FEB-A-10
OPENING DAY IN
TOURING THE BRITISH COLONIAL PAVILION
STYLE 350-BED HOSPITAL TO SEE THE PATIENTS AND THE PROCEDURES
BY WHICH WE ARE GONG TO BE IMMERSED IN
THE MISERIES OF AFRICAN PROBLEMS OF HEALTH AND ITS HEALTH CARE DELIVERY,
ALL OBSERVED FROM OUR COMFORTABLE HOTEL
MANSOOR NEARLY FIRST-WORLD BASE
February 4, 2004
I did not
need to get up early this morning. I was
already up, having awakened at 2:30 AM, after all I had come through eight time
zones east, which is always more “orienting” (as opposed to “occidizing?”) than
westward travel in re-setting my hypothalamic/ pituitary/ adrenal axis
clock. I set to work recording the
events of our first full day of arrival in
So, I was
already up at sunrise and as ready when the gang gathered ‘round and we had a
bit of breakfast. “Somali Tea” is a lot
like the Chai Masala in India, in which tea with milk is spiced to make it a
bit tangier, a phenomenon with much of the dining and drinking that occurs in
any desert tropical environment without refrigeration—the over-spicing being
for reasons readily apparent in the preservation of any foodstuffs near the
Equator. I also found a small stock of
very limited kinds of postcards here in the
We went to the directors’ office where at first there was a bit of leeriness about us and our visit, since they had glowing reports through the emails of our coming and the kinds of experience we would bring and were seeking, but then, what can you expect of pampered Americans who might want to have all kinds of things that we don’t have here as baseline essentials without which we cannot work? It was the reports from my students that seemed to get them from being bemused and interested in us to actually quite forthcoming and eager to see us at work in action. “Remember, he has been coming to Africa regularly for over 36 years.” “You are worried about our reaction to insecurity; he has been working over the past decades in the Congo, Mozambique, Zimbabwe and South African homelands; would you like to talk to him about that?” Now, they are eager to hear a lecture or two from me, as would my own students, a topic they request entitled “Medical Mission 101.”
For this purpose, the faculty member of the newly struggling and not yet vested, funded oar ready for matriculation Faculty of Medicine of the University of Hargeisa is eager to bring in his applicants to hear a lecture, and the point man of the eighty students in the Technical College of Health Sciences is eager to set the time for its setting up; the one lone hang-up for this? They are embarrassed to say that they know of no slide projector and will look into the homes of some of the ex-pats to see if any of them might have a projector available so that I could shop pictorials which are more readily understood than the language they were not born into. So, we are, as always, off to a slow stagger start, but will crescendo until we end with a frantic hurry as we get more and more people who are aware of us and want to take advantage of our donated services, and there will be a long queue of disappointed people still standing by when it comes time for us to leave. But, this distribution of tasks during a medical mission is very like life; it is underappreciated until it is nearly too late, and there is always too much left undone when it is over!
You will only be here two weeks? That is hardly worth starting! That would be true if the long courtship of getting to know you and trust you were to take place on the schedule of African time, but I have little interest in frittering away a large part of the opening days with each leisurely start-up, since I know the smersh that comes next on each of these missions, so I want to ‘front-load” these obligations to be at least half way done with them when we get closer to the end.
RIDE THROUGH TOWN TO HARGEISA GENERAL
HOSPITAL:
TOUR, GO TO GYNECOLOGY THEATRE SESSION,
AND MAKE WARD ROUNDS WITH SURGEON
We were picked up after our pick-up breakfast, and rode to the Hospital along very bumpy unpaved streets. We had already some idea about the state of post-war Hargeisa, but this was a re-enforcement. Plastic trash bags were festooned on each scraggly thorn bush which looked lie a top gallant racing set of sails. The streets are ALL unpaved rutted sand tracks, with billowing clouds of dust which cover the hovels alongside them in a fine powder. Dust and trash are the two common denominator features of the environment, with the same forlorn looking figures ghosting along the roads emerging from the hovels or kiosks as though they are not touched by them since they remain a different color than the drab desert camouflage. The buildings are all single story with pockmarked bullet holes lavishly scattered in strafing patterns over the finer structures and some have big buildings with imposing facades, but the only signs of life are the people, goats, and donkeys wandering in and around the hovels made of rubble in their bigger structures courtyards. The drab background might be depressing if one had this as a regular feature of background, but every so often a splash of glorious color hits the eye in the bougainvillea that are scarlet, the jacaranda which are purple, or the tree for which I cannot remember the name but it looks like the plummeria, which is blossoming in yellow even now in the dry time of the year. The dry river bed is not an empty channel, but is filled with trash and the rubble which catches and is decorated by the plastic bags—fluttering like the forlorn Somaliland flags.
We got to the hospital which is a sprawling British colonial pavilion style hospital, with the separate buildings along walkways housing the Florence Nightingale large wards, marked off as the male surgical, female surgical, male medical, female medical, pediatric, psychiatry, orthopedic, and maternity wards. There are accessory buildings which are the poorly stocked pharmacy with picked over shelves which are mainly central store obsolete boxes refilled from the WHO essential generic drug list, the most abundant supplies being the medicines for which there is no use.
We went to the Director’s office, where a gaggle of hangers on waited, each seeming to be quite content for us to get in ahead of them so they could have the entertainment value of seeing the only happening game in town under observation. There had been a King’s College “TEAM” here last week, which is supposed to encourage and provide some continuing education. One fellow had been giving out a dirge of questions after he had learned that we were Americans, after first being mistaken for Frenchmen or Dutch. “I thought you Americans were so busy fighting Iraq that you would not have time for anything else!!” A few of the inner circle of the nurses or physicians (a total of five doctors work here for the 350- beds, one hundred of the beds are devoted to psychiatry, but there are no psychiatric meds since the money ran out of that budget early in the year—two months into the supply.
The Director of the hospital confided in us that his MONTHLY salary (Not daily, Not weekly, he repeated MONTHLY) was $40.00. And you wonder why there would only be five phsyicans working in this hospital with 350 filled beds. “Who would not be elsewhere if they could be?” he asks. They kept looking at us for our reaction to the conditions we were seeing, as the “Admin Officer” Hassan who had come for us this morning along with our pickup truck driver Essa would snort, ”You will see!”
The only way they listen to me when I have something to say is for me to remind them. I have made rounds in Truk Hospital which the Chamber of Commerce booklet describes about its only hospital facility “Truk Hospital is the place you come to die.” I have worked in Maputo General Hospital, the largest and only teaching Hospital in a nation of 28 million souls which has no bed linen, aspirin, penicillin or electricity most of the time, and I have seen what was left in the countryside after the RENOMO and FRELIMO rebels had been at each other for so long, they had specifically targeted health care facilities to trash and health care personnel to kill and maim. And they listen to me further when I mention one brief word “Congo.”
The Director had heard by email from WHO that we were here to do operations, and had seen a list of the kinds of operations we would consider doing, saying “I thought in America everyone had picked a very small specialty, and the list of operations you had submitted is very broad; what kinds of specialists are you?” I replied, “I am a ‘Skin Doctor;’ I take care of the skin and its contents.” I told him we would set up in the intake and outpatient for consultation and select from the patients reviewed those that might need operation and do that which was most useful that otherwise might not get done. I told him we would bring in our own supplies and would review what it is that was needed here and hold back some of the rest for the other villages and remote centers we would be visiting, on an itinerary as yet unplanned.
We came to the Theatre with the Director, and observed protocol by wearing shoe covers—probably all four “disposable” shoe covers they had, and caps and masks and gowns to go in to the theatre where a woman was writhing under a second dose of Ketamine while the only gynecologist was excising a prolapsed uterus. It was a rather course affair with less finesse than that which would be seen in an orthopedic heavy duty operation, with big and clumsy instruments which were few in number. He kept calling for “Gauze” and individual topping sponges would be torn out of paper packets and shaken on to cloth field. A woman with Somali robes but with her face uncovered held the patients' legs apart. At first I wondered what he was doing undermining the vaginal mucosa, and then excising it. He said matter-of-factly as he closed the mucosa with a running locked nonabsorbable suture: “She is now post menopausal, and has had six pregnancies---‘para six’—so there is no sexual contact.” This certainly is a self-fulfilling prophecy!
We then went to a second room where a younger woman had pulled her gown up over her face. We examined her to see “What kind of female circumcision she had undergone.” To his surprise, she showed very little evidence of mutilation, since I asked, “Is it usually infibulation?” He recognized that I was not unfamiliar with the process, so he added to what I already knew: “No, usually it is excision of both labia, and amputation of the clitoris.” I said I had seen urinary tract outlet strictures that had resulted from this practice, and he added, “Yes, but I have also seen large dermoid inclusion cysts—one woman eighty years old with a labial cyst larger than my head, so that you can imagine how it had accumulated all her life from the time in her youth when it was done to her!”
The younger woman before us was a “habitual aborter” so the procedure to be performed was a cervical cerclage—the Shirodkar operation. He almost apologetically showed me a big needle and the material he was about to use. “This is not what we would want for the suture, but it is all we have!” And he tied on a big chunk of umbilical tape—which surely will be a festering mess after a few months in the vagina. He also explained, “We do not need anesthesia for this operation.” As much as the cervix does not have cutaneous innervations he may be correct, but need it or not, she did not get any, and the quick crude operation was completed.
I am not sure I would be delighted to be the only operator in town in the practice of my trade and have the intrusion of a Professor of Surgery from America looking over my shoulder giving a running commentary to his own accompanying students, so I went out of my way to say little that was unflattering. But, it may be a very god thing that they do NOT do many operations here—in the referral center of the capital of the wannabe nation---and of all those that are done, very few are non-emergency elective operations, two of which I had just seen on the alternate two days of the week (excluding Friday, the “Sunday-equivalent” holy day off here) Thursday the Theatre is also closed for refurbishing, and its off status is reflected by there being no electricity during that time. Sunday and Tuesday are the general surgery operating days for elective cases, which do not often occur. We came back to the Director’s office in the company of Musa, a fellow who is proud of his job in the Theatre, doing what he can to still make things work despite shortages of everything. There we met with the surgeon, who wanted to talk with me and get the measure of me and my team to see if it was worth even entertaining us.
WARD ROUNDS AND A REVIEW OF THE PATIENTS
AND FACILITIES OF HARGEISA GENRAL HOSPITAL
Doctor Suleiman (he rejects my calling him by the higher British term “Mister Suleiman” since he does not have the formal British qualification of the barber/surgeon having completed no one of the formal surgical training programs) found out quickly that I had seen much of what he was describing before and had brief constructive comments to make about those problems, so we made a repeat ward round on each of the services. It was instructive and eye-opening, if not overwhelming for the students, since it was rapid, telegraphic and each patients’ chart was a single sheet.
We started in the OPS which was quite crowded with one of the physicians, not the brightest penny in the box, Suleiman seemed to be hinting, and a number of more competent male nurses and technicians who screened and alerted the physician if they found something that needed to be fixed, and the physician then admitted it to the surgeon’s ward—so this is very British meaning that the surgeon sees only what the physician refers and is never a primary physician screening his own patients in primary care. We saw probably the single most useful “high tech” item that I consider “appropriate technology “ in this setting, that is the use of ultrasound. A portable ultrasound, as we used it so often in Malawi is the MRI, CT scanner, angiogram, and biplanar X-Ray unit of the bush. It surely goes well beyond OB and the measurement of position and biparietal diameter of a fetal head. It can find pus, and large cysts and tumors and give a lot of information on the wards, and one of the two units that they have here is portable.
We made a quick round on female ward, but spent more time in the male ward. One of the older men had a BK amputation of unhealing ulcers of a neuropathic foot due to diabetes, while he denied that there is any leprosy her to give any other source of neuropathy. A young man had a stab wound of the chest and had just had his chest tube removed. Another was not so lucky. He was stabbed in the neck and had a Brown-Sequard Syndrome with paralysis on one side and a sensory loss on the other reflecting a hemi-sected spinal cord. While we were there he had a grand mal seizure in our presence, reflecting that he also had meningitis from the contaminated entry into this spinal cord with an ascending inflammation. I suggested that they might need to add some phenobarb and Valium after they did a spinal tap. An older man had a catheter in place after a supra-pubic prostatectomy—I smiled at Kevin since he remembers well the irrigation of the catheter as a necessity in the long vigils of my own over the post prostatectomy patients at Embangweni in a simple maneuver that I could not convince the nursing staff were important labor intensive procedures to keep the clots from plugging the catheter. There were two more men on the ward with prostatism awaiting this operation, and it may yet fall to me to prove this point allover again.
One man had a lesser curve gastric perforated ulcer and an intrabdominal abcess, which was drained and he now has a gastric outlet obstruction. He might need a gastrointestinal bypass, but more importantly, the lesser curve ulcers have a tendency to be malignant. There was no biopsy done, after all; this is a referral medical center and there is no pathologist in this country.
Another was said to have a colon tumor which was resected with a colostomy and he is no in to have the colostomy taken down, but in the interval he developed Tb now under treatment. That is important to distinguish also, since peritoneal Tb looks a lot like cancer and can be confused with it.
A young boy had been in an accident, and had a slowly recovering decorticate posture. He would need a great deal of PT and rehabilitative nursing care, and his likelihood of achieving such services here despite the labor intensity for which this sour be ideal in such a place, without the skills, his future is limited, and his contracture are very likely.
\A young boy was in a vehicle accident and “de-gloved” all the skin of f the right thigh. It is being watched with wet to dry dressings and granulating awaiting a skin graft, but before that, I noted that the Hemoglobin is probably less than seven, and that he was severely anemic that would endanger the chance of the graft taking. He picked up the chart and pointed out that it was not bad, actually a Hbg of 10—but that was in April last!
WE RETURN IN A DRWOSY SHELL-SHOCKED
STATE
TO THE HOTEL MANSOOR, AND WILL APPORTION
SUPPLIES AND GET TO WORK IN THIS AND OTHER CENTERS
IN SOMALIAND AS WE WORKOUT OUR WN SLOWLY
DEVELOPING SCHEDULE
The very forthcoming and compassionate WHO Director for all Somalia is a woman named Asea Osmania, who called this morning and asked repeatedly what she could do for us. “Whatever you need, if it is transport, I will send a car and driver, or any equipment we will see what we can do, and we will arrange your schedule of visits to your itinerary throughout the Somali region.” She came to the Hotel Mansoor to meet with us and to give her own assessment of the conditions in Somalia in general and in Somaliland in specific. She said “You have seen our so-called ‘Hospital’—let me tell you something more shocking than what you have already seen---this is the best that we have!” She went on to outline the list of first—except for Afghanistan, Somaliland is first in infant mortality, and maternal mortality. It is very high in malaria and malarial deaths. It leads many lists in the morbidity of preventable diseases. And she is not lying down and taking any of this but has a couple dozen vertical health care programs to attack each problem, each of which have run out of any of the state’s own extremely limited resources, an they have been unable to attract the attention of international donors because of the invisible status of Somaliland in international law. Then came the unfortunately timed murders of three health care workers in October in political assassination along the disputed Somali border to the South where we will not be going, a British couple and a German health aid. “How can you work in a lawless country without rules?” was the rhetorical question asked by the defeatist fellow in the hospital this morning, but she had a different spin on it. Almost any help you give can make a difference and let’s get started with whatever can get set up for a continuing relationship now and for the future.
We promised to do our sorting of the drug and equipment supply and come up with a schedule of my lectures to the health care workers of the capital here in Hargeisa, both nurses and health care science students from the University of Hargeisa, and a clinical schedule of the Hargeisa Hospital, then we will come to her for transport and an itinerary of visits to other hospital s in the country, to include Berbera on the Red Sea and we will carry the rest of the supplies to them with further help. This we did right after meeting with her.
We start the clinical activity at eight o’clock tomorrow morning and will begin operating the cases we find to fix, and pass out the medicines for the illnesses we encounter. We will make a regular schedule here for the coming week, and then will travel, possibly on the days when there is no scheduled elective work—their “weekend” Thursday afternoon and Friday “off”
So, there is an overwhelming amount to be done, so now is not nap time. We cannot do it all, but what we can do can be done with few resources other than willingness to get started, so “Let’s Roll!”