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To the President Royal College of Surgeons of Edinburgh President Association of Surgeons of East Africa The Chairman Rahima Dawood Foundation The Rahima Dawood Travelling Fellowship 2001 Report presented by: I. J. P. Loefler
DAR-ES-SALAAM SEPTEMBER 2 - 4 Notwithstanding the fact that my selection to be the Rahima Dawood Travelling Fellow for the year 2001 was occasioned by the failure of the Edinburgh College to identify a suitable candidate, I am honoured to have been selected to carry on with the task. Unfortunately my appointment has been confirmed in late August. By this time I had been committed to travel on a lecture tour to Germany and to Hungary, also I had my practice to think of and I had a number of other important functions scheduled. Inspite of all these difficulties it was possible, with the help of Rosemary Hepworth and Yussuf Kodwavwala to work out a timetable that allowed me to visit eight medical schools in the region and to attend two conferences one in Mombasa and one in Lusaka. In preparation to my visit, I have informed all the regional representatives and those heads of department who have contacted me that I shall like to give one main lecture to surgeons, including post-graduates, anaesthetists, gynaecologists and ICU nurses and that the topic I have chosen was "Damage Control and 'Second Look' in Emergency Abdominal Surgery". In addition, I offered a number of lectures and tutorials. I asked that, if possible, I should partake in rounds on the surgical wards and that I should be given time to meet the postgraduate students in the hospital as well as off duty, in a social setting. I have been received everywhere - except in Nairobi and Lusaka - by the heads of departments and the senior staff cordially and the country representatives of the Association looked after me with ardour and entertained me royally. I shall, in the following, summarize the particulars of my travels in chronological order. I am appending to the report a number of observations. Mr. Shariff has met and looked after me admirably. My main lecture was attended by many colleagues and nurses senior and junior, although I did not know most people in the audience. The discussion was lively and I was asked to follow with another lecture. I spoke about pain management, this time to a slightly smaller audience and thereafter I was invited to accompany my colleagues on rounds through various wards. As I always, refused to look at the "interesting cases" only and asked to see every patient, even the ones treated by surgical subspecialists. Thus I had the opportunity to see a very large number of patients, whereby the postgraduates and the interns presented to me the data and the seniors tended to add their observations. I have planned to spend the afternoon with the postgraduates, this was not to be, neither were they present in the evening when the seniors arranged a dinner for me. On the next morning I gave one more lecture, this was well attended. Thereafter I was told that I am free. My host, very graciously, took time off to show me Dar Es Salaam. I was asked to attend the regional meeting of the Association in Mombasa, a meeting organized together with the Kenya Surgical Society. I was happy to travel there. I was astonished to find a large number of colleagues from all corners of the region. I delivered my "Damage Control" lecture, not exactly at the time when I was supposed to, for we had the usual difficulty with the chief guest who did not materialize. (I have, over the years, observed, with disdain, that inviting big men to "open" meetings leads more often than not to embarrassment. Also, I came to the conclusion that a long time ago the choice of the guest of honour is a sub-plot designed to advance the interests of the local organizer). During the conference I had ample opportunity to meet many of the younger surgeons and to listen to their concerns and grievances. Mr. Fred Mutyaba was waiting for me in Entebbe and took me straight to Mbarara where in the evening I met a number of senior surgeons at my lodgings, where I was also visited by the Vice Chancellor. The "Damage Control" lecture took place in the main lecture theatre in the presence of Vice-Chancellor (not a medical doctor), Dean and the entire senior staff, many junior doctors and all undergraduate students. The discussion was lively, students participating. Thereafter I gave two more lectures from my repertoire, "Snake Bites" and "Pain in the Anus". The rounds were extensive and thorough, I have seen all surgical patients. The junior doctors presented the data, the seniors commenting. We spent considerable time examining burn wounds, for this department, under the guidance of a plastic surgeon, has embarked on a research project using honey in olive oil as dressing. (The burn wounds look very nice and clean, one wonders whether this is so because of honey or because of the lavish attention.) In the evening we drove to Kampala. My schedule at Makerere was well planned. I lectured in the morning in the department to seniors and post-graduates and thereafter I participated in teaching rounds on ward 2B whereby I was able to see every patient. Senior and junior clerks, interns, post-graduates as well as senior surgeons accompanied me, altogether an enormous crowd. Upon enquiry I was told that the size of the crowd had nothing to do with my presence but was a routine occurrence. In the afternoon I gave tutorials to the assembled postgraduates, they chose from among the topics on offer. Altogether I taught uninterruptedly for nine hours without sitting down once. My exertions were immediately followed by a party in the department. The post-graduates were in attendance. The occasion was graced by the presence of many seniors, including the Professor of Surgery, the Head of the Department, the Superintendent, the Dean, the Director General of Medical Services and the Chairman of the Health Service Commission. Every senior who spoke (and all of them did) spoke of the old Makerere days and spoke kindly of my years at Makerere. Most of these grey haired men have been my students some thirty years ago. Next morning, I gave yet another lecture in the department to an audience consisting of seniors and post-graduates before I was taken to the airport. NAIROBI NOVEMBER 1ST; (and thereafter) The Kenya representative of the Association, Mr. Moses Okatch, had some difficulty arranging the Rahima Dawood lecture in my hometown. Eventually I was told that the main lecture would be on the 1st of November in the afternoon. My audience consisted solely of postgraduates, one professor and one lecturer (this young man present because he was in charge of Thursday afternoon lecturers). My "Damage Control" lecture was well received by the post-graduates and we had a long discussion. This lifted my spirits which had been depressed because of the dirty lecture theatre, the blackboard that had not been cleaned for some time and the lectern which one could not touch, so smeary it was. After the lecture I met the Head of Department in the parking lot. "I just finished my Rahima Dawood Lecture," said I. "Well done" said the Head of the Department, driving away. Subsequently, the post-graduates, apparently without discussing the matter with anyone in the department, have arranged for me to meet them once or twice a week to give tutorials. This I have done throughout November, I think, with great success - However, I had to express my disdain that only one third of the audience came on time, the rest drifted in the Nairobi manner and I also had to protest against the use of mobile phones in the room during my tutorials. Doctor Milliard has met me and has throughout my stay looked after me with exceptional circumspection and courtesy. On the first evening we met with a number of senior surgeons in my hotel. In Addis Ababa the working day begins early in the morning. Before 8 a.m the entire staff of the department gathers for the morning conference. Exactly at 8 the senior surgeon enters and all units, one after the other report on all the complications, diagnostic problems and other matters. These are then discussed. (This is how it has been at Makerere 35 years ago. Sir Ian McAdam and I acted as advisors in setting up the school in Addis. To see Makerere traditions surviving there was gratifying). Again I was taken on rounds, we have seen every patient of one unit. I was very impressed with the diagnostic acumen and the surgical skill of my colleagues and kept congratulating them on their results. I was equally impressed with the post-graduates. I have learned on that day in Addis a number of interesting operative maneuvers. Most of the senior surgeons I came across in the Black Lion Hospital are more experienced than I am - and they do the operating together with the postgraduates. In the afternoon I gave my "Damage Control" lecture to a very interested, critical and outspoken audience, consisting of surgeons of all grades. On the evening I was entertained lavishly in a little restaurant. There I learned from my three hosts many details about the fast changing country. Next morning I gave two more lectures before it was time to hurry to the airport. Zech Gaya, my generous host, invited the entire surgical department to dinner at his house. There have been more than two dozen surgeons and doctors of various ages present This was a very useful. get-together, when we gathered on the next morning, I could say that I know most Eldoret Surgeons. I was taken to pay a courtesy visit to the Dean and to the Director of the hospital. For the next four hours we made rounds. Good, properly structured rounds with under-graduates, interns, registrars and seniors interacting admirably. My lecture in the afternoon attracted a full house, including the Director of the hospital and the Matron and Zech Gaya had to literally extricate me from the throng so that I reach my flight. HARARE NOVEMBER 30 - DECEMBER 2 On behalf of the country representative Mr. Mbuwayesango met me. After lunch we proceeded to the department of surgery where I was supposed to give two lectures to the postgraduates beginning at 2. p.m. By 2:30 only five had come. It was not quite clear whether this is so because of a strike in the university which had began on that day, lack of preparation or lack of interest. I spent the afternoon discussing wound care. My "Damage Control" lecture was scheduled to take place in the Zima (Zimbabwe Medical Association) House in the evening. The Lecture room was prepared for more than hundred people. About a dozen have come. The lecture elicited much discussion, mostly opposition. On Saturday morning I was scheduled to lecture on snakebites in the main lecture theatre. The audience consisted of the dozen surgeons a few postgraduates. Thereafter I was to partake on teaching rounds on one of the wards of Parimenyatwa Hospital. The ward was empty. The unit that hosted me consisted of far more staff and students (post and under graduates) than the number of patients. It was time to go and birdwatch. Although I reported to the department of surgery on Monday morning, it was obvious that everyone was occupied with the workshops and the conference that there was nothing useful for me to do. I invited myself to partake in rounds with one of the general surgical firms. This round took place on Tuesday morning. The head of the unit with whom I had made the arrangements was absent. The senior registrar took me around together with postgraduates, interns and clerks. As I had not been given any instructions what to do and when and where, I almost went to the wrong venue on Wednesday morning to register and to receive the program from which I learned when I was expected to deliver the Rahima Dawood Oration and when my "Damage Control" lecture was to take place. Much to my surprise a large crowd had assembled to listen to the Oration, a text of which I append to this report. The conference was well attended, well organized and there were a number of very interesting papers and most papers were well delivered. My "Damage Control" contribution had a surprising effect: having delivered it on eight occasions before I was braced for the conservative backlash, however, a Canadian surgeon stole the thunder, calmly explaining that my recipe for Damage Control is standard fare but not radical enough... During the dinner dance - which suffered from the simultaneous celebration of another dinner dance in the next room - I was once more asked to speak... One remark about the award of the various prices: I thought that the adjudication of the prices was fair and thoughtful, actually I found, to my astonishment, that for the first time ever, I agreed with the jury. All departments of surgery I visited struggle with the same set of handicaps: political interference, shortage of money translated into shortage of staff, equipment, facilities and drugs, shortage of theatre time, the split between public responsibility and commercial practice, the environment in the public hospitals characterized by dilapidation and squalor and the unreasonably high number of students. The various departments have developed varying strategies to try to cope. Although Addis Ababa is labouring under the worst constraints, its performance, in comparison to the others is outstanding. I think there are many reasons for this, one is social discipline: punctuality and reliability not seen anywhere else in the region, the other is that the Ethiopians are the least pretentious and the least arrogant (probably because they have been around for a very long time...). Moreover in the Black Lion Hospital the senior surgeons know their patients personally. Only in Addis have I seen series of really major surgery: in bed after bed I found patients who had gastrectomies, esophagectomies with colonic replacement, common duct explorations, aortic grafts, abdomino-perineal resections, pheochromocytomas and tumours of the adrenal cortex. The discussion during rounds was focussed and I had the impression that some of my hosts are far more experienced surgeons than I am. However even in Addis there is the threat that the seniors will sequestrate themselves into the commercial niche and will abandon their public patients and students. I am certain that the lure of commercial practice cannot be countermanded by prohibition, regulations and exhortations. In my opinion the solution to the threat of sequestration into private and public surgery is in the incorporation of private hospitals and commercial practices into teaching, training and research. If Addis impresses with its discipline, experience and the quality of its surgery, Eldoret radiates enthusiasm. In Eldoret the seniors are young and have a remarkably cordial relationship to their juniors. The result is that the patients are looked after well, appropriately under the circumstances. True, most surgery in Eldoret is emergency or urgent in nature, there is little of major elective surgery, but the emergencies themselves are very major and attended to competently by general surgeons. The only department in the region where I saw general surgeons routinely treating burns and head injuries and even fractures - and do it well, was in Eldoret. Mbarara is severely handicapped by lack of space and facilities - by the lack of everything. Yet Mbarara is marked by the spirit of inventiveness: the postgraduate course there, aiming at producing district doctors competent in conservative (medical) and operative treatment of common disorders, is probably more promising than the old M. Med. (Surgery) programs presently are, not at last because the recognition that gynecological surgery is part and parcel of surgery. Although in Dar Es Salaam the symptoms and signs of the plague that devastates postcolonial surgery are clearly recognizable, Dar Es Salaam is not as ill as the other large Medical Schools I visited. This is so because Tanzanians are less arrogant and less pretentious than say Kenyans and Zimbabweans who inherited this curse from the former masters of those countries, and because Tanzanians have no cause to think - and do not think that Muhimbili Hospital has a glorious past, hence they are not handicapped by a real or an imagined great history. Still the signs of decay are there: half of the patients are waiting, some for days, some for weeks for something to happen. Dar is already advancing on the specialization journey: on teaching grounds we were to by pass patients with the remark "This is urology", "This is neurosurgery." In Dar Es Salaam I saw a patient who was found to have tuberculous peritonitis but who was not treated with chemotherapy because only the tuberculosis consultant can prescribe chemotherapy and he will not see the patient (he cannot even be called) before the histology report is available and that might take two more weeks: the post colonial big hospital syndrome... This syndrome is fully developed in Lusaka... Rounds in Lusaka were far more distressing than in Dar. This was so, firstly, because in Lusaka the juniors - clerks, interns, and postgraduates - did not know their patients. I was given histories by a committee, spiritedly discussing details. In Lusaka X-rays and laboratory reports could not be found and nurses have been abused and shouted at in my presence. These are signs of system failure. There were plenty of signs of system failure. I have seen a man who had a brain lesion manifested by acute onset of fits and hemiplegia, having had a febrile illness (acute thyroiditis) before hand, who was sent for an EEG but no one has done a lumbar puncture - fortunately, as no one had looked at his fundi either. In my presence a consultation form was sent to the ophthalmologist to attend to the latter. When I suggested that the patient might need an urgent craniotomy, for I thought, that he is likely to have a brain abcess, I was told that the neurosurgeon would not see the patient before he had a CT scan... This is the same ward where I saw several children who had been burnt six and eight weeks ago and who were in splints to avoid contracture but whose wounds have not been grafted... This is also the ward where I was told the sentences "we cannot help this man because we have no angiography" and "we cannot operate this man’s goiter because he cannot afford to pay for the thyroid function tests..." But at least in Lusaka the wounds were clean, the sutured ones were neat and healing well, the open ones were washed and soaked. Not in Mulago where the stench on the ward, a blend of the odour or excrements, of pus and of rotting flesh represented the olfactory frame to the picture of the ultimate alienation between patients and the medical profession: in the dirty beds lay the patients in puddles of urine and piles of stool showing their festering wounds to a large crowd of professionals of both sexes and various ages, all clad in snow white coats or in starched uniforms, the men wearing white shirts and sombre patterned ties. The imagery of Dante and Kaffka and Solzenicyn is surpassed by the Makerere Medical School reality. I think I have seen some 85 patients in four and a half hours. I do not think that more than a quarter of these actually benefited from their admission to the Continent’s most famous hospital. My immaculately dressed and well educated and most gracious and concerned company of colleagues presented to me their patients well and fluently and with erudition, among them two lady patients whose fate shall be recorded here to demonstrate the phenomenon of alienation. One was a lady in her late sixties who had a below knee amputation and whose stump was now gangrenous. Apparently she was because of a gangrenous forefoot. It took some time to investigate her problem. Eventually the arteriogram and the doppler could not be reconciled, neither report was compatible with the finding that upon examination the popliteal pulse was judged to be barely palpable. In the meantime her gangrene progressed. Her leg was amputated below the knee. Now the stump was gangrenous... My question as to what benefit she had from those investigations and for that matter, having no access to prostheses and, being rather frail, no prospect of active locomotion, what benefit she would have had from the knee - my colleagues looked at me with consternation. The other lady, in her forties, had presented about four weeks prior to my visit with a lump in her breast. An open biopsy was performed and now the tumor was growing though the otherwise healed biopsy incision whilst the lady and the unit were waiting for the biopsy report without which no decision can be taken... When I suggested that this is a sign of system failure my colleagues were aghast: how could I countenance treating the lady without histological diagnosis...This is not what I was teaching in my days at Makerere 35 years ago! My reply, that in those days a histology report was available in 48 hours was met with incredulity on the part of the young and was dismissed by the old as an unimportant circumstance, not altering the principle of the matter. At Makerere, my own alma mater, I had the impression that past glory hangs like a millstone around the neck of the institution and people are simply unable to see reality, unable to adjust, the begin again. After my snakebite lecture one of my esteemed colleagues came to me and said "But this is very different from what you used to teach!" Zimbabwe is going through a severe political and economic crisis that preoccupied everyone. This is, I think, the main reason why my visit was so ephemeral. The fact that the main teaching hospital is empty, that many wards and the casualty are closed, has a different explanation. This huge hospital is a parastatal that is presently cast off by government. I was told that in Harare Central Hospital the rounds would have been more interesting... I am sure, however, that I would have had a more interesting time in the private hospitals. Judging by the telephone conversations that my colleagues conducted during my lectures and during rounds, surgery in Harare is only for those who can afford it. Whether the distinct lack of enthusiasm for the Rahima Dawood Travelling Fellow that I experienced in my home town, Nairobi, is the result of my bad reputation or whether such complete disinterest on the part of the department would have been the fate of any visitor - I do not know. As I had no contact and no invitation to make contact with anyone, I was unable to make rounds and in absence of that experience, specifically the Rahima Dawood Travelling Fellow experience, I cannot say anything about the welfare of surgical patients in Kenyatta National Hospital. Altogether the most important observation I made is this: although my contacts with post-graduates were not as frequent and as intimate as I would have wished, I was able to form the opinion that there is a rift between the postgraduates and their teachers everywhere and that the postgraduates are very critical of their seniors. This was particularly noticeable at Makerere, Lusaka and Nairobi. Interestingly the Makerere postgraduates appeared to be very well read and very articulate. They and the Nairobi group appeared to me to be largely self thought. It behoves me to add here two remarks. One concerns the state of surgery in the region and the other the HIV pandemic. With regard to the state of surgery in the region I would like to refer to the oration that I delivered in Lusaka on the 5th of December, and that should be regarded as an integral part of this report. I am aware of the harshness of the oration and of the harshness of this report. I wish to state clearly that my criticisms are directed at the profession as a whole and therefore they are, to a large extent self criticisms. For I have contributed to the disasters I spoke about in the oration and write about in this report prominently everywhere, in all the eight schools I visited, I met former students of mine. In Mulago I found yellowed notices bearing my signature, dated 1967. In Addis I recognized sentences in the postgraduate curriculum, sentences I wrote with Sir Ian McAdam in 1969 - long before there were postgraduates in Addis. In Lusaka I was astounded to see the collection of journals I donated to the departmental library: they were exactly on the shelves where I put them with my own hands 26 years ago. Both in Lusaka and in Makerere my former students, now grey haired seniors, remonstrated with me for I was teaching something different than what they remembered I used to teach: "Have you changed your mind?" they said, protesting that I would proceed to treatment on the strength of clinical diagnosis without laboratory proof. The frustration and the humiliation for me on this journey was the recognition that I am responsible, I have contributed towards this sorry state of surgery in the region… With regard to the HIV pandemic I have to say this: the exeptionalisation of HIV and AIDS is in itself a major social pathology. On every round in every corner of the region, I assume, 20-30% of the patients I saw were HIV positive. Yet whenever I mentioned the words, whenever I inquired about pathology related to AIDS, my hosts, professors, doctors, students, nurses fell silent, were uneasy, used euphemisms, and referred to nebulous politically correct notions. As long as society continues to exceptionalize HIV and AIDS there is no hope for getting some grip on the pandemic and as long as doctors and surgeons do not take the lead in de-exceptionalizing, as long as they look over their shoulders, embarrassed, when they speak of these things, the virus will triumph. It is with these thoughts in mind that I append to this report an editorial I have recently wrote for the East African Medical Journal. I also append a reprint of another leader, one, on "Damage Control and 'Second Look' in Emergency Abdominal Surgery" from SURGERY, published in November. This I do for the record sake because this piece summarizes fairly the "Damage Control" lecture I gave in all nine locations - and hopefully rectifies some of the misunderstandings, that bedevilled the discussion following the lecture in most places - no doubt triggered by my manner of lecturing. I very much regret that I was unable to visit Maputo, Blantyre and Moshi. Judging from the papers I heard in Lusaka I think I would have enjoyed the visit to Blantyre. The fact that I could not visit all Medical Schools in the region is the result of insufficient preparation on the part of the Association and the College. To be told in August that Edinburgh cannot find a suitable Fellow is quite scandalous. The Rahima Dawood Travelling Fellowship is too valuable to be treated in this nonchalant manner. One hopes in future the Fellow is identified a year a head of time and his program is prepared and structured well in advance. The Rahima Dawood Travelling Fellowship must not become another casualty of the postcolonial world - not like a whole generation of surgeons and countless multitudes of patients. History is created by ourselves as much as by circumstances. I have understanding for the plight of my colleagues, I feel compassion for them, for the whole generation of disappointed professionals. The splendid castle of academic surgery we were building turned out to be a cardhouse… It is not too late to begin anew, it is never too late. But we ought not to continue to cheat our people and cheat ourselves: the foundation on which we must build is realism and the reality of academic surgery in our region is unsatisfactory. Return to History of Surgery in East Africa
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