This year our group went to a small town in the Eastern part of Senegal called Ourossogie. Ivy, one of the Peace Corps Volunteers (PCV) who was with us last year, offered to organize a mission there. She said that to her knowledge, there had never been any cataract missions organized in this town (which turned out later to not be true) and the need was huge.
There was already a problem before we left home. One of the doctors in the group cancelled at the last minute and we had two hundred blind patients prescheduled, waiting for surgery. The local ophthalmologist, Dr. Diallo and two eye-nurses, Dr. Baa and Dr. Sall have been screening patients for cataract surgery during the past weeks with the help of the PCVs. It was doubtful that we would be able to handle all the patients but it was already too late to get another doctor.
The five members of our group arrived to Dakar with all of the twelve large bags, which is always a great joy and relief. The first time in six years we were asked for permission at the customs. We always request it months ahead from the health ministry and we usually receive it after we return to the US. I had a forged copy as usual from last year, I just changed the date.. But there was a change of government in the meantime and the custom officers were staring at the permission form very suspiciously. I quickly yanked it out of their hands and offered some reading glasses for their parents. After this everything went smoothly.
Next morning we left for Ourossogie, a mere twelve-hour drive from Dakar. It’s a small town in an underdeveloped Eastern area with 20,000 inhabitants, and a regional center for health care. It’s the only hospital providing eye-care for several hours drive in each direction. We arrived late and unloaded the bags in the hospital in total darkness. The next day we took some more bags from the hotel (a twenty minute walk) with a donkey-cart. (a twenty-five minute ride.) This was the local taxi, driven by young boys. The drivers were usually hitting the donkeys mercilessly and the more we protested the harder they hit them. They probably believed we wanted to go faster. After a couple of days we gave up on the carts and walked.
We unpacked on Sunday and set up the operating room, the consultation room and the postoperative care room. These tasks are never easy, fraught by hundreds of small problems common to developing countries, i.e. missing keys, non-functioning outlets, (the electrician is still on his way…) no operating tables/chairs/etc, no water, sink clogged, AC does not work and it is over 100 degrees, etc. But where there’s a will there’s a way, by the afternoon we were ready. The volunteers came to our hotel in the evening to discuss the logistics of the whole operation. Luckily a few of them were with us last year so they already had experience. Also, the main organizer, Meredith was an extremely strong, well organized and thorough person, she thought of nearly everything ahead of time and this made things go relatively smoothly.
Next morning we started to see the preoperative patients and in two hours we started surgery. Meredith called in only fifteen patients out of the twenty scheduled, and if a few didn’t show she called in more during the morning for the afternoon. All patients (or their relatives) had cell phones, which made the organization much easier. During previous missions this was not the case and frequently we had too few or too many patients for the day. About 15-20% of prescreened patients weren’t good surgical candidates so they had to be sent home. (We paid for everyone’s transportation.) I first believed this was due to the lack of training of the screening personnel but later we found out that none of them had the right instrument for cataract screening, a direct ophthalmoscope. This costs $400 in the US and developing countries just can’t afford it. There is one now invented for poor countries, it costs 10$ and functions with solar power. It’s questionable though whether it will ever be manufactured on a large scale.
The first surgical day went a bit slowly as usual. Dr. Diallo showed us his technique of cataract surgery. It took over an hour and used about six different sutures! I saw immediately that we could make a big impact in patient care if I taught him the so-called “sutureless small incision cataract surgery” technique. I started to train him the second day. He was an extremely talented surgeon and he picked up the steps relatively fast. He also knew when to stop and let me take over, which requires a lot of insight. I see it very rarely. Most doctors are either too aggressive or too timid surgically.
We were supposed to operate with two microscopes so we could perform more surgeries. The local hospital had one, and we brought one from the US. But it was close to impossible to operate with their microscope, as it was not made for ophthalmic but for ENT surgery. Dr. Diallo was aware of this but somehow never mentioned it to the hospital director. Probably he wouldn’t have been able to order a new one anyway. It was actually miraculous that he got relatively good results with this one. (I saw the OR log, that’s how I knew.) Also, after I found out about the problem with the local microscope it became obvious why more than half of the cases selected for our group were complicated cataracts: Dr. Diallo knew better than to operate on them with substandard equipment.
So we decided to use only our microscope and we had two beds, with the scope swinging back and forth between them. This way we had time to prepare the next patient on the second bed and it speeded up the surgeries. I saw this only in an article (in the US we never need to do this) but it worked.
There was also a huge problem with our autoclave. (The instrument used for sterilization.) It was leaking steam and the cycle took too long to complete. Sterilization became the rate-limiting step for the surgeries. We scouted around to see if there was a small autoclave we could use. (The large ones they use for their OR take several hours to sterilize.) In an abandoned room we discovered a brand new one, just perfect for eye-surgery, apparently never used. It was donated a year or two ago by a Spanish NGO. The locals had no idea how to use it. Not because they are stupid but because no one had ever explained it. In the developing world people are simply unable to figure out how to use instruments from manuals. Technology is completely alien to them. (Similarly, I wouldn’t be able to figure out how to herd cattle from a written description.) We asked for the manual, and were told they didn’t have it. It was sitting on top of the autoclave. We couldn’t make it work so I called the manufacturer in Germany. Next morning technical support called me back and with one sentence explained what to do. After this it worked perfectly and sterilized in forty-five minutes! Thanks to the autoclave we completed all the surgeries we had planned. Also, we trained the locals how to use it – it was quite simple. This was probably the biggest impact of our mission!
The following story happened not on this trip, but on the one last year, also in Senegal. (That mission was pretty much a nightmare so I decided not to write a diary about it.) I will include it here though, as it is worth mentioning.
On the weekend we decided to visit Bema, the same village we visited four years ago, during our first Senegal trip. Mark, the PCV who organized our first mission lived there for two years and created a large garden there. (See the diary from 2007: https://www.righttosightandhealth.org/bakel-senegal-2007/#more-139 ) We went with Brian, another PCV who has been working part-time in Bema, trying to develop the garden further with the help of a local farmer. To my disappointment, the garden was nearly completely dried out, sporting only a few cachectic plants, a miserable remnant of Mark’s earlier one. (Which didn’t impress me too much either at the time, but I guess I had nothing to compare it to.) Brian was working on having a well dug by manual labor. It seemed an extremely challenging task, and he was kind enough to familiarize us with the details of well-digging in Senegal. Who would have believed it was so complicated? The problem was that the well diggers – who were from Mali, as labor is cheaper there – were “too lazy” to dig with their picks after a few meters in the hard, rocky soil so they started to use dynamite much earlier than they were supposed to. This depleted the funds for the well. A few weeks later Brian obtained some more funds and these were once again spent quickly on dynamite sticks. As this area is extremely arid the well had to be at least thirty meters deep. We also donated a few hundred dollars for the well but never received any feedback about its completion.
On the way back we waved down a “cab” after an hour wait, as there’s no bus service back from Bema. There were already eight people sitting in the 7-seater, a very old and decrepit car making scary noises. To our great surprise, it stopped and we squeezed in, two of us to one seat, next to the driver. Later the car stopped twice more and took two more passengers. One of them sat next to the driver from the outside, making driving a bit of a challenge. Later we took one more man who sat on the roof. Then the car swerved into the desert where there was no road. No one seemed to mind. We crossed dry river-beds and the car made louder and more frightening noises, ready to fall apart at any second. I thought we were going to drop someone in a village but there was no village. It was getting late, the heat was unbearable and the hope of ever getting back to town seemed more and more remote. All of a sudden the car jerked to a stop and tilted to the side. The driver cursed loudly. All the passengers got out and we discovered one of the wheels about ten feet behind the car. It was immensely difficult not to laugh out aloud, as the locals did not find the situation funny. We thought we had better walk than wait as the wheel seemed irreversibly damaged, and climbing a small hill we discovered that actually we were only half a mile from the town! By the time we climbed down the car was already fixed–the passenger who sat on the roof happened to carry a wheel and this was put on the car. We never learned why the driver chose to drive through the desert instead of the asphalt road. On arrival we shared our adventure with the PCVs who were totally unimpressed–these things happen to them on a regular basis.
The second week of work went relatively smoothly. We operated on a blind ten-year-old using general anesthesia. We offered bilateral cataract surgery at the same time but the father did not consent. The child could see quite well the next day but didn’t show any emotion. (The father though seemed quite pleased.)
The primary goal of our mission wasn’t to perform cataract surgeries but to train Dr. Diallo in the small incision cataract surgery method. (“Give a man a fish and you feed him for a day, teach a man to fish and you feed him for a lifetime.”) By the end of the second week he could perform the surgery in fifteen minutes with good results! He was a truly talented surgeon. Seeing him doing well made me much happier than getting good surgical results myself – teaching someone else is the real challenge. He asked us to return next year, so I told him that by then he’d be the one to teach us new things! I really meant it–with the surgical volume they have in most places in Africa a talented surgeon can become excellent quickly.
On the way home we stopped in St Louis, which used to be the regional capital of whole Western Francophone Africa until 1902. It is wedged between two arms of the mouth of the Senegal river, with an orthogonal street grid and beautiful colonial architecture. It was declared a Unesco World Heritage Site in 2000. The city received several millions of dollars for restauration and maintenance. Unfortunately the money was not used wisely, the buildings are crumbling and the streets are covered with trash emanating a horrible stench. We went to the beach which has the potential of becoming a tourist paradise, but there was so much garbage on the sand and also in the ocean that it was impossible to enjoy it.
Finally, after twelve hours of driving, late at night our group arrived to Dakar. Next day we took a long flight back to the US, tired but exhilarated. We might return again next year – Insha’Allah!!!