical care and training of medical students and doctors in The Gambia?
Kebba: I would really like to see what we call local solutions for local problems. I think if everybody had that mentality where for example, you walk into a ward and see a patient with a femur fracture who needs traction, so instead of saying we can't do it, we get together and have welders make the frame, get tailors to make sandbags, you know, have everything sorted from out here. Have people with innovative thinking. So if we have those people, that would be the most significant change. We start changing from within and not waiting for things from outside to help us change and improve the situation. But that's not really something that we can teach but maybe can train. So I don't know how we'll get to that stage, but if we did, that would be the perfect thing for me.
Marcella: I think you can train minds to think in a certain way. So train them to be innovative instead of being totally reliant on external support
Kebba: We have the minds, we have the resources, but we waste so much because we don't use them. We don't put things together and try to make something out of them.
Marcella: In one of your previous posts on Twitter, I saw a humerus 3D brace printed in the Gambia. That was really cool. More innovative things like that should be done, don't you think?
Kebba: Yes. The group I'm working with we're in the finals for the Royal Academy of Engineering Awards. We're the top three finalists for that, and that has been something outstanding. We have been trying to see what things we can do for the OR that use 3D printing to make things we need that will otherwise cost a lot more to buy from outside- the simple things. That is a possibility
Marcella: Just before I let you go, what advice would you give to junior doctors and residents in their early surgical training, especially regarding orthopedics, based on your experiences so far?
Kebba: I would say the best thing you can do is not give up and get frustrated. The second thing will be to set your sights on something and go for it. Don't let people tell you that you can't or you shouldn't. Decide that this is what I want to do; I want to be an Ortho Surgeon and then see how things will fall into place. Sometimes, you'll get discouraged because of the path you may have to take because it's not straightforward. It may be longer than usual or financial things, but you just have to keep going, and I think you need that conviction. Sometimes you need to tell yourself why you want to do this and see that you get there. It may take longer or be a lot harder than you planned, but the end will make it all the more rewarding. You know how they say that nothing worth having comes easy, which is true to some extent. But this doesn't mean life should be hard for us. We need people we don't seem to have in Africa. We don't tend to have leaders who want to bring up the next generation. And it would be so much easier if you had those people who would just push you and make sure your path is made easier, but we don't have many of those. So often, you just have to fight for your own course. But remember when you get there, that just because it was difficult for you doesn't mean it has to be for others coming after you. That's the mentality many people have, but for me, it's the complete opposite. If it was difficult for me, I'm going to make sure the person who comes after me has it more straightforward. Because they will do better than me. If you become that person, you will be the change maker, and others will find it easier after you. I'm looking forward to celebrating you doing Sierra Leone's first hip and knee replacement surgeries and so on.
Marcella: I hope we can celebrate those hip and knee replacement surgeries in the near future. Thank you so much for your time.
Kebba: My pleasure.