Humanitariansurgery.org

Read about Dr. Glen Geelhoed’s mission to Sudan on the Global Health Progress website: http://www.globalhealthprogress.org/blog/?p=40

Adam Fox spent 2 weeks on a surgical mission in The Gambia, here are some of his observations.

Greetings.

…this international work is continuously fascinating to me.

To give you an update about my recent travels

-just got back from my 2 weeks in The Gambia.  was quite an experience…much different than my previous 3 trips to the Philippines.  It actually caught me somewhat off guard with the significant differences that i encountered.  It sort of made the places in the Philippines look 1st worldly

-pulling up to the “hospital” I was greeting by the veritable zoo that lived on the campus…dogs, chickens and goats were the main inhabitants plus the occasional donkey….all cute and i got some really good pictures but never imagined this for a hospital

-electricity for only a few hours during the day, which may or may not change soon given the new solar panels that were just installed…

-bucket showers…not always my idea of fun, but at least i had the opportunity to shower

-realization that there were so many obstacles to patient care the way we know it…your chest tube story struck a cord…..could not be done in my institution either …no suction, no pleurevac/bottles or chest tubes for that matter…

-without mechanisms by which to do things, I realized that the knowledge base about the “next step” was limited both among the nursing staff and the new medical students that I dealt with….every time I gave a lecture I found myself backtracking to some extremely basic concepts….a military guy from our group commented to me one day after I realized that I could not really teach the basics of trauma (via primary assessment/treatment through an atls model) that what the people of this hospital need is a wilderness medicine class…cant say that I disagree with him

-had my first deaths during one of these trips….one that nothing could be done about ( 90% + total body surface burns (partial and full thickness with inhalation component)) and one that probably should not have….was very disturbing to me….50 ish y/o female admitted for an  epigastric hernia that they would not let me operate on because she had 4+ glucose in her urine….IM docs (from Cuba) were consulted to help get her sugar under control…found her one morning obtunded and turns out that they had given her a long acting oral agent and not really checking her sugars frequently…after I provided the requisite D50 and started her on D5w drip, she was transferred to the medical ward where she became hypoglycemic again, seized and died…..me and my colleagues were very disturbed by this….

-realized and confirmed what you had told me when we spoke….education may in fact be the most valuable thing we can provide….the surgery is always fun but they are truly lacking education….it seems to me that curriculum should be developed for places like this that provide for basics (like a wilderness survival course on steroids)

-the local cultural stuff was great

All in all, I’d have to say it was a great trip…made me significantly reevaluate how I should be going about things on my future trips…..

The President of Guinea, a press conference, and a chest tube

The President of Guinea:

A muted “pop!” then silence. We all flinched, hastily glanced around, laughed - nervously, and then breathed an audible sigh of relief. Dr. Kabineh, the young Sierra Leonean ear, nose and throat specialist had just opened a can of Coke. It had made a bit more noise than usual, nothing dramatic - that is, nothing dramatic were it not for the presence of fifty or so heavily armed young soldiers in camouflage fatigues, red berets and wrap around sunglasses frenetically scurrying about the main hall of the Palace du Peuple. Is there a manual that these guys read about how to dress and act? Are they required to watch a lot of late night TV? Why did they all look like hip-hop gangstas or B-movie mercenaries? I sorta understand the majority carrying automatic weapons; but one especially fashionable chap had a long belt of large caliber machine gun bullets draped around his neck like a shawl. All this was occurring just minutes before the opening ceremonies of the 49th West African College of Surgeons (WACS) annual conference. We were in Conakry, the capital of Guinea. Surreal is really the only word to describe it.

So sure, last time I checked in I was in Freetown, Sierra Leone, however, this past week I was in Guinea. Yup, the same Guinea where there was recently a military coup d’etat. The country that is now run by a military junta led by Captain Moussa Dadis Camara - His Excellency, President of the Republic of Guinea, Commander-in-Chief of the Armed Forces, President of the Conseil National de la Démocratie et du Développement, CNDD. Yep, quite a mouthful and I’m still not sure how a Captain can outrank a General, but I guess in third world politics this is how it goes. As a bit of background, Guinea was the first former French colony in Africa to gain independence in 1958. On December 23, 2008, Lansana Conté who had been President since 1984 died; that’s when Captain Camera stepped in. The people so far are supportive. So far.

So, what was I doing in Guinea? Well, as the WACS conference was being held in Conakry; and it is relatively close to Freetown; and almost all the Sierra Leonean surgeons were going - heck, I decided to go too. We assembled on Saturday morning and by 10:30 a.m. had hit the road. Unfortunately, we were unable to use the air-conditioned large bus promised to us by the Sierra Leonean President. Instead 22 of us jammed into a smaller vehicle for the 300 mile journey. It only took us 11 hours. We passed over-laden minivans and at times traveled over rutted unpaved roads. As this is the dry season, we used surgical masks to breathe through the clouds of dust that enveloped us as we drove with the windows open in the un-air conditioned 90+ degree heat.

Overall the trip was rather uneventful, and of course at the border crossing there was the obligatory - fill out a form, then get an exit stamp in your passport, then go to customs, then get an entrance stamp, then, oh, this country just had a coup and you’re not getting paid and you want to eat and so you will demand money - well, the senior surgeons in the group were adamant that they would not pay any bribes. So discussions went back and forth. At one point the local army commander appeared in order to “solve the problem.” He and I were actually able to communicate in Spanish (I’m thinking the Cubans had a hand in that) as my French is not so hot. Finally we were on the road again; we hadn’t had to pay, however, we agreed to transport two junior officers to Conakry, and then give them the equivalent of $10 for return car fare. We hadn’t paid. But we had.

We arrived in Conakry at night and were met by a vehicle from the Sierra Leonean Embassy and guided to our hotel, Le Petite Bateau. It was a relatively lovely place, large swimming pool, out on a jetty, a restaurant with tables overlooking the water. The rooms were not the greatest, but we got a decent rate - and there was even air conditioning and running water: so, a veritable palace.

We arrived on Saturday, toured the Medina (the market section of town) on Sunday and on Monday went to the opening of the conference. Things were rather disorganized. Sessions didn’t begin on time, and then there was the swarm of soldiers taking over the building, Ultimately His Excellency, Captain Camara spoke. He looked rather eccentric, appearing on stage wearing sunglasses and the academic gown and hat of the College over his military uniform. I listened to his speech with the simultaneous translation, a rambling discourse, something about respecting science and medicine; something about asking the people of Guinea to forgive the government’s previous transgressions. There were supposed to be more academic sessions in the afternoon, however, that never happened as the building was literally taken over by the President, his cabinet, other party loyalists and of course the young soldiers. Outside the building, the scene was completed by a few “technicals” (black pickup trucks with a large caliber machine gun mounted on the back) to assure security.

So, what was my overall impression? The city was peaceful and relatively calm; the people seemed content. The president seemed medicated and the soldiers seemed nervous and inexperienced. Actually, I’m not too optimistic that there will be stability in Guinea in the long-run; but I’m hopeful that we were there at the beginning of a new peaceful era, rather than (to mix metaphors) during the honeymoon before the storm. Time will tell.

A press conference:

When Susan Braun, a profession portrait photographer and the wife of my college roommate, Eric Braun, offered to come out to Sierra Leone for about 10 days to document some of the work Surgeons OverSeas (SOS) is doing at Connaught Hospital I thought it would be a great opportunity. Early in her stay, she met with the hospital Matron and Mr. Turay, the hospital administrator. They asked her what specifically she was going to do with the photographs - I got to thinking (always a trouble inducing event), yes, we were planning to use the photos for the website and to help with fundraising and for presentations, and maybe even a traveling exhibition, but weren’t these pictures really the property of Connaught Hospital, and the Ministry of Health, and the people of Sierra Leone?

Photo by Susan Braun

So, my first thought was that we should have a final slideshow presentation for the Connaught Hospital staff. After a bit more thinking and discussing we came up with a larger plan. Things at Connaught Hospital have improved dramatically over the last year - that was good news and something that the general public and the international community should be aware of. At the same time it is not really the role of SOS to promote that. I asked Dr. TB Kamara and Mr. Turay how they felt about having a press conference at the hospital during which we would show Susan’s photographs. That led to some discussions with the Ministry of Health. The final decision was for a press briefing with the Minister of Health, Dr. Soccah A. Kabia on the developments at Connaught Hospital along with a slideshow presentation and a formal delivery of the pictures to the Minister.

So, on Friday morning at 11 a.m., after the requisite delay and minor logistics issues, the press briefing began. There were over a dozen journalists, plus a TV cameraman and photographers, the Minister and other ministry senior staff, along with Connaught Hospital senior staff, Susan, me, and Dr. Richard Gosselin. As an aside, Richard is an orthopaedic surgeon who has worked in Sierra Leone at the Italian NGO hospital on 12 separate occasions and who I’m very happy to say agreed for this visit to take a look at Connaught and help TB and the guys come up with a plan for improving orthopaedics (and do a few operations). As there is no orthopaedic surgeon at Connaught and almost no orthopaedic equipment, in the short-term we are trying to figure out how to improve basic ortho care and batting around ideas to improve care for the country as a whole. We’ve got some interesting ideas.

As for the press briefing, the presentations went well, everyone really enjoyed the slideshow and then the questions began. There were real questions. Why were there deficiencies? What was being done about it? What about the water situation? Sterility? There were answers and a good exchange. A decision was made to host similar press briefing on a quarterly basis so that accomplishments could be highlighted and problems addressed. Overall everyone, the press and the ministry, seemed very pleased. So, what had started out as a visit to take pictures to document SOS’ work led to an even bigger and very positive development for the local Ministry of Health and the press. I’m pretty pleased and am eagerly waiting to see what gets printed on Monday.

Photo by Susan Braun

A chest tube:

On the clinical side, I’ve only done about a dozen operations; however, the other day one of the house officers, Dr. Smalle, showed me a chest x-ray of a patient with a very large pneumothorax (air trapped around the lung). Fortunately now there are chest tubes at Connaught (due to SOS efforts) and Dr. Smalle was able to place the tube, under my observation. This may not see like too big a deal, however, this is the third such case I’ve supervised, and remarkably this time last year the patient would have been referred to another hospital about an hour away and might easily have died. Last February, Peter and TB determined that this relatively simple procedure could only be performed in 36% of hospitals in Sierra Leone due to either a lack of supplies or training. Through the supplies and training provided by SOS and in partnership with the World Health Organization, we are looking to significantly improve this statistic.

Photo by Susan Braun

I also got some feedback from Dr. Sesay, the only Sierra Leonean surgeon for the entire south and east of the country. He participated in one of the emergency surgery training workshops we ran this summer and told me that the training was definitely useful and that he and the other participants frequently refer to the WHO manual “Surgical Care at the District Hospital.” He is now eager to lead workshops where he will train other health care workers. We are planning to have our first district workshop next weekend in the town of Makeni. The plan will be to have a 2 day session when doctors and nurses from three of the surrounding districts assemble to be taught by local surgeons.

As for what’s next? Well, when I was in Conakry I met up with Dr. Lawrence Sherman one of only about three Liberian surgeons currently working in Liberia and the person who conducted a surgical assessment of all 16 government district hospitals using a standardized WHO survey. As there have been some issues at the JFK Hospital in Monrovia; Lawrence and I had some interesting and productive discussions. Bottom-line is that if I can coordinate the logistics, I’ll fly to Monrovia for a few days later this week to meet with him and the folks at the Ministry of Health. Also in Conakry I met up with Dr. Sani Rashid, a general surgeon from Niger who is the Coordinator for Training in District Surgery. I asked him about the possibility of assisting and he was very eager to have some help. When I mentioned that Reinou was in Dakoro, he said it would be no problem for me to work at their district hospital along with the local doctor and help to improve the level of emergency surgery. So looks like some time in the coming months I’ll be able to brush up on my French.

Best to everyone,

Adam

51%, the President of Sierra Leone and MIT.

I hope that 2009 is off to a good start for all of you; for me, once again I’m back at Connaught Hospital in Freetown, the capital of Sierra Leone. Back in the same duty house, the one without running water - but its fine, in fact, I’m just now after almost 3 weeks getting over my initial shock. The shock wasn’t just the fact that Sierra Leone was recently ranked last (177th) on the United Nations Development Index, or the fact that 26% of children born here die before their 5th birthday, but the fact that through the Society of International Humanitarian Surgeons and our program, Surgeons OverSeas (SOS), we have actually had a significant impact.

A year ago, Peter Kingham along with Dr. TB Kamara, the Chief of Surgery, and now also the Director of Connaught Hospital, did an assessment of surgery at hospitals throughout Sierra Leone. We then sat down with the local surgeons and the Ministry of Health and developed a strategy to tackle the most pressing problems as they related to surgical care. Subsequently, we conducted training workshops, began supplementing the salary of surgical support staff, provided goggles, boots and aprons to limit possible HIV exposure, and brought in a 40′ container of supplies and equipment.

We had hoped that our contributions would have some sort of benefit - but we never dreamed at the actual results. We tallied the operative caseload at Connaught, and what we found was a 51% increase in the number of operations performed in 2008 versus 2007. In discussing this with TB, he fully credits SIHS. He stated that our interventions directly led to an increase in staff morale, decreased absenteeism and the ability to undertake emergency operations. The total caseload went from 460 to 697 - because of SIHS, and of course with the help and support of many of you.

But before we take all the credit, I really have to credit TB, the other local surgeons and the staff. They were the ones who did the majority of the work, we just provided some support (mainly moral and some financial). It was encouraging to hear that another emergency surgery workshop was completely organized and undertaken by the local surgeons last fall. We are now planning to continue the workshops at many of the fourteen district hospitals throughout the country in an effort to help train the local nurses and support staff. These workshops will almost totally be conducted by the local surgeons and physicians.

So, that’s all great news from a short-term prospective, but what about the long-term, what about sustainability? Well, for that we are assisting with the initiation of post-graduate medical training - a surgical residency program. TB and the other surgeons hit a slight snag when the funding for the accreditation for this program was caught up in government bureaucracy. It is for this reason, that I and a number of other surgeons, all Fellows of the West African College of Surgeons, visited the State House and had an audience with the Honorable Ernest Bai Koroma, President of the Republic of Sierra Leone. I must admit, I was a bit nervous having never spoken to a President. We spent almost half an hour discussing post-graduate training, support for the health system and I even had the opportunity to explain briefly about our successes and the great work being done at Connaught by TB.

So, all in all, things are progressing. I’ve met numerous times with Dr. Soccah Kabia, the Minister of Health and he is pleased and excited. He has put effort into upgrading the intensive care unit at Connaught, and I’m excited to say that Dr. Michael Sinclair will be arriving in March to spend six weeks in Connaught; hopefully teaching the new residents and assisting to upgrade the standards of the ICU. Also, Dr. Richard Gosselin, an orthopaedic surgeon who has been on 13 missions to Sierra Leone, will be arriving on February 8th to assist with orthopaedic cases and make recommendations for improving orthopaedic care at Connaught. In fact, the operating room staff was so excited to hear about Dr. Richard’s arrival that they are readying an additional operating room to be designated strictly for orthopaedic surgery.

Really, the hospital is abuzz. A major concern for us is the continued lack of running water. We’ve had multiple meetings with the Ministry of Health, and I even mentioned it to the President’s chief of staff. The most promising development is a meeting that TB and I had with the chief British military engineer at IMATT (International Military Assistance and Training Team) - the international military unit stationed in Freetown that was initially for security, and now mainly a training organization. I’ll keep you posted on developments.

The last bit of news was that for the past 3 weeks a team of four MIT Sloan School of Management MBA students stayed in the duty house (yes, the one without running water) to undertake research into developing a sustainable business plan for improving surgical care locally. A local newspaper wrote about their visit and it is on-line here. I don’t want to give away too many details at the moment, but I will say that they were wildly successful and have even been approached by a Venture Capitalist. As things with that project develop, I’ll certainly pass the news on.

So, that’s it for now. Sorry no pictures this time, but on February 1, Susan Braun, a professional photographer is arriving and will be documenting our work and profiling many of the staff, so I’ll try to include some of her photos in the next update.

Best to all,

Adam

PS: For those of you who are curious, Reinou is not here this time, she’s heading off to Niger to work at an emergency obstetrics program for Doctors Without Border, but we’re planning to meet up in June or July in Mali and take a camel caravan to Timbuktu.

www.adamkushnermd.com
www.humanitariansurgery.org

Dear SOS friend,

In my trip to Sierra Leone in September, I had the privilege of lecturing to the final year medical student class. After spending an exciting few hours with them, we talked about their futures as doctors in Sierra Leone. They were bright, motivated students, similar to students I have taught in the US. Their unanimous wish was to have residency programs so they could get further training and become surgeons, obstetricians, pediatricians, etc. Hearing this impressive group of students beg for opportunity is at the center of what SOS is trying to accomplish.

We are excited to report about our recent successes with SOS and would like to let you know what is planned for 2009. For an organization that began a little over a year ago, we have grown immensely in a short period of time. The majority of our attention has been focused on saving lives in Sierra Leone by building surgical capacity. We feel that our unique collaboration with the Ministry of Health and the few local surgeons that are left in Sierra Leone has the potential to fill the massive gap in surgical care that currently exists in Sierra Leone. Over the last few months, we are excited to report that we:

• Continued monthly stipends to the surgical staff at Connaught Hospital, the main public hospital in Sierra Leone, to maintain staffing at a functional level.

• Helped increase surgeries from 30 a month at Connaught in June to 59 in September.

• Delivered the first container of surgical supplies in September. The response was truly overwhelming, and included front page newspaper headlines and radio interviews.

• Formed the first residency program in any field in Sierra Leone, and hope to have the first trainees begin the path of formal surgical training in January.

• Established a strong relationship with the Minister of Health, who has set post-graduate education as a priority for the ministry.

• Provided HIV protective goggles and boots to the surgical staff at Connaught, in order to protect what is an invaluable local resource - Sierra Leonean health care workers.

• Became close partners with the WHO by performing essential surgery courses and gauging surgical capacity.

We have many plans for 2009:

• Adam will be returning to Sierra Leone in January and February with a team of MBA students from MIT to develop innovative ways to fund our surgical development program in Sierra Leone.

• We have additional surgeons who are scheduled to work with Adam and I to continue our training and development programs over the winter and spring.

• As the residency program begins, we are working to build basic orthopedic surgical skills at Connaught Hospital, and our next container will include basic orthopedics supplies.

• We plan to continue helping the surgeons at Connaught Hospital build their hospital as the surgical center of Sierra Leone, with additional supplies and salary assistance, so that there is a healthy environment for patients to receive surgical care and for the next generation of surgeons to learn effective surgical care.

• We plan to extend our training programs to district hospitals, in order to improve the surgical skills of the medical officers that are the lone physicians for the 2-500,000 people who live in each district.

In a year where much of the financial backbone of the US has changed, we have been overwhelmed by the financial and logistical support that you all have provided to SOS, the flagship program of the Society of International Humanitarian Surgeons. We are a small organization where all donations are used for surgical development that is already saving lives in Sierra Leone. We have been welcomed as family in Sierra Leone, and that appreciation extends to all of our SOS friends.

So in the kreothat Adam and I have had the pleasure of hearing so many times, many more patients can now say, di bodi fine, when asked how they are doing, thanks to your support of SOS.

We wish you a safe and successful 2009.

Peter Kingham

Adam Kushner

Glenn Geelhoed has posted pictures from his mission to Afghanistan. They are available here:

The SIHS Fall 2008 Newsletter is now on-line at:

http://www.humanitariansurgery.org/page4/page17/files/SIHS%20Newsletter%20Fall%202008.pdf

Container Follow-up:

The adventure of the container started with Mr. Kallon. He is the procurement officer of the Ministry of Health. Dr. TB Kamara, my contact at Connaught Hospital, submitted the paperwork to the Ministry and it was finally approved by the Minister of Health, Dr. Kabia, and sent to Mr. Kallon. I learned more than I ever thought I would about the inner workings of the ministry and politics in general in Sierra Leone. It appears the World Bank has required anti-corruption measures to be instituted that require multiple signatures for everything, which causes unbelievable redundancy and a stagnant process. It probably does reduce corruption, because it prevents anything from getting done. Mr. Kallon had to get the paperwork to the Ministry of Finance because they are the only ministry that can approve waiving the duty fees. I was told that the paperwork was on Kallon’s desk, but that he was out of the country and hadn’t left his keys. I was visibly enraged and the very nice secretaries started giving me cell phone numbers to appease me. I was told all of the high up people in the ministry were at a conference across town.

I first called Umu, Mr. Kallon’s secretary, who was home sick. She thought the papers were on Kallon’s desk but he didn’t leave his keys and he wouldn’t be back for days. Next I called E.B. Kamara, the Senior Permanent Secretary of the Ministry of Health. He told me Mr. Kallon was in his office and he didn’t know about the container. I next called Shieku Kamara, the Junior Permanent Secretary of the Ministry of Health, and Mr. Kallon’s direct boss. He was mad he wasn’t told of the container, and that Kallon hadn’t left his keys. I told him I would be happy to donate a new lock to Mr. Kallon, after we broke his door down. He laughed a lot at that, until he realized I was dead serious. I explained that I flew from NY to free the container, and a lock wasn’t getting in the way. He was helpful, and got J.B. Mansuray, the guy who runs the Ministries Procurement wharehouse (where supplies go and never make it to hospitals I suspect) to take me across town to the Finance dept to see if by chance the paperwork had been sent there. I met with Mr. Momoh, one of the senior Ministry of Finance people. The meeting started like all others – his secretary said he would be in shortly, I said please give me his mobile number so I can speak to him directly and if he is going to be more than 15 minutes I’ll drive to where he is. This was a new tact for many of the government employees there, because Sierra Leone time means someone may be there soon…. And show up tomorrow. We went through Momoh’s desk, and amazingly, buried 10 files deep was our forms. He had to write a letter and stamp a bunch of things so said to come back at 2pm. Time was short, so I sat in front of his desk at 130pm and while he grumbled a little, he did appreciate the effort, and gave us the letter. The papers then left his desk and went to Mr. Vandy’s desk who is the head of duties at the Ministry of Finance. I got him to sign it after I asked, “what should I tell President Koroma’s people when I meet with them at 4 about the container – just tell me how I describe the status of it.” I’m no good at poker, but had a pretty good poker face for outlandish statements like this.

The last place I needed to go before heading to the port was Mr. Bamba, the acting Commisioner General of the National Revenue Authority and the Commissioner of Customs– the duties and customs branch of government that was in another part of town. I made it there at 3:30 to find Mrs. Kamara, the lone secretary there. Apparantly a member of their division had died so everyone was out of the office. I pulled all my usual lines but had to back off when I said I would drive all the papers to where the minister was, because he was a the burial. I returned at 830am the next morning, when Mr. Bamba was supposed to be in the office, and I waited until 930 until I started making noise. I had met a few Sierra Leonean business men and I began calling them because they work with imports and I wanted them to lean on Bamba. I used a fairly loud voice to ensure everyone in the office knew I was making calls, and magically Mr. Bamba appeared and signed the papers.

Next it was off to the shipper. They were very reasonable. They tried to add on some indemnity fees for a few hundred and I told them that that wasn’t part of the deal, and they backed off and were then helpful. Raymond was one of their lower level guys. He walked me across the street to customs house and we spent about 6 hours bringing the papers desk to desk to get the appropriate signatures. He went above and beyond the call of duty and was very helpful in expediting stuff. At the end of the night I paid the demurrage fee and port storage fee (about 1,000) that the government was technically responsible for but given what I had gone through to get signatures, getting cash from them was not a viable option. I had to leave that money with the shipper on faith that they would officially pay it all the next day and deliver the container. The next day they did so, and the container was set to be released at 7pm. It was so big that the government won’t allow it on the city streets until after 7pm. Somewhat last minute I got a call from the shipper that the Minister of Health wanted it to go to the Procurement Storage Wharehouse that Mr. Monserrary was in charge of. My driver was a bit shocked at hearing me “that f’ing container does not go anywhere but to me at Connaught Hospital. Do not leave the ground of the port without hearing from me.” The Minister didn’t realize that I would be receiving it at Connaught and it would be locked, so all was sorted out, and it came to me, much to the chagrin of the central supply guys. The container got a police escort through town, and filled half the parking lot. Raymond rode shotgun to make sure it was delivered to me with the keys to the lock. After the delivery, I told Raymond it would make me happy to give him something to thank him for all his help. He told me it would make him happier for me to not give him anything, because what we were doing in Sierra Leone was amazing, and he wished he had met me earlier, because he would have tried to be a doctor. Wow. In fact, I didn’t pay a single person anything at any point along the way. People were very supportive.

The following day, we unloaded the container and sorted everything into three locked areas of the hospital. It was as hot then as it was when we loaded the container up, and it was comical to see them work out how to get the beds out that we forced in sideways. They hand carried everything on their heads and were very efficient. I sorted every box into the correct category of material, and the nurses were all thrilled to have supplies. There was a massive buzz about the whole container, with patients and employees lining the railing watching us. There were two reporters present, and one of the articles was front page headlines of the local newspaper. In addition, radio interviews with me and TB Kamara were played for 3 days. The Minister of Health stopped by for photos as well. In the end it is impossible to convey the effect of the container, without a single piece of it being actually used. For the first time in god knows how long, people were really psyched to be part of the surgical unit at Connaught. I had a 30 minute send off ceremony, where the head nurse of the hospital said we had rejuvenated the hospital, that now nurses didn’t have to scale walls to hang IV bags from the rafters because we had IV poles, and patients in the intensive care unit could be cared for properly in beds that functioned, and there was now suture and gauze to perform emergency surgeries, and the list went on and on. SIHS was called the savior of surgery at Connaught and Sierra Leone. And this is without us/them even using the supplies. Loading the container was challenging, and I can tell you that unloading it was a similar challenge, but being there on both ends meant a lot to me, because I was able to connect the family that loaded the container with the family that unloaded it, and I can tell you all that you are now on the hearts and minds of many people in Sierra Leone. When they spoke about how we are the deliverers of love and support that they will use to build their skills and treat their patients more effectively, they were speaking to me, and asking me to convey this back here. There are many times throughout my work here and in Sierra Leone that I wonder why I am doing what I am doing, because it is difficult and time consuming. The 30 minutes of unbelievable emotional outpouring of gratitude and friendship erased those doubts. You guys have helped us establish ourselves as a true partner working to build surgical capacity in Sierra Leone, because I went around the country to look at what they needed, told them I would be back with stuff (which they have been told before only never to see that person again) and I showed up with a 40 foot container. Our relationship is now concrete, and we are helping them start their surgical residency training program over the next few months. The supplies we loaded in Yonkers will be used to help train the first surgeons in Sierra Leone – they will no longer have to go outside of their country to get trained – which realistically just doesn’t happen anymore because they don’t have the money for it. I can’t thank you guys enough. I hope that I was able to convey some sense of the emotion that this container evoked in me and those on the receiving end. I attached some photos and a copy of one of the newspaper articles. I hope you are all well and I’ll keep you updated as to what is happening in Sierra Leone.

A 40-foot container crammed with an operating room table, vital sign monitors, a medical refrigerator, centrifuge, computer, hundreds of medical textbooks, adult mannequins for CPR training, and hundreds of boxes of consumable supplies including sutures, gauze, syringes and other disparately needed material is currently en route to Sierra Leone. The equipment and supplies were part of a wish list created by the surgeons at Connaught Hospital and the Sierra Leonean Ministry of Health. NYSIHS members TB Kamara and Peter Kingham highlighted the massive need after conducting a country assessment based on the WHO surgical capacity situational analysis tool. Back in New York, NYSIHS collaborated with the Afya Foundation (www.afyafoundation.org); a New York based non-profit organization specializing in recovering and shipping surplus medical supplies and equipment from New York hospitals. On June 9th in near 100 degree (32 degrees C) heat, a team of Afya staff and NYSIHS volunteers met at the Afya warehouse and load the container. The scheduled arrival is for mid-July to coincide with the Surgeons OverSeas (SOS) mission and the Emergency and Essential Surgical Care (E2SC) workshops.

Photo by Jim Metzger

In February 2008, NYSIHS conducted a needs assessment in Sierra Leone and based on the WHO surgical capacity situational analysis tool,a needs assessment in February, 2008 in Sierra Leone. One of the striking findings was that all of the public hospitals lack even the simplest supplies, and no hospital has any emergency stores. After identifying this problem, we collaborated with the AFYA Foundation, a non-profit organization that collects excess supplies from New York hospitals. A group of private donors agreed to cover all the costs of the container, and on June 9th, a 40 foot container was filled with surgical and hospital supplies and shipped to Connaught Hospital, Freetown, Sierra Leone. The shipment is timed to arrive when Adam is in Sierra Leone assisting in organizing WHO training courses. The supplies in the container will assist Dr. TB Kamara, the head of surgery at Connaught, and Adam with both the training courses and general patient care.

Items in the container include OR tables, surgical instruments, training mannequins, disposable supplies, and surgical textbooks. There are enough books to create a small library at Connaught. We look forward to hearing from Dr. Kamara and Adam once the container arrives and the supplies have been put to use.

Afya teamed up with the New York Society of International Humanitarian Surgeons to fulfill their request to send a container to Connaught Hospital in Freetown, Sierra Leone Dr Peter Kingham, after conducting a thorough needs assessment at the hospital (using World health Organization criteria), submitted a significant “surgical suite” wish list to Afya in order to create improved surgical capacity with improved access to essential items for care. The container included an operating room table. 40 IV poles, vital sign monitors, medical refrigerator, centrifuge, computer and hundreds of medical textbooks. We even packed adult mannequins for CPR training, In addition, hundreds of boxes of consumable supplies were packed. The supplies will arrive in time for Dr. Adam Kushner to lead a surgical training program at the hospital this summer.

Glenn Geelhoed Surgical Missions 2007

MULTIPLE MISSIONS ‘ROUND THE GLOBE

PHILIPPINES: FIVE WEEKS IN FIVE ISLAND VENUES

We can begin this travelog early in the year in the Philippines. I was serenaded well before dawn in Hilangos, Leyte on a significant birthday in January, since my operating team colleagues were concerned that they catch me before I went out on the run along the Canigao Strait of the Philippine Sea toward a village named “Arok” (a great name, since it is the sound their totemic raven makes in its croaking.) We operated for a week in Leyte Baptist Hospital, completing our visit with a “lechon” feast outdoors on the night of my birthday under lights and a thick cloud of flying insects the lights attracted to plague the celebrants and to delight the toads gathered around us for an even bigger feast. In flying through Manila and Kalibo to Aklan, we worked for another week in Aklan Baptist Hospital Caticlan, within sight of Boracay Island. After operating on many challenging cases all week, we made several visits to Boracay Beach, “the most beautiful tropical beach in the world.”

Now, for a new exploration of the “frontier” territory, I flew to Puerto Princessa, Palawan, the furthest southern and western remote island of the Philippines. It has several of the world’s unique wonders, such as the longest underground navigable river in the world, which we paddled through under stalactites and the bats hanging from them, and tropical reefs in deserted islands like Pandamus and Snake Islands we reached by outrigger in Honda Bay. We traveled by coastal road to Roxas in the north to work at Palawan Baptist Hospital, and could further appreciate the severity of the health care shortage in the Philippines, from which almost all the medical graduates are exported (with MD graduates eagerly seeking to be nurses in the US and Middle East) for remission home to families of the ten-fold salaries they can earn outside their homeland, health care personnel being the Philippine’s single biggest export commodity and the largest source of economic “foreign exchange” value. We also visited the Badjao seafaring indigenous tribe along the beaches near Roxas and climbed a mountain through thirteen river crossings to reach the villages of the Batak to conduct clinics in these remote tribal regions.

Next stop in the five week/five island venues is a familiar one—Malaybalay in Bukidnon Province of Mindanao. We worked hard in our usual surgical extravaganza among dedicated colleagues at BBH before taking a one day holiday doing what none of the older nurses had anticipated they would ever be doing—we went white water rafting down the Cagayan de Oro River rapids! All the survivors went on to be honored in the usual pageant put on by the hospital staff for our annual visit.

In the fifth week we traveled by road through Davao and visited the Philippine Eagle Center seeing the performing raptors in the gardens, then turned up into South Cotabato for a favorite venue, the TECH group awaiting us in Edwards in full force. We worked on so many surgical cases that we exhausted the team who recovered on a brief boat trip around the Tiboli’s indigenous Lake Sebu before their heart-felt farewell program. I left to board my flight at General Santos City, but discovered it was delayed a few hours—so, immediately boarding a motorbike, I visited the Tuna Port—and saw the largest and most numerous tuna catch in the world coming in from the individual hook and line fishermen in outrigger canoes (remember “Old Man and the Sea?”) returning lashed to the “catch boat” offloaded along with their impressive tuna catch for rapid refrigerated distribution to the sushi-loving world. This protected port in GenSan is restricted and photography is off-limits; but the chief was suspicious about an American in a safari shirt, and asked if he were a US Army advisor training the Philippine Army Unit pursuing Abu Sayef through Mindanao. When it was explained to him in Tagalog who I was and what it is that I do, he opened the whole fishing fleet and port to me urging me to take pictures of him with me—as it happens, his grandmother has an obstructing goiter—and is now scheduled for next year’s mission to Mindanao.

The long return flights originating from GenSanCity brought me to Gainesville, Florida half a world away, but that will be a story to be picked up in the first of the Father and Son Runs of 2007.

KHARTOUM, NORTHERN SUDAN

You will not have to wait long for another medical mission in 2007, since I landed back in Washington in time to go to the Sudanese Embassy for a reception with the small GWU student team I would take on the next trip—this one to Khartoum, the capitol of (northern) Sudan. We flew from Washington via Amsterdam into a VIP reception at Khartoum International and a special accommodation in the University of Khartoum. Arriving on their non-working day Friday, we had a cruise on the Nile down to Omdurman and visits to the National Museum before beginning the intensive schedule of visits. A great deal of my efforts was engaged in “medical diplomacy” in giving lectures and receptions with university and government agencies, since it has been a long time since any American professionals have been hosted in Sudan and they made up for lost opportunity in celebrating this visit, with televised receptions, speeches, lectures and clinics, including operating in several venues from Khartoum to Gazeera with TV cameras broadcasting from the overhead OR lights to waiting audiences outside. I have attempted to understand some of the implications of their eager rapprochement while keeping a firm stand on the oppression of Darfur and the Nuba Mountains and other venues of the South, which, I reminded them, were the sites of my earlier visits to Sudan during the eighteen years of Civil War, when the government was overtly hostile to these areas, strafing both them and their presently honored guest, who took neither of these government attentions, then or now, personally. Dr. Tabitha, Minister of Health, voted the most effective of the government ministers, is unique in that she is the only woman, the only one born in the south, and the one who is hoping for a genuine reunion of the Federated Unity Government of the Republic of the New Sudan. In our multiple meetings, she had asked me to return from places she is still unable to visit and to report back to her the problems and potentials on return trips—which I have done, in representing each side’s views to each other.

Our team visited, and I lectured in, made rounds in each of the major university medical faculties in and around Khartoum, then went to Al-Gazeera University in Wad Medani, where I had my team scrubbed in on several demonstration cases in the university and gave several lectures to the students and the government and private health schemes around this area which is a fertile product of the Nile floodplain. The Gazeera Scheme—a giant irrigation agricultural engineering of the Nile’s flood waters—has been an economic boom, with high health costs—uncontrolled schistosomiasis from the snails in the impounded irrigation open canals, and the breeding of mosquitoes now carrying drug-resistant malaria. Gena Foundation is a group of American expatriate Sudanese who are interested in the conditions of the homeland and Al-Sawaid is a humanitarian agency based in Khartoum attempting to address some of these problems and I worked with them both in the orphanages they sponsor as well as in other health projects.

A major focus of my visit to Sudan on this trip was to be the health team to visit the IDP (Internally Displaced Persons) Camps around Khartoum as well as to orphanages and rehabilitation facilities. On my opening lecture at the Sudan Medical Association I had said to a fellow dressed in long flowing robes who sat next to me at the dinner that followed that I had hoped to carry in medical packs for treatment in the IDP camps when we set up our clinics there, but had been prevented from carrying in any of my usual MAP packs because of the US embargo on supplies to Sudan. I did not know it at the time, but he was the right person to mention this to, since he turned out to be the chief of the agency that purchases all medical and drug supplies for Sudan, and he merely ordered his agencies to make available all of the “wish list” I was asked to submit. We could then go into the barren and bleak IDP Camps all festooned with big banners announcing our presence in many misspellings and lots of promises for free health care with at least a large supply of basic drugs and equipment.

We worked hard in the IDP Camps, with both the medical students from GWU and Al Fahad University mixed together as many of them were examining the first patients of their professional lives under my tutelage. Illnesses included some entities they might never see otherwise—such as Pott’s Disease (Tb of the spine) leprosy, and the mutilations from the inhumanity of the civil war and of several cultural practices that have led to female genital mutilation and vesico-vaginal fistulae. Several patients were found that needed significant further follow-up treatment for serious illnesses such as advanced breast cancer in a young mother, and a sarcoma in a young man—which were able to be taken in to our affiliated university teaching hospitals without going through the waiting queue. One of the IDP patients with a large goiter I operated with the residents in the following week at Khartoum Teaching Hospital. I also gave the major plenary lecture at the 100th anniversary celebration of Al Fahad University—uniquely in an Islamic Society, an all-women’s University with its own more recent faculty of medicine. I had one wish not yet fulfilled—all of my life since reading of the mysteries of the Nile and its origins, I knew I would someday stand at the junction of the Blue and White Niles at the “Khartoum” (+“Elephant’s Trunk”) and see the two rivers run in the same course down to Omdurman before mixing. Not yet—but hold that thought! (I did just that on my subsequent visit to Khartoum four months later.) We had a special farewell celebration as we departed Khartoum and I continued on to Toledo to host the MMHOF Induction Ceremonies of this year’s awardees.

AFRICAN ODYSSEY—PART I:
ETHIOPIA: ADDIS AND SODDO

My most ambitious undertaking of the year was in planning three different African medical missions and then stringing them together in a back and forth criss-crossing of the heart of the continent, picking up and packing off different constituent teams along the way. With all the anticipation of the plans and the Packing Party at Derwood, we loaded up the many SCI bags stuffed with surgical kits and departed on Air Ethiopia for Addis Ababa. One of my students who had been with me on the earlier excursion to Sudan was making a homecoming into Ethiopia for the first time since leaving at age 8, so we were able to witness the reunion and family ties. I used the several bases in Addis to get ready for the excursion to Soddo eight hours by a bus we chartered south in Woillatta Province, and packed up a UN of eighteen of our own—since among my GWU freshman students who have never seen a patient or treated anyone for any diagnosis, I may have been the only one who was US –born. This very mixed group spent considerable time perseverating about the “Best Croissants Ever!” and current pop culture in movies and TV sitcoms in another part of the world to take the focus off the immediacy of impoverished, ill, and very inconveniently ubiquitously present in-their-face Africans in Soddo, where the indecencies included the lack of hot showers, A/C and cold beers.

Despite this “cultural deprivation,” we got them involved in patient care and even got most of them scrubbed in for the first times in their lives in surgical care of patients in the OR of Soddo Christian Hospital. In a skill closer to their own abilities, they took on the project of painting a series of animal murals in the children’s ward, a project that I called the “GWU Sistine Chapel.” After seeing everything from “Mossy Foot” to Mycetoma and lots of exotic conditions in the very good facilities of the new SCH, we returned to what they were craving—in Addis Ababa, the Hotel Afrique with a gym and pool and facilities they were used to and presumably deserved—at a fifty percent reduction in price I had to negotiate for them as “humanitarian missionaries.” I brought them to Mother Teresa Clinic where, with last year’s MMHOF inductee, my friend Rick Hodes, we toured through the “Museum of Human Pathology” spread out all around them in an overwhelming burden of illness and poverty. At our farewell dinner in the Armenian Club, they gave expressions of their appreciation for my introducing them to clinical practice in such an unusual setting—then promptly after my departure, they refused to fill out the PIHMQ Questionnaires for me that they had all promised to do, and all of the SCI bags vanished before I could recycle them for the next mission. Rick Hodes brought me and one other student who would continue on only as far as Khartoum to meet with the next team to begin the Sudan five weeks of African Odyssey Part II.

AFRICAN ODDYSSEY: PART II
SUDAN: NUBA MOUNTAINS

It took me a couple of tries to reach Sudan. Air Ethiopia took off at night for our four hour flight to Khartoum, and approaching the airport, abruptly the wheels were retracted and a voice came on that due to the “Hamool”—the Sahara sandstorms that blot out visibility, we would be returning to the nearest airport—which turned out to be Addis Ababa! So, we returned to Ethiopia and sat through the night until a later daytime try which got us to Khartoum exhausted—but in perfect timing for the TV and print media that came to interview me and the grubby team in the airport VIP Suite. We were put up in the Khartoum Hilton in luxury that included in room internet access and continuous buffet dinners and A/C and a pool. I reminded them that we had come to care for the destitute, but the new team was in no hurry to leave accommodations that comported more with their own requirements in roughing it. We were overdue in the South Sudan state of Kordufan, but an expanding list of “family house calls,” lectures and “medical diplomacy” receptions seemed to keep us for nearly a week in the luxuries of the capitol. We had a formal state dinner and reception with Dr. Tabitha, Minister of Health, and had TV interviews and an evening on the Nile River banks visiting with her cabinet ministers. I repeated that we were here to treat the oppressed people of the Nuba Mountains, but most were reluctant to leave the easy living in the Khartoum Hilton to get into a convoy of eight 4-WD vehicles and drive all night to Kordufan—but that is what we did, starting off the hardships with A/C closed vehicles bouncing along roadways at night passing baobab trees and camel caravans.

We seemed always to be moving on toward some destination not yet reached. We were formally received by the Governor of South Kordufan in an entourage that included the district commissioners and further welcome speeches. Sudan is Africa’s largest “nation-state” (awaiting later plebiscite determination if the South will secede in 2011) and Kordufan is only the size of France, Germany and Spain combined, so we have a lot of territory to cover. We arrived in Kardugli in accommodations declared “unacceptable” by many of the group—most notably by the Sudanese Americans who had “UN envy”—“Look at all those white vehicles and that big guarded camp—they must have A/C, internet and hot showers there and we should see what they will do to help us since we are doing good.” The UN is here to take care of the UN, and we are part of the great unwashed we have come to serve—but that was quickly apparent to all, that there were thousands of patients awaiting our advertised arrival, but neither the local staff nor our mixed team were too eager to service this insatiable demand, nor elevate expectations for care that would never be rendered after our departure. We made rounds at the “referral center” in Kardugli Hospital, to uncover many “worst case scenarios” that could be used as bad examples, such as my teaching infant resuscitation and leaving spinal anesthesia kits for OB/GYN and neonatal resuscitators—and witnessing four consecutive C-sections under maternal general anesthesia with unresucitatable infants. “There is nothing we can do for these people” was the continuing refrain—a self-fulfilling prophecy if ever I have heard one!

We packed up the whole crew and made several more stops in villages where we saw thousands of patients and would refer them—to the Kardugli which we had just left! The people who could not get transported were the fortunate ones, since they would not be disappointed twice. We had a scrub tech, a professor of surgery and anesthesia and OR kits and they advised us against operating on easily solvable problems—“We do not want to get these people thinking that they can get help, since we can give no such help after you’re gone.” “That is why we are here to train your own people to handle these problems and equip them to do so.” “There is nothing we can do for these people.” So, we did outpatient clinics in Billing, in La Goya (where we were caught up in an international incident, in which Arabic forces tried to drive out any Bantu non-Arabic speakers before we came to town, and a firefight in the hills overlooking the hospital killed the leader of the offensive forces—we were spirited away in mid-clinic under police escort without further incident—to us.) We returned to Kardugli and then toured the UN camp and got permission through my credentials to get airlifted by UN-owned Indian Air Force-operated MER-13 Russian helicopter to Kauda, a remote village still under only SPLA rule.

A sound truck had been sent around in advance to advertise that the Americans were coming at last and would dispense free care to all who needed it; we were greeted by the entire county’s officials who welcomed us and said they were happy we were here to take over their health care, education and economic aid to get them rehabilitated after eighteen years of war, and now two years since the CPA (Comprehensive Peace Agreement,) since the GOS (Government of Sudan) had never delivered one single benefit of all those promised. So they were sure that their only hope was from the Americans—who had, at last, appeared, in an entire extended community of comrades in arms, without a single doctor. I cautioned them that we were not here to solve their problems but to help them get a start on resolving them through their own resources, and set about seeing what it was that a big UN helicopter landing and a pick-up truck- mounted sound system had stirred up. The waiting queue surrounding the German Emergency Doctors’ Clinic was several thousand patients to be treated by the four members of the team I had picked to make the excursion by chopper to Kauda.

We started in and treated all those that could be treated simply and lined up some of the surgical patients—that included older men who had a catheter (not any catheter but that very one) in place for eight to ten years, hernias, tumors, mycetomas, eye complaints, and other chronic conditions that could be fixable, then went through all the rest in the abscesses, lumps bumps and acute conditions that could be fixed on the spot. We had to do this swiftly, aware that the group was restless when they saw how many we were with a two day clinic to see them all. I suggested that we screen patients, treat the medical ones and triage among the surgical ones—a good plan, it was agreed. With a surgical scrub tech, midwife and two surgeons, we could line up the most critical needs and do them first in the newly refurbished OR. “Oh, no—we do not want you to operate; that would just lead these people to expect too much of us when you are gone. We just refer them.” I asked “To whom and where do you refer them for what?” “Oh, we just tell them to take their catheter and their problem to Kardugli where they have a hospital specialized to handle such patients.”

It is as fatuous and cruel to tell them to travel to one of the outer rings of Saturn for almost all of these patients, and even those who could be mobilized for the grueling walking trip of weeks (we had jumped it in an hour by helicopter—presumably not accessible to most of the region’s citizens!) would be arriving at the “referral institution” I had just left with abundant object lessons and the recurring refrain “There is nothing we can do for these people.” It is tempting to retort: “That may be true for you, but now step aside and do not obstruct those who can do something for them and can train a few folk with enough hope to continue.”

When, at last, we finished seeing the last of the patients, a big farewell ceremony with speeches was carried out honoring us as citizens of Kauda, conducted as I was continuing to caution them about over-promising great expectations. One of the locals who was the leading candidate for the heading up the health team and whom I had tried to train most during my stay pulled me aside. After thanking me for helping him personally develop several new skills, he let slip that this would be the springboard that would get him out of Kauda and employed in a new job in an urban center for which he was leaving the next day right after we flew out in the UN helicopter. “But what about Kauda?” I asked. “There is nothing that we can do here for these people…” it must be a mantra in one of the indigenous languages!

I will tell one story of one heroic woman to illustrate the life of the surviving oppressed peoples in the South Sudan and Darfur areas targeted by the GOS (Government of Sudan.) She had five children, an infant boy on her back and a five year-old boy being led by the hand with three older daughters as she fled from Darfur with the Janjaweed in pursuit. To give you a cultural background of this environment, similar to the one witnessed later on the other side of Darfur in Chad, a woman with her hair uncovered is a prostitute and is treated accordingly, so all women and even young girls must have head covers on emerging outside their homes. She was caught by the Janjaweed and serially raped, in the course of which her lower lip was bitten off. She escaped, and ran with her baby boy on her back, her daughters ahead of her and leading the five year old boy by the hand when the Janjaweed again pursued her firing at her and the family. Without a moment’s hesitation, she reflexly whipped off her head cover and immediately wrapped it around the head of her toddler son, instantly converting him into a small girl—of no interest to her pursuers. She had already been raped and injured so she had nothing to lose herself, and ran swiftly unaware that the baby boy on her back had been shot and was no longer alive. She was seen at Kauda in our clinic and then we went to visit her in the IDP camp for Darfur refugees admiring her for her resourcefulness in saving four of her five children. We interviewed her and took photos, and then went to see another Darfur refugee who was rumored to have a breast tumor we were planning to biopsy and treat. And this woman represents just one of the stories as numerous as the several thousand patients we had seen and treated in the Nuba Mountains.

After our Russian MER-13 noisy helicopter ride back, we were stranded in Kardugli by weather and lack of travel permits, and we waited with the 4WD vehicles loaded as we sorted the collection of photos and texts that I hoped to email back from Khartoum before departing from it. We left when the permits were hand-carried over from the Kordufan Governor and then took off by night over the rain-rutted roads to Al-Obeid where we had to stop again for another set of government clearances for onward passage. We took the time to tour the faculty of medicine at Al-Obeid University in this ancient caravanserai on the slave trade route across Sudan and were welcomed to meet with the dean and faculty of the facility. We also saw the original church of Father Comboni and Mother Bakhita and reviewed the early history of Christianity in South Sudan. Immediately across from the Comboni Church is a new very large mosque, just built with the minaret’s spires higher, of course, than the church’s steeple.

AFRICAN ODYSSEY—PART III: CHAD
N’DJAMENA AND AMTIMAN

Everything we might have hoped the Sudan mission to the Nuba Mountains could have been, Chad was, and much more besides! With a very lean and anything but mean team, we arrived in the Chadian capital of N’Djamena. Arriving in Chad was not easy, in coming through an “epic” of attempts at close connections and canceled passages, and all of my ticketed and pre-paid itinerary seemed to dissolve (“incompatible computers”) whenever I tried to check in for an onward passage at each critical start of the next new mission. In this one, Air Ethiopia only had me ticketed as far as from Khartoum to Addis, so my bags, of course, were only tagged to Addis. I ran at the late flight from Addis to N’Djamena and clamored aboard between two nomadic Chadians who had never been on a plane before. This meant that they were scrambling over me when only the back wheels had touched down and at least a half hour before the door opened and the seatbelt sign was turned off—“what seat belt?” In a very pleasant surprise, whom should I meet in the N’Djamena airport after 2:00 AM touchdown? Both my GWU students (one the medical school Dean’s daughter) and Scott Downing who had come to the capital specifically to pick us up and tour us around before our MAF Cessna 208 Caravan charter flight to AmTiman.

We viewed the markets and the camera-shy populations in the capitol of N’Djamena while awaiting the arrival of the other two people in our team and my late- arriving lost luggage with some of the surgical supplies for the mission. When we had assembled all that we could put together, we took off in our MAF charter and flew over the Saharan nation of Chad that had once been immersed by the much larger Lake Chad southeast to the “Swamp” and AmTiman. The Downings have been conducting a low key ministry there with services that needed a jump start. The inauspicious start to this mission is a nation-wide government strike for all services, including heath care. The application for our inaugural surgical mission was submitted and –incredibly enough—signed off, since no harm can come from permitting us to work in hospitals that are already closed anyway. The “Miracle Mission” it came to be called, since the next step was to approach the “Syndicat”—the labor unions—to ask if this one hospital in AmTiman could be opened for this one visiting professor and his team this once for surgical care of a waiting list of patients. The Syndicat said it would be OK if a few volunteers wanted to show up for work and instruction, but they would not be paid. Not a single worker did not report to work with us, and we operated into the night on the day of our arrival on a series of cases of long neglected problems. We operated on prostates that were obstructing, hernias that were incarcerated, goiters that were compromising airways, and a number of the tragic consequences of another kind of “child labor”—vesico-vaginal fistulae from unattended obstructed labor in young girls married off for the bridewealth while they are still children. We did all this in the dramatic setting of the rainy season in the “Swamp” which prohibited our moving around beyond AmTiman even though we were eager to see Africa’s newest and most abundantly populated elephant wilderness park, Zakouma, within an hour of where we were working—along the Western border of Sudan’s Darfur region.

There were dramatic events including drownings in the seasonal Bharazoum River, and issues of anthropologic fascination as we worked in the restricted Islamic Society. We also joined with MSF (Doctors Without Borders) in helping establish a new IDP camp adjacent to AmTiman of refugees from the internal tribal struggles among the 72 distinct language groups of the indigenous ethnic peoples and nomadic herders. The “Miracle Mission” would have been considered improbable by anyone at the start, but it was an enjoyable and rewarding success with far fewer resources than we had squandered in our wanderings in the Nuba Mountains, with one fifth of the staff and one tenth of the vehicles and a quarter of the supplies, largely because of the advanced preparation made by Scott and Suze Downing and their young family. We are already booked for a return in February with patients lined up expecting the same “miracle” suspension of the national strike for us and our navigating through the barriers to successful treatment of scores of the impoverished people of AmTiman—with next visit in the dry season also giving us access to the wonders of Zakouma to be seen first hand.

SOUTHEAST ASIA:
CAMBODIA SURGICAL MISSION AND VISIT TO ANGKOR WAT

My next long haul across the dateline came within hours of dropping off Donald and his running mates in DCA for their three hour return trip to Gainesville, as I went to IAD to begin my three day trip to Phnom Penh, Cambodia. I transited a few places familiar to my generation when I was a medical student; SGN is still the airport designation of Tan Son Nhat International, even if it is now in the Ho Chi Minh City capital of Vietnam. I had left directly from the Father and Son MCM Marathon Run and touched down to begin a series of difficult cases in the Cambodian capitol helped by CSI (Cooperative Services International.) We operated into the night, and then took the only paved road from the capitol to Siem Reep to visit the legendary ruins of Angkor Wat. We wandered among the overgrown ficus clutching and reclaiming Ta Prohm (the “Temple of Doom”) and chuckled with the 56 smiling Buddha faces of Bayon, as well as witnessed the ancient mythology of the Mahabharata in stone bas-relief as young bridal parties and a middle aged Cambodian Prime Minister also visited on the same day, using these world’s largest religious buildings as background for their own agenda. It was an impressive sight to see, as the new flood of tourism is starting to stretch Cambodia and awaken it from its awful recent history of the Pol Pot Regime.

We moved on to Komphung Thom (home town of the said reclusive Pol Pot) where we set up for an additional week of surgical cases. We performed scores of operations on dozens of goiters and reconstructions of burns, tumor excisions, giant ovarian tumor removals and unusual congenital abnormalities rarely seen at the adult stage. It was an intensive and extensive surgical repertoire and we finished our last cases late at night and immediately began packing the surgical kits for the next mission to be scheduled for my return to Aklan in Panay, Philippines.

We made our way by road back through the same charming sales girls offering us the great delicacies of fried spiders, frogs, grubs and crickets to return to Phnom Penh. I had spilled a lot of blood from Cambodians during my intensive surgical weeks here, so turnaround was fair play. I reported to the National Blood Bank and gave a unit of blood for patients requiring it in subsequent operations here. I had arranged a chilling tour of the Killing Fields nearby the capitol, and watched Zebu cattle in deceptive peaceful pose grazing on the grass nourished by the mass graves beneath the sod, and stacks of skulls from the two million or more eliminated by the Pol Pot Regime. I have come through five mass genocides in my brief life, starting with the first of them here in Cambodia which was still ongoing when I was last here in the mid-70’s; in the “civilized” twentieth century I have gone on to work in Rwanda, Congo, and now in South Sudan and Darfur where “never again” keeps on happening again, and again. The Tuol Sleng Genocide Museum back in Phnom Penh shows the almost Nazi-like methodical documentation of the interrogated prisoners, including young girls looking like they are posing for their high school year book portrait, or holding an infant born to them in this brief stop in the transient process of their inevitable deaths. Their rag-like clothes are extruding from the ground and their skulls piled in anonymous pyramids as a humanitarian monument to our modern industrial efficiency era’s concern for others’ human rights.

NEXT: A RETURN TO SOUTH SUDAN,
DEDICATING THE NEW “LOST BOYS CLINIC” IN DUK PAYUEL
WITH JOHN BUL DAU AND MY STUDENT TEAM

As you read this, I am on my last mission of the year (and the first of next year’s!) traveling through Nairobi for our AIM Air charter into the Jonglei Province of South Sudan from which John Dau fled along with most of the devastated population during the long Sudanese Civil War. This visit will usher in a newer era as some of the surviving refugees may be coming back into their former homelands for resettlement since the CPA has allowed repatriation, and the new medical clinic made possible by the success of the movie “God Grew Tired of Us” will have its first physician on site before New Year’s Eve in the person of your present writer and will be dedicated in the presence of John
Bul Dau who will be with us as the Dinka/American leader who made it possible. I will be returning in later spring with another team for further medical and surgical services.