FEB-A-21
THE PREDICTED PATTERN HAS DEVELOPED IN
FACT:
LIKE LIFE, THE SOMALILAND MEDICAL
MISSION HAS DEVELOPED TENTATIVELY AND HESITANTLY AT THE
INNOCENT BEGINNING, WITH MORE
FAMILIARITY AND ADAPTATION TO THE LEARNED ENVIRONMENT AS WE BECOME MORE OPERATIONAL
WITH THE HELP OF MANY FRIENDS, AND WITH INCREASING EXPECTATIONS ON ONE SIDE AND
EXPERIENCE ON THE OTHER, A “GROUND RUSH” TOWARD THE FINISH WITH EXPEDITED PLANS
AND CONTINUING RELATIONS HAVE BEEN CARRIED THROUGH TO LEAVE AS FEW AS POSSIBLE
DISAPPOINTED,
BUT ALWAYS WITH MUCH MORE TO DO THAN
ACCOMPLISHED AT THE END
February 12, 2004
I wrote an email early this morning. I woke up hungry, as my father had occasionally done, whereas I could seldom remember whether I had eaten or not. But since I could remember coming in late and having a small sandwich as a substitute for supper last night, I felt justified in coming down early for breakfast, and while the order was being processed, I went to the Business Center and emailed a high school group in McLean Virginia. A nurse in the GWU ER named Amy had gathered sutures and instruments for our use and her daughter had started a group in the McLean High School calling itself the Student Association for International Health and collected some money to be entrusted to us and given to someone or small groups who needed their help in a special way. We had been carefully parceling out the support of these students a world away in one of the more affluent suburbs on earth, who are at least aware that we would be dealing with people as destitute as any on earth. So, I wanted them to know I appreciated their thoughtful help and that I had taken special pictures and made notes on the recipients of their own brand of “foreign aid.” I offered to visit their SAIHmhs (with its own AOL website email address) to report directly on the mission and the future plans for further help. Like Operation Smile, which always includes high school students in its missions, I am intrigued that there are people who have not even started into the healing or helping processes yet that are getting a precocious start in what it is that I see regularly.
I knew that today would be a long one. I also knew that there will be a frantic rush on the part of everyone who wishes to be seen and knows that we will be gone tomorrow that they will extend all our clinic hours regardless of cutoff times to go from one to the other sites of our major clinics today in HGH and in Edna Aden Hospital. Before breakfast I had logged into my Email account for the second time this trip to find out that at least one package of my emailed reports had made it through to recipients who were either intrigued or overwhelmed by what they had read usually only partly due to the volume that one reported had extended to 422 K of text. I am not yet completed on much of the reporting of this experience that I would like to share with as many people as possible that could “commiserate” with the people here.
The affluent part of the world has some idea that Somaliland exists, and is in some perpetual crisis of starvation because of warlords who are at each other's throats and think nothing of holding hostage whole populations in their power struggles. That each of these impressions are also true means that the images of a vivid nature have had to substitute for ongoing lives, such as a vulture standing close to a dying baby or mothers carrying shrouded small bodies to a mass grave, and—most indelibly—the images of American Special Forces soldiers shot down in “Black Hawk Down” being dragged through the Mogadishu streets. The “bad taste” from reveres seen in the humanitarian support mission gone awry had made Americans gun-shy literally on the Horn of Africa. Meanwhile, there are persistent peoples her with problems unchanged at best and intensified at worst since the era of intervention has been cooled down after the meddling got burned. So, reality continues on with a lot of very poor people struggling to survive and daily many of them managing just barely to adapt somehow, while 29,000 kids a day die of very preventable problems based in want—lack of food, knowledge, medicines, immunizations, and parents.
One of the success stories that I did not have a chance to report on is the HoVoYoCo—Horn of Africa Youth Council supported by a Dutch NGO. These are the orphans and displaced people from the long civil war who would otherwise be on the streets, are brought into a community with schools and a very viable way of making a living---they set up “Circus Hargeisa” a gymnastic tumbling act of the young and homeless who have knit together a “family” of the young athletes, who not only perform for the groups around Hargeisa, but are using their circus acts to earn money that supports their schooling. They were good! The youngest of the kids was hoisted high in the air on a pole, and was clinging to it for dear life, as he had no doubt been instructed to do, as the pole was passed up the pyramid of balancing acrobats and then the top one would rest the base of the pole on his head. If he had a mother he might have shouted out “Look Ma! No hands!” If he had a mother, she would never allow him to be put into such a perilous position. If any of them had a mother they would not be a part of Circus Hargeisa, a successful venture of HoVoYoCo. We enjoyed the show, and also got a chance to talk with each of the performers, and posed with them to get our picture taken with them. We also went over each to answer some of their complaints and scheduled a few for small procedures in our final day in HGH—such as aspiration of a sebaceous cyst or the removal of a splintered nailbed in the heavy lifting base building muscle man in the bottom tier of the acrobats.
But, a consultation bordering on the bizarre took place during the performance, as well, since the secretary of the HoVoYoCo group had a “daughter” born with ambiguous genitalia, and small gonads could be felt in the labial folds. If these are testes, they should be removed and she should be raised as a female continuing that which she is already doing. If they are ovaries, they could be re-sited back into the peritoneal cavity, or they too should be later excised, but with endocrine support to get their through puberty. These are complex cases to manage and to examine a two year old on a tumbling mat at the side of the ring of high climbing performers with cursory examination being the basis for serious life-long advice for the support and rearing of this child is not a “quick study.” Yet, there are on other teams with greater expertise anywhere near this child and she will be unlikely to be making any trips out of this country and accessing better advice anywhere else anytime soon---by which time all the options will be closed off. So, we recommended a biopsy of the subcutaneous gonads, and we would carry back a sliver of the biopsy to be read at GWU. This is the only way she is going to get this information, since there is no pathologist in Somaliland, and any critical information must go very expensively to Dubai where it may take a few weeks to be read. This is hardly at “Frozen Section Speed.” But, it is the best foundation we can give to the advice also given at the same time: continue to raise the child as a girl, and we will determine future treatment on the basis of the biopsy report to be emailed back to Dr Suleiman.
We also went to the school and dormitories of the HoVoYoCo project headquarters, and passed out some of the toys and goodies we had on our arrival in Somaliland. While we were standing in the courtyard, I looked up above the city in the clear desert sky, and there, floating on a thermal was the Lammerguaier , the magnificent raptor that is a “lifer” for a number of the bird watchers I have told about my earlier experiences in sighing it, on the Ngong Hills (the giant's “knuckles” along the Rift Valley in Kenya) and named the “bonecrusher” in the Himalayas. I had not expected to see it in the Horn of Africa, but there it was showing off as it rode the thermal updraft from the desert. Ismail, our host at HoVoYoCo said to me “Oh, yes, you have noted him! They are quite frequent around here!”
FINAL DAY OF CLINIC AND THEATRE
IN HARGEISA GROUP HOSPITAL
I walked briskly by the overflowing clinic—this time they had got the message. Typically, we arrive at the appointed time, and no one shows up for an hour after starting time. They have little appreciation for clock time, and know that if they are still here, we will have to be also, so they first check to see that we are really here before they come in. But, in the last days, they have noticed that not only are we here at the time we say we are going to come, but we will also go nearly the time we say we will go, and if they are still standing here unseen when we leave, it is their problem for not being here during the clinic hours rather than sauntering in after their designated times. So, that message has come through, particularly with guards throwing switches made of thorn scrub, whipping the crowds back into line if they thought they could sneak in to our attention. But, I would be taking one of the senior students at a time to theater to complete our operative lists. So, there would be two stations working and one “swing” member would be shuttling to theater as we worked.
The first “surgeon-designate” was Kevin, who had done his first operating with me in Malawi, after seeing his first patients with me in Ladakh. We did a hernia repair and he excised a lipoma, for the latter half of which I backed off and watched as the classic “Portrait of an Internist at Operation” was snapped. With his nose hanging over his mask, and his cap perched on an angle on his head untied, and leaning over to get as close to his work as he could, he looked like the portrait of an internist tangled up with his tools. I teased him about this, but he was trying valiantly, and he has done a good job. I will obviously need to be somewhere near GWU at the May 16 time of its graduation ceremony of the Medical School so that I can “Hood” Kevin, as well as others, my protégés of the foreign fields we have worked, that have worked such wonders on them.
The younger fellow in the turban and flowing robes obscuring his bent and foul-smelling leg with the broken down Marjolin Ulcer came rushing toward me to ask again when we would be leaving. He had obtained the formal and written permission of all but his senior brother which apparently was critical for the operation proposed, but if it were later than noon, the operation could not take place here, since we would be booked to take on an even bigger clinic at Edna Aden hospital. He uses English, and in this borrowed tongue, struggling with matters of his own life or death, he must now shuttle himself back to seek out the elder brother to let him in on the consensus that his leg should be coming off. He is aware that we are wrapping up our clinical; work here, but that we are gong on to Berbera for a couple of full days clinical activity there.
A poor patient had been brought in to the clinic and was referred over to theatre for evaluation, since she had already had an operation to correct her socially tragic situation and it had failed. She could be diagnosed at a distance, since she reeks of urine and the urea-splitting proteus organisms that advertise for the presence of such patients in advance. She has a VVF.
Vesico-vaginal Fistulae (VVF, the Recto-Vaginal Fistula is an RVF) is a complication of unattended or prolonged labor. When the undeliverable infant head is pushed down hard upon the perineum for an extended period of time, the devitalized perineum breaks down in ischemia and necrosis. After delivery by whatever means (often of a non-viable infant, as in this case) the bladder wall that has necrosed through to the vaginal wall causes a communication to the vagina. The bladder is open so no longer contains the urine, which leaks out the vagina through the fistula, the VVF. If that has also been the fate of the sigmoid colon wall separating the vagina from the rectum, an RVF can result, and the poor patient is not only incontinent of urine but also feces. In the extreme, there is simply a “cloaca” present, with no control over any of the excretion fluids, which cause a constant soiling leak, maceration and the colonization of the urine with the fecal organisms. These are miserable women.
The most frequent social complication is that the husband leaves such an afflicted woman, since there is very little incentive to stay with her. Quite apart from her having “failed motherhood” in the most frequent case that the prolonged labor has left a dead infant, she is hardly a sexual partner with a cloaca, nor even a sociable one, as she is not very pleasant to be in the same room with as a dinner companion. This is the next step up from dying in childbirth, and many feel that it is the lesser of the two fates form an obstructed delivery.
The VVF has been know a long time, and a few repairs have been suggested, one by a pioneer named Simms, and the simple Simms repair had been tired in this patient before, and it broke down—as they often do. After that, it takes some ingenuity to take on the more complicated re-do's of the VVF repairs, and especially of the reconstruction of the VVF/RVF cloaca. I am not an expert. I have tried a few times, and have done a few Simms repairs. About half of these stayed together, a not unrespectable batting average for this sad operation. After that, the surgeon needs to bring in fresh tissue with its own blood supply into the foul and infected scared tissue of the fistula. It is not enough to close it in multiple layers; some new vascularized tissue needs to be brought in with its own blood supply. Looking around the topography of the perineal anatomy, there is a nearby muscle that can contribute to the healing supply of oxygenated blood without making too much deficit in its move out of its neighborhood. That muscle is the gracilis muscle of the thigh, which can be sectioned lower down and twisted back up along with its blood supply to try to re-do a failed repair. I have done this procedure, but would prefer that someone who knows more would do it. There are few people who would want to know more about this kind of salvage operation, and they must have a very philosophic frame of mind for a high failure rate.
A few such exist. When I was working in East Africa, I met a fellow surgeon in the ASEA (Association of Surgeons of East Africa, of which oldest scientific organization in Africa I became a member during my Fulbright year in 1996 and can sport the tie to prove it!) who was going to a hospital specialized in the repair of VVF's. He was a Dutch surgeon working for AMREF (the former “Flying Doctors” based out of Wilson Field in Nairobi, but now grown more mature and re-named African Medical Research and Education Foundation.) I was intrigued that there might be such long-suffering folk as to try to specialize in the salvage of these outcaste women. Then I learned later about the Hamlin's.
A husband and wife team named Hamlin was working a long time in this area in a “Hospital by the River” in Addis Ababa. He died, but she, Catherine Hamlin carried on. She quietly went about her business of trying to restore these folk, and she appeared at the American College of Surgeons at this past year's clinical congress to report on her operations and their results. She was made an honorary Fellow of the American College of Surgeons, a high award for an Australian graduate working in Africa. A much more high profile appearance was made as she came to America this fall to receive the ACS fellowship. She appeared on Oprah. At the end of a TV program seen by millions, Oprah asked how much it cost to run her hospital for a year, and she replied $850,000. One of America's (and hence, the world's,) richest women whipped out her checkbook and wrote her a check covering the next year. Not all of us are so lucky, and obviously, a lot of time has to be put in with less successful outcomes, but Catherine Hamlin deserves the attention she is unwillingly receiving in her late widowhood.
And, now, I have before me a recurrent VVF. She is one of the really lucky ones. Her husband has not left her—probably unique in my own experience. In an Islamic nation, all that is necessary is to say “I divorce thee” three times, dropping three stones, and it is over. I went out to shake his hand to let him know I appreciated his hanging in there. Later I was told that he was still her husband, but that did not mean he was not out pursuing children through other willing means and mates.
We took her to theatre to examine her. At first, little is apparent except the wet thighs and foul smelling robes. On speculum exam up high in the vaginal vault is an old whitish scar, and after that nothing but a pink cavern of the dome of the bladder. She has a large defect and it will take some considerable ingenuity to close it. She needs more than me at this moment and she should get some specialized attention. I asked if it would be possible for her to get to Addis to the “hospital by the River.” Right! Suggest instead that she go to Memorial Sloan Kettering in New York. OK. That means, in the phrase I seem to keep coming back to every so often here in the Islamic horn of Africa, “The Mountain must be brought to Muhammad.” I put her on our list of cases to be seen on a return visit and will consult along the way to see if someone would be wiling to undertake a re-do on a large recurrent VVF. As the refrain often echoed in my experience in ex-Zaire “la prochain frois.” I cautioned her husband to hold on, and that may be the only hope I could give to her is that I might retain him (and her livelihood) for some time longer.
I was planning to postpone the side note that she had, of course, also undergone the FGM, “Female Genital Mutilation”, that I had briefly described as a cultural practice, and was gong to discuss further after the clinics in Edna Aden Hospital later tonight. But, one of the supreme ironies here is that the very people who are at risk for the VVF's are also those who live in a culture that accepts or at least practices FGM. This means that one means of repair is no longer available. One of the techniques is to use the labia to transfer vital and viable tissue with its own pedicled blood supply to help secure the layered closure of the VVF. In a twist that is more than ironic, the very people who might need those labia as a reserve backup for tissue repair of a complication of pregnancy are the people who have undergone a cultural practice e that has removed, scarred, or mutilated them. Life, it is true, is unfair.
SURGICAL RE-SUPPLY,
AND SEQUESTERING SUPPLIES FOR OUR NEXT
“MOBILE CLINIC” AND FIELD OPERATING ROOM
If the patients in clinic were not ready to call it a day, the staff in Theatre certainly were, since our presence seemed to have brought about a cascade of surgical activity in their workload. As we concluded a few of the cases and postponed some elective cases, it was again suggested that we simply pack up those patients who were still pre-operative and carry them down with us to Berbera. I am sure that we will have more than enough patients to be operated on there, so I suggested that this “referral” to a place where there were no surgeons was inappropriate. It is a universal way of squirming out form under the point of the falling dagger—REFER them somewhere. That this place you send them to (“turfing” is the vernacular in hospitalese) is no better prepared to handle them than the present place is not so important as that they are not standing in front of me expecting me to take care of them. It is a sense of some accomplishment—“something is being done” for them—to send a patient for an X-Ray, or lab test, or consultation—any or all of which may or may not be available or done—postponing the decisions on what should be done for them, losing the valuable commodity of time in the process. I try to discourage this predilection, often a ‘Physician's affliction” as much as I try to curb the “Surgeon's intervention imperative” [OK, see? I have granted equal time for rebuttal.] But, in many instances during this trip, a sense that something definitive has been done when a referral has been made. We are already standing in the capital city, in the commercial center, and in the highest density of health care or any other aspect of Somaliland civilization; just where and by whom do you expect this patient to receive care that is available elsewhere if not here? “Well, I hear that there are resources in Nairobi, or in Addis Ababa, or Johannesburg….”yes, and there is an abundance of green cheese on the moon, every bit as accessible to this patient. When I visited Gondar College of Medial Sciences later in this same Horn of Africa trip, there were frequent referrals accompanied by a sense of relief that a patient could be referred to Addis Ababa, the capital, where there were fewer resources than in Gondar to address specialized problems. “Turfing”—a universal phenomenon to accomplish a sense of relief for the practitioner, even if there is no change except for added inconvenience for the afflicted patient—but, “we are doing the best we can for them!” No doubt by spreading frustration out of over a wider base.
This same point would mean that I cannot hold out hope that we will try to return with some specialized care to treat the selected patients we have deferred for such care without carrying through on that promise. The kids with bilateral clefts or gnoma (the infected “cancrum oris” face-destroying necrosis) are not turfed. They are logged, with their names, places they might be found with the appropriate parents or care-givers identified, and a plan is given to them, that we will seek their care; not now, but in the near-term future, for which we will be notifying the host instructions of our return and plan for them that can then be put into action.
I had carried in two large duffel bags that I had re-packed for our excursion to both the HGH and Edna Aden Hospitals today, and the anticipated surgical and medical load we would be seeing in Berbera the following days. My “Sportsman's Guide” order of the biggest duffel bags they could provide, had furnished several large duffels which will be left here with their contents. The very large stock of surgical instruments that Amy had collected at GWUMC and the selected medicines and sutures and kits are packed in one such duffel bag and carried to Dr. Yasine's office where they will be distributed to those in need. The Theatre here is in need of smaller and finer instruments, which we just happen to have in great quantity. I had selected out a batch of such instruments and sutures for the Berbera Hospital and left all the remainder with the HGH—quadrupling their stock of surgical supplies.
As I came over to the Director Dr. Yasine's office, I saw him carry in with large bundles of currency. When I had come in in the HGH hospital pick up truck this morning, I had rested my feet on the large stacks of the bills, rubber banded together. I had seen vendors on the street with huge stacks of bills in front of them—the “cambio shop” equivalents, out in the open with not a security worry in the world. The love of money cools considerably in ardor as the currency plummets in value. The largest bill here is a 500 Somaliland Shilling bill, and at 7,900 to the dollar, no one is too careful to guard their pile of 50 Shilling notes—hardly noticeable in value. As in Russia, or Cuba, or much of the world not thought of as particularly capitalist, the official currency is the US dollar. It is remarkably similar to the state of money in the last stages of the Mobutu regime, when patients would come to the clinic to pay for their services in “Zaires”—several million to the dollar. The question for the medical student would be, which is the most valuable use of time—counting currency when the largest bill printed is a 100 “Noveau Zaire” bill, or seeing the patient and dumping whatever total kilos of currency they had brought. Two planeloads carried the currency for the payroll of the small clinic, at a value less than the fuel for the trip. So, Dr. Yasine set the stacks of Shillings on the desk, and turned his back on them for the much more valuable surgical gear and medical kits I had brought in the duffel bag which he locked up.
It remains to be seen what postage carries my abundantly addressed postcards back to the US, which will be hand carried to Dubai or Nairobi, to be posted with a frank that will be accepted by international carriers—which can ignore a candidate “wannabe” nation, even if it designed and printed fancy stamps that only philatelists would appreciate.
The second surprise is at the office is the arrival of the Director and the two drivers from the Berbera hospital who have come to “carry us down to Berbera now!” I explained that we have not yet finished the clinic here at HGH, and that after that, we will have an advertised clinic at Edna Aden Hospital, that I predicted would be very large on our second day's visit. “That is OK; we will wait for you, since you should be finished in an hour. We have a lot of patients awaiting you, and maybe you can get a start on them this evening!” Right!
I pushed my way through the crowds at the clinic and announced that we would be finished here in an hour, but that we would then have a huge clinic in Edna Aden hospital which I predicted would go far into the night, and then the Berbera Hospital group which had hoped to carry us down there to start “perhaps by five o'clock” could not possibly be accommodated until tomorrow morning when we would try to get an early start in going down with them then. I shuttled between rooms and in a ramrod fashion, we did manage to see all of the patients that had wormed their way inside the building by the one-hour deadline I had set. We left the medicines and instructions to the nurses for the disposition of the latter, and moved over to Edna Aden hospital. The Berbera Hospital crew said they would go along and then carry us down to Berbera this evening after “you finish the patients at the other clinic.” Right!
AT EDNA ADEN GOES ON PAST MIDNIGHT
TO COMPLETE OUR CLINICAL WORK AT HARGEISA
Even our eager accompanying crew from Berbera got the picture when they saw the crowds outside the Edna Aden hospital clinic. I suggested they go to find a place to stay in Hargeisa overnight and we would then be up and out at six o'clock AM for an early start to Berbera. I had tried to explain that we were here until midnight the previous night, and that was before the word-of-mouth and TV coverage had advertised our presence. “Remember? This is the advertising for patients you had suggested we should try on the first days of our visit. I had told you that the volume would crescendo to unmanageable proportions without that added inflammation, and crowd control is one way of not only good patient care but also avoiding your getting killed. This was the fate of two naïve relief workers who opened up a semi-truck of food and medicines in the Dominican Republic at the first of my foreign mission trips, when I learned a few lessons about trying to manage unruly crowds of over-promised delivery of high demand and limited resources.” The Berbera team went on into town, and we sat to have lunch and watch as the crowd continued to gather. We worked out with Edna that we would carry two of her nurse-midwife students, one of whom comes form Berbera, as well as Rhoda and other staff members who could go with us in the morning and we would just start up at the Clinic now and run until the last patient was standing. The student team and a couple of Edna's staffers asked if they could first go up on the roof of the hospital and take a brief nap. I agreed, saying that they were going to need it. I arranged with Edna to see her videotape clip on the performance of the FGM .
The patients in this queue were more affluent—they had to be to have access to the media and the TV message that there were American doctors coming to give out free consultations and medicines. Many of them had carried in their prior records from the care they had already received and were eager to get second opinions on the kind of care they might further get. Obviously, in a Maternity Hospital, most of them were women. We divided the consultation rooms into Surgical, Gynecologic, and general, with some pediatrics seen in each. Then Edna herself went out into the clinic waiting room area and announced the rules and the gatekeeper function of her staff and the processes by which these patients would be seen in some sort of orderly arrangement. Edna herself joked with me that the patients themselves in their enthusiasm to be seen, had obviously overlooked the site of her hospital and its prior reputation as the “killing fields” of Siyad Barre's thugs, and had overcome any reluctance to be visiting here now. How soon we can forget, if our immediate interests are better served.
I SEE SCORES OF WOMEN AND CHILDREN
AND EACH TEAM WORKS OVERTIME
One genuine needy woman was dressed more like she had just come in from the desert, as indeed she had. Her story was that she was a nomad, and had squatted to relive herself in the desert scrub while following the sheep that her family grazed in the meager forage of the Horn of Africa. In so doing, she had a stick perforate her peritoneum, and that was nine years ago. Ever since then she had a foul drainage from the perineum---and added a tag line that amounted to “And that's my story and I'm sticking to it.” She obviously has a torn perineum, from whatever source, and quite probably a foreign body, but when I suggested we examine it, and see what could be done, it was explained that she was a traditional woman and needed a Somali woman to examine her. We did not have a doctor to do it, but we have a whole school full of Somali nurse/midwife trainees, so I brought one in, and Rhoda translated. Rhoda herself is Qatari, but has very excellent people skills and can relate across the gulfs of cultural and interpersonal differences. She helped resolve this problem by simply nodding when I expressed my doubts about the history and suggested that there might have been a complication of an early FGM procedure that would need a local woman to see evaluate, and clean up.
Several women expressed fears that any Somali speaking doctor would see them, but that it was just fine for a foreign doctor to examine them. So, I became privy to many secrets that the closer clinic would not have been admitted to since I could carry away their stories with me, so that no one local would know. Perhaps any woman entering such a contractual agreement with an examining physician should be told that at least one physician is also a photojournalist! I was amazed that veiled women who had kept the veil during the exam would allow my gynecologic exams and even the photographing of their scarred pudenda as a consequence, in several cases, of their FGM complications. I discussed some of these complications with Edna and made a special referral list of some of these patients for this unique form of culture-bound illness in this one facility that is better able than most any other to handle them.
I saw three hemophiliac brothers, each of whom had been diagnosed and started on treatment in Dubai. This is the kind of illness that requires huge resources and continuing care—and a move away form such an urban center is a death sentience. But, there were other reasons that the family wanted to come back to Hargeisa. I suggested that if they were here for a prolonged period, they would have to institutionalize around themselves the same kind of care they had when they had been seen in Dubai. I listed those resources they would need to have, and they said that they could begin working on them. I saw a child with reflux from a “UPJ” (ureteral pelvic junction) problem that had given massive hydronephrosis. Since no pyelonephritis had occurred as yet, the child was of such an age that a Y-V-platy could save the kidney as well as the child, and they also should have this done—and it turns out they could get to a center in which it would be done. This is the reasonable kind of referral, and not “turfing” them to an unknown resource, but a real plan of action for their continued care. . I saw multiple goiters, which were said to be symptomatic, and a number of the left sided lesions were probably accountable for the dysphagia. I began medical treatment with a suggestion that over time if the symptoms persist or return, there might be relief through thyroidectomy, thereby “stocking the larder” for the next surgical mission with a number of recurrent symptomatic goiters.
THE PROCESS OF “FGM” AND ITS CULTURAL AND CLINICAL IMPLICATIONS
I had seen several other women who had either incidentally had FGM and presented with an unrelated complaint, or a few who had significant complications from it. I then went over the FGM tape that Edna had made much earlier, in which a nurse midwife is carrying out the more extreme of the procedures, given what is said to be the best of technique and even a modicum of anesthesia, although the patients did not appear to be happy about the operation even if they also did not appear to be unwilling. The overly rigorous dissection and the suturing together of the remnants of the labia were said to be the best example of a procedure otherwise done with limited sterility and coarser technique, since this practitioner even used local anesthesia. Edna had made this videotape in 1970 when this kind of tape could be produced, since today it would be criminal evidence. She has been a pioneer in championing against the cultural practice, something that can be done from her “inside” position as a Somali woman and as a highly educated and successful one they would listen to. Western women, particularly post-modern anthropologists who decry the practice from a great distance and a feminists agenda are not particularly effective at communicating with a Somali culture that views them as extra-planetary, and unsympathetic from the outset. I made notes on the procedures I had seen on the videotape, to which I could relate from the post-operative results I had seen. It is not quite enough to say about FGM: “I am against it.”
I had a large number of goiters, on a recurrence after thyroidectomy with a 150-gram submental recurrence. I used a lot of prescriptions for lipiodal, which I was told is available here. I saw two thyrotoxic patients who got started on the methimazole and beta-blockers for their control and promised to return to clinic for follow-up.
In another unusual twist of tropical medicine, I diagnosed brucellosis in a woman who was a habitual aborter. She had a normal competent cervix, but had a Weil test run in their own Edna Aden laboratory. They added that they could also test for typhoid and toxoplasmosis, which I believe might be difficult for the GWUMC laboratory to do. In the sense of irony of advances in one area that are rather primitive in others, I had a woman who seemed to have symptoms of early carcinoma of the cervix, and did a Pap smear. In this the largest of the Women's Health Clinics in Somaliland, they cannot (or, at least, do not) do pap smears, since there would be no purpose—there is no pathologist, let alone cytologist in Somaliland. So, we packed the slide back to be read I GWU Cytology.
We staggered over after the last surgical patients had been seen at midnight, and tried to help see the last of the general patients and the gynecologic backlog. I waited as the last of the patents were seen, deciding to lie down on the patients' waiting room benches—after all, it will be an early start on an even bigger day tomorrow—the patient crowds they had been expecting us to be seeing already at 6:00 PM today in Berbera 193 kilometers away, after an “hour of patient consultation sat Edna Aden maternity Hospital” which has become eight hours. I suggested to the other students that there were three rules I had learned early in my surgical house officership and they should try to practice them beginning now: 1) When standing, look for a place to sit; 2) when sitting, look for a place to lie; 3) and, the dinner you have had, they cannot take away from you.
When we piled into the van after the last patients had been cleared after 1:00 AM, there were no giddy bursts of Spanish phrases tonight; there were no sung choruses of the Macarena as the proffered Somaliland national anthem; there were no “can you top this” patient clinical stories. I only heard only one phrase as we headed back to the Maansoor hotel: “Are we there yet?”