Mosquitos, Crochet, and the Cost of Free Medical Care
Amanda has declared war on mosquitos in the housing dedicated to the women suffering from fistulas. It’s bad enough that they are suffering, but then to get sick with malaria when they are waiting to have their surgeries seems to add insult to injury. “There are hundreds of mosquitos in there,” she exclaimed as she came to the hospital with a can of insecticide, “and all of the mosquito nets are gone except one.” Periodically, the nets need to be replaced because folks take them home. No one has apparently checked on this recently, and they have disappeared again.
“We’ve had a couple of deaths from malaria for these women who are taken to surgery,” explains Sam. Getting sick around the time of surgery adds additional stress and can overwhelm a woman who has just had this major operation. Anemia, fevers, vomiting, and other complications from malaria worsen the outcomes from surgery. It’s important.
Amanda provides support to the women in another way. The women stay for an average of four weeks, one week in the shelter, two weeks in the hospital and another week in the recovery area. Amanda and others support the women by teaching them crochet. It gives them something to do, a skill they can use, and the companionship of other women who do not ostracize them. Makes them feel human.
Sam told me that he had a conversation with a young colleague who works at one of the clinics, but there aren’t any medicines there. We talked about the system of care, which is free, but there are challenges within that system. While the leadership is working hard to fight graft, there are examples of medicines not being available in the hospital, but the exact medicines could be purchased at the pharmacy. There were rumors that medicines intended for the hospital were diverted to pharmacies where patients who were supposed to have free care had to pay for them. It’s hard on his young colleagues, Sam says, because they genuinely want to help the patients, but they are without the tools to care for them.
(On the same day, I received an email from our peace initiative in northern Kenya. “We are out of vital medicines at the clinic,” wrote one of our project leaders. “and we think that the medicines intended for the clinic may have been diverted.” It appears to be a common problem in many areas.)
Later we saw a child with a distorted face. She looks like she is 15 months or so. The right eye is bulging and pushed to the right. The nose is distorted to the left and completely plugged. The face is bulging on the right side as well. It is clear that the child has a mass growing in the right maxillary sinus and behind the right eye. The family came from quite a distance to get help. They brought some xrays with them which shows loss of bone. The child will continue to deteriorate unless the problem is addressed rapidly. We order a CT of the facial bones so that whatever surgeon cares for the child will have the best information possible prior to doing any procedure on the child. But we are told that the hospital where CT’s are done is not accepting any “outside” referrals for CT’s. It’s hard to know how to proceed. The child needs our help, so we need to advocate for our patient. We write the order anyway, hoping they’ll make an exception.
A Day at the Office
Bridgett arrived last night in Lubango. She is a surgeon from Germany who has come to this hospital annually for the past 14 years and has supported the hospital by providing surgical care for a few weeks so that one of the surgeons could take a vacation. She is bright, chipper, and my goodness, does she love surgery. She said, “just put me on call for the next six weeks,” and she means it. Whatever she can do to help, she is ready to work. She used to use these trips to Angola in place of her vacation time. That meant she worked for years without a vacation. Now, she uses unpaid leave to come here to help, but she still takes vacations. She loves mountains, so she travels to places like Pakistan and Kyrgystan for a nice relaxing vacation climbing mountains.
I scrubbed in with her today on several cases. She really hit the ground running. The first was a patient needing a gallbladder removed. “I’ve never seen this before,” she expressed. The gallstones were sitting on the outside of the gallbladder, sort of stuck to the thickened gallbladder wall.
The next patient was very ill. At 19 years of age, she was emaciated, a poster child for Auschwitz, two tubes in her kidneys draining her urine, an open wound in the front of her abdomen draining infected material, and a colostomy tube with a makeshift bag over it. She is very poor and comes from quite a distance. We have no records to know what really happened in her case. She is here for a cystoscopy, a look at her bladder to see whether things can be fixed on her insides.
We attempt looking in the bladder. There is no urethra. How does that happen, we wonder? We examine her vagina. It’s only a centimeter long. We wonder out loud what in the world happened. The best we can do is piece together information from her report. In July of this year, she had a baby. Might have been complicated, we don’t know. A couple of weeks later, she was bleeding heavily and was infected. She had a surgery, which we think was a hysterectomy. We think the surgery went really badly. Tied off both ureters so that the nephrostomy tubes were necessary? Uterus was taken along with the bladder and urethra was injured as well? Most of the vagina? There was a story about urine leaking into the abdomen, suggesting that the bladder was injured or removed. We really don’t know.
We have no idea if any of this is fixable. We attempt an ultrasound, but all we can say is that the kidneys are both there, and the right kidney is only minimally affected by back pressure We can’t see a bladder. “The only way to even make a plan is to look inside,” concludes Bridgett. Sam agrees. “We need to have a look at what’s there, whether she has any bladder left, whether the ureters can be reattached and whether a urethra can be remade.” Before the surgery next week, she’ll need to be fed with some fortified rice mix so she can get a little stronger than she is. Our patient lies listlessly on the exam table, her cheeks sunken, ribs all visible, muscles of her thighs and arms wasted, two tubes in her back, murky drainage coming from her abdomen. There is no way she can survive without our help. There is no guarantee she will survive even if we do everything we can. Another casualty of becoming a mother.
Other cases today, a weird abdominal wall mass that bleeds like crazy, a man with his right arm stuck to his chest wall due to a burn from a year ago, a colostomy that is taken down. We talk during the cases about life, hiking, the joy of our work, her (and my) time in Ethiopia, splitting our time between home and Africa, the importance of teaching, and the 19 year old patient. We keep coming back to her. “You know, these fistulas and obstetrical complications can virtually all be prevented,” says Bridgett. I nod. “They need good obstetrical care, prenatal care and access to c/sections.” I nod again. She gets it. She just underlined the reasons why we dream of doing our project in Cavango. One mission hospital, one site, on medical training program at a time. Timely screening of obstetrical patients to identify high risk individuals, improved delivery outcomes at the hospitals so that women feel like hospital delivery is better than at home, and timely c/section access. “You don’t need to learn these surgical techniques for fistula repair,” she goes on. “You need to teach the doctors how to prevent them.” Spoken like a family doctor.
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