FEB-A-14
THE NOTE WRITTEN FROM SAAD NOOR IN
FOLLOWING OUR
AND MY RESPONSE IN A COVERING LETER
FROM HARGEISA,
February 7, 2004
Hello, from the Horn of Africa, from
Hargeisa,
This, if you are reading some
form of text transmitted to you, may be my first logging on to my own internet
server through my own email address.
But, it certainly is not my
first attempt at communicating with you, as you may be able to see, if there
are several more recent chapters attached to this response to Saad Noor’s kind
comments in response to the partial message forwarded through Kevin Bergman’s
account. I had just typed an email of
over an hour’s text as a cover note for these more recent chapters in the “Book” Saad referred to
that I seem to be forever writing, and when I clicked on “Send”, the computer
at the Hotel Monsoor Business Center smugly responded that I had “timed out”
and I should log in again—of course, with all prior messages irretrievably
lost.
So, I have returned to
my laptop, even if it has failed me in
several spectacular crashes recently, as the relatively more reliable device,
through which I hope to “copy, cut and paste” to save the log-in time for the
seemingly endless process of attaching the files, and still have an internet
access through which to “Send.” If you
have this text in hand, this discussion of the glitches through which the
triumph of an “end-run” has been achieved is irrelevant.
This effort to communicate
might serve as the model for an attempt to work in an environment where the
wheel must be re-invented to roll with it.
The single requirement for a medical mission in the developing world, I
have always told each group of students and first-time attending physicians who
are eager to join in such an effort, is that they exhibit “an infinite
threshold for frustration” and go about getting under, over or around each
barrier in the way of small steps for progress, never giving up or stopping
caring.
We have come close to this “infinite limit” in
the accommodation of our very forthcoming hosts and our own adaptability and
improvisation in the seeming impasse between immovable objects and irresistible
forces here in our initial efforts in
Even the most ardent
advocates of the nation-building process here are continually pointing out that
what post-colonial residual is left here after the savagery of civil war is
woefully inadequate, and can only come up to any standard worthy of the name by
significant outside help which is dependent upon some form of recognition, For them, this will be a process of
relationship building, rather than the receipt of stuff, or the performance of
a number of skilled achievements—such as a couple of operations that can be
pointed to as flagships that sailed, so there must now be some kind of
capability within a resurrected infrastructure in the major referring hospital
teaching center in the capital of the wannabe nation.
Remember that I have often operated without
power or plumbing, let alone drugs and surgical supplies, in other “developing”
areas of the world in the same post-war lawless chaos of Nigeria, Mozambique,
Congo, South Africa, Dominican Republic, Haiti, Philippines, so I may be less
“in a hurry” to operate on scores of patients to force a system where none has
existed, for the benefit, perhaps, of those patients fixed, but with the casualty
of the relationship they hope to build to further develop a sustainable
partnership. That is not immediately
apparent to some senior medical students whose first time experience here
“coming to operate in Africa” might represent a once-in-a-lifetime event, and
whose take-home souvenir would be a photo of them operating on their first
hernia repair, rather than the more significant development of a capability to
serve and to teach others in a renovated service environment; talk of the next
time enhancements may be less exhilarating for them. So, they are understandably frustrated by the
number of patients with neglected disease, knowing that if the hospital
infrastructure is not able to handle them because of reluctant personnel with
no equipment or supplies---both are now present and some are very eager.
On rounds today, I pointed out that the cases
scheduled for tomorrow –two transvesical suprapubic prostatectomies—are not
generally the kinds of cases that I could tell them to proceed and call me if
they run into any difficulty. There are
two patients we found on the wards during our rounds this morning that were
suggested as cases we could take to the “Theatre” today, to operate on
someone—just about anyone—to break the impasse: one is a woman with an adherent
mass in her abdomen which is probably an ovarian carcinomatosis left after a
prior failed operation by the only surgeon of note in Hargeisa and the other was a young man with heart failure
from a tight mitral stenosis---shouldn’t we just start with a closed mitral
commissurotomy?
So, we are slowly expanding
into the opportunities for another kind of learning experience here in Hargeisa
in the severely limited resources meeting an unlimited demand. If the problem is not enough patients ready
to be operated on, one suggestion was quite simple: use Radio Somaliland to
advertise “Free operations to all who want them by a US Surgical Team!”
Can you imagine the crush of the chaos that
would result from such an uncorking of pent up demand? A team of four surgical consultants from the
UK were the last to do this, and had planned on examining about forty patients
to select a few for operation from the kits they had brought with them. The thousands of patients who poured in from
all over and slept against the locked hospital gates paralyzed the process, and
they had to leave out the back way leaving tremendous disappointment in their
wake. Even if such a system were possible, it would institutionalize and
perpetuate a colonial hand out model which is 180* out of alignment with what I
have hoped for a sustainable indigenous skill.
We will interrupt the hospital schedule on Monday for the first
international lectures at the fledgling Hargeisa University and its “Faculty of
Medicine,” an entity that I hold in hand in its entirety on three sheets of
paper.
I have described in Feb-A-13
the longer term goals of a continuing self-help process of
institution-building, enhancing pride in the process that they must own in full
responsibility for it, with decreasing help levels from outside consultants as
the process matures. This may
understandably not be a primary objective for senior students who may not have
another chance to operate with a US Professor of Surgery in an exotic African
environment of improvisational ingenuity, before they begin residencies in
family, internal or emergency medicine.
They are looking wistfully over their shoulders at a new boutique
facility for patients who are not so impoverished that they can pay fees for
care by volunteer specialists recruited from international agencies: it would
be so easy to work there, in a system
in which they can be plugged in without inventing and sustaining it—and they
would be as redundant as they could now be if they took the same elective in
GWU’s affiliate at Holy Cross Hospital in Silver Springs Maryland, an
alternative already available to them.
It is hard to take the long
view of international development as the days are melting away to just a week
longer in Hargeisa, now that they have got to know and trust us, before
decamping to the even less well developed hospital in Berbera to repeat the
introductory process—and we still don’t have that picture of me fixing my first
hernia!
But, we must remind each of
us, remember that single requirement for service in such settings. Find what you can do to help them do it
better, with that “infinite threshold for frustration” and never give up.
Even when you find yourself alone as a medical student in the
chaotic wards of 350 inpatients in Hargeisa Group Hospital after noon, (or
Takum, Nigeria) when there is no other doctor, nor even a nurse, among the
abandoned patients left with a few family to fend for themselves, as you go
over to Casualty to see a young girl with a compound fracture of both bones of
her right leg, and find that the expertise and supplies that make the
difference for or against life and limb are in your hands and in your head,
find it in your weary heart to never stop caring.
Cheers! From Somaliland, on the short end of a curve,
but at least the slope is up!
GWG
Kevin:
I am doing my best. Yesterday, Sunday, I was in the office hoping
that I would fine an answer to a previous message on the subject. But there
was none, so I fired a very strong message and demanded an answer. If I
don't find it by tomorrow or you are not told, I will follow another path. I
am happy that you are getting busy at last. I read the latest report by the
man from Ann Arbor yesterday and I noted the "de-mined" tit of Nassa
Hablood! I wonder whether he has heard that here in
the States, Janet
Jackson's seems to be heavily mined to the extend that some might have
considered it a threat to national security! Who knows--the good Doc may
agree with some of us that a quick flash of a shapely amber brown breast is
no threat but an exhibition of a work of art.
We will solve the payment issue one way or the other. Keep on doing the good
work.
P.S. No one has ever described better the facial features of my friend
Mohamed Hashi, Minister of Commerce, than the Doc. I
have known him for many
years.
Best.
Saad
-----Original Message-----
From: kevin bergman [mailto:kbergman@yahoo.com]
Sent: Monday, February 09, 2004 12:24 PM
To: sl-us@wesi.com
Subject: help!
saad,
please confirm that our accomodations are covered as
you promised. and
please let us know either way.
in other news, things are starting to really pick up here in hargeisa.
seeing alot of outpatients - over 100 today - and
doing some surgeries
tomorrow. lots to tell and im sure dr. glenn will fill you in.
looking forward to hearing something back from you soon.
kevin
> From: "Somaliland-U.S." <sl-us@wesi.com>
> To: "'kevin bergman'"
<kbergman@yahoo.com>,
> <msdgwg@gwumc.edu>
> Subject: update
> Date: Fri, 6 Feb 2004 12:01:05 -0500
>
> Hi Kevin, the fast-moving Wolverine has given a vivid picture of
> Hargeisa at the first glance. Of course there is
more than that meets
> the eye to it. But it takes time, even for some of us, to see the full
> picture gradually unfolding. I tell you, fore a while, I thought I was
> standing next to the team at Hargeisa hospital!
What a description?! I
> Think Dr. "Grin" should write, about such an experience, a book
that
> will be fascinating not only to "the students of development",
but
> also to the public at large. Eventually, this could become base
> material for a TV program.
> I'm sure that in the the following few days the
team will get used to
> the habitat and put the show on the road. By the way, you guys stand
> your grown if need be. Keep me informed.
> Best.
> Saad
>
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