The Call

 

It’s pronounced oh-hi-oooda!

 

Information about the background of ohayoda came from Naftali Naman, Herman Malleyeck, Paolo Kangaga, and Amani Paul.

 

In 2011, Amani Paul started a newspaper called Oyahoda. According to Paul, a government official decided that the name, a Datoga word, might inflame ethnic tensions and demanded that it be changed. Henceforth, it became Mbio xa Jamii, roughly “Community Trumpet.”

 

PART I: See One

 

Chapter 1

 

I observed Dilan Ellegala (pronounced Ella-ghalla) perform the suck, spread, suck technique during the standstill operation in Lynchburg, Virginia. The patient’s identifying characteristics in Boston have been changed.

 

For a history and more scientific description of cardiac standstill procedures, see James M. Wright et al., “Cardiac Standstill and Circulatory Flow Arrest in Surgical Treatment of Intracranial Aneurysms: A Historical review,” Journal of Neurosurgery, vol. 36 (April 2014).

 

For information about mortality and complication rates of standstills, see “Cardiac Standstill for Cerebral Aneurysms in 103 Patients: An Update on the Experience at the Barrow Neurological Institute,” Francisco A. Ponce et al., Journal of Neurosurgery, vol. 114 (March 2011). For information about the Yasargil-type clips and their more recent iterations, see “A Brief History of Aneurysm Clips,” Deon F. Louw et al., Neurosurgical Focus (2011). For extensive descriptions about aneurysms and their treatments, see The Brain Aneurysm by Robert F. Spetzler and Vini G. Khurana, AuthorHouse (2006). Edward J. Sylvester writes about Spetzler and the standstill operation in The Healing Blade, Simon & Schuster (1993).

 

Spetzler has done more than five thousand aneurisms and is known for doing a standstill on a musician named Pam Reynolds.

During the operation, Reynolds was clinically dead for about an hour, but when she woke up, she said that she had felt herself “pop” out of her body and hover over Spetzler and his team. She described sounds and tools that she couldn’t have heard or seen. Some doctors claimed that this was evidence of life after death. See Michael Sabom’s Light & Death: One Doctor’s Fascinating Account of Near-Death Experiences, Zondervan Publishing House (1998).

 

Descriptions about the pain of aneurysm ruptures often sound like hyperbole, but emergency doctors are trained to recognize a potential aneurysm when they hear someone say, “It feels like the worst headache of my life.” In 1974, the musician Quincy Jones was working on his album Mellow Madness when he felt “as if someone had blown through the back of my head with a shotgun.”

 

In 1988, then-Senator Joe Biden gave a campaign speech. “As soon as I stood up to take the podium, a pain shot up the back of my neck . . . My head felt like it was about to explode.” They were lucky. According to the Brain Aneurysm Foundation, half a million people worldwide die every year from ruptured  naeurysms.

 

Chapter 2

 

For a discussion about how our brains process odors, see Janny Scott,“The Biomechanics of the Sense of Smell,” Los Angeles Times (Sept. 8, 1988). Our sense of smell actually begins its evolution the first time we breathe. See Michael A. Patterson, Samuel Lagier, and Alan Carleton, “Odor Representations in the Olfactory Bulb Evolve After the First Breath and Persist as an Odor Afterimage,” Proceedings of the National Academy of Sciences (2013).

 

The mean height of an adult Sri Lankan male is five-foot-five.

 

Descriptions about the landscape between Arusha and Haydom were drawn from Dilan’s memory and my observations on a similar trip. For information about the area’s problems with bubonic plague, see Makundi H. Rhodes et al., “Potential Mammalian reservoirs in a Bubonic Plague Focus in Mbulu District, Northern Tanzania in 2007,” Mammalia (2008).

 

For more about the geology of the storied region between Arusha and Haydom, see “Lake Manyara Watershed Assessment, Progress report December 2003” by the Africa Wildlife Foundation. In earlier decades, Olduvai Gorge was previously spelled as Oldupai, a Maasai word for sisal.

 

Haydom is pronounced several ways, most often like “Hi-dom” but also “Hay-dom.”

 

Chapter 3

 

The guinea worm, fortunately, has been eradicated in Tanzania.

 

One of the seminal books on Africa’s history and the roots of its present challenges is John Iliffe’s Africans: The History of a Continent, Cambridge University Press (2007). The Maji Maji rebellion is a fascinating moment in the history of both Tanzania and Germany. Some historians argue that Germany’s successful scorched-earth tactics in its African colonies fostered German imperialism and eventually the rise of Nazism. One problem with that hypothesis: The British and other European powers were often as bad or worse—even after World War II. See Caroline Elkins, Imperial Reckoning: The Untold Story of Britain’s Gulag in Kenya, Random House (2007). For more information about the Maji Maji rebellion, see Felicias Becker,“Traders, ‘Big Men’ and Prophets: Political Continuity and Crisis in the Maji Maji rebellion in Southeast Tanzania,” Journal of African History (2004).

 

For information about changing scientific views about serotonin, see Gary Greenburg,“The Psychiatric Drug Crisis,” New Yorker (Sept. 3, 2013). The reference to the German invasion near Mount Hanang comes from Bjorn Enes, The Haydom Adventure, published by the Friends of Haydom Foundation (2005).

 

Chapter 4

 

For an overview about the dearth of local neurosurgeons in Africa, see Adelola Adeloye, “Black African Neurosurgeons Practicing on the African Continent,” Journal of the National Medical Association (2001).

 

Descriptions about patient conditions come from medical records in Haydom, as well as observations from Jenny Edwards and Dilan.

 

The number of Canadian neurosurgeons in 2013 was 306, according to the Canadian Medical Association. Average clinical earnings exceeded $424,000. The American Association of Neurological Surgeons pegged the number of  American  brain  surgeons  at  3,700  in  2012, according to its 2012 statement to the Institute of Health. Average pay for an American neurosurgeon is more than $609,000, according to Doximity, a compensation tracking company. Becker’s Hospital review said the average annual salary was $767,627 in 2010. The New England Journal of Medicine pegged median salaries at $625,300 that year.

 

For an in-depth look at the impact of malnutrition in Haydom, see Estomih R. Mduma et al., “The Etiology, risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Study: Description of the Tanzanian Site,” Clinical Infectious Diseases, vol. 59 (November 2014). Data on physician ratios come from the World Bank.

 

For a thorough examination of the East African famine in 2005, see Kristin D. Phillips, “Hunger, Healing, and Citizenship in Central Tanzania,” African Studies Review, vol. 52 (April 2009). The New Zealand company’s donation offer made international headlines, including “Dog Food Maker’s Offer of Aid Insults Many in Kenya” by Edmund Sanders in the Los Angeles Times (Feb. 2, 2006). The company’s owner insisted that the meat powder she would send wasn’t really dog food, and that it was “yummy.” Kenyans reacted by saying that if it was so delicious, New Zealand children should eat it.

 

For data on CT and MrI scanners, see the Centers for Disease Control’s roster: www.cdc.gov/nchs/data/hus/2011/123.pdf. Japan has the most of any country—more than twelve thousand units for its 127 million people.

 

Chapter 5

 

The Glasgow Coma Scale is scored from three to fifteen, with three the lowest score. Doctors calculate it by assigning points based on three parameters: eye response, verbal response, and motor response. A score of thirteen or higher is a mild brain injury, nine to twelve is moderate, and eight or less is considered severe.

 

For information about the skull’s weak points, see Noel T. Boaz and russell L. Ciochon, “Headstrong Hominids,” Natural History Magazine (February 2004). For a look at our long history of trepanation, see Charles G. Goss, “A Hole in the Head,” Neuroscientist, vol. 5 (1999).

 

Researchers continue to debate how many neurons are in a brain. Until recently, scientists had a suspiciously round estimate of one hundred billion neurons. More recent research estimates put it at eighty-six billion. See Suzana Herculano-Houzel, “The Human Brain in Numbers: A Linearly Scaled-up Primate Brain,” Frontiers in Human Neuroscience, vol. 3 (Nov. 9, 2009).

 

Many books have been written about Harvey Cushing. One thorough treatment is Harvey Cushing: A Life in Surgery by Michael Bliss, Oxford University Press (2005).

 

Chapter 6

 

Robert Liston’s famous surgery with the triple mortality has been recounted in many places but is particularly well told by Atul Gawande in “Two Hundred Years of Surgery,” New England Journal of Medicine, vol. 366 (May 23, 2012). Also, see Matt Soniac’s “On the Table with One of History’s Most Infamous Surgeons,” Mental Floss (Oct. 23, 2012).

 

Another engaging book about the history of surgery is Richard Hollingham’s Blood and Guts: A History of Surgery, Ebury Publishing (2009). Bellevue’s “Prepare to meet your God” sign was described in the New York Times on Nov. 23, 1884, as well as Howard Markel’s excellent book on William Halsted’s struggles: An Anatomy of Addiction: Sigmund Freud, Wiliam Halsted, and the Miracle Drug Cocaine, Pantheon Books (2011). Gerald Imber’s Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted, Kaplan Publishing (2011), is another excellent source.

 

The description of surgery at Bellevue came from The Rise of Surgery: From Empiric Craft to Scientific Discipline by Owen H. Wangensteen and Sarah D. Wangensteen, University of Minnesota Press (1979). Donald Effler’s quote is from “The Best Hope of All,” Time (May 3, 1963). Effler’s obituary appeared in the New York Times on Sept. 4, 2004.

 

Chapter 7

 

The origin of medical pimping is thought to have begun in the 1600s when a British physician got fed up with his drunken and lazy students and said, “Oh that I might see them pimped.” See “The Art of Pimping” by Allan S. Detsky, JAMA, vol. 301 (April 1, 2009).

 

Hans Nielsen Hauge had a huge impact on Norway’s development, both spiritual and economic. For more information about Hauge, see www.haugeinstitute.org.

 

Oystein Olsen wrote about the importance of trust in “The Impact of Global Health Initiatives on Trust in Health Care Provision Under Extreme resource Scarcity,” Health Research and Policy Systems, vol. 8 (May 2010).

 

Chapter 8

 

For information about Kandy’s warrior past, see John Gimlette, “Sri Lanka: In the Kingdom of Kandy,” Telegraph (Aug. 25, 2013). Information about King Buddhadasa came from multiple sources, including,“The King Who Treated a Snake” by Premasara Epasinghe, Sunday Observer (May 22, 2011).

 

The front-page article in the Brookings Register, “After 19 years, Long- distance Love Affair Has Happy Ending,” is a charming story about how Somisara Ellegala fell in love with Brookings during his Fulbright visit in 1956. The article features a photograph of the entire family.

 

Richard Furman’s To Be a Surgeon, Frederick Fell Publishers (1982), was a study in goal obsession. At its heart was a message that what you do in this minute helps shape your outcomes, for better or worse.

 

For a discussion about flashbulb memories, see Antonietta Curci and Tiziana Lanciano, “Features of Autobiographical Memory: Theoretical and Empirical Issues in the Measurement of Flashbulb Memory,” Journal of General Psychology (2009).

 

David Eagleman discusses flashbulb memories in his brilliant book Incognito: The Secret Lives of the Brain, Pantheon Books (2011).

 

Chapter 9

 

Charles Bosk’s Forgive and Remember: Managing Medical Failure, University of Chicago Press (1979), remains an illuminating look at how surgeons tick. Bosk’s focus on neurosurgeons and obsession of failure is in a chapter of Clinical Neurosurgery, Congress of Neurological Surgeons, vol. 35 (1979). He writes about how doctors train like professional athletes to ignore aches and pains: “In my more cynical moments, I think of residency, during which such work values are learned, as a vast training for impairment—a time when physicians learn to deny their own needs, are rewarded for doing so, and are rewarded as well, for pushing themselves well beyond any normally tolerated limits and for tolerating a near total estrangement from the world outside the hospital. All of this self-denial, of course, has consequences.”

 

Malcolm Gladwell, also citing Bosk, probes the neurosurgeon’s mind in “The Physical Genius,” New Yorker (Aug. 2, 1999).

 

Chapter 10

 

On its website, Johns Hopkins University has an excellent history of its founders, including William Halsted and William Osler. In an interview, John Jane, chairman of the neurosurgery department at the University of Virginia, told me about the “stress” comment he made during a panel.

 

The descriptions of the brain’s subroutines and the biological mechanics of intuition are culled from David Eagleman’s Incognito.

 

Chapter 11

 

One of the best stories you can find in Harvard’s Countway Library of Medicine is about Phineas Gage. Gage was working on a railroad in Vermont one day in 1848 when an explosion launched a forty-three-inch tamping rod through his frontal cortex. Despite losing an eye and part of his brain, Gage survived but became impulsive and prone to bursts of profanity. This personality change led to a major breakthrough in neuroscience: The frontal cortex controlled emotions and judgment. Gage’s skull and tamping rod eventually ended up in Harvard’s anatomical museum a few floors above Dilan’s favorite spot in the old journal stacks.

 

Harvey Cushing worked in the old Peter Bent Brigham Hospital building, which is connected by “the Pike” to the sprawling modern Brigham and Women’s Hospital complex. The strains in Cushing’s marriage and possible bouts with depression are discussed in Bliss’s Harvey Cushing: A Life in Surgery.

 

The workplace case against the Brigham and Women’s Hospital was appealed to the U.S. First Circuit Court of Appeals, which sided against the hospital and Day. The ruling can be found here: http://caselaw.findlaw. com/us-1st-circuit/1578745.html.

 

Chapter 12

 

Harvard surgeon Atul Gawande’s Complications: A Surgeon’s Notes on an Imperfect Science, Metropolitan Books (2002), is a probing look at the ethical tension inherent in any surgeon’s education.

 

In a letter to a friend, Jenny Edwards described in beautiful and haunting detail her trip with Dilan to Tanzania, along with the challenges she faced in the wards and in the suffering around her. She graciously shared the letter with me as well as other details about her Tanzanian experience.

 

Chapter 13

 

Before medical school, Dilan bought a book by Ken Iserson, Getting into Residency, Galen Printing Ltd. (2003), which discusses personality traits that certain specialties tend to attract.

 

Chapter 14

 

Frank Vertosick Jr.’s plank metaphor is found in his book When the Air Hits Your Brain: Tales from Neurosurgery, W. W. Norton (1996).

 

Chapter 15

 

Mayegga’s name is pronounced My-eh-guh. Emmanuel is a common first name in Haydom and has numerous spelling iterations.

 

To build Emmanuel Mayegga’s story, I spent many nights on the patio with him at Mama Naman’s, his home in Haydom, and in Dar es Salaam when he was in medical school. I noticed one night at Mama Naman’s that he was looking into the distance and seemed preoccupied. He told me: “I always sit here so I can see where I came from.”

 

Chapter 16

 

Mayegga’s home place is a two-hour ride from Haydom. During a visit there, he showed me the ochre hieroglyphics he saw as a child and the rock where he sat and waited for the monkeys to invade. He gave me a lesson on how to catch dik-diks with sisal ropes, and pointed to rock cliffs in the distance where he found clay to make his pots. He brought along his wife, three children, father, and brother, which is how interviews sometimes happen in Tanzania. It was the first time he had been back to that area for ten years, and he was stunned to see how many new huts had been built. “There was nothing here when I was a child,” he said.

 

For effects of cerebral malaria on the brain, see Richard Idro et al., “Cerebral Malaria: Mechanisms of Brain Injury and Strategies for Improved Neuro-Cognitive Outcome,” Pediatric Research, vol. 68 (October 2010). The World Health Organization says there are between 124 million and 283 million malaria cases a year and an estimated 584,000 deaths. Thanks to an international campaign, malaria mortality rates have fallen by forty- seven percent globally since 2000 and by fifty-four percent in Africa.

 

For statistics about Haydom Lutheran Hospital’s patient counts, I drew from “Haydom Final review,” a consultant’s report for the royal Norwegian Embassy published in 2012. In 2006, the hospital had roughly 11,000 inpatients, 64,000 outpatients, 3,222 deliveries, 111,120 outreach clinic exams, 61,000 immunizations, and about 3,300 minor and major operations.

 

Chapter 17

 

For more information on the “setting sun” phenomenon, see Mariana Boragina and Eyal Cohen, “An Infant with the ‘Setting-sun’ Eye Phenomenon,” Canadian Medical Association Journal, vol. 175 (Oct. 10, 2006).

For statistics on spina bifida, see  www.spinabifidaassociation.org. For the economic costs of hydrocephalus, see Chevis N. Shannon et al., “The Economic Impact of Ventriculoperitoneal Shunt Failure,” Journal of Neurosurgery: Pediatrics, vol. 8 (December, 2011).

 

Roughly five percent of those diagnosed with dementia and Alzheimer’s disease in fact have hydrocephalus, symptoms that often can be reversed through shunt surgery. Benjamin Warf is another neurosurgeon who has done impressive work on hydrocephalus in Africa. Warf went to Uganda in 2000 to work in a new hospital built by CURE International, a Christian NGO. As in Haydom, the area had a large number of hydrocephalus cases. But Warf found that inserting shunts was impractical in a low-income area. Shunts require follow-up visits, and in remote places, finding and returning to a neurosurgeon was difficult. To solve this problem, Warf combined two procedures—one using endoscopy to reduce tissue inside the brain that produces cerebrospinal fluid, and another to make a small opening to allow fluid to escape. No shunts were needed. He eventually returned to the United States but began work in 2012 on a teaching program that trained twenty-four surgeons throughout Africa. Two years later, the surgeons had treated more than one thousand hydrocephalus cases using this process. See Benjamin Warf, “Pediatric Hydrocephalus in East Africa: Prevalence, Causes, Treatments, and Strategies for the Future,” World Neurosurgery, vol. 73 (April 2010).

 

Atul Gawande in Complications writes extensively about the morbidity and mortality conferences.

 

Among other things, the Yasawa Islands off Fiji are known as the site of movie The Blue Lagoon, starring Brooke Shields.

For more information about the Maji Maji rebellion, see Thomas Pakenham’s The Scramble for Africa: White Man’s Conquest of the Dark Continent from 1876 to 1912, HarperCollins (1992). Also, John Iliffe’s A Modern History of Tanganyika, Cambridge University Press (1979).

 

For information about the infamous groundnut scheme, see Stefan Esselborn’s “Environment, Memory, and the Groundnut Scheme: Britain’s Largest Colonial Agricultural Development Project and Its Global Legacy,” Global Environment, vol. 11 (2013).

 

For more on the Canadian Wheat Complex, see John Stackhouse’s Out of Poverty, Random House (2000). Perhaps the most interesting account was written by George Monbiot in No Man’s Land: An Investigative Journey Through Kenya and Tanzania, MacMillan (1994). Monbiot writes about the importance of the bung’eda funeral rite, and how tombs were plowed under to make way for the wheat.

 

Chapter 18

 

Naftali Naman told me that before Dilan arrived, he and Dr. Ole Halgrim Olsen sometimes drilled burr holes into the heads of people with subdural hematomas. Before the CT scan arrived, they simply had to guess whether they were drilling in the correct spot. If fluid came out, they knew they were right. Naman showed me a photo album of his two trips with Lucas to Norway.

 

Chapter 19

 

This chapter was reconstructed from memories of several participants, including Dilan Ellegala, Emmanuel Mayegga, and Victor Musa. A photograph also was taken during the operation. It shows the nurses and clinicians gathering around Mayegga, with Dilan behind them and peering over their shoulders just before he leaves.

 

Chapter 20

 

Tanzania inhabited Jenny Edwards’s thoughts and dreams after she left. All of this would send her on paths she might otherwise not have chosen. She would eventually create and run a large university’s Morbidity and Mortality Conference to help others learn from their mistakes.