FEB-A-12
FRIDAY, THE ISLAMIC HOLY DAY,
AND OUR “WEEKEND SCHEDULE” OF ACTIVITIES
BEGINS
WITH LATE ROUNDS AT
AND A TANTALIZING TOUR OF
ALREADY STAFFED AND OPERATIONAL FOR
PAYING PATIENTS
February 6, 2004
I am up well before dawn, in fact,
even before the first prayer call from the muezzin in the minaret within a few
hundred meters from my balcony overlooking an
as-yet-to-be-constructed-and-irrigated desert garden (“al Bhustran” in Arabic)
here at the Hotel Mansoor. The meaning
of the term Mansoor is “collective” or “consensus” I learned last night from
the owner and his brother Muhammad, the Minister of Commerce—a name chosen for
this barren bit of dessert scrub which was purchased following the war’s
ravages for $300 for these several hectares.
They are now being rehabilitated, meaning that the plastic bags that
festoon every thorn scrub bush have been plucked, some of the sand paved with
stones, and a formal garden laid out, so far represented only as squares. This garden, as others in Koranic tradition,
is what
ISLAM 101-
A CURSORY
REVIEW FROM A TRAVELER’S MEMORY,
WHILE
AWATING EVENTS ON THIS HOLY DAY
OF EXTRA
PRAYERS FOR EXTRA CREDIT
One of the five pathways to that
A second pillar, which should take place at least once in the lifetime of any good Moslem, if able, is the Hajj. The month for that Hajj has just been completed, and is over when the committee of the wise mullahs who look to see the new moon rising declare that the month of fasting Ramadan is over, and a celebration of feasting may begin—Eid Fitr—Christmas New Year’s and fourth of July all rolled into one. The Hajj month has just been concluded, and the usual deaths from epidemics from the crowding of an epidemiologic fermenting stew is mixed from allover the world is less a problem than it once was with a Hajj Terminal in Jeddah replacing the Arabic Dhows that had to carry the pilgrims before to the port of Jeddah to offload on camels or donkeys to go up to the holy sites of Mecca from which the Kafir are prohibited entry (“Kafir” =”unbeliever” and a term of despising in Arabic but also in Afrikaanse where it means the same but is there used to designated “Blacks”) But, as the epidemics of cholera or Black Death have decreased with this mass movement of religious ecstatic people observing few precautions, dressed in their two folded towels leaving the right arm and shoulder free so that a “Salaam!” salute can be raised upon entry into the Paradise garden (the two towels are the burial costume for this reason, as well as the de rigueur Hajj couture), epidemics of violence have increased. The Hajj pilgrims were always subject to banditry, but now they have the political and extremist sectarian violence to worry about. Two million of the faithful descended upon Mecca under the titular care of the “Custodian of the Two Holy Mosques” (the only official title of King Fahad of Saudi Arabia, and the only title that legitimizes his temporal reign) and they are distributed across the spectrum of Islam, including the two major factions who are shooting at each other in many of the places from which they are originating. The Sunni are the followers of the prophet Mohammed and comport their lives, reputedly, according to the ‘Sayings” (=”Sunna”) of the prophet, recorded, sometimes imperfectly, by his disciples. There is room for theologic debate and “lower criticism” among such followers of the Sunna. The Koran, in contrast, is directly inspired Holy Writ, so that even its typos are unchangeable and infallible, since these are the words of Allah—who speaks Arabic. (My ancestry, the true believers, know that this is untrue, since the Deity speaks primarily in Dutch.)
The other major faction, the Shia, believe that the caliphate at the origin of Islam got it all wrong. It was not the Prophet Mohammed but his nephew Ali, who was the divinely inspired messenger of Allah, and the heretics of the time murdered him to usurp [his rightful place by the merchant Mohammed. They both have to follow the five pillars of Islam, however, and that includes the Hajj and circling the Qabah five times in the prescribed way, and stoning the pillars representing the devil, and the other stylized worship rituals. This has allowed violence to be a part of this ritual as the Iranians desecrated the Hajj by attacking the Sunni several years ago having smuggle automatic arms into the ritual towels, and just his last week, a rush of panic crushed 255 al Hajjis to death in one of the bigger mishaps of recent times. But, this would be a royal road to paradise to die on the Hajj, especially within site of the Qabah. As the prayers are valued differently, a prayer in the Holy Mosque is worth a thousand elsewhere, but the highest “value added” is a prayer in the Hajj at the Qabah, worth 100,000 prayers elsewhere, as in Indonesia, the single largest Islamic nation of the 30+ countries in which Islam is either dominant of the state religion. So, it may be worth more to be at prayer today, but one could really bank away extra credit by crossing the Red Sea her and appearing in the Mosque and at the site of the “meteorite set in silver” in the corner of the square Qabah, covered in an embroidered hanging cloth raised on silk ropes at one corner. Since what is now Saudi Arabia was then a very destitute peninsula of nomadic poor Bedouins, they could not afford such an elegant cover for the Qabah, which had to be replaced each year because of the tearing of the fringes by pilgrims eager to carry away relics of this blessed experience, a very wealth Islamic neighbor had to provide this cover. Egypt, at that time a central part of the Islamic Ottoman Empire has to this day a special cadre of people who supply the Qabah covers, and I had once since the display of past Qabah covers in the Al Aleamin Mosque in Cairo.
I am synthesizing these warps and woofs from memory of several Islamic world regions that I have visited often, and the al Bhustran under my contemplative eye just now as the muezzin’s prayer call is fading with the dawn light rising is reminiscent of the Al-Bhustran I had seen in Muscat Oman, or a similar formal pattern garden at the Taj Mahal or inside the Red Fort at Agra, where the Moguls were fervent beliers who were trying to enhance the value of their own prayer sites. If this gives you more Moslem worship than you needed at the dawn of this Holy Day following the Hajj month during the days of the Eid as I am near the Red Sea base of Mecca toward which all prayers are directed, I will get on to other business, as I cannot easily do here while others have suspended that business to pause to pray today
TROPICAL
TORPOR:
COMPOUNDED
ON A FRIDAY
AS “ALLAH
WILLS IT”
It has been a good thing that I began the day describing the prayer call on this Islamic holy day and the influence of Islam on the affairs of the otherwise bleak life in the desert under that torpor of the torrid mid-day sun, since we have experienced the “dis-connect” of being health care workers attempting to care for urgently needed treatments to desperately sick patients---alone, without support, supplies or even rudimentary process in the central “referral hospital” which is for all practical purposes “closed for the day.” Despite the “off day” the patients could hardly be expected to avoid getting sick and sicker on this day with respect to the calendar, and the desperately needed care was simply foregone. We waited for our scheduled 9:00 AM pickup, and no one appeared.
We called a taxi, and got a ride to the hospital, where we arrived, prepared to make rounds and do the treatments on quite a number of the patients whom we knew would need care and to see if there were any new patients who needed to be evaluated. So, ready to work, and full of therapeutic enthusiasm, we strode out through the wards and found---no one. No one, that is, not sick or in any helping capacity. Patients were still being admitted, but largely to fend for themselves or to have a cluster of worried relatives struggling around them. We went to the male surgical ward to see at least the patients I had met and to see what progress there was in any of their care. We found no nurse or orderly, or anyone who could translate for us. We could find no charts or data on any of the patients to see if anything had been written or ordered. We asked for help, to see if anyone could find someone who knew what was going on and who could go a round with us and translate what the patients’ complaints or requests might be for us. Nothing.
Rather frustrated, we backed up toward the office to see if there were anyone who had come in to work today. Everything we had tried was locked up. We heard from someone that there was some unusual amount of activity in Maternity Ward, since some cars had come up and a number of doctors were there doing rounds or something. We went to the maternity ward and knocked on the locked door. We were let in with a group of women in Somali veils and gowns mixed with men who looked like advanced medical students and one woman wearing a white coat over her Kenyan gown. Her name was Nancy. She was asking clinical questions in testing the others, and if they wandered off she would say “Let’s make just one Round here.” The group would gather around a patient to examine and suggest a plan. Many were pre-eclamptic with no apparent game plans, especially if they were poor and could not afford the hydralazine that was keeping their BP from being controlled and jeopardizing their life and health. The woman, Nancy, asked authoritative questions, such as “What single factor would determine that this patient should be delivered to day even if she is only at 26 weeks gestation?” There would be a round of answers, and she would assign the patient to one of the practitioners in front of her. Another woman who came from Somaliland was an employee of CARE and another from a Safe Motherhood NGO. As you have already learned in these accounts, they certainly needed this, and that also explained the presence on this ward of the Doctor Nancy, a Western Kenyan who had come from Jomo Kenyatta Hospital where I have been. It turned out that she also knew about the Rift Valley Academy and the centers at Kijabe and Tenwek. In fact, she had circulated from her home village as a Louo Kalingen language speaker to the mission hospitals and had been at the East African Conference at Brackenhurst in Tigoni—the course in which I have lectured in the highland retreat among the tea plantations!
She is here for a three week tutorial to teach some of the doctors and midwives engaged in Obstetric care to try to reduce the horrific maternal and perinatal mortality here in Somaliland. That explained her “teaching rounds” and it also gave us an opportunity to see the same factors previously noted and at least one of the reasons therefore. The local population is familiar with operations, since they castrate their cattle, and they are not eager to have their women experiencing such an operation. It seems there is an even bigger cultural factor to be reckoned with. The opinion of an Islamic woman does not count. If a woman has an obstructed labor and a C-Section is recommended, the woman cannot give such consent, but the husband must be located, an explanation given to him, and he must approve, often only after he consults with his brothers or other elder males as to whether they would recommend such a course. Even if the woman’s life is at stake, and she is pleading for operation, it cannot be performed without the husband’s permission and he is unlikely to give it, at least not before consulting with other male relatives and elders as advisors. Their opinion quite frequently is that women have been delivering babies for millennia out of mind, and that they should be capable of continuing to do so, without assistance of an operation of which the men are leery, especially from another man handling his wife’s body so intimately, a property belonging to only one man. The term for “operate” in Somali is unfortunate. “We want to kalleen you” translates literally into “We want to slaughter you.” This is a group that has had a long history of familiarity with slaughter and none with professional operations for healing. The war surgeons were on-the-job trained uneducated workers in refugee camps, so their history of doing unsterile operations made the slaughter a not very wide miss of the mark as a term of similarity in the two activities. If the doctor operates without the permission of the husband if he cannot be found or he does not approve in writing, then the husband has every Islamic right to recourse to come after the doctor for this assault. There is no doctor here so foolish as to take that chance, so they have literally transfused and watched the patients die before their eyes of preventable obstetric disasters rather than run the risk.
“What about the law?” asked Jay. “You forget,” replied Nancy, “That this is a lawless land.” This is frustrating to a doctor from a real nation like Kenya where there may be such laws by a recognized state with authority to reinforce them or at least interdict revenge by a husband on a well-intentioned doctor. But, it is triply frustrating for the first-world American senior medical students who are here to operate, treat, and intervene in the natural history of disease. This is the biggest culture shock to date---another will be coming up shortly.
We saw each patient, including
several who were pre-eclamptic and who would not be able to go through the full
pregnancy and would probably have a destructive delivery for an in utero
death. The protocols that Nancy is
trying to spread around the world seem to be started on reduction in maternal
mortality, with the irreversible factor of the required husband’s permissions
for any operation and the likely refusal until later, when it is too late for
salvage of the infant. So, maternal mortality
may be reduced but fetal wastage is high and going higher. There were several such new examples since
yesterday.
FIND DR.
YASINE AND DISCUSS THE “SHORT STAFFING”
ON FRIDAY,
AND THEN FIND ONE TRANSLATOR FOR ROUNDS ON OUR OWN, WITH AMAZING FINDINGS
The Medical Director Dr. Yasine was in briefly and learned that we were interested in trying to go around and see the patients, at which he was somewhat surprised, it being Friday. He was only there briefly, but offered to interrupt what he was doing for our rounds, but we found a translator potential in Joseph, and suggested to him that we could use him and I would conduct the rounds with the students over all the patients in the hospital to se the pre-ops and any new ones who might have been admitted especially. Dr. Yasine explained with that one phrase I remember so well for the London School of Hygiene and Tropical Medicine “It is very difficult.” This was his summary in pointing out that he had no allotment of funds from the government, which had no resources of its own to give. The only money coming in to the hospital was the minimal amount of money that could be charged to, and harder still, collected from, the patients and their families for the services provided—often in the two dollar range. This could bring in at Maximum $4,000 per month, 75% of which went to salaries, and that had to cover 175 personnel, the highest paid skilled nurse of which earned $20 per month, less than our lunch yesterday at the Mansoor Hotel. So, with this amount of monetary reward, and almost nothing but negative incentives in the professionalism they had to extract from working in such a marginal facility, the employees were not very punctual or very dedicated in their attendance when not immediately supervised—as, for example, on Friday, when we were pretty much the only game in town in the hospital. “Who can blame them? We do what we can, but…It is very difficult.”
So, off we went with Joseph serving as our translator, and he could use the language but did not know many of the patients. We began on the male orthopedic ward for the most resounding response yet on the “non-violent nature of this nation at peace.” Four of our first five orthopedic patients were penetrating gun shot wounds, with smashed long bones and septic osteomyelitis in plaster casts that were redolent of the odors of pseudomonas and anaerobes. Many of the, at least, had their X-rays in an envelope at their bedsides and most of them had been here for a long period of time, long enough to develop purulent discharges and contracture of joints. One man had a huge sequestrum (“dead bone”) inside a not yet solidly callused “involucrum” of the gunshot wound of the shattered femur, all of it displayed well on his X-Ray. He would need a “sequestrectomy” but only after several more months of healing in the bone callus to prevent a non-union and allow the critical weight-bearing, which is the function of the lower extremity. He would be here for months more and obviously would be incapable of paying for that hospital bed and its attendant feeding, so he is a large loss economically, but also a whole cadre of these men were lying side by side watching nothing happen very slowly, and they were infected with disillusionment and despair. There were many of the external fixators in use, but even they did not keep some lower extremity non unions from happening in the infected bone—countering the all-important STABILITY, the goal of fracture care in the lower extremity. By ironic contrast, there were several solid unions of the elbow or wrist where the all-important feature is MOBILITY in order to position the hand in a position of function. So, I looked over a large number of orthopedic complications all warehoused in one place, most draining pus and reeking, while headed opposite the direction they should be---stability in a useless upper extremity, and mobility in the lower extremity that made stable weight bearing impossible through the non-unions that were resulting.
Fully half of the orthopedic cases were long-term residents from gunshot wounds and septic fractures that were complicated, and one of the men with a shattered femur and knee joint had been shot in the Civil War in 1994, and he was still here and still draining pus ten years later! So, the orthopedic ward rounds was a very instructive lesson in all the ways things might go wrong. It is very difficult, indeed.
We then adjourned to the male ward. We could give out some good pearls on the pre-ops all lined up for the week, and see some of the patients who were also being warehoused with little more than feeding being done for them. A “new patient” not know to me before was lying in the corner bed. He was a nursing assistant in the hospital who was going home yesterday when he was assaulted and clubbed over the head, opening a scalp laceration that was bandaged, but more importantly had a neurologic deficit that had been unevaluated though the scalp laceration had been closed. If there were a scan available it would be appropriate to study him hat way to see what the nature of his closed heard injury might be, but as it is we will just have to examine him serially to see if he is getting better or worse.
We found a child with a three week old femur fracture who was in a short leg cast, and had been discharged with half the cast cut off since it had caused a slough of the skin which was a full thickness loss. He had fallen at home and had re-fractured his unhealed bone callus, and was crying over the pain of the bone fragments no longer stabilized. We started him on wet to dry wound care dressings—that is, only after we got into our bag of surgical stock to get what was needed since there was nothing available in the hospital for this purpose. I could not correct many of the problems we encountered so I selected a half dozen and split them up among the three students who could go around as the intern and chief resident all rolled into one taking charge of a couple of the patients each in re-dressing them or changing their care plan in some way that had been pointed out during the rapid expedited round so as to cover more of the patients we could see.
In the end of the female surgical ward, we encountered a new patient that startled even me. She was surrounded by a gaggle of relatives, mainly female, who were holding up blankets to shield her from the view of the curious. What I saw was a full frontal body burn, most probably a flame burn in a lobola dispute over bride dowry, a case that in India would be referred to as a “bride burning” in “making a Sati of her.” She will need topical burn care, IV fluids and if she comes through that prolonged ordeal, some skin grafting.
THE TORPOR
OF THE TROPICS
WHERE
DISINCENTIVES OUTWEIGH MANY GOOD INTENTIONS, AND THE SINECURE OF A POSITION
COMMANDS
LITTLE RESPECT AND DEMANDS LITTLE PERFORMANCE- A FOREIGN “VA SYNDROME”
The overwhelming burden of the “It is very Difficult” mentality is collectively energy sapping. It becomes a self-fulfilling prophecy when it infects co-workers with the same fatalism. “I can’t solve even a fraction of the problems layered out upon me, so why bother trying?” is an easy cop out. To overcome the enervating shell-shock of the team in this expedited lightning rounds through the myriad of unsolved problems we parceled out the most likely fixable ones to do first with limited resources that we happen to be packing along. Jay was assigned to the Casualty Department where a woman had come in in Diabetic keto-acidosis coma—and still had no IV or fluids to put through it. We got started with the kits we retrieved from the Mansoor hotel and she became less obtunded with a blood sugar coming down to 70 when she was given some of the insulin, that, luckily, she was carrying , since there was none to be found in the hospital. After repeated visits, she seemed to be out of immediate danger, but she did soak up a lot of supplies and attention on repeated visits. Kevin and Juan busied themselves with wound care. They had gone from complaints of inadequate patient care responsibilities in new patients coming to them to being overwhelmed by the volume of just those that are already her in the hospital without any new fresh operative cases recruited, and two prostatectomies, and several other elective cases are posted for the next several days which will be labor-intensive, such as keeping irrigated catheters unobstructed. I stood back so as not to unburden them of any direct hands on care, and served as consultant to their suggestions. We had to go back to the Hotel to retrieve more expendable drugs and equipment and supplies to keep up with this lazy holy day’s emergency intake, without any further elective cases coming to clinic as they will be doing tomorrow.
I had always told each student applicant for an international experience in a medical mission that the single requirement was an infinite threshold for frustration. Point made—for them and, once again, for me. Besides, we had a social call to pay on another hospital to see “how the other half lives” in a dose of privately endowed facilities with better equipment and standards—albeit at charges to each patient for their care that almost none of our patients can afford. We went to the Edna Adan Maternity Hospital the private non-profit run by the full time fund raising efforts of the former WHO worker Edna Adan, who is out raising funds in Europe now, as NGO volunteers are in residence in her 23 bed specialty “Niche Market.”
We toured the clean and new facility of 23 beds with classrooms, a library, and even a computer center. It had a new laboratory and pharmacy—in stark contrast to the absence of any of these facilities in a ten-times larger patient population in the Group Hospital where we have to take on all comers in the admission of last resort for the impoverished and neglected. The Edna Adan Hospital has to serve an up-market clientele to offset some of its subsidized care, and Edna has been successful in recruiting NGO grants to build or support visiting volunteers. Rhoda is a Qatari from Doha who had no male relative to look after her family when her father died, so she came here. She took us around this well-situated small specialty hospital and nurses training center. Also on board are an Egyptian pediatrician supplied by the Arab League, a Philippino obstetrician by UNICEF safe motherhood programs, and a Nigerian midwife from CARE and a young woman volunteer from Leeds England named Stacy from the ICD, a UK NGO. The students immediately responded that they should work her since it would be easier, since it was already set up in a model that they could relate to and work in smoothly, but gradually realized that they were not really needed here as they are in the Group Hospital which has to take on all comers from the poor who enter its doors
The setting is beautiful. It overlooks the city from just enough distance to romanticize it a bit, as the sun was setting and the full moon rising. We posed for pictures on the roof in front of the “signature features” of Hargeisa, twin peaks called “Naso Hablod” or. “Maiden’s Breasts.” One of the volunteers suggested that “You can climb the ‘right tit’ on a path in twenty minutes—it has been demined!”
So, the frustrations of a long day waiting for something to happen to facilitate what we had come to do, was followed by a tour of the facilities already in place—but a gradual realization, “We must get to work and quickly to try to address the problems we can do something about in the context of the flood of desperate people who now will know we are here through the bush telegraph that will bring them her for free care, and we had better accelerate our pace, since there will be a long queue of the disappointed unless we get busy now.” So, we have come back to the Hotel Mansoor, with the tantalizing glimmer that it would be so much easier to do a small niche specialty work in something already set up without our input where we could simply operate if allowed to do on people who can pay, and for whose service we would be redundant. The need for our services is best fulfilled by the frustratingly painful approach of aggressive assembling the wheel before rolling with it, and escaping the enervating despair of the poor people trapped in this tropical torpor, get back to work—stating at 7:30 AM at Hargeisa General Hospital—where we may not be sufficient, but we and are supplies will certainly not be redundant or make little difference to those around whom this work is centered. Back to work—the holy off day of leisure is over!
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