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This year we returned to Senegal for the 4th time for another eye mission. We went to Tambacounda, a town of 80,000 inhabitants, 300 miles from Dakar. One of the Peace Corps volunteers, Katie Sterba, who worked with us last year offered to organize a mission there. We stopped in this town in March of 2010 on our way back from Kedougou and visited the hospital to meet with their doctors,nurses and administrators to assess the need for our mission work. Subsequently it took over nine months of groundwork by the Peace Corps volunteers and at home by us to organize it.
Our group consisted of two nurses, two ophthalmologists (all four participated in the mission last year) and an optometrist. We nearly missed our connecting flight, but all 12 bags arrived with the supplies, so we were off to a good start. We spent half a day in Dakar. There are not many tourist attractions, so we went to see the new African Renaissance Monument which was built last year to commemorate the 50th anniversary of Senegal’s independence. It is 49m tall, made of bronze, cost $27 million and is the tallest statue in the world outside Asia and the former Soviet Union. It created a lot of controversy because of its “Stalinist” style and that it depicts scantily clothed people, as well as the high cost.
In the evening we had a meeting with the ophthalmologist who works in the Ministry of Health as the director of the “Fight Against Blindness”. He told us about the deplorable state of eye-care in Senegal. There are only 53 ophthalmologists for 14 million people, and 80% of them are in Dakar, where only 1 million people live. The government does not provide incentives for most specialists to work in underserved areas. The specialty of ophthalmology is very unpopular, as the money is in the prevention and treatment of AIDS and other infectious diseases, and maternal health, as these are the cause of most deaths. Presently no one is even training to be an ophthalmologist, but the population is growing at one of the fastest rates on the world, so the situation will just get worse in the future.
We left for Tamba at 6 a.m. on Saturday, as the driver was expecting major delays due to traffic. On Sunday there was the “Magal”, a major Muslim Holiday, when people make a pilgrimage to Tuba, the center of the mourides, a large Islamic Sufi order. Magal commemorates the return of the “saint” Amadou Bamba from exile and is marked by a mass assembly of the faithful at the tomb of Bamba. This year 3.5 million people gathered there for a one hour long celebration. People started to leave a week before and were still returning a week later. In a country with minimal infrastructure—i.e. only a 2-lane road leads there—it is indeed a major undertaking. There was bumper-to-bumper traffic in Dakar, hardly moving, from 4 a.m on through the day. Luckily our chauffeurs knew the outskirts, or so it seemed, so we took a “shortcut” winding through a labyrinth of narrow alleys between ugly concrete buildings in the dark, frequently having to turn back because of a dead end or a car blocking the street. There are no street names, which made it a bit difficult to navigate. Finally the sun rose, and we saw hundreds of cars, buses and trucks crammed with people, stalled in traffic, talking, eating, or just staring into nothingness. They did not seem to be upset or in a hurry. We were winding through now in a desert-like landscape on dirt roads, amid huge trash heaps with a few goats, chickens and dogs. This is as far as we got to an African safari. It seemed that we would never ever arrive, but in three hours we left Dakar and took the road to Tamba, which was deserted.
We arrived in the late afternoon and went to our hotel, which was luxurious compared to where we stayed the years before. There were sheets, even towels and pillows, excellent food and internet!
The next day we went to the hospital to unpack our supplies. The usual scene welcomed us: a big mess, boxes and unidentifiable objects scattered everywhere, rusting instruments in dirty fluid, but at least the place was not too dirty. We set about fixing the slit-lamps and microscopes, finding bulbs for them, etc., with the help of their “electrician” who had no clue how to use a screwdriver. It took us five hours instead of the usual two, but finally everything was ready for Monday. Then we had a meeting with the 15 Peace Corps volunteers who were planning to work with us.
Monday morning we bicycled to the hospital, which was a challenge in itself. The road was being built, full of small hills, detours, holes and ditches, a true obstacle course, changing each day to keep us on our toes. We had to weave by pedestrians, bikes, motorbikes, cars, pigs, chickens, goats and horse-drawn carriages. By the time we arrived we were covered with sweat and a reddish layer of dust.
The ophthalmology department in Tamba consists of 3 eye-nurses, an “operator” who does not have even a nursing degree, but was trained to perform eye-surgery, an OR nurse, and a nurse’s aid. Previously there had been an ophthalmologist with the military, but he left to Dakar when he was discharged. This is the only place where they perform eye-surgery in several hours drive in every direction, for probably well over a million people. Patients come from the surrounding countries too, including Mauritania, Mali and Guinea, where the situation is even worse. They pay $3.5 for consultation and $100 for cataract surgery, less for trachoma surgery, not including the totally unnecessary preoperative testing, the eye-drops and postoperative visits. Those above 60 and with an insurance card, which about one-third of the patients did not have due to bureaucratic difficulties, get free surgery. We made a deal with the hospital to charge our patients only $40, and nothing to those who could not pay. In exchange we gave a donation of instruments, eyeglasses and money to the hospital (see website).
Work started at 8 am. It was a relief not to have to deal with the usual crowd – the patients were prescreened for cataract surgery by the local eye-nurses, and about 20 of them were scheduled per day. The Peace Corps volunteers lined up the patients for each day with their charts, registration, proof of payment and insurance papers, which was no easy task. For a patient to obtain the necessary papers for free surgery took several days of going to different offices in different locations, of lining up, paying fees, collecting stamps and signatures. The word “kafkaesque” seems an understatement describing this incredibly complicated process. (None of our young helpers ever heard of Kafka…) The horrendous bureaucracy in the hospital was evident in other areas also. For instance, it took 2 days and several visits to different offices for us to get a receipt for the supplies we purchased. A large portion of the hospital staff is dedicated to these totally useless tasks, while they constantly complain about how understaffed they are and patient care suffers. We saw this puzzling problem in every single mission we participated in.
We had to learn the nurse’s terminology and abbreviations in French. It was not very difficult, as their charts were not too detailed. Most of them just stated that the patient had a cataract and which eye to operate on. We still had to examine each patient to ascertain that they were good surgical candidates, and every day we had to turn away 3-5 people, as they would not have benefitted from surgery. First we believed that this was because the eye-nurses had poor training and performed a superficial exam. In a few days we figured out that they did not have a functioning ophthalmoscope, the basic instrument of eye-care. The battery was missing and they had no money to buy them. They also had no eye drops necessary to measure eye-pressure.
Of the 4 times we have been to Senegal, Tamba had the worst problem with languages. There were so many of them, and also different dialects of the same language spoken, that it made communication with the patients extremely difficult and challenging. There was French, Pulaar, Wolof, Mandinka, Malinke, Jaxanke, Bambara and several other ones. Just to ascertain which language a patient speaks proved impossible in many instances. They frequently answered “yes” to a question if they spoke a certain language, but then it came out their knowledge consisted of a mere few words and they did not understand the explanation given to them. Informed consent is an unknown concept there anyway; the doctor decides what is right for the patient.
The work was nearly the same every day. We had 2 microscopes, so we could perform twice as many surgeries this way as we usually do. In the morning one of our doctors operated, and the other one saw the pre- and postoperative patients, and after this trained the Senegalese “operator” in a new, better, cheaper and faster technique for cataract surgery. In the afternoon both doctors operated, as the “operator” was exhausted and needed a rest. First we thought he was lazy, but after we learned he made $250 a month, we understood why he was not working any harder. Because our mission had been well publicized, the other eye-nurses, who make $300 a month, were working until 6 or 7 pm every day to see the many patients. Probably they hated us! (although they did not show it). One of the volunteers remarked that they probably never worked as hard as this in all their lives and they never will. Well, for that much money one should not wonder.
On Sunday we planned a visit to a nearby national park to watch hippos in the Gambia river. The head of the department, Dr. Cisse offered to take us, but he changed his mind and summoned the hospital bus instead in the last minute. We waited for an hour for the bus and one more for the authorization. In the meantime we had a tour of the hospital by one of the African surgeons. He showed us the ER, a small hut with 4 beds, the wards and the OR. The patients were a mix of acute and chronic problems, about 50%-50%: Motorbike and car-accidents, injuries, snake-bites, diarrhea, AIDS, stroke, typhus, etc. There was no malaria as it was the dry season. The doctor was performing the work of 5-6 US specialists: General abdominal surgery, thyroid, gynecologic, urologic, orthopedic surgery, hand-surgery….he was a man of many talents. He was very popular and loved by his patients and staff. We asked what happens if the doctor is incompetent and there are frequent poor outcomes, if the hospital ever discharges someone. We were told that in their culture everything is in God’s hands. If a patient does poorly or dies it was God’s will and not the doctor’s or anyone else’s fault.
Finally the bus arrived, and though it did not look like it could take us at any distance without breaking down, it did. We rented a small motorboat to experience the rich wildlife of the river and banks, and view the hippos up close. They looked very peaceful, but probably this is not always so. We learned that they gain the confidence of the men who feed them and then they attack and kill them. None of our Senegalese friends joined us – they knew better. Also, Africans are usually very afraid of the water as they cannot swim. On the way back we visited the village of Dr. Cisse. He has a wife in Tamba, and another one in the village. His house was a large compound with several smaller buildings, a courtyard and a shack for animals. He said 30 people lived there. Only he and his brother work and they support everyone else – as life is “cheap” in Senegal according to him.
At noon each day we ate in the “chabshacks” across the hospital. One day we saw one of our postoperative patients, a girl of 23 sitting on a mat with her sister in front of the shack. The sister thanked us for the surgery and reported that she did not need to lead her around any more. We believed they were the relatives of the owners, but we learned that they came from a distant village and were camping out there for a week. She was waiting for her other eye to be operated on. The owners let them stay for free and gave them leftover food, even though they were strangers. Many of our other patients were in the same situation. To offer help like this is not and individual act of kindness, but one of the basic rules of Senegalese society. When we gave food or sweets to children, they immediately shared it with the rest, in every instance, without hesitation. This behavior is extremely difficult to comprehend for us Westerners who come from a very individualistic society.
One afternoon we went to see the garden of one of the Peace Corps volunteers. It was a “demo” sustainable garden to show the locals that one can farm even in this weather and on this earth. It took him 3 months just to dig all the rocks out of the earth, even though the garden was tiny, and it took an hour daily for a family of 4 to water it, for which he had to pay them. When we visited, the women in the family watered, including a 5 years old daughter, while the husband was sitting in front of the garden setting a tire on fire and staring at it. This is a common scene in Senegal, the women work and men do not do much. The garden can never be self-sustaining, but it is supposed to teach locals certain farming techniques such as composting, fertilizer use, saving seeds, etc.
We kept on drilling our hosts about polygamy, as it still intrigued us, even after our 4th visit. The educated people and those living in the city nowadays have only one wife, as they say they cannot afford any more. Polygamy is still widely practiced in the villages, and it is a measure of social status. They shared with us this wise rule: The first wife is for convenience, the second is for lust, the third is for love, and the fourth is for fun!
The biggest problem for Senegal, and for all 3rd World countries, is uncontrolled population growth. Contraception is available to women in the form of a subcutaneous implant, even in small villages, and the majority is interested in using it. It is relatively cheap but is unavailable from time to time. Women usually keep it hidden from their husbands, as most of them would not consent to its use.
At the end of the second week we completed 184 cataract surgeries and had no major surgical complications. About 1/3 of the patients had their second eye operated on also. For the last 4 days we had more patients than we could handle, so those who could see well with one eye were told to return later for surgery. It would be great to receive more feedback about our patients, but this is usually unfeasible. Doing follow-up, statistics and e-mailing is not a strength of medical (or any other) personnel in 3rd World countries. Since we returned, we wrote several e-mails to the local nurses asking about our patients but we did not get a reply as of now.
It was flattering that three Peace Corps volunteers offered to organize an eye-mission next year, without us asking them. This shows that they consider the work meaningful and satisfying. They told us that our eye mission has become the highlight of their year. Next year we are planning to return to Bakel, where we were 3 years ago. So we can already start planning our trip-Insallah!