A Journey to Africa by Dave Christie (@bagheera79)

At a little half past eight in the morning on the 25th of November last year I started on the ICU ward round with the team of residents, at the Black Lion Hospital in central Addis Ababa – the capital of Ethiopia. There were sixteen patients to see, with a high proportion of trauma – especially brain injury – and severe life-threatening infections. It looked so different from the unit here in Dumfries. It had big wide windows allowing in daylight, for a start. In a UK hospital, windows at this height would be securely fixed so as to avoid the kind of unfortunate incident that makes the headlines. Here, in Addis, one of the nurses was leaning right out of the window and yelling cheerfully to a colleague in the carpark over a hundred feet below.

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As I looked around I took in more differences. The beds were quite close together, with a low wall separating the heads of beds between the divided area. Instead of uniform ranks of identical equipment all bought at the same time, the pumps and ventilators were a mishmash of ancient and relatively modern kit. Huge, head height tanks of oxygen sat beside each ventilator, as there was no built in oxygen supply in the walls. Beside most beds sat a big bottle of caramel liquid – it took me a moment to work out that this was nasogastric feed. Of course! – they don’t have the pumps to delivery a trickle of feed continuously, so they have a supply for the day and administer it at intervals. Each patient’s bedsheets were different, brightly coloured, and obviously donated or brought in from home. Nobody was wearing aprons, or gloves – the bright smurf blue and purple hands of healthcare that are so ubiquitous in UK ICU were nowhere to be seen. I could imagine our own infection control team spontaneously combusting at the sight. Of course, they would likely have already lost consciousness at the sight of an entire team of doctors standing around the bedside in long-sleeved white coats – something which has been verboten in the UK for years.

But then, I looked closer and readjusted. Put into context, they were doing the same stuff we do. Airways were protected. Patients were being rolled, washed, and cleaned every day, with a change of sheets. Physiological parameters were being diligently recorded on big charts in close detail. Because pumps were usually either broken or in very short supply, sedation and analgesia were given by injection at regular intervals. They were being fed – one way or another. Patients were receiving regular chest physiotherapy to try to shift stubborn sputum and prevent pneumonias. Blood tests. The nurses still laughed and joked and teased each other. It’s the same stuff that we do, but in a much simpler, less precise way. And, a lot of the time, it worked. Which, to be brutally honest, is just as true of our own, ‘modern’ intensive care.

I turned my attention to the lady in the bed. Clearly profoundly affected by a severe head injury as a result of trauma, she also had signs of a severe chest infection. Here in the UK, it would be standard practice to send sputum samples off to the lab to identify the offending organism, certain specific blood tests might be done, and a chest x-ray would be a routine investigation in order to see the extent of the infection. I asked if they could do any of those things. Dr. Woubadel looked at me with a wry, slightly sheepish smile. “Well, we can. But we only have two antibiotics and our microbiologists have refused to analyse our sputum samples. And the lifts are out at the moment.”

Right. Wait, what? “You only have two antibiotics?”

“Yes, ceftriaxone and ceftazidime.”

If you don’t speak antibiotic, that’s a little like going to the supermarket and discovering that the only two cleaning products available are napalm and a hydrogen bomb. Given that antibiotic resistance is a real and growing threat, this is a disaster for the future.

And the lifts…. ah. The building of the Black Lion is definitely a little bit past its best, and was undergoing a phase of refurbishment. Almost all of the lifts were removed and in true, relaxed Ethiopian style, there was occasionally a warning sign. I had had a look at one of the lift shafts and it really was an open door onto a seven storey drop. Later that day, I watched a patient being taken urgently to theatre from one of the wards on the floor above the theatre complex. Four orderlies and a nurse were carrying the entire bed – with the patient lying on it – down a flight of stairs. Another nurse was carrying the drip. That morning, if they really wanted a chest x-ray, they’d have to do the same thing if the lift was out as there was no portable facility to take x-rays on the unit. And if need be, they’d have done it.

Dave C 1So why was I there? It’s worth pointing out that the Black Lion is a large teaching hospital in the city centre. It’s one of the lucky ones, as the facilities it has are relatively modern. They can even do cardiac bypass – provided there’s a visiting perfusionist from overseas to work the machinery. This definitely wasn’t one of the small hospitals out in the country. I was there along with Fanus Dreyer, a consultant in General Surgery here in Dumfries, to teach on a critical care course that he organises. The College of Surgeons of East, Central and Southern Africa overseas the training of surgeons in that part of the world, and the critical care course is part of the mandatory requirements of their training. It is a charity – the aim is to make the course (along with the others which deal with surgical skills, and research) self-sustaining in each of the involved countries. The idea behind all of this is to try to improve the healthcare in that part of the world, by standardising surgical training, ensuring basic competencies etc, in an area where healthcare is sporadic and frequently poor or non-existent. Peri-operative and critical care is a vital part of that – being able to competently do an emergency bowel operation is nothing if the patient dies post-operatively from a lack of care.

Being out there and teaching on the course was an extraordinary experience. Having had the chance to spend some time in the actual clinical areas, to see how they worked on a day-to-day basis, helped hugely as it helped give me direction on what the course attendants needed. The junior surgeons on the course had excellent clinical knowledge and ability – the real difference was the approach. They have the same knowledge as our junior surgeons – medicine is universal, fundamentally – but what they needed was guidance on how to organise the approach to sick patients, and how to structure their management. They were highly motivated, and very keen to learn. But as I knew, they would often be working in facilities that had next to zero resources, hundreds of miles from Addis. There’s no value in teaching about the potential uses of dialysis in critical care in that sort of scenario – but there is enormous benefit in teaching about the approach to sepsis. Being able to manage a patient with a critically endangered airway with simple techniques would be life-saving – even in the most rural surgical facilities there will be some sort of scalpel.

David C 3And over the two days of the course, in the four days that I spent there, I realised that the simplicity of approach is something that we are still striving to teach here, even with the advanced facilities available to us. Their ICU looked primitive in comparison to the UK, but it was still striving to provide the basics of critical care. I realised I was teaching the same things that I teach here – sort out the basics and communicate well. Recognise illness, recognise dying, and treat each thing in turn, with compassion. These things are universal – and we shouldn’t allow a distraction with technology to cost us our humanity.

 Dave Christie is a Consultant Anaesthetist at NHS Dumfries and Galloway

Global Surgery, Public Health and MDGs by @fanusdreyer

@fanusdreyer chairs the International Development Committee of ASGBI, is a member of Edinburgh University’s Global Health Academy and of the WHO’s Global Initiative on Essential and Emergency Surgery.

What is the primary care of obstructed labour, or a cleft lip, an imperforate anus or other birth defect? In the mid-1980s I worked in a small mission hospital at Nkhoma, Malawi as a medical officer. One day a boy was born with imperforate anus. It was the rainy season and there was no way he could be sent to the city. So I looked in the book how to do a defunctioning colostomy in a newborn, gave him ketamine and did the operation. Afterwards he stopped breathing every few minutes but started again when we flicked the soles of his feet. Our few incubators were all in use, each with three prem babies inside. So, over lunchtime and while the nurses kept our baby breathing, I built a wooden incubator, with plastic sheeting as a transparent top. That way we could give him oxygen, put two warm water bottles next to him and keep watch. I sat with our boy through the night, stroking him and flicking his soles so he would breathe, until the ketamine had worn off by the early hours of the next morning. He left hospital a few days later, ready to wait for the Canadian paediatric surgeon who was visiting a few months later. And I learnt that surgery can be primary care …

The declaration of Alma Ata (1978), which is a cornerstone of WHO healthcare states in section VII.3 that primary health care “includes at least: education concerning prevailing health problems,…maternal and child health care, …appropriate treatment of common diseases and injuries.” What place then for surgical conditions within “prevailing health problems”?

Of the global disease burden 11% needs surgery, mainly due to injuries (38%), malignancies (19%), congenital anomalies (9%), complications of pregnancy (6%) and peri-natal conditions (4%). Only 3.5% of 234 million annual surgical procedures worldwide are performed on the poorest 33% of people, but 80% of surgical deaths occur in low and middle income countries (LMICs). About 800 women die every day due to complications of pregnancy and childbirth e.g. obstructed labour, haemorrhage, sepsis, uncontrolled high blood pressure and unsafe abortion, i.e. mostly conditions that can be managed surgically. A significant complication for mothers who survive obstructed labour is obstetric fistula, which means that they are continually wet, smell badly and are ostracised by families and communities. With appropriate training fistulae can be repaired by non-doctors.


Girl's hands holding globe --- Image by © Royalty-Free/Corbis
In non-communicable diseases (NCDs), the diseases of “rich countries” e.g. diabetes, vascular disease, hypertension and cancer, the highest incidences and mortality are in LMICs. The WHO expects 16million cancer deaths by 2020; 70% of these will occur in LMICs. Worldwide 5.8 million people die yearly from injuries, which is 32% more than from malaria, TB and HIV/AIDS combined. That means that 2300 children die daily from injuries. Road traffic crashes are responsible for 23% of all injury deaths, with 20 injured patients per fatality, reaching epidemic proportions in sub-Saharan Africa (50/100000 vehicles compared with 1.7/100000 in high income countries).

Household surveys in Rwanda and Sierra Leone have shown that the immediate surgical need is higher than the HIV rate, that 15-25% of respondents had a surgical need in the previous year that affected their ability to earn a living or their quality of life significantly, and that 25% of household deaths in the preceding year were due to surgical conditions.


The Millennium Development Goals (MDGs) have to report in 2015. At present there is a worldwide review of what global goals should replace the MDGs, with the WHO, the Gates Foundation and other philanthropic institutions all recently asking for submissions. The problem is that only MDG 1 (eradicating extreme poverty and hunger by >50%) is expected to be achieved worldwide by 2015. There has been some progress with MDGs 4, 5 (Child and Maternal Health) e.g. in Ethiopia through the work of community health workers, but in sub-Saharan Africa it might be that Rwanda is the only country to achieve all targets. The question can rightly be asked “Did the MDGs fail because these were drawn up in a room by rich countries for poor countries?”. For development to be real and sustainable it needs to be based on indigenous knowledge and solutions, not donor-led philanthropy.

What role then for global surgery after 2015? I have no doubt that the provision of safe and effective surgery should form part of the post-2015 development goals, and surgeons have a responsibility to contribute to this global debate. How can this be achieved? When we started our critical care teaching programme in Africa, now under the name of Alba CC Course Design, we first went to Hawassa in rural Ethiopia to teach health officers (non-doctors) who were doing an MSc course in emergency surgery. With funding from the Clinton-foundation they are taught to do 12 operations well and look after these patients; this covers 85-90% of surgical emergencies in rural Ethiopia e.g. Caesarean section, ectopic pregnancy, incarcerated hernia, debridement of open fracture. When I asked the first intake of students in Hawassa “Why are you doing this course?”, 6 of 8 answered “Because I have seen women in obstructed labour die”. When we went back for a second visit 18 months later, one of those same students had already done 70 Caesarean sections, under spinal, alone in theatre except for a midwife and a scrub nurse. Now that is public health worth fighting for.

Cost studies in surgery provision in Bangladesh and Sierra Leone have shown that the cost per disability life-year (DALY) averted is equivalent to the costs of a measles vaccination programme. Providing essential and emergency surgery saves more than it costs.

With various other groups we are proposing a programme called “15-by-15”, which will aim to teach 15 essential and emergency operations to the same minimum standard worldwide by 2015, to decrease the physical, psychological, social and economic burdens of untreated surgical disease in even the poorest communities. Everyone has “the right to heal” (http://vimeo.com/59388957).

(References available on request).

Next weeks blog will be by Penny Halliday, Non-Executive Director of NHS Dumfries and Galloway and is titled “Woman Interrupted”