Extreme Pathologies

Nigel writes:
Another problem faced in Africa is the huge need. In Malawi, the hospital I worked in treated children with orthopaedic deformities and also burn contractures. Here in Liberia, we treat similar conditions including facial tumours and malformations, vesico-vaginal fistulas (VVF), thyroid tumours, hernias and cataracts, both in adults and children. A lot of what we see here are pathologies we rarely, if ever see in the West. This is usually as a result of the lack of clean running water and basic medical care. Some examples are:

1. Club Feet – a congenital condition where the foot is turned in and if not corrected the child learns to walk on the outside aspects of his feet. At home this would be treated by a series of casts over the first few months of life. Left untreated, it involves complex surgery followed by months of intensive physiotherapy.


2. Facial Tumours – Often these are benign but grow dangerously throughout the mouth and face. They can affect eating, breathing and threaten eyesight, not to mention the hideous disfigurement and smell that they produce, destroying not only tissue but the person’s self esteem.



3. VVF – Due to a long and protracted labour where the baby is obstructed in the mother’s pelvis, the tissues in the bladder and urethra become compromised of their blood supply and die. After a few days, the mother delivers a dead baby. Later, a fistula or opening occurs between the bladder and the outside world so that the woman is now incontinent of urine and becomes outcast from her husband, family and community. Good obstetric healthcare can stop this from happening. Worse still perhaps, in Liberia, 1 in 16 mothers die in childbirth, 1 in 2500 in the US, and 1 in 29,800 in Sweden.

4. Noma (cancrum oris) - is derived from the Greek meaning “to devour”. It is an opportunistic infection promoted by extreme poverty. It could be treated with an antibiotic as simple and cheap as penicillin. The peak incidence is in malnourished children aged 1-4 with a mortality of around 80%. Survivors are subject to disfigurement and disability caused by soft tissue and bony damage –some are missing lips, cheeks and even noses. This condition was last seen in Europe in prisoners of the concentration camps of the second world-war.

5. Burns – severe burns are common in Africa. Most cooking takes place over charcoal fires and since many places have no electricity, light is provided by candles and lanterns. Children are especially vulnerable. The aim is to correct the healed contracture so eyes can blink again, mouths open and elbows and knees move once more.


6. Cleft Lips and Palates are common all over the world. They are repaired in the first year of life but the outcome is not purely cosmetic. The repair promotes feeding, speech and development of teeth. Apparently it is not uncommon in West Africa for such babies to be buried soon after birth by local witch doctors in an attempt to kill the perceived “bad spirits”.


7. Cataracts in children are often congenital in nature or sometimes due to infection. If left, the sight of the child will never develop. In adults with this condition, one becomes slowly blind, reliant on family members and walking aids.

With all of these problems, the person becomes marginalised by their community. They may look unsightly. They may even smell from their fungating tumour or constant leak of stale urine. Often considered to be possessed by an evil spirit, they become more and more outcast in a society where survival is hard enough for the able.

Limits

Nigel writes:
I know one of the hardest things I have seen and been involved in is saying no. Turning people away from a modern hospital ship. Of course to them, we can treat anything and why shouldn’t they queue for hours? They are desperate.
I can see the difference between those working here for a short time and the approach of those that have been here many years. As healthcare providers, we are not used to turning people away. If we can treat someone, then we do. As a short-termer, the instinct is to treat anybody that can be helped. Both Cure and Mercy Ships could treat more conditions; trauma in the case of Cure, infection (abscesses, osteomyelitis) along with some medical conditions in the case of Mercy Ships.

Those that have built up the services and programmes offered by these organisations have done so after several years of living and working in Africa. They have had their many successes and failures. They know what works well and what doesn’t. They too find it hard to say no and they are always trying to push boundaries and see who else can be helped. However, they also have a bigger picture of their surroundings and realise their limitations and what impact, for example, accepting one patient with an abscess might do if that infection spreads to the many patients with healing wounds, implants and skin grafts.

In my first week on the Africa Mercy, we received some insights on bringing hope and healing to the poor and needy. Two things amongst many stood out in my mind. Both were insights Mother Teresa had.

The first was, “If you can’t feed a hundred people, then feed one”.

The second was, “God has not called me to be successful, He called me to be faithful”.

Finally, Micah 6:8, “He has showed you, O man, what is good. And what does the Lord require of you? To act justly and to love mercy and to walk humbly with your God”.

Scratching the Surface

Nigel writes:
The two organisations I have worked with this year are Cure Hospital in Malawi and Mercy Ships in Liberia. Both have a similar objective to follow the example of the figure of Jesus, trying to be his hands in a needy world. The mandate of the Mercy Ship’s is to ‘bring hope and healing to the forgotten poor’. The practicalities of bringing these two things are overwhelming. One of the reasons is that many people don’t fall into the Extreme Pathologies that these organisations target. When people do, however, they are received regardless of their ethnic background, religious affiliation or ability to pay.

Typical town life in Bong Town, Liberia

These organisations provide first class care and the results are impressive; physically, emotionally, and spiritually. Both organisations have had to adopt limitations for who they can help. For Cure, they are not able to treat trauma in children as there is simply too much of it for their small hospital. They have to leave that to others. Instead they are making huge inroads into wiping out club feet in Malawi following a successful model in Uganda.

The Ponsetti Technique of casting being used in Malawi to treat club feet.

Meanwhile, over the last 30 years, Mercy Ships has been performing complex surgeries on a hospital ship, travelling from country to country. They have performed over 35,000 surgeries along with many land based health initiatives and construction projects. This will be the ship’s 4th visit to Liberia over the last 3 years. Those who have been here for all that time, feel we are now dealing with less serious pathology, a sign that the work here has been successful.

However, you only have to look beyond the ship and you see a war torn country, people dying of malnutrition, infection and diarrhoea. There has been no electricity or running water for 14 years. We really are scratching the surface in terms of who we can help. The important thing to remember is that for those individuals we do treat, it makes a 100% difference. Their felt need is being met. It offers the enormous opportunity to no longer be an outcast in your own culture and to gain health and healing. This is my simple view and the basic level at which I cope.

A Year of African Anaesthesia

Nigel:
Having spent almost a year in Africa as an anaesthetist, first in Malawi for 4 months and now in Liberia with Mercy Ships for what will be 7 months, there is both a satisfaction and frustration.

Teaching local biomedical students in Liberia about the working of anaesthetic machines on Mercy Ships.

Firstly, I have learned that it was God who was willing to use me as his hands for this time and it is through his strength that I am here, not my own. I have been fortunate enough to have been born in a country where achieving a medical training was an opportunity at my door as long as I was willing to work at it. My training was free and I only had a small amount of debt after 5 years of study. Back then, and still now, a job is pretty much guaranteed and the financial reward is handsome.

In Africa, even if I wanted to become a doctor, the chances are as slim as becoming the next president. Such is the daily struggle just to earn a simple living and put food on the table.

The next thing I have observed is how ‘easy’ it is to practice in the West. Don’t get me wrong, medicine at home has its own stresses in terms of complex patients, quality assurance, targets to meet and departments to run on a fixed budget. This however is relative to the situation in Africa.

Two Malawian anaesthetists prepare a patient for surgery at Biet Cure Hospital.

Here, the majority do not have access to even basic medical care. 70,000 people die each day needlessly of causes such as water, basic sanitation, AIDS and easily treatable conditions. Where there is a hospital, it works on a system of payment and bribes for your treatment. The anaesthetic facilities are basic and the conditions the anaesthetists work in are difficult. The equipment is out of date and often non-functional, there is often little or no monitoring of the patient, drugs are scarce and techniques are kept simple. Looking after a patient for even moderately complicated surgery is beyond their boundaries. Recovery rooms in these hospitals do not even have oxygen!

Queens Hospital, Blantyre (Malawi), anaesthesia cart with draw-over apparatus and a brick to hold the syringes.

In Malawi, there is only one anaesthetic doctor and in Liberia there are none. As in most of Africa, nurses provide this care in harsh circumstances and I stand and watch them in complete admiration. The 3 nurses I helped teach in Malawi (and let’s face it, I learnt much from them too) still did not earn enough to travel or buy a house. They would tell me that their wages went to feed and clothe their extended families which could be up to 10 people. I can go home, find a job, work with other doctors and a trained assistant and have all the drugs and equipment that I need at my disposal. If something does not work, you simply swap it for one that does. I know my patients are going back to a ward where they will be cared for properly. It makes me angry when people complain about the NHS (National Health Service) in the UK. You do not need to travel far to have a reality check.

Our friends, Polina and Patricia, in Malawi.