“You Should Talk to Marijn About It”
We flew back in the rain, wet, tired, excited to get back to internet and our own beds and rest. Marijn is our pilot. He’s been here in Angola for several years, flying for MAF. Multiple mission stations that he services, but a couple of hot spots include Kalukembe and Cavango. After we landed back in Lubango, Marijn gave me a ride to a party for one of the folks working at the mission. He told me of his plans to move to Cavango. His family is excited. It’s a remote site without internet, electricity (except for solar), or a house, yet. He hopes to move there to oversee the building of his house, perhaps as soon as next month. His oldest boy loves to explore the wilderness, and this is an ideal spot for a kid with such an inquisitive mind.
Later, we spoke together with Andrew, a second pilot for MAF here in Angola. I learn that Cavango is a 100 bed hospital. But they don’t do any surgeries. Every patient who needs a c/section currently is being flown to CEML hospital in Lubango for care. The doctors in Cavango are interested in expanding their services, but the two physicians who are providing care at the hospital are overwhelmed. The flight team really wants to expand their medical outreach to other remote areas, but right now they can’t because it is one of the doctors at Cavango who was doing this. MAF is looking for their own doctor to hire to do this kind of outreach, since the doctor at Cavango doesn’t have the time.
It started me thinking. Could there be another solution? Maybe someone with c/section skills who could stay with the doctors at Cavango for a few months while they hone their skills, launch the c/section program, and look for a third partner who will help them permanently? This would solve both problems- allow for outreach by one of the Cavango physicians; and allow women requiring c/sections to be cared for locally, greatly reducing expense and risk for the patient. There are a few issues that need to be addressed, including approval by the government. But the goals are worthwhile and life-saving.
Overnight I contacted the folks at the headquarters for MAF and also the physicians at Cavango. I received a response from Cavango. They really like the idea of making this work. I’ll put the idea out to other colleagues to see if anyone is available to provide this level of support.
More medical encounters
“Dr. Barry, can you come and take a look at this patient with me?” one of the interns asked me. She was performing an ultrasound on a large mass in the lower abdomen of the patient. The young man had needed surgery early in his life because neither of his testes had descended into the scrotum. We performed an ultrasound of this part of the body, then turned our attention to the large mass in the right lower abdomen. It was the size of a large kidney. The ultrasound appeared to show a large tumor. Subsequent xrays failed to show any additional disease. Dr. Annaliese will plan for surgery for this patient in the near future.
Other procedures today: two surgeries for vesicovaginal fistulas, the leaky messy complications from lack of access to c/sections, by Annaliese. One was terribly complex. The bladder is almost completely absent. She needed to attempt to completely reconstruct a bladder from the vagina. Meanwhile, Sam and I worked on a young kid who needed reversal of a colostomy and fixing a wrecked lower leg. Lots of orthopedic cases here. There are plenty of opportunities for additional medical care. Lack of well qualified surgeons is a disparity. In this province, for example, with a population about 2 million, there are five general surgeons.
It’s not possible to fix everything. But I know where there is one mission hospital where there is no surgical capacity where we can make a difference for patients by introducing c/section services. I will be visiting the site tomorrow.
Cavango Visit:
Today I visited Cavango, an outpost mission hospital 147 miles from anywhere. Surrounded by villages in remote central Angola, 3 hours over rough 4 wheel drive road (first hour) and tarmac to go shopping for groceries. It’s what you might imagine a mission hospital to have been 60 years ago, but it is still the reality for many remote areas of Africa. West of here, what we call civilization gradually grows as you move toward the sea. East of here, you would need to redefine civilization. I am flown here today by Marijn and Andrew to talk with Tim and Betsy Cubacki, an ER doctor and his wife who have worked and sweated and rebuilt this place over the past 10 years after it was decimated by war. In the old days, it was a leprosarium. Then it was destroyed. In 1970, another physician built a clinic which ran until 1975 when it was destroyed again by war. It sat dormant, only foundations, until 2013 when Tim and Betsy arrived. It is remarkable how much has been done since then. 100 beds. Multiple additions just for TB alone. An emergency department, an ICU, consultation rooms, operating room, maternity room, multiple inpatient wards, a laboratory, an xray room, a pharmacy.
The day didn’t start out so great. There were supposed to be four patients to travel back to Cavango with us on the plane, but no one showed up- folks Tim and his colleagues had referred to Lubango for care. We don’t know why they didn’t show for the flight back home. No one seems to know where they are. So we must leave without them. We fly over miles of cultivated farm land for a little over an hour until we reach a green area covered with forests which go on for miles, and rivers that flow first into the Okavanga River then south to Botswana where the river empties its bounty into the desert sands and creates an oasis for wild things. We do a touch and go landing, then circle around and land again. We see the hippo pool, the cascades, a boggy area, and finally land on a dirt runway shaped like a hyperbola. Betsy is there waiting in a maroon Toyota pickup with a topper to haul us and the bounty of supplies we brought back to the mission less than a mile away. “We used to land two hours away,” explains Marijn. “Someone had to come all that way to pick us up. This is so much better.” I look around me at the trees, the flaccid wind sock, the red clay soil runway that drops off into the bog on each end. I like it.
We drive down the well rutted road to the mission homes, off load a few things, then on past the locally made brick church positioned next to a soccer field, and make our way to the hospital. A small covered area where women have created a local market. Steel containers with supplies stacked on top and inside. Well kept grounds, beautiful buildings constructed of block and plaster, steel frame and roofing, all recent developments as the need has dictated. We meet Tim, and he takes a break from the lines of patients he is seeing in order to show me around. He knows I’m on a bit of a mission.
We start in the operating room, a plain cemented room without adequate lighting. This is where they have been doing procedures up until now. They have a bed, a sink, some tables and equipment and medicines. We’ll make a list together for other things needed for what we are imagining. The room next door is the maternity area. It’s dingy and poorly lit, a few items available for deliveries. The ICU is next door. It’s full. There are no monitored beds. A couple of oxygen concentrators run by solar power. A few curtains divide the patients from each other. A woman who delivered her baby a week ago lies alone. She had been in labor for three days, then came to the hospital, difficult delivery, the baby needed resuscitation for 15 minutes, then stabilized on oxygen, but died the next day. A few days later, the mother came back to the hospital with fever and bleeding, hemoglobin dropped to 4 (normal is 12), severe infection of the uterus, needed blood, but her blood type is O neg. The staff went from sick bed to sick bed hoping to find another hospitalized patient who matched this blood type and who was willing to donate blood. Finally found someone, one unit was transfused, but the patient suffered a reaction to the blood so they needed to stop. In spite of all of that, she is getting better.
Another patient nearby with heart failure who needed three liters of fluid removed from around her lungs. She ran out of medicine at home and didn’t have transportation to get back to get some more medicine. Another young woman with rheumatic heart disease and a bad heart valve. A baby with a tight airway, maybe epiglottitis. Another recovering from pneumonia. A chicken under someone’s bed.
We look around the grounds. Tim shows me the generator room. Mostly everything runs on solar, but there is a generator as backup. Water is spring fed from up in the hills, feeds into the hospital’s water system. Water pressure is weak. TB wards, individual houses built for insulin dependent diabetics who keep running out of their medicine and come in comatose. “We’ve had a rat problem,” explains Tim. “so we decided to collect four cats.” Patients didn’t seem to mind the rats nibbling on their toes, but Tim wasn’t pleased with the rats chewing up the wires for the generator. “Now the rat problem is taken care of,” he points to one of the new and improved mousetraps ambling around the courtyard.
“We had too many animals wandering around the grounds. So I started paying anyone $10 for any dead animal they brought me- pigs, goats, dogs. We eat the goats and pigs, and the others we bury.” Sounds a bit like Stevens County where I live.
We visit the pharmacy, inpatient and TB wards, the xray department (they have the exact xray machine, a Battaray, that I use in my clinic at home), nice ultrasounds, the lab with a microscope and some nice chemistry and cbc analyzers. We look over the brand new hospital being built, larger than the others, and the covered area where worship and health education are provided each week. This is a remarkable place, I think to myself.
We head to the consultation room. On the way, I use the bathroom. They have one. It has a faucet and a toilet that flushes. It’s wonderful.
Tim sits down with an interpreter, and between questions, fills me in on what he is seeing and thinking. He practices medicine here a lot like I do. Practical, based on probability, not ordering every test, looking for treatable causes and ignoring largely what can’t be treated. Because there are many diseases here that can’t be treated. On the other hand, there are many lives to be saved. Tim knows the difference.
The translator goes from Portuguese to one of the three local languages. Tim moves from Portuguese to English, for my benefit. I recognize some of the words. “sansa” is vomiting in Chichewa, from Malawi, and also here in this part of Angola. “ati” means “he is saying,” like “akuti” in Chichewa.
We’re called next door to evaluate a woman whose liver is failing. Tim tells me that many women die here after consulting with a traditional healer for infertility. They haven’t been able to determine the particular herb which causes liver failure, but it is deadly. Slow, gradual death, but if they catch the process early enough, they can save some. This woman has the telltale signs on her ultrasound. Fluid in the belly, liver that looks like a piece of cardboard. Fortunately, no jaundice yet. “She might make it,” explains Tim. “She came in after only a month.”
Back in his office, an array of problems awaits us. An elderly woman with dementia. An elderly man recovering from delirium due to pneumonia. Low back pain. A young woman with TB of the spine. She pleads with Tim to be treated as an outpatient so she can continue with school, but he says no. There are reasons based on his experience that I don’t yet understand. He insists on treating everyone with TB for the first two months as inpatients. Then he leans forward, hand on her shoulder, and prays for her as she attempts to hold back her tears. A 3 year old boy with swelling of his face, hands, legs, cough and lack of appetite, most likely malnutrition due to parasites. A skinny guy with pancreatic TB. I asked about HIV prevalence here, but Tim doesn’t know. For years, Angola was isolated due to the war, but now that the borders are open, HIV is spreading rapidly. A couple of folks with hypertension. Someone with heart failure . Another with a pericardial effusion, fluid around the heart, most likely due to TB. Another person with bladder cancer, a complication of a parasite called schistosomiasis, second leading cause of parasite death in the world after malaria. A 29 year old woman with huge tumors in her liver. Peptic ulcer disease, typhoid, malaria, abdominal pain, comatose patients nearly raised from the dead. Patients from near and far, having heard of the reputation of the hospital, they come from hours away, from cities where there are doctors, but looking for someone with competence who cares. Ten people a day from the cities. All word of mouth advertising.
“The first two years were terrible. Everyone died,” Tim laments. “That’s because only people ready to die came to see us. Now things are different. The last five years, things have exploded. We’re overwhelmed with patients.” As a result Tim has stopped doing outreach clinics. He just can’t make it work with the volumes of patients they are now seeing. Which is half of the reason I am here. What if we found someone who could help for a little while so you could start the outreach clinics again, I had written to him in an email two nights ago. The pilots want to restart that program again. In fact, their organization is willing to hire a physician themselves to do just that. Tim had responded overnight, elated that I had asked. Here I am to see for myself, thanks to the pilots of MAF and the supportive team back at Lubango. They understand my mission here.
One thing puzzles me though, and it is related to the second reason for my trip here. Why do so few pregnant women get their care here? Tim responds that few even get one prenatal visit with them. The ultrasound is a big draw, so some will come. But he needs more opportunities to see them, screen for conditions that really should be delivered at the hospital, like twins, breech babies, placenta previa, and conditions of pregnancy like preeclampsia, anemia, diabetes, malaria, etc. As it is, only the very worst cases come to the hospital, which doesn’t help their image, nor the health of the community. There will be work to do in order to achieve what we dream of doing. We want to launch a c/section program so that women can safely have deliveries locally, rather than airlifting each one who needs a c/section to Kalukembe at great expense and risk. That’s our goal. Find a physician with the skill set to do precisely these things.
Later, Betsy talks to me about the living situation. There is solar power. A generator as backup to each home, of which there are an adequate number. Spring fed water source, and a well for some of the more distant houses. Cell phone coverage is 2 kilometers away. Wifi internet, so Whatsap is the communication link to the outside world. Grocery shopping happens once a month, and the MAF pilots bring in supplies regularly.
It all leaves me wondering, hoping, dreaming again of what is possible. But wouldn’t it be great to save some lives, get Tim back on the flights to distant, more remote and primitive places to provide basic care, down along the Zambia/Angola border? Hard to imagine that we are only half way across the country, and there are places more remote and isolated beyond us to the east and south. And give the team the ability to provide safe c/sections here. There is much to be done. We have a plan and confidence that we are not alone in this venture. We will take this as the chance to bring a bit of justice to this part of the world.
Menu