FEB-B-6
HALE AND FAREWELL, SOMALILAND!
FOLLOWING TWO NON-STOP DAYS OF A CLINICAL CRUSH IN HARGEISA AND
BERBERA…
February 15, 2004
We are in “departure mode” as you see from the attached brief outline of four days in four clinical venues in two cities 93 kilometers apart, in which our activities could best be described as very much like “an ordinary interval (there were no such things as demarcated days and nights) in my Peter Bent Brigham Surgical Residency” in which the time was only characterized by the through-put of huge numbers of patients. Many of these patents were quite remarkable, with spectacular advanced neglected illness for which treatment had never been attempted (if a Western physician does not count the multiple attempts on the part of traditional healers to burn, prod or incant away the evil within) among an even larger number of the curious, the acquisitive mendicants, or the excitement and entertainment novelty that we were the only game in town.
Some of the stories were tragic building on epic. The young man whose diagnosis was made when Juan brought him over to me in Hargeisa Group Hospital having recognized his diagnosis from a slide I had shown him shortly before at Hargeisa University in my lecture there—a foul smelling degenerating Marjolin ulcer of the right leg—had agreed to the amputation we had suggested to him as his only treatment option, other than no treatment at all. In the drama of this life-and-limb-altering decision with freshmen clinicians from Hargeisa and a GWU world far away participating in these hard decisions, he had gone back to consult with his brothers and village elders, and had waffled back and forth on the decision for therapy, but missed his time we reserved for him in Theatre at Hargeisa. He had then pursued us down to Berbera, somehow getting a ride to the Red Sea coast, and we found him at the gate of the Surgical Hospital waiting for me, saying he was here for his operation now. To try to pack in the operation into the dozen cases we had booked for the Valentine’s Day Theatre list had overwhelmed the resources of Berbera’s theatre staff and stuff (drapes, gowns and autoclaved kits, the last ones still wet from having been recycled as quickly as they could be returned to service in this battlefront scene of operating) but we had put him on at the end of the list, only to be bumped again by more urgent cases. Alas, he is still waiting.
He was standing there as we came out of theatre in a rush to leave to get out before dark when travel through the war-lord bandit country of rural desert without an armed guard was unsafe—but then, al the time saved by hurrying some cases and deferring others of the five we left undone was used up in the elaborate ceremonial departure “sit downs” with the Mayor of Berbera and others, even though we had repeatedly begged off the formal dinners. Each wanted to spend further time going over and over again their gratitude for our visit and help, adding that next time we would have to come earlier, stay longer and do more, but could we first get their son into a US medical school an/or surgery residency to equip him to return to beleaguered Somaliland to help the struggling people to scramble up off the floor of their destitution?
The duffel bags I had carried down that were packed with the precious suture and the last of our MAP Med Packs were distributed with no accurate count as to the total number of patients benefited, but it was well over a thousand in each venue in Hargeisa, split between Hargeisa Group Hospital and Edna Aden Maternity Hospital and another thousand in the two venues of Medical and Surgical Hospitals in Berbera. I finally tallied over a dozen operations in the “St. Valentine’s Day Un-Massacre” here in Berbera added to the two dozens done at Hargeisa Group Hospital, and probably far more importantly, the training of the local “operators” (note that I did not say “surgeons”, or for that matter “doctors”, since, like Inikpiu in Assa, or Mister Tembo in Embangweni, or any number of my heroes on the front lines in places like Mozambique, Zimbabwe, Mindanao, and over a dozen more such venues, the local “positive deviant”, the key person who stands up in the adverse circumstances that would sap any other person in the desperation that enervates the beaten down population, get up and set about doing what needs to be done with the improvisation of almost al their own resources to use ingenuity in place of formal training or store-bought hardware.
Those people are here called Musa in Hargeisa Group Hospital theatre and Suleiman in Berbera, each innocent of any Medical School course in what are called the basic sciences, but long on caring enough to keep on trying. Each of them learned a few new tricks for the Visiting Professor and a promise of his return with another team to lead through this inspiring triumph of the human spirit against overwhelming odds. No, I could not help them do a hip replacement in Berbera, but I could help them recognize a rare disease here and so common a disease in other parts of the world and treat a late stage breast cancer, or recommend that the African melanoma be managed by local excision since they could feel the involved groin nodes, or treat the massive unilateral elephantiasis with diethyl carbamazine, elevation and compression before the skin broke down and required amputation. Some of the help involved small tricks—like doing a bowel anastamosis using a Connell running suture for the mucosal layer with absorbable sutures I had brought and the interrupted Lembert stitch on the seromuscular layer—these techniques are easily transplantable since they do not depend on a specific tool or material and can be applied anywhere. Some of the information offered came directly from the degree in Tropical Medicine and Hygiene applied to classic problems of the sub-Saharan African tropics. And most came straightaway from the “OJT” of having confronted a lot of such “insurmountable problems” in resource-constrained environments where someone before me had failed to give up and had tried to “make do” often with results that surpassed the wastage of a lot of high tech stuff thrown at the problem in the developed part of the world for no well-thought-out purpose other than that such extravagance was available, at least for that time being, for such disposal.
As I had said to Kevin Bergman on his freshman experience with me in Ladakh as we were in screening clinics in the Himalayas, I would do my best to teach him what tricks there are that might be applied to medical and surgical human problems in the somewhat controlled and well-supervised environments of on-going running programs such as we participated in last year in Embangweni Malawi; but, I warned him, that after working his way through the earlier stages with me, in his senior year, he would, as I had, precisely the length of his lifetime before him, be “thrown into the deep end of the pool” to try to help these desperately poor people keep from sinking and rapidly learn swimming with whatever resources he would be carrying inside him by this point.
We have enjoyed our time here in the very deep end of the pool, beginning, as we always are fated to do in the frustrations of treading water while improvising water wings as we thrash in the turbulence. But with a little help in the form of support from a few knowledgeable friends, it can turn around into a remarkably positive experience, in which not only do you learn to swim while saving lives of the drowning, but can help others do likewise. The only buoyancy required is to never give up that hope that you might have started with, but now, in full glorious deployment, you can work your heart out, in the deep end of a very big and very deep and very needy disturbed pool.
We have done it here in Somaliland—we have made a start
Now, for me, it is on to Ethiopia to start all over again. For the team, it is up to them to choose; they now know how it can happen and have a few new friends who have helped them in this struggle with a few life rafts. It almost does not matter which pool they might choose, since there certainly are enough deep ones out there—I know I have never run out of such opportunities. There are but two things left after that first requirement of an “infinite threshold for frustration:” that you still care and that you start trying.
You now know enough: “Bastante para Commencar!”
Bon voyage!
GWG