One small step for surgery, one gi­ant leap for a na­tion

Ear­lier this year, for the first time in Zam­bia, con­joined twins were sep­a­rated – with Ire­land play­ing a big part in mak­ing the surgery pos­si­ble

The Irish Times - Tuesday - Health - - Front Page - Damian Cullen

This is a story about how two very small deals . . .

When Ly­dia Mwape ar­rived at a dis­trict hospi­tal in Kawambwa, an iso­lated town in north Zam­bia, in May, 2017, she did not know she was about to give birth to twins. But that wasn’t even half the story. The girls were born about 1,000km north of the coun­try’s cap­i­tal. “At the time it was not known it was a twin preg­nancy, or that they were con­joined twins,” says pae­di­atric sur­geon Dr Bruce Bvu­lani of Lusaka’s Univer­sity Teach­ing Hospi­tal (UTH), the largest and main hospi­tal in Zam­bia. “So, be­cause of a pro­longed labour, a C-sec­tion was done by the lo­cal doc­tor there. When it was re­alised they were con­joined, they were re­ferred to UTH. They were in Lusaka within two days.”

. . . be­came one very big deal

It was the be­gin­ning of a long jour­ney for the girls, their fam­ily, the hospi­tal, and the south­ern African coun­try known for its wildlife, wa­ter­falls and rugged ter­rain. And it cul­mi­nated, ear­lier this year, in a team of sur­geons con­duct­ing the first med­i­cal pro­ce­dure in Zam­bia where a set of con­joined twins was suc­cess­fully sep­a­rated.

It was a land­mark mo­ment for the coun­try, a com­plex surgery many western coun­tries have not yet at­tempted. In 2010, Has­san and Hus­sein Ben­haf­faf from Cork were suc­cess­fully sep­a­rated fol­low­ing a 14-hour op­er­a­tion in Lon­don. Cork-born consultant pae­di­atric sur­geon Ed­ward Kiely car­ried out the op­er­a­tion at Great Or­mond Street Hospi­tal for Children, along with a team of up to 30 doc­tors. Sim­i­lar to Bupe and Ma­palo Mwape, the Ir­ish twins were joined at the chest.

The Zam­bian ba­bies were om­phalopa­gus twins – con­nected from the breast­bone to the waist. For the busy Lusaka hospi­tal, the un­usual guests pre­sented an ex­cit­ing op­por­tu­nity.

Up to now, a rare, com­pli­cated con­di­tion such as con­joined twins would have meant one thing – se­cur­ing for­eign in­ter­ven­tion.

This a story about re­sources . . .

“In the past, these cases would be sent for surgery in South Africa or In­dia or wher­ever,” says Dr Robert Zulu, one of the lead sur­geons in­volved in the sep­a­ra­tion and head of one of the five spe­cialised hospi­tals with UTH. “We had sev­eral meet­ings – de­bat­ing, ar­gu­ing, look­ing at the X-rays, scans, ul­tra­sound, lab re­sults, look­ing at the en­vi­ron­ment, the in­fra­struc­ture that we have and the in­ten­sive care. Whether we were able to man­age. So, for eight months, we were meet­ing.”

Hav­ing the surgery in Zam­bia was never a lock. There was a plan to se­cure pass­ports for the twins when the ar­gu­ment looked to be edg­ing to­wards send­ing them abroad. “But when the team de­cided they had the re­quire­ments to sep­a­rate the girls, we in­formed the min­istry for health and the stake­hold­ers that we were go­ing to go ahead and sep­a­rate them,” says Dr Zulu. “It was mam­moth work. Buy­ing things we did not have. It was a step­ping stone. Be­fore the twins ar­rived, we were de­vel­op­ing skills. COSECSA com­ing to this re­gion, it has been a bless­ing.”

. . . and the lack of re­sources

The Col­lege of Sur­geons of East, Cen­tral and South­ern Africa (COSECSA) was set up 19 years ago to pro­mote sur­gi­cal train­ing in the re­gion. How­ever, hav­ing the right per­son­nel was only one part of the jig­saw. As is the case in many African coun­tries, med­i­cal in­fra­struc­ture lags far be­hind any­thing avail­able in Europe.

“To com­pare our­selves to other coun­tries is not right,” says Dr Zulu. “Fund­ing in Zam­bia through the min­istry of health could help a lot. We could buy a lot of sur­gi­cal and med­i­cal sup­plies. We need them. There’s a lot of equip­ment we would love to have. Fund­ing to health care in Zam­bia is not yet there. It is like this in many African coun­tries. When we reach a good level of fund­ing that will help us a lot.”

In Oc­to­ber’s bud­get, Min­is­ter for Fi­nance Pas­cal Dono­hue al­lo­cated a 2018 health bud­get of ¤17 bil­lion for Ire­land.

In Zam­bia, a coun­try with more than four times the pop­u­la­tion of Ire­land, just over ¤300 mil­lion is spent on health­care each year.

This is a story about team­work . . .

The first op­er­a­tion to sep­a­rate con­joined twins in Zam­bia be­gan on the morn­ing of Fe­bru­ary 2nd, 2018. “The team was big – with all the sup­port staff,” says pae­di­atric sur­geon Dr Bvu­lani. “The op­er­at­ing team was six sur­geons. The surgery started with two sur­geons, each with an as­sis­tant. And then, af­ter the sep­a­ra­tion, an­other sur­geon scrubbed in for each ta­ble. “We started around 10am, and it was com­pleted around 5pm in the evening.”

The op­er­a­tion was only part of the task fac­ing the med­i­cal pro­fes­sion­als in the hospi­tal. The ba­bies had now been joined to­gether for more than seven months. “When they came out of surgery the team felt they needed to be re­ha­bil­i­tated in terms of nu­tri­tion, to in­crease their calo­rie in­take and help them gain weight,” says pae­di­a­tri­cian Dr Mabo Fun­danga. “That was in the short-term. In the medium to longer time, it was to try to re­gain the mile­stones that they lost. A lot of in­ten­sive phys­io­ther­apy came into play, and also, be­lieve it or not, play ther­apy. “The children had been at­tached to­gether – had not been in­de­pen­dent, so we in­sti­tuted play ther­apy with the nurs­ing staff and doc­tors, and also en­cour­aged the par­ents.

“It’s a big, big step. This is our land­ing on the moon, our gi­ant step for mankind. This case show­cased the im­por­tance of team­work – the mul­ti­dis­ci­plinary ap­proach. The pae­di­atric sur­geons handed over the children to the pae­di­atric care. When the children first ar­rived they it was the neona­tol­ogy team look­ing af­ter them. We couldn’t have suc­ceeded with­out the nurs­ing staff, and of course the so­cial work. So this is a very big mile­stone, and prob­a­bly the first of more to come.”

Dr Zulu sees the surgery as an­other mile­stone for the coun­try. “We’ve come from very far – as a hospi­tal and as a team of doc­tors, and as a na­tion as a whole. Work­ing well with var­i­ous part­ners, we have come now to de­velop hu­man re­sources, skills in surgery, skills in ra­di­ol­ogy, skills in the lab, and var­i­ous other sec­tors of the health sys­tem. To be able to say: ‘Yes, some of these cases we are now able to do.’

“That’s why we put up a mul­ti­dis­ci­plinary team, which was com­posed of gen­eral sur­geons, pae­di­atric sur­geons, pathol­o­gist, ra­di­ol­o­gist, pub­lic re­la­tions, nurs­ing, bio­med­i­cal – a lot of peo­ple to make sure ev­ery­thing was in place.”

. . . and need­ing more team-mates

Zam­bia has a pop­u­la­tion about four times that of Ire­land and is more than 10 times the size in area. How­ever, there are more pae­di­atric sur­geons in Dublin than there are in all of Zam­bia.

And Ire­land is not ex­actly over-sub­scribed.

In fact, while there is one pae­di­atric sur­geon per 100,000 peo­ple in North­ern Ire­land, in Zam­bia (pop­u­la­tion of nearly 17 mil­lion peo­ple), it’s roughly one per four mil­lion peo­ple.

“We have five pae­di­atric sur­geons in Zam­bia,” says Dr Bvu­lani, be­fore cor­rect­ing him­self. “One has just re­tired, so you could say we are down to four. Our pop­u­la­tion – 50 per cent are children be­low the age of 15.”

Dr Zulu was de­lighted when Dr Bruce grad­u­ated from COSECSA last year. “We were ex­cited, be­cause we knew the ex­per­tise [needed] in dif­fi­cult pae­di­atric sur­gi­cal con­di­tions.”

The num­bers are so small, ev­ery sin­gle med­i­cal grad­u­ate counts, ev­ery up­graded skill is cru­cial – and ev­ery one “lost” to a hospi­tal in Europe or North Amer­ica hurts.

For over a decade now COSECSA and the Royal Col­lege of Sur­geons in Ire­land (RCSI) have been work­ing to­gether to in­crease the number, and ex­per­tise, of sur­geons in sub-Sa­ha­ran Africa, across twelve mem­ber coun­tries: Bu­rundi, Ethiopia, Kenya, Malawi, Mozam­bique, Namibia, Rwanda, South Su­dan, Tan­za­nia, Uganda, Zam­bia and Zim­babwe. The pro­gramme is funded by Ir­ish Aid, the State’s de­vel­op­ment arm, and works quite sim­ply – trainee sur­geons en­ter a mem­ber­ship or fel­low­ship pro­gramme and un­der­take their clin­i­cal train­ing un­der the su­per­vi­sion of a trainer in a ac­cred­ited hospi­tal. The aca­demic part is de­liv­ered on­line, with work­shops in each coun­try. Ex­am­i­na­tions ro­tate be­tween the mem­ber coun­tries, with Ki­gali in Rwanda host­ing ex­ams in De­cem­ber, 2018.

One of the ma­jor ad­van­tages of the pro­gramme is that the trainee sur­geon can stay in their home coun­try – and there­fore

is far more likely to stay work­ing in their home coun­try long-term.

It is not rocket sci­ence, but it might as well be con­sid­er­ing its im­por­tance in a de­prived area of the world: to date, 260 spe­cial­ist sur­geons have grad­u­ated in the 10 years of the COSECSA/RCSI pro­gramme, with 85 per cent be­ing re­tained in their home coun­try af­ter grad­u­a­tion.

“As you can see, the prod­uct is al­ready show­ing,” says Mable Kat­iba Phiri, a med­i­cal so­cial worker in UTH. “If we can have many more tak­ing such a ca­reer, I think we’ll be lead­ing some­where. We need many to be trained, to be knowl­edge­able, so we don’t lose life.”

This is also a story about faith . . .

Chris­tian­ity is on dis­play in ev­ery corner of Zam­bia. Shops and restau­rants of­ten have re­li­gious ti­tles, ev­ery school is named af­ter a re­li­gious or­der or saint, even buses pro­claim the good news. The coun­try has many sim­i­lar­i­ties with Ire­land, though per­haps not mod­ern Ire­land.

“From now on I’ll just place my trust and faith in the hands of God, and still give grat­i­tude to the peo­ple that have helped us be­cause they are con­tin­u­ing to help us,” says Moses, the fa­ther of the twins. His wife agrees. “We give thanks, each and ev­ery mo­ment and each and ev­ery day,” says Ly­dia. “I don’t be­lieve that this has hap­pened to me and I give thanks to God.”

The sur­geons also reg­u­larly ref­er­ence their faith when talk­ing about the surgery. “It’s like God knew,” says Dr Zulu, when asked about the de­ci­sion to go ahead with the surgery in Lusaka. “Maybe it was to test our skills.”

. . . and fate

“Be­fore the twins were brought in, we were de­vel­op­ing skills [in UTH]”, says Dr Zulu. “I’m a COSECSA fel­low my­self, I’m a gen­eral sur­geon. Dr Bvu­lani, the lead sur­geon, is a pae­di­atric fel­low of the col­lege. So that was a good part­ner­ship.”

“Be­fore it was de­cided to do the surgery in Zam­bia, a mul­ti­dis­ci­plinary team was set up,” says Dr Bvu­lani. “And it dis­cussed the var­i­ous op­tions. And we looked at what sort of equip­ment we had avail­able. And we looked at the ex­per­tise, in terms of how they were joined. They were joined at the liver, and we thought that was some­thing we could han­dle, with the re­sources avail­able here.

“In the past we’d prob­a­bly have had them flown out of the coun­try, but at that time we thought it was some­thing we be­lieved we could achieve, in Lusaka.

This is a story about tri­umph . . .

Dr Rae Oran­more-Brown was part of the team that sep­a­rated the twins. She has a fel­low­ship in gen­eral surgery with COSECSA, but has been do­ing pae­di­atric surgery at UTH since 2013 and is cur­rently com­plet­ing a sec­ond fel­low­ship, this time in pae­di­atric surgery.

“We were di­vided into two teams when we were sep­a­rat­ing the twins. It was an in­cred­i­bly mov­ing mo­ment when Dr Bruce Bvu­lani told the anaes­thetist that we are now go­ing to have the two ba­bies on two sep­a­rate op­er­at­ing ta­bles. Be­cause, of course, they were on the same op­er­at­ing ta­ble. And we were all pre­pared to put Ma­palo on to the other op­er­at­ing ta­ble. Dr Bvu­lani said, ‘stand by to re­ceive the twin on the other ta­ble’. And so the anaes­thetists were ready to push the anaes­thetic ma­chine over. And as they sep­a­rated, and I moved with one twin, there was a lit­tle sigh.

“And they had a cam­era so that peo­ple out­side the theatre suite could see what was go­ing on, and there was a lit­tle rip­ple of sound. Out­side you could hear peo­ple cheer­ing. And what I found ex­tremely mov­ing was that at the end of surgery the anaes­thetists had rolled out the first twin to ICU and sud­denly peo­ple re­alised the op­er­a­tion was over and it was suc­cess­ful. There was a crowd of well-wish­ers out­side. And as they were get­ting ready to take the sec­ond twin to in­ten­sive care a group of nurses came to the front of theatre and stopped at the red line, and sang, in per­fect har­mony, a hymn of thanks­giv­ing. It was in­cred­i­bly mov­ing the whole at­mos­phere of joy and thanks.

“And then Dr Bvu­lani brought the par­ents in and ex­plained it had all gone well and it was so far so good, and that there was still a road to travel. And in very tra­di­tional Zam­bian fash­ion, they both spon­ta­neously fell on their knees to thank him. It was in­cred­i­bly mov­ing. It was quite an ex­pe­ri­ence.”

. . . and wait­ing for tri­umphs

In the days, weeks and months af­ter the op­er­a­tion, an­other is­sue con­cerned those in­volved in the care of the twins.

The girls would ob­vi­ously need reg­u­lar care, ther­apy and ob­ser­va­tion by med­i­cal pro­fes­sion­als. All of which was avail­able in Lusaka, but not eas­ily ac­ces­si­ble in the re­mote vil­lage of Cha­batama Chisembe in the Kawambwa re­gion of north Zam­bia. The fam­ily’s liv­ing quar­ters were also far from ideal, with no elec­tric­ity or run­ning water be­ing just part of the dif­fi­culty of liv­ing in the area.

How­ever, the bustling, rel­a­tively mod­ern feel of Lusaka was a world away from what Moses and Ly­dia were used to. “They [par­ents and children] stayed in the hospi­tal for a long time,” says Ms Phiri. “They missed home. So the mo­ment the ba­bies were op­er­ated on and they felt the ba­bies were okay, they wanted to go home. You can’t force them to stay, you just have to re­lease them, We had lit­tle in­for­ma­tion from Kawambwa. The [fam­ily] house is not okay.

“Look­ing at the ba­bies from the op­er­a­tion, ar­range­ments were made for the ba­bies to stay for a short pe­riod in a children’s home [in Kawambwa]. And, af­ter some time, they have been given back to the par­ents. We are happy to see them. We are so grate­ful, and they are be­ing looked af­ter nicely. We need to con­tinue com­ing, so some­thing can be done.”

Af­ter such a huge mo­ment for health care in the coun­try, the fam­ily are de­ter­mined not be for­got­ten. In the wave of good­will and pride that fol­lowed the suc­cess­ful sep­a­ra­tion, au­thor­i­ties promised to help con­struct ad­e­quate liv­ing quar­ters for the fam­ily. Bricks ar­rived, but lit­tle else.

“The big­gest thing I would like in my life at the mo­ment is a house – a house to keep my children in, and any other kind of help that can be given to me and my children who have been sep­a­rated [by surgery],” says Ly­dia.

“The children have been sep­a­rated and it means they will keep be­ing mon­i­tored by the peo­ple who sep­a­rated them, they will want to see how they grow. And as they are grow­ing they will have other needs, and they will con­tinue to need sup­port, they will need help to get an ed­u­ca­tion, and I would not like them to grow up the way I did. I was brought up in the bush, and their fa­ther was brought up in the bush. We were brought up in the bush and lived in the bush all our lives – that can­not hap­pen.

“I would like these children to live pro­gres­sive lives, I would like them to get ahead in life. And not have to face the same chal­lenges that my­self and their fa­ther went through. That is what I would re­quire from you peo­ple of God.”

Moses agrees. “It doesn’t mat­ter where the house is built or bought, it could be Lusaka or Kawambwa, as long as the health of the girls is guar­an­teed,” he says. “I don’t know what will hap­pen in the fu­ture. I didn’t know that they would be alive and well up to this point.

“What I would like to see is that the peo­ple of the coun­try will not for­get about us, will con­tinue to think about us. My­self and my wife will not be able to do this alone so we will still need help from the peo­ple in the coun­try.”

One of the ma­jor ad­van­tages of the pro­gramme is that the trainee sur­geon can stay in their home coun­try – and there­fore is far more likely to stay work­ing in their home coun­try long-term

The fam­ily of Moses and Ly­dia Mwape, in­clud­ing the grand­par­ents of twins Bupe and Ma­palo, in the re­mote vil­lage of Cha­batama in the Kawambwa re­gion of Zam­bia.

Above: Dr Bruce Bvu­lani, Dr Seith Kalota and Dr Mu­lenga Mulewa at Univer­sity Teach­ing Hospi­tal, Lusaka. Left: The con­joined twins Bupe and Ma­palo. Right, Dr Bruce Bvu­lani with the seper­ated twins.

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