Mission Diary 2010, Kedougou, Senegal

This year we returned to Senegal for the 3^rd time for another eye – mission trip. Our group visited Kedougou again. A year ago we could take care of only about 2/3 of the patients in need there, so we promised to return. The group consisted of two nurses, two ophthalmologists and a French medical student, who was an extremely useful in translating for us. English is not spoken there at all, even by the doctors.

Kedougou is a town with 15 000 inhabitants, 500 miles (about 12 hours of drive) from the capital, Dakar, in the south-eastern part of the country. The road has improved considerably since last year, so it took us only a day (versus a day and a half last year) to get there. We arrived at 10 p.m. Getting out of the car and feeling the suffocating heat, smelling the smoke and the burning stench of trash brought back pleasant memories from last year.

We went to our hotel, called Thomas Sankara. It is named after the progressive president of Burkina Faso who was murdered in a coup. The hotel owner, Musa, welcomed us as old friends. He fixed up his hotel quite nicely since last year. It was freshly painted, sink in each bathroom instead of a tap on the floor, comfortable dining area. Now it could be classified as a ¾ star hotel up from ½ star last year. The food also improved considerably, which shattered our hopes of losing a few pounds during the trip. We asked Musa if he was ready to take a third wife now (he took his second last year) but he complained how expensive the second wedding was: 2 cows given to the wife’s family and more than 2000$ (a fortune in Senegal) for the wedding ceremony. Now he will need at least a few years to collect enough money for third one.

Polygamy intrigues us westerners, but in Senegal it is the way of life. Nearly all men we asked have or are planning to have a second wife. We also learned that surprisingly most wives are happy when their husband takes a second wife: As the marriages are always arranged (except in very educated circles) and women are not “in love” with their husband, it is usually a relief to have a fellow wife, someone to share the burden of housework and of sleeping with the husband, and also for companionship. Every Peace Corps volunteer I asked (who learn the local language, and live with local families for 2 years, so they really know what is going on) said that they did not know of any Senegalese couple in the villages who are “in love” according to our Western definition.

Sunday we unpacked our supplies and set up the clinic, the glasses room and the operating room (OR). Upon entering it, we found a huge mess: Dirty supplies, scattered instruments, empty boxes…some of our supplies and papers were still there from last year! It is a scary thought that they perform C-sections in this environment. We tidied up as much as we could and had the place cleaned after some altercations with the hospital personnel. I experienced the same state of affairs in every single clinic or hospital I have worked in the 3^rd World, and still I cannot figure out the reason: One can still be clean and tidy even if he is poor. Probably they have never seen a good example in this regard and think that this is how things should be.

The hospital was functioning a little better than last year: The head doctor, Dr.Sene was present most of the time. We learned the reason of his frequent disappearance to Dakar, which puzzled us last year: His second wife lives there. There were 2 other doctors working in the hospital: an internist and a public health doctor. They promised to take us on a tour and explain us what they do there exactly, but this never took place, as they were always “too busy”. This year we saw a few patients being seen at clinics, in the maternity ward, and also in the general wards. The wards looked horrendous for those of us used to American standards: a few iron beds without linen, terrible heat, dirt and trash, the whole family is camping in the room on mats on the floor or on the patient’s bed, cooking, eating, drinking, no nurse or doctor in sight…..it seemed to me that only the fittest survive in these conditions. The Kedougou District Hospital is partially government run and partially private: All maternity care, vaccinations and care for patients above 60 is free. For all other care patients have to pay (e.g.: 1$ for exam), but a social worker assesses the patient’s financial status and if he/she is destitute, the care is free.

Sunday evening we had a meeting with the PC volunteers about our work. Luckily, some of the best workers from last year were still there to help us – this was reassuring. The most difficult part of the mission is to train everyone in the work and make sure things go smoothly. The volunteers also figured out a better way to control patient flow: Each patient was registered and triaged at entry to priority 1, 2 and 3 and to patient needing only glasses. There were less mob scenes and crowds than last year. We also had somewhat less patients: Since our last mission, there were 2 other eye missions at the area. One of them was from Spain, and they operated on cataracts with the modern Western ultrasound technique. This is totally inappropriate for advanced cataracts seen in 3^rd W countries, and we have seen a few bad complications from them. But the most heartbreaking was to see the results of the local cataract mission from Tambacounda, the nearest hospital 3 hours away where there is eye care: Over half of the patients we saw had a poor outcome with bad vision and chronic pain. I know the only ophthalmologist who was working there and invited him to join us this time so we could exchange stories but unfortunately he is working in Dakar now. We called the 3 eye-nurses in Tambacounda, who heroically manage the department without a doctor now, but they did not come either.

Monday the work started: The volunteers registered and triaged the patients, checked their vision and took history. All of them had a nametag with the local language they spoke, so we could dispatch them accordingly. Luckily nearly half of our patients spoke pulaar, and the other half mandinka, with the occasional exception of other languages, so it was not too complicated. We also had Hassana with us, who was adopted by the present president of Peace Corps Senegal at age 7. He spoke all local languages AND English, and was an immense help to us just like last year. For vision check we modified our “African Eye Chart” from last year and included a cow, foot, hand, cup, star, flag instead of elephant, giraffe, snake and palm-tree. This was also almost completely useless so we decided to use the old E-game, which surprisingly was understood by most people. The doctors examined the priority 1 patient (the ones with poor vision or visible gross eye-problem) and signed them up for cataract surgery. Those who were not surgical candidates received detailed information about their eye-condition: Glaucoma, early cataract, corneal scar, retinal scar, optic nerve problem, reading trouble, dry eye, allergies, headaches, etc. The most important was to get through to patients if their condition could not be treated. These people frequently spend their family’s fortune searching for a cure, in vain. The most heartbreaking was a young woman who came with her husband and baby, completely blind from a botched surgery in one eye and injury in the other. We told her that she would never see again, all eyedrops are useless. She broke out in a loud wailing, which continued for a long time. (A very unusual behaviour from these stoic people.) Reassurance regarding harmless conditions is also important, and also to stress that the eye with the problem is not going to “attack” or “ruin” the other eye.

We started do surgeries on Monday, one doctor in clinic and the other in the OR. Everything went relatively smoothly, but every other day we were interrupted by emergency C-sections, which delayed us at least 2 hours. We could watch the surgeon who was quick, very skilled and efficient, but the postoperative care was nearly nonexistent: the patient lay on the OR bed alone, naked, unmonitored for at least another hour, finally they threw her on a stretcher and carried her out. All the drapes were washed with hand, for hours to get all the blood out. I asked the doctor about tubal ligation, which is a quick procedure done during the surgery as a permanent way of contraception – a good idea after having 5,6,7 or 8 children. He said they offer it but most of the time the father refuses it! (The mother’s consent is obviously not sufficient.)

We examined our postoperative patients on the next day and even that most of them could see objectively better, very few showed an emotional response, especially women. The strangest was a 13-year-old girl with bilateral cataracts and very poor vision. She could see fine the next day but she did not smile at all, just continued to stare apathetically. We were explained by a volunteer that women in Senegalese society are not used to express their emotions at all, as it has no point anyway: No one ever asks them for their opinion, if they want to marry or whom, if they want to have children, etc. Her brother was with her who assured us that he would try to prevent her father from selling her postoperative eye drops!

Another example for women’s situation in this society was when we explained cataract surgery to an old lady and asked her to think about it, she answered: I cook, I pound rice and I farm. I don’t think. We burst out in laughter, but it really is not funny. We noticed that with a few exceptions, women were working constantly, from early morning to late at night, but men were mainly sitting around talking or giving orders.

Overall, this year we felt much more welcome. The locals were more friendly, trusting and talkative. This is normal, as they knew us already and the feedback about us in the community was positive. We also had the opportunity to examine a lot of our postoperative patients from last year, and we found with great surprise, that all of them had quite good vision except one. We have never had any kind of objective feedback about our patients before (only the information from the local eye-nurse that “everybody’s fine”), so this was very encouraging and reassuring to see.

After working for a week we took Sunday off and went to a nearby village called Dindifelo, population 300, where Hassana is from. There is a 300ft waterfall nearby which is a big tourist attraction of the area. He showed us the “hotel” he manages now, built by a nonprofit organization for the village. He had to cut down all the trees as they suck the water out of the ground, install solar panels, fix the well and the roofs, etc. He also wages continuous war on the millions of termites who ruin everything extremely fast. We visited his family, as last year and were invited to a delicious meal. He told us about the school system: There is elementary school in the villages, middle school in Kedougou (15 000), high school in Tambacounda (90 000), and university only in Dakar. (2.5 million) As one has to live far from home, the higher the education is, the fewer can afford to pay living costs in addition to school fees. In spite of the compulsory schooling, only 71% of children are enrolled in primary education, 16% to secondary, and a mere 3% makes it to university. 44% of man and 72% of women are illiterate, which means that most of them do not learn even to read or write in primary school. One of the main reasons is that the education is in French, but the children do not speak it.

It is also a dream of the Senegalese to move to a bigger city: from Dindifelo even Kedougou looks like a great place: some restaurants, bars, a bank, (opened only last year), post office, stores, a bigger market, large mosque, other churches, a radio station, a library. People of Kedougou dream of Tambacounda, which features more of the same things, though from a western point of view it is still the end of the world, with no museum, movie or theater. The ultimate dream is to move to Dakar, where the quality of life is probably much worse for most people than on the countryside, terribly crowded, polluted, dangerous, with high unemployment and trash everywhere. But at least there is hope of breaking out of poverty, though this hope is never realized for the vast majority.

On the way home we stopped over in Tambacounda, the capital of the region. The Peace Corps volunteers would like to organize an eye mission for us there next year. I became quite enthusiastic, as the need is even greater there than in Kedougou; also we can have a long-standing impact by training the 3 local eye nurses in medical ophthalmology, in a better technique for cataract surgery, and mainly in organizational skills which they desperately lack. It is a huge challenge. It is always much more difficult to integrate ourselves into an already functioning department – as we saw last year in Ghana – than to do our own well-tested and practiced work routine. Also, there is a language barrier, as the nurses speak only French. They were extremely welcoming to us, including the hospital director, who spoke some English and who dreams of going to the US for postgraduate studies. Next year we will go to Tambacounda, Insallah! (God willing.)

Judith Simon