PART II: Do One
Michael Buerk’s broadcast can be found on YouTube. A Dec. 13, 1984, report by UPI reporter Vernon Scott describes Charlton Heston’s return from Ethiopia, quoting Heston: “In one camp there was a single spigot supplying water for some 16,000 people. What caught my eye was the spigot. It glittered like gold, polished by the hands of so many people turning it on. A statistic that struck me was a listing of the volunteer personnel in one camp: three doctors, six nurses and 32 grave-diggers.”
Former BBC journalist Suzanne Franks’s book, Reporting Disasters: Famine, Aid, Politics and the Media, Hurst (2014), is a thorough expose of the famine in Ethiopia and its ripple effect on global health leaders and the public.
For statistics on the number of youth groups doing religious service projects, see Don Fanning’s paper “Short-Term Missions: A Trend That Is Growing Exponentially,” for Liberty University’s Center for Global Ministries (2009). For information about airfare trends and how they influenced Christian outreach work, see Robert Wuthnow’s authoritative book Boundless Faith: The Global Outreach of American Churches, University of California Press (2009).
For David Livermore’s discussion about short-term missions, see Serving with Eyes Wide Open: Doing Short-term Missions with Cultural Intelligence, Baker Books (2006). Emma’s name has been changed.
For statistics about the number and expenditures of short-term medical missions, see Jesse Maki et al., “Health Impact Assessment and Short-term Medical Missions: A Methods Study to Evaluate Quality of Care,” BMC Health Services Research (June 2008).
For information about the Lena Ward’s origins, see Valentine Marc Nkwame, “Murdered Norwegian Girl Saves Local Children,” Arusha Times (April 13, 2002).
Elizabeth Molyneux describes her experience in Malawi in “Fighting Childhood Illness: Elizabeth Molyneux,” The Guardian (April 10, 2015). The Lancet profiled Molyneux and her husband in“Malcolm and Elizabeth Molyneux: Making Better Health in Malawi” by Clare Kapp, vol. 372 (November 2008).
Molyneux writes about her triage techniques in a paper: “Improved Triage and Emergency Care for Children reduce Inpatient Mortality in a resource-constrained Setting,” Bulletin of the World Health Organization, vol. 84 (April 2006).
Jo Ann Van Egan’s comments can be found in several publications, including “The Cost of Short-Term Missions,” The Other Side (January- February 2000). I also drew on the work of Sharon Joy McLennan’s thesis, “An Exploration of the Role of Short Term Medical Missions in the Provision of Health Care in Honduras,” for Massey University in New Zealand.
One of the most widely quoted scholars on short-term medical missions is Kurt Allen Ver Beek of Calvin University, whose 2007 paper, “Lessons from the Sapling: Review of Quantitative Research on Short- term Missions,” is a fascinating account of his work. His paper “The Impact of Short-term Missions: A Case Study of House Construction in Honduras,” appeared in Missiology, vol. 34 (October 2006).
The clubfoot technique used in Haydom is known as the Ponseti method. Because tissues of a newborn’s feet are supple, doctors can manipulate them with a series of new casts every few weeks without the need of reconstructive surgery.
The first George Patton quote Dilan told me was, “L’audace, l’audace, toujours l’audace” (Audacity, audacity, always audacity), on a plane trip from Haydom to Dar es Salaam. The quote, in fact, came from the movie Patton, not the general himself. However, Dilan said it expressed the emotions that surgeons must deploy to survive long and particularly complex cases. “Compared to war . . .” can be found in The Maxims of General Patton, Gary L. Bloomfield, Gretna Publishing (2013). Patton reportedly said this in response to an artillery barrage in France in 1944.
In a Psychology Today article, “A Hunger for Certainty” (Oct. 25, 2009), David Rock describes how the brain is wired to seek certainty and avoid uncertainty as if it’s a form of pain. “A sense of uncertainty about the future generates a strong threat or ‘alert’ response in your limbic system. Your brain detects something is wrong, and your ability to focus on other issues diminishes.” When that craving for certainty is met, there’s a feeling of reward. Perhaps this helps explain the addictive nature of surgery.
T. Peter Kingham and Adam Kushner et al. documented the desperate shortage of surgeons in Sierra Leone in their paper “Quantifying Surgical Capacity in Sierra Leone,” Archives of Surgery, vol. 144 (February 2009). The authors identified ten practicing surgeons in that country of four million people.
The information about Haile Debas was drawn from interviews and several papers, including his report in Disease Control Priorities in Developing Countries, Second Edition, published by the World Bank (2006). Brian Mullaney, cofounder of Smile Train, said the “biggest global health problem no one has ever heard of” to me in an interview as well as in “How to Save Millions of Lives Now,” The Daily News (August 12, 2013). A blogger questioned the use of the photos of deformed children and received a response from Smile Train, saying that “As much as we would love to show the beautiful smiles of the children after their surgeries in all of our advertising, our latest market research tests have shown that, presently, we do receive a higher donation response to advertisements that only feature the before pictures. In order to help more children, we have to go with what our market tests tell us.” See Tom Murphy, “What Kind of Images Are Appropriate for NGO Campaigns?” Huffington Post (Sept. 16, 2010).
Life expectancy data for that year come from the World Health Organization.
A discussion about Haiti and its “republic of NGO” nickname can be found in The Nation, “The NGO republic of Haiti: How the International relief Effort After the 2010 Earthquake Excluded Haitians from Their Own recovery,” by Kathie Klarreich and Linda Polman (Oct. 31, 2012).
David Eagleman describes his subroutine hypothesis in Incognito.
The End of Poverty, by Jeffrey Sachs, was published by the Penguin Press (2005). Dambisa Moyo’s book Dead Aid was published by Farrar, Straus and Giroux (2009). Moyo’s comments to Newsweek were made in “Dambisa Moyo’s ‘Dead Aid’ Says Stop Aid to Africa,” Lisa Miller (March 20, 2009).
Merwyn Bagan of New England and David Fairholm of Vancouver were ahead of their times when they went overseas to teach neurosurgery. Bagan describes his early work in “Neurosurgery in Nepal,” World Neurosurgery, vol. 47 (May 1997). Fairholm’s work in Taiwan is described in “International Education: A Third Alternative,” Neurosurgery, vol. 18 (1986). Three decades before Dilan’s first visit to Tanzania, Fairholm wrote that “education is the key to the delivery of medical care in the developing world.”
Dilan coauthored a paper on microbubbles with the catchy title “Imaging Tumor Angiogenesis with Contrast Ultrasound and vβ3,” Circulation, vol. 108 (June 30, 2003).
According to the American Association of Neurological Surgeons, it costs a teaching hospital about $1.2 million to train a neurological resident over seven years. This can be found in the report to the Institute of Medicine entitled “Ensuring an Adequate Neurosurgical Workforce for the 21st Century” (Dec. 19, 2012).
Paul Farmer writes in “How We Can Save Millions of Lives,” Washington Post (Nov. 17, 2011),“Ten million people—many of them young and most of them poor—will die around the world this year from diseases for which safe, effective and affordable treatments exist. In Haiti, these are known as ‘stupid deaths.’ What’s more, inadequate health services predominate precisely where the burden of disease is heaviest, keeping a billion souls from leading full lives in good health.” Farmer also describes his philosophy and work in Partner to the Poor, University of California Press (2010). Tracy Kidder’s book about Farmer, Mountains Beyond Mountains, random House (2003), is as inspirational as Jonah Attebery described.
Jonah kept online journals about his trips to Uganda and Tanzania, writing eloquently about his disappointments and achievements. He graciously allowed me to borrow details from his reports.
In April, 2010, four years after Dilan arrived in Haydom, World Neurosurgery published the findings in a paper, “Initial Audit of a Basic and Emergency Neurosurgical Training Program in rural Tanzania.” Its listed authors were Jonah E. Attebery, Emmanuel Mayegga, Robert G. Louis, Rachel Chard, Abednego Kinasha, and Dilantha B. Ellegala.
The study cited the cases performed: VP shunts; repair of myelomeningoceles; burr holes and craniotomies for trauma and biopsies. “Of 51 patients initially identified, 14 (27%) were confirmed deceased and 20 (39%) confirmed living. The remaining 17 (33%) were lost to follow-up. There were no significant differences in the mortality rates of patients receiving care from the American-trained neurosurgeon and those receiving care from the Tanzanian AMO trained and mentored by the American neurosurgeon.”
Descriptions of Petro and Mayegga’s office are drawn from photographs that Dilan snapped at the time.
About this time, Carin and Mayegga worked on another interesting case: a girl who arrived with her skull fractured from a rabid hyena. Thinking her brain had been exposed directly to the rabies virus, they feared that her bite wounds would be fatal. Finally, Mayegga suggested that they put the rabies vaccine directly into her brain. Looking for teeth marks, they injected the vaccine into the girl’s open skull, then wheeled her into the operating theater, where Mayegga spent hours stitching her skull and face back together. Several months later, the girl walked into Lena Ward, her wounds completely healed. “Is this you? Is this you?” Mayegga repeated.
Robert Hamilton kindly shared notes from his journals about the trip to and from Arusha with the East African neurosurgeons.
Paul Young was a master of getting people together on two continents. In 2005, just before the scene in this chapter, Young and Moody Qureshi set up a meeting in Nairobi with the few other neurosurgeons in East Africa. “I was astounded to find that most had never met each other,” Young told me later. He asked each physician to describe their work. As they spoke, he scribbled their names on a blackboard. When they were finished, he wrote “East Africa Training” in the center and drew lines to each doctor’s name. Suddenly, he said, everyone realized that if they worked together for a higher goal, they could move forward.
Emanuel Nuwas (pronounced New-ahs) was kind enough to take me to his family’s boma in the village of Getanyamba where he grew up.
After saying goodbye, Carin wondered why Dilan only shook her hand, but not because she was in love with him at the time. “Americans are just big huggers. And Dilan is a big hugger. It was a little odd.”
The doctor deficit statistics are from American Association of Medical Colleges, “Center for Workforce Studies,” June 2010 analysis. An updated analysis in 2015 found the projected shortage to be between 46,100 and 90,400 physicians by 2025. Other estimates and discussions about historical factors can be found in The Coming Shortage of Surgeons by Thomas E. Williams Jr., Bhagwan Satiani, and E. Christopher Ellison, ABC Clio (2009).
For a prescient view about the incorrect forecast about the number of doctors, see “There’s a Shortage of Specialists: Is Anyone Listening?” by Richard A. Cooper, Academic Medicine, vol. 77 (2002).
Canadian figures are from a paper by Nazrul Islan, “The Dilemma of Physician Shortage and International recruitment in Canada,” International Journal of Health Policy Manager (June 2014).
Vikram Patel wrote about the British perspective in “Recruiting Doctors from Poor Countries: The Great Brain robbery?” Health Systems Trust (Nov. 21, 2003).
The Walter Mondale quote and 1974 Congressional report reference are from a Wall Street Journal commentary by E. Fuller Torrey: “How the U.S. Made the Ebola Crisis Worse” (Oct. 14, 2014). Torrey wrote: “The total number of Liberian doctors in America is about two-thirds the total now working in their homeland.”
One of the most thorough sources for the extent and impact of the shortage of doctors is the Milbank Memorial Fund’s report “Health Worker Shortages and Global Justice” by Paula O’Brien and Lawrence O. Gostin (2011). The report also describes the recruiting industry.
The costs of brain drain are richly described by Edward J. Mills et al., in “The Financial Cost of Doctors Emigrating from Sub-Saharan Africa: Human Capital Analysis,” BMJ, vol. 343 (Nov. 24, 2011). The Guardian exposed the ongoing brain-drain problem in Great Britain in “NHS Hires Up to 3,000 Foreign-trained Doctors in a Year to Plug Staff Shortage,” by Denis Campbell, Haroon Siddique, Ashley Kirk, and James Meikle (Jan. 28, 2015).
The pilot’s name was changed. Two missionary aviation groups, Mission Aviation Fellowship and Flying Medical Service, work in the area, and both organizations do heroic work.
Pat Patten runs Flying Medical Service from a farm just outside Arusha and has uncommon wisdom and insights. I asked him, “What is the single defining feature of this region?” His answer: “People know they need one another.”
I found Patrice Bura cutting some trees near his shamba in Tumatti. He showed me his scars and said that he sometimes still has headaches but was perfectly healthy.
During a camping trip in Yaida Chini before the wedding, Carin and Dilan heard a melody in the distance. Moments later, several Hadza men appeared between the thorn bushes. The Hadza are among the last of the world’s true hunter-gatherer groups and speak a Khoisan click language. They sat by the fire until a honeyguide bird appeared. One of the Hadza men began to whistle, and the bird circled around him, chirping back. Suddenly, the man took a stick from the fire and signaled for everyone to follow. The bird flew to a tree where there was supposed to be some honey, but the man looked irritated and chirped angrily back at the bird, which promptly took off in another direction. The man followed and returned a few minutes later with a comb full of honey. It was an example of the symbiotic relationship the Hadza have with their environment.
Researchers in recent years have studied the Hadza’s diet, and more specifically, their fecal matter because of its rich bacterial diversity. For an interesting read an hour or so after you’ve eaten, see Jeff Leach’s work at humanfoodproject.com. In 2005, a wealthy family from the United Arab Emirates stirred international outrage when it tried to acquire the Yaidi Chini valley for a massive private helicopter hunting preserve. Human rights groups eventually beat back this incursion.
Some of the hospital’s looming financial problems were described in, “Haydom Lutheran Hospital—Final Project review” by Ottar Mæstad and Aziza Mwisongo of the Chr. Michelsen Institute (CMI) Norway.
In 2011, Hlin Irene Sagen Grung, a master’s thesis student from Norway, made waves in Haydom with her thesis for the University of Adger, “Haydom Lutheran Hospital: A Sustainable Health-Providing Organization or a ‘White Elephant’?”
A few days before the wedding, Angela and the other nurses threw Carin a “kitchen party.” They presented her with gifts and advice: a yellow kanga skirt (“No more pants and dressing like a man”), a homemade broom (“He’ll be happy and bright because the home is happy and bright”), a long wooden stick with a polished handle for making ugali (“You must feed your husband before you feed yourself, but make a little extra food for yourself because you’re so thin”). When they were done, everyone danced, with one of the nurses tapping on the side of a wooden sofa to keep the beat.
The pulse oximetry study is called “Global Operating Theatre Distribution and Pulse Oximetry Supply: An Estimation from reported Data,” by Luke M. Funk et al., The Lancet, vol. 376 (Sept. 25, 2010).
Atul A. Gawande was a coauthor of that study as well as one that found that more than 234 million surgeries were done worldwide every year: “An Estimation of the Global Volume of Surgery: A Modeling Strategy Based on Available Data,” Thomas G. Weiser et al., The Lancet, vol. 372 (July 12, 2008). Gawande’s quote comes from a paper he wrote for The Lancet, “Global Surgery,” vol. 386 (April 26, 2015).
Paul Farmer’s and Jim Kim’s calls for action can be found in “Surgery and Global Health: A View from Beyond the Or,” World Journal of Surgery, vol. 32 (April 2008).
For the study on how medical equipment fares after it has been donated, see “Effectiveness of Medical Equipment Donations to Improve Health Systems: How Much Medical Equipment Is Broken in the Developing World?” by Lora Perry and Robert Malkin, Medical & Biological Engineering & Computing, vol. 49 (July 2011).
For more information about the study that compared short-term missions with other surgical platforms, see “Charitable Platforms in Global Surgery: A Systematic review of Their Effectiveness, Cost-Effectiveness, Sustainability, and role Training,” by Mark G. Shrime, Ambereen Sleemi, and Thulasiraj D. ravilla, World Journal of Surgery (Published online March 2014).
BBC video about Ethiopian famine.
Carin introduced to staff in Hayom.
Outside the Chinese-themed hotel in Arusha, where Dilan and Carin first knew they would be together. Photo/Annie Duryee
Dilan teaches Nuwas in 2010. Photo/Bartelme
Nuwas showing me a hut in his family's boma. Photo/Bartelme
Nuwas, his daughter, wife, father in Getanyamba boma where he grew up. Photo/Bartelme
Pat Patten of Flying Medical Services at their headquarters near Arusha.
Patrice Bura (center) near Tumatti. Photo/Bartelme
Hadza elder. Photo/Bartelme
The wedding. Photos provided by Carin and Dilan Ellegala.