Im­prov­ing global health, one surgery at a time

The Washington Post Sunday - - BOOK WORLD - MEDICINE RE­VIEW BY NAZILA FATHI

In 2006, when Amer­i­can doc­tor Di­lan El­le­gala ar­rived in Hay­dom, on the edge of Tan­za­nia’s Great Rift Val­ley, he un­cov­ered a shock­ing re­al­ity: This coun­try of more than 40 mil­lion peo­ple had only three neu­ro­sur­geons. All of them were in the cap­i­tal, Dar es Salaam.

El­le­gala, who had re­cently grad­u­ated from Har­vard Med­i­cal School, was the first brain sur­geon at Hay­dom Lutheran Hos­pi­tal, a med­i­cal cen­ter that de­pended on vol­un­teer doc­tors from Europe and the United States. The fa­cil­ity lacked the most ba­sic sur­gi­cal tools. Pa­tients with head in­juries or brain tu­mors healed on their own or died. The op­er­at­ing the­ater did not have a func­tional mi­cro­scope; the light was too dim; pa­tients un­der anes­the­sia were ven­ti­lated by an as­sis­tant squeez­ing an oxy­gen bag by hand. Ev­ery bed in the hos­pi­tal was oc­cu­pied. Some pa­tients slept two to a bed; some slept on floors or benches out­side the rooms.

In “A Sur­geon in the Vil­lage,” jour­nal­ist Tony Bartelme re­counts El­le­gala’s ef­forts to im­prove the med­i­cal sys­tem in Tan­za­nia. Bartelme fol­lowed El­le­gala for four years, staying at the hos­pi­tal where he worked, wit­ness­ing the dire con­di­tions that made his mis­sion so dif­fi­cult. The re­sult is a har­row­ing and im­por­tant book that cap­tures the tremen­dous health-care chal­lenges fac­ing East Africa and opens our eyes to a com­pli­cated global health prob­lem: lack of ac­cess to safe, af­ford­able surgery and anes­the­sia. Bartelme says an es­ti­mated 17 mil­lion peo­ple die ev­ery year from con­di­tions that could have been treated sur­gi­cally.

Early on, El­le­gala was forced to make some dif­fi­cult de­ci­sions. One day, for ex­am­ple, an un­con­scious man was brought to the hos­pi­tal; cere­brospinal fluid was leak­ing from his ear. El­le­gala needed a Gigli saw, a $20 in­stru­ment used for cut­ting bones, to open the man’s skull and save his life. The only one at the hos­pi­tal was rusty and bro­ken. De­feated, El­le­gala de­cided to go out for a run to clear his mind. On his way, he came across a farmer who was cut­ting a tree limb with a wire saw. El­le­gala bought the tool and rushed back to the hos­pi­tal, where he ster­il­ized it and used it to per­form the surgery.

El­le­gala saved the man’s life, but a ques­tion haunted him: What hap­pens af­ter vis­it­ing doc­tors leave Hay­dom?

El­le­gala couldn’t cure ev­ery Tan­za­nian with his own two hands, so he tried the next best thing: train­ing other sur­geons. His first stu­dent was a Tan­za­nian med­i­cal as­sis­tant, Em­manuel Mayegga, whose ed­u­ca­tion was com­pa­ra­ble to that of a high school grad­u­ate in Amer­ica. Over a few weeks, El­le­gala taught Mayegga some brain surgery tech­niques and built his con­fi­dence to per­form surg­eries. It was a risky move, Bartelme ad­mits, but, given “that mil­lions of peo­ple had no ac­cess to even the most ba­sic forms of neu­ro­surgery,” the op­tions were lim­ited. “Was it eth­i­cal,” he asks, “to wait un­til a coun­try built a sta­ble of ex­pe­ri­enced sur­geons, a process that might take decades, if it would hap­pen at all?”

Af­ter El­le­gala left Tan­za­nia a few months later, Mayegga be­gan op­er­at­ing on pa­tients with head wounds. He helped another health­care worker, Emanuel Nuwas, to mas­ter the tech­niques and per­form neu­ro­surgery. Nuwas would also, as part of El­le­gala’s “train-for­ward” phi­los­o­phy, teach oth­ers.

El­le­gala, who also prac­ticed in Portland, Ore., and later in Charleston, S.C., founded a non­govern­men­tal or­ga­ni­za­tion called Madak­tari Africa. It sends hun­dreds of doc­tors around the world to serve as men­tors and to cre­ate a sus­tain­able model for global health. To ad­dress con­cerns about in­struct­ing clin­i­cians to per­form com­pli­cated brain pro­ce­dures, El­le­gala en­cour­aged Mayegga and Nuwas to at­tend med­i­cal school in Dar es Salaam. Both men re­turned to Hay­dom af­ter com­plet­ing their stud­ies to ad­vo­cate El­le­gala’s teach-first phi­los­o­phy — a tes­ti­mony that em­pow­er­ing peo­ple turns them into agents of change.

“Teach­ing has the power to change peo­ple’s in­ter­nal wiring, help them do things they never thought pos­si­ble. And teach­ing is a univer­sal value, as ba­sic as a fa­ther teach­ing a son to tie his shoes, which means it can be a uni­fy­ing force,” Bartelme writes.

Bartelme ar­gues that El­le­gala’s ef­fort to build a func­tional health sys­tem, even though it means re­ly­ing on lo­cals who lack cre­den­tials re­quired in the West, is more im­por­tant than the hu­man­i­tar­ian aid that has poured into Africa for decades. Such pro­grams are well in­ten­tioned but keep low-in­come coun­tries de­pen­dent.

The Ebola cri­sis in West Africa in 2014 un­der­lined the im­por­tance of a health-care sys­tem that can stand on its feet. Nearly 95 per­cent of for­eign health-care work­ers packed their bags af­ter the Ebola out­break, and the lo­cals were left on their own to fight the deadly virus. “Hos­pi­tals and clin­ics closed; the dis­ease spread to Nige­ria, Mali, Sene­gal, and then the United States and Spain. West Africa’s prob­lem be­came the world’s prob­lem,” Bartelme writes.

It wasn’t un­til thou­sands had died that gov­ern­ments and hu­man­i­tar­ian aid groups stood to­gether to stop the dis­ease. If African doc­tors had been em­pow­ered to fight it in the first place, Bartelme ar­gues, the scale of the cri­sis would have been dif­fer­ent.

“In a world of trauma and dis­ease,” he con­cludes, “des­tinies are of­ten shaped by ac­cess to heal­ers. And with­out this ac­cess, rip­ples of suf­fer­ing can be­come waves.” Train­ing heal­ers can stop that wave. Nazila Fathi was a cor­re­spon­dent for the New York Times based in Tehran from 1999 to 2009 and is the au­thor of “The Lonely War: One Woman’s Ac­count of the Strug­gle for Mod­ern Iran.”

By Tony Bartelme Bea­con. 274 pp. $27.95

A SUR­GEON IN THE VIL­LAGE An Amer­i­can Doc­tor Teaches Brain Surgery in Africa

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