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Association of Surgeons of East
Africa (ASEA)
It is my great honour to come before you and address this year's ASEA AGM in the quality of the President of the Association. As you can imagine it is not without deep emotion; I feel greatly privileged to be here today in this position. This is because I now see passing before my eyes many images related to my participation in this Association that I would like to share with you today. I recall now the first time I attended an ASEA meeting, the AGM in Mombasa in 1980, the year Zimbabwe became independent. I was then a surgical trainee in Maputo - five years after Mozambique's independence - an immature product of the Portuguese colonial medical school. Listening to John Jellis' words addressing the AGM on his inauguration as that year's president, and avidly drinking from the fountain of surgical knowledge to which I was being exposed in a concentrated manner was a real boost to my professional life. I immediately recognised then that if I wanted to be a good surgeon in my country I would need to participate in the ASEA. I felt that the surgical issues being discussed there were exactly those that I was beginning to be faced with. I had found my true peers, my fellows, my professional guides, and friends. And this was particularly so at that time in Mozambique, when there were only a few expatriate surgeons and surgical dialogue was scarce. At the same time, I had the privilege to break the isolation Mozambique had imposed on itself and to do it in the service of the Art and Science of Surgery. My expectations were fully met and I have stayed linked to this Association for all these years. I am proud to say that the Association has been instrumental in my constant endeavour to practise good professional standards. It is thanks to this Association that I have the opportunity to keep abreast of the most recent developments in the practice of surgery in our region. When I joined the ASEA, having been brought up in a non-English speaking country, I could hardly speak English. It is also in the great part thanks to my participation in the ASEA that I am now able to communicate with this august audience in this manner. Now I ask you to follow me and watch some of the many images I see now related to my surgical work: I see the faced of the child upon whom I performed my first operation as a surgeon under the guidance of my first surgical teacher in Nampula, northern Mozambique, in the year of Mozambique's independence. The logbook registers: Diagnosis - necrosis of the lower extremity due to snakebite. Operation - below knee amputation. I see also the deep wounds provoked by shrapnel from 600 Kg bombs dropped by Mirages, massacring hundreds of youngsters of both sexes. This was in Manica, central Mozambique, bordering Zimbabwe in 1978. That was when we worked in the theatre non-stop for 24 hours. Limb amputation was the commonest operation performed on the survivors of that massacre. That was also where I realised how important maggots could be for wound debridement after having removing wriggling maggots covering these wounds, only to discover the neatest wounds. Incidentally this was the subject of a paper that received an award in one of our previous AGMs, providing scientific evidence on it's benefits for wound healing. I can also see now very vividly the face of the pilot of the Hawker Hunter jet fighter flying low over my head over the Choke Hospital, in southern Mozambique, in the late 70's. I had been urgently posted to this hospital the day before, in the aftermath of an air bombing that left around 60 dead and there was no doctor at the time. The thunderous noise of the jet engine had sent patients crawling between my legs and under the hospital beds at 10:30 am during my first ward round there. Another image I see now is the one that some of you have also seen in Beira, central Mozambique on the occasion of a previous regional meeting. It is the shattered hands and forearms as well as the burnt face of a youngster who had seen a landmine blow up in his face. I must solicit your indulgence to keep on listening to these sad and violent events. But I would not be fair if I did not pay homage here also to the dozens of children, women, and men, who I have witnessed as victims of vicious traumatic amputations of ears, lips, noses and penises. And I also cannot avoid recalling sadly the death of a man I operated upon in Soroti, northern Uganda some years ago. It was at the time of a Surgical Camp - a commendable initiative promoted by Ugandan colleagues, in parallel to surgical meetings. We had removed 14 kgs. of chronic lymphoedematous tissue from his scrotum. This gigantic operation ended up in an odyssey with the patient balancing between life and death for four or five hours. Part of this was at sunset and I see now the waves of thousands of bats taking off from the nearby trees at Ngora Hospital. This was a former model hospital patronised by the ASEA a project that later failed because of war. The hospital was even bombarded, and later temporarily used as a refugee camp. That odyssey was the result of unforgivable bad clinical judgment. This coupled with ignorance of the real local conditions for surgical work was the recipe for failure. This poor man died two weeks later, long after I last saw him. No better lesson was learnt in my professional life with regard to the Hippocrates quote "Do no harm". But our profession also brings joy and gratitude. I remember the many children, women and men in whom I have been able to reduce suffering and provide happiness and dignity. I feel honoured to have spent time and effort as a plastic surgeon to help correct deformities, especially those in the head and neck that turn their victims into social outcasts. I am glad that I have been able to provide surgical reconstruction to people, who as a result were able to do perform functions that they had been previously denied. For example, the gentlest human gesture, - kissing - restored by reconstructing lips. Or embracing, walking, using hands, restored by releasing contractures or correcting deformities, and even the dignity of a man urinating standing after reconstruction of the penis. Fellows, Members and Associates In my country 70% of the population is now living below the poverty line, and virtually all of them have no access to the health services. This grim picture that is not much different throughout our region saps the energies of even the strongest. In most of our countries we have had to this moment, incompetent governments and corrupt societies. Governments cannot pay the surgeons, cannot provide environments, in which surgeons work, cannot supervise, and cannot ensure equality. As a result, surgery has become highly commercialized, surgeons come and live mainly from the new upper class emerging in all our East African main towns and many among them aspire, and some have succeeded, in belonging to that class. As a result, we are witnessing a strong urbanization of surgery, with a bizarre maldistribution of surgeons. Much of the countryside - where the majority of our population live, as well as the poorest of the poor - stays in its only too well known underprivileged position. The countryside is not benefiting visibly from the increase in the number of surgeons. Even in the towns, the poor rarely have access to an acceptable standard of surgery. It is with sadness that we all have to recognise that it will take a long time before governments can and will pay salaries and provide working environments that will attract high quality of surgery to the periphery. In my opinion, it is not only the governments that are responsible for this state of affairs. The maldistribution of surgeons is also the result of sub-specialization within surgery. And this has been our responsibility. Surgery as a whole - training, practice, research and morality - is deteriorating. Medical school standards need to be lifted. Strengthening their regionalization and internationalization would be a first good step. The Association has the basic requirements to develop a surgical quality control policy. The College needs to re-discuss the issue of sub-specialization. Surgery in the region needs to regain some respect. It needs to become more affordable and accessible. And in this regard, we must consider mid-level surgical technicians - of which we have pioneering experience in my country (although not always successful). I still think that such technicians, well trained in highly specialized routine diagnostic and operative techniques are the best bet for our region. Surgical technicians would benefit the rich and the poor. Not only would they be cheaper, potentially they would be better at their jobs within well-defined limits. We surgeons, who are nearest to the immense sufferings of the people, ought to rise above the mediocrity so rampant around us and provide the vision. I cannot finish without mentioning that we as health workers - although mostly highly specialized in Surgery - must also face up to the three great health threats to our countries - HIV/AIDS, Tuberculosis and Malaria - all of which also impact strongly in our surgical practice. In this regards my words would be nothing when compared to the lucid address that was delivered by Malawi's Vice President Justin Malewezi at a Global Fund Consolidation, in Malawi last month. For this I quote parts of his statement: "Every minute we have been sitting in this room, ten people have died of the three diseases HIV/AIDS, Tuberculosis and Malaria. This translates to 15,000 people a day. This is not only appalling and tragic, it is scandalous. It is scandalous because we have the knowledge, the technology and the resources to address the challenges posed by HIV/AIDS, Tuberculosis and Malaria, but have not yet mobilized sufficient political will to prevent and treat these diseases in a comprehensive manner and on a scale commensurate with the devastation facing the human family". He also said that "People are suffering and people are dying. A whole generation of children is growing up without their parents condemned to live their lives in poverty. Tens of millions of people have died of AIDS, Tuberculosis and Malaria. This is a new holocaust. Without serious action now, tens of millions more will die. Every single death is an indictment on our consciousness. The HIV/AIDS pandemic threatens world security. How long is the world prepared to wait? How many tens of millions more people have to die before we address this situation seriously? Future generations of historians will debate why it took the world so long to respond to the challenges posed by HIV/AIDS, Tuberculosis and Malaria. They will probably conclude that the delay is as immoral as it is incomprehensible. "We need to make essential drugs and vaccines available to the worlds poor. Every nation has signed the Universal Declaration of Human Rights. It states that all human beings are equal in rights and dignity. The Universal Declaration of Human Rights places a moral obligation on the international community to invest in human development. I am not asking for charity, I am asking for justice." And the Malawian Vice President ended by saying: "Now is the time to take action. Now is the time to translate our commitments into reality and fully finance the Global Fund. Humanity demands that we do not delay or prevaricate or find excuses any longer. Let us build an international alliance for justice as the foundation of a lasting peace. I believe that "once in a lifetime that justice can rise up and hope and history rhyme". Let us commit ourselves to this goal and ensure that the end of the first year of the new millennium is the time that we finally make the global commitment to health." I couldn't agree more with this vision and this is now my great hope for the future of health and also for surgery in our region. I would not like finish without a word of optimism. We are more than 100 surgeons here today. At the inaugural meeting of the ASEA in Nairobi on 9th November 1950 no more than 20 surgeons attended. We cannot avoid admiring that surgeons in our region have been meeting for more than 50 years to share experiences, discuss ideas and get inspiration and courage to be able to proceed. Many of these surgeons have been celebrated academicians and devoted practitioners of the art of surgery. It has been amidst the often horrifying and threatening environment that has been a characteristic of our region, that many of our associates have managed to keep attending these important gatherings that we are proud to celebrate once again today. This has to be encouraging. It falls upon us to assume responsibility to keep alive the flame those surgeons have kept burning brightly until now. Let's hope that Pliny's words will be proven right again: "Ex Africa semper aliquid novi". Return to History of Surgery in East Africa
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