A new normal for an American surgeon in Africa

A surgeon finds dire poverty — as well as everything he needs — in the Central African Republic

David Lauter By David Lauter

The Latitude News Op-Ed column is a space where people from all walks of life can share their opinions on the links and parallels between the U.S. and the rest of the world.

The operating room, or Bloc Oper, in Pah. (David Lauter)

It’s Wednesday afternoon in Paoua in the Central African Republic. We had an average busy day in the operating room, interrupted by only one emergency — another young woman with a ruptured ectopic pregnancy who needed emergency surgery.

Although I’ve fallen into a familiar routine as a surgeon with Doctors Without Borders/Médecins Sans Frontières (MSF), coming to the hospital in Paoua seems less like traveling to a different country and more like a different world or a different time. Western literature and film have presented various visions of a post-apocalyptic world with limited resources under adverse conditions, where remnants of a more sophisticated technology are still used and the human spirit abides and sometimes even soars. When I walk around the hospital compound, I sometimes feel that I am in such a world. We have technology, but it is very limited compared to what I am used to, and its use is dependent on the planning and abilities of our logistics team. The local people are so poor and have so little, but the common humanity is obvious: mothers stand canted to one side with their one year olds on their hips, brothers and sisters play and fight, men and women laugh at jokes, cry at sadness, all like at home.

In the morning I walk to the hospital, a 15-minute stroll down a dirt road made of sand and clay. If it rained the night before, there are new potholes and rivulets carved in the road, challenges for the infrequent vehicle. Almost everybody I see is walking. There is the occasional bicycle, but the only vehicles I ever see on my morning walk are the MSF truck, the occasional “moto-taxi” and a half dozen motorcycles belonging to young men who work at the hospital.  I pass people on foot the entire way. There are young men pushing twowheeled carts filled with wood they have gathered, women carrying pans of food or goods balanced on their heads and a baby strapped onto their back with a cloth, young men and some not so young heading to the town center, sometimes dressed in t-shirts and sandals but sometimes wearing a worn but clean sport coat. As I get closer to the hospital, I exchange greetings with the local hospital workers, the nurses, midwives and hospital assistants headed home from the night shift.

Our morning report is held in a concrete one-room building, approximately 25 by 35 feet with a corrugated metal roof. The door and windows are gone, with an older white vinyl tarp covering the largest window. We sit in a square on worn wooden benches while the occasional salamander scampers about on the wall. We lean forward to hear the report if it’s raining because of the noise from the roof. Just north of this building are a pair of raised concrete slabs, each about 50 feet square, covered by metal roofs but otherwise open to the elements. Patients’ families are able to sleep here, and, in the morning, there is a great deal of activity with people getting up and about. There are no tents or screens for privacy, no cots or pads for comfort other than the occasional blanket or flattened cardboard.

After the morning report, we start our rounds in the maternity ward, a large one-story building adjacent to the Bloc Operatoire. There are plastic water barrels with a basin at the entrance to this building and the other patient wards to promote hand washing. In American hospitals, so-called “hand hygiene” — diligent hand washing or disinfecting between patients — is a high priority to minimize the spread of antibiotic-resistant bacteria from patient to patient; but here in Paoua the goal seems more to be a simple decrease in the bacterial load brought from the outside, as everyone uses the same bar of soap and drying towel.

When coming into the ward, removing your shoes is a higher priority than washing your hands. Patients and visitors walk in barefoot, their footwear in hand. Although no one insists that I wash my hands between patients — the nursing assistants are very good about presenting a bottle of spray disinfectant, and I’m diligent about using it — I am not allowed to enter the ward unless I remove my shoes (I now wear sandals to work because of this) and put on a pair of plastic clogs that are kept on the ward for medical personnel. If you are squeamish about walking through airport TSA screening in the U.S. barefoot, you would not like putting on plastic clogs worn by everyone and anyone at the hospital in Paoua. We check the patients who have had deliveries by caesarian section in the past few days. Other than women in labor in the delivery rooms, the maternity patients are all grouped in four rooms with between three and six patient beds each. The beds are simple wood frames with a foam mattress and a mosquito net. The patients lay in bed with their newborns and rounds are made from bed to bed with little if any privacy for the women, much like the “ward rounds” I’ve heard about in U.S. hospitals during the 1950s and 1960s.

Refugees in Paoua in the Central African Republic in 2007, when war ravaged the region. (Reuters)

Our next stop is the medical/surgical ward, where they are not as concerned about shoe hygiene and I get to keep my sandals on. We see the patients who have had operations and the ones who will have elective surgery today. Unlike home, where everything is done on an outpatient basis, patients will come into the hospital the night before surgery and often stay for several days to be certain there is no infection at their incision. Yesterday morning we saw a young man from the night before who had been brought by a friend on a “moto-taxi” after being stabbed in the chest, one inch to the left of his midline and below the collarbone, a potentially lethal injury. In the U.S., he would have had a battery of X-ray tests, but in Paoua, even a chest X-ray wasn’t available until the morning. Our best option was to examine him (his blood pressure was normal and equal in both arms, and you could hear breath sounds on both sides of his chest, making it unlikely that he had an injury to a large artery or collapsed a lung) and watch him overnight for signs of worsening problems. Luckily, he was fine and went home today, and hopefully he won’t go out tonight.

The pediatrics ward comes next. Frustratingly, they always have the door closed and bolted even though we arrive at the same time every day. I think they do it to keep visitors out during the morning floor mopping, but, like all surgical teams, the surgical team here (actually it’s just me, the anesthesiologist and the OR charge nurse) hates to be slowed down on rounds. Each of the ward buildings is one story with an unpainted concrete slab floor, and they are mopped multiple times each day. The pediatric ward always seems the busiest; it may be the case, or it may be the crying babies that gives that impression. There are three rectangular rooms with six beds each at the north end, with the center one reserved for the pediatric ICU (another place that practices “footwear hygiene”) and the other two for older children. In the center of the building are two individual exam rooms for doctors to see new patients, plus an exam table that doubles as a place to start IVs and a resuscitation center for emergencies (I continue to be impressed with the wards ability to obtain and maintain IV access in the children, even the infants). At the south end are three other rectangular rooms where we find the infants and small children. Again we make “ward rounds” with little privacy for the patients or families. Sometimes there will be two infants in the same bed, though I haven’t figured out whether this is more the mothers being social or overcrowding. There is an overflow ward behind the main building. To get there, you walk outside to a concrete walk with mud puddles on either side, past the kitchen which feeds the entire hospital, to another long, masonry, one-story building with approximately 30 wood frame beds set up barracks style.

The kitchen feeds all the patients in the hospital. I believe it also feeds many of the patients’ families. The logistics coordinator here, a young man from Arizona, told me they purchase corn from another NGO and contract with local women to supply fresh vegetables. Meat is only served once a week. I am aware there are MSF nutrition initiatives in place here, especially for the children under five, but I haven’t yet made time to find out those details.

Next it’s off to the OR or, as it is called here, the Bloc. This is where I spend most of my day and the occasional night. The operating room has worked well for me because I remember the advice given to me during my residency (big thanks to Dr. Julie Freischlag, now chair of surgery at John Hopkins, in case she reads this) that a surgeon needs to learn to operate with the instruments that he or she is given. Every set here has two pairs of scissors, a Metzenbaum and a Mayo, and usually one of them is sharp. The needle drivers are generic (no asking for my special eight-inch, fine tipped vascular needle driver with the gold colored finger holes), and the forceps come either long or short, toothed or not (no fine tipped Adsons here). Choice of sutures and needles are limited, but here again it always seems that I have everything needed to do the operations. Plus the staff is great: whenever I need something in the middle of an operation, they either have it ready or get it within a few moments.

At the end of the workday, I walk back to the residential compound. The sky is either clear or clearing most days, a dramatic, beautiful sky with wild and varied cloud formations streaked with yellow and red hues, sometimes with enormous grey thunderheads in one direction or the other. There is more activity on the road in the afternoon. Roadside vendors with peanuts, potatoes and cigarettes, the occasional large truck filled with bags of peanuts or beans or goods or workmen headed south toward Bangui or north toward Chad, more “moto-taxis” and bicycles, but still all at a rural pace. The small children playing by the local houses, one-story, clay-brick buildings with thatched roofs and no plumbing, wave and call out “Bonjour,” and I wave back and ask “Ça va?”

I have easily become accustomed to the work and living conditions of my new normal here, though that may be partly because I know it is only temporary. The degree of deprivation here compared to home is dramatic (though I know there is also a face of poverty in America that I don’t see in my day-to-day life there), and I am still on the steep part of my learning curve about Paoua and the Central African Republic. After only two weeks, I have a long way to go from making these early observations to having anything close to a true understanding of the situation here. I’ve downloaded an MSF report from 2011 titled “Central African Republic: A State of Silent Crisis” and plan to read it tonight as the next step in my education.

Five years after graduation from Oberlin College, David Lauter went to medical school. He received an MD from the University of Rochester and his surgical training at the University of Washington and UC San Diego. He has practiced surgery in the Seattle area for 21 years, specializing in minimally invasive GI and visceral surgery including advanced laparoscopic and robotic surgery. He lives in Bellevue, Washington with his three children and three cats. He arrived in the Central African Republic on August 29 for his first mission with MSF. This story was an excerpt from his blog, which you can find here.

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