The 8-year-old boy lay in the hospital bed, his head and face swathed in bloody gauze. He’d been there for a day and a half, a quiet presence in the swirling universe that is Nyanza Provincial General Hospital in Kisumu, Kenya. Through open windows, the heat and the din from the street swarmed into the room where eight children shared four metal cots. Doctors and nurses jostled through the crush of family members, some of whom were sleeping under the cots on the scuffed linoleum floor.
Dr. Stephanie Cohen-Walsh had seen the boy earlier, but given the long list of surgical cases she faced, her attention was elsewhere. Cohen-Walsh, a plastic surgeon with a practice in Hackensack, had come to Kisumu on behalf of the nonprofit Operation Kids, a chapter of International Surgical Mission Support that she cofounded in 2008 to bring modern medical care to the children least likely to find or afford it. One of her colleagues had asked a doctor about the boy and was told he was waiting to see a Kenyan ophthalmologist. That was all Cohen-Walsh knew about the boy until the next day, when her nephew, then a pre-med student, rushed into the operating room where Cohen-Walsh was finishing her last surgery of the eight-day mission.
The student had come across the boy and decided to unwrap the gauze. What he saw nearly floored him. “The boy’s brother, possibly deranged, had attacked him with a machete,” Cohen-Walsh remembers, “and his face literally wasn’t on. His nose, his eyelids, his lips—they were all hanging.”
Members of Cohen-Walsh’s team were already stowing their equipment in trucks, but at her insistence they unloaded the gear and carried what remained of their supplies into the operating room, where Cohen sutured the boy’s face back on, restoring all his facial function except for the tear duct in his left eye, which would require additional surgery.
“If we hadn’t been there,” she says, “somebody at some point would probably have tried to put a few sutures in, but his eyelids and lips probably wouldn’t have worked, his nose wouldn’t have gone back on right.” When she finished the three-hour surgery, Cohen-Walsh remembers, the boy “looked like a normal kid.”
Having mounted eight trips in as many years, Operation Kids remains dedicated to providing as many surgical services as possible to children in developing countries—and not just surgery, but also clinical work, including well visits, sick visits and vaccinations. Cohen-Walsh mends cleft lips and palates, but spends a lot of her time operating on kids who have been burned—and in the third world, there are plenty of them. Where there’s no electricity, open fires predominate, and kids fall into them. (The World Health Organization estimates that the rate of child deaths from burn injuries is seven times higher in low- and middle-income countries than in wealthier nations.) And while doctors in poorer countries do a good job of saving the lives of burn victims, the kids who Cohen-Walsh sees are often heavily scarred, with serious contractures—shortening and hardening of tissue that frequently results in loss of mobility. Cohen-Walsh remembers a boy with such severe contractures that his calf had fused to his buttocks, and he couldn’t walk or wear clothes. Cohen-Walsh’s team restored the boy’s mobility. “I feel super lucky to be able to do that kind of work,” says the plastic surgeon.
Each year, an untold number of New Jersey health care professionals give up vacation time and spend their own money to practice medicine in the developing world under challenging, sometimes primitive conditions. Like Cohen-Walsh, most treasure the opportunity. Some, like Dr. Leonard Y. Lee, Robert Wood Johnson’s chief of cardiothoracic surgery, do mission work to pass along Western medical techniques. His missions, he says, “are about sustainability—trying to teach the surgeons how to carry on when we’re gone.” Other practitioners are simply out to help as many patients as they can. Dr. Reza Momeni, a plastic surgeon with the Summit Medical Group in Berkeley Heights who volunteers with the group Destination Hope, says, “We do as many cleft lips and palates on as many kids as possible until we run out of supplies and equipment.”
The challenges can be enormous. Depending on where they serve, many of the doctors, nurses and nonmedical volunteers do so in the face of danger. Evangeline “Evan” Epper, a nurse at Hackensack University Medical Center, has gotten used to being accompanied by men gripping assault rifles. The soldiers are there to protect the medical team, she says, “but it’s still a little scary.”
Communication with native personnel is often difficult, and Western practitioners have to be careful not to antagonize the doctors they have come to assist. “It’s an elegant dance,” says Dr. Sanjeev Kaul, chief of trauma and surgical critical care at HackensackUMC. “Local doctors often charge patients directly for procedures, so they can feel economically threatened when a medical mission shows up.” There’s the risk, too, of telegraphing arrogance. “You have to find a diplomatic way to offer advice so it doesn’t come off as ‘I know best,’” says Dr. Saifuddin Mama, head of minimal invasive gynecology and robotics at Cooper University Hospital.
Another risk is contagion, especially for practitioners who treat infectious diseases—a reality that the recent Ebola epidemic in West Africa brought home so dramatically. Medical volunteers like Saman Perera, a nurse from Jersey City who travels around the world with the international nonprofit Doctors Without Borders, tend to take potential infection in stride. “I follow common-sense precautions,” Perera says. “When I’m working with cholera, I wash my hands with chlorine before and after I encounter patients. I’ve never been sick in the field.”
One of the greatest challenges the missions face is a dearth of supplies. Many medical volunteers bring their own, often donated by the hospitals at which they work or the donors who support the nonprofit organizations they travel with. But you can bring only so much, since airlines charge for each suitcase (or carton). As a result, these workers are often faced with anesthesia machines that break down, IVs that can only be titrated by sight (workers literally have to count the drops), and a constant threat of brownouts.
But if the missions lack supplies and modern equipment, there is no shortage of inspiring moments: saving a child who might otherwise have died from malnutrition; passing along basic medical knowledge, like the way to repair rather than replace a heart valve; receiving a gift of beans you can’t take home with you but that represents an unfathomable well of gratitude from a family whose lives you’ve transformed. The doctors and nurses who donate their energy, money and time (from a week to nine months or longer) to bring Western medicine—and along with it, a wellspring of hope—to patients in the developing world return with stories of privation and peril, but also of reward and renewal. Their stories are, quite literally, tales of life and death, and they remind us that, at a time when cultural, religious and political antagonisms threaten to cleave the world, it can still be changed one hard-working person at a time.
Bearing Witness: Saman Perera
Saman Perera was learning patience the Congo way. Since 1997, the central African nation—known officially as the Democratic Republic of Congo—has been embroiled in civil war. Poverty, and along with it disease and malnutrition, are endemic. The country’s infant mortality rate—71.47 deaths per 1,000 live births—is one of the highest in the world, and its Human Development Index, a composite of life expectancy, education and income, is the second lowest on the planet. Idealism had compelled Perera, 35, to join Doctors Without Borders in 2010, but that sensibility was being sorely tested. During his nine-month mission to Congo, Perera had to deal with the isolation, the potential danger from local conflicts, the dearth of supplies and the inevitability of death.
“Learning to be patient was a huge challenge, as was learning to refocus mentally and see the good that we do instead of the ones we can’t help,” he says. In Congo, Perera learned to focus on the eight or nine kids who got better rather than the one who didn’t, the kid who died of malnutrition in a country so green and fertile “that you can throw down seeds anywhere and they’ll sprout.”
Like many of his colleagues, Perera had become nearly inured to the sorrow around him. “When you’re there for a while,” he says, “you accept that Congolese children die.” One morning, toward the end of his mission, malnutrition claimed yet another child under his watch. Perera found a scrap of cloth to wrap the child in, but wanted to do more than simply hand him off to his mother. So he looked around for a container, and the first thing he found was an empty Plumpy’nut box. Developed in 1996, Plumpy’nut is an enriched, high-protein, peanut-based paste designed to restore and maintain body weight in children with severe malnutrition. There’s no doubt that it’s done the trick in thousands, perhaps hundreds of thousands, of cases. But not in this one.
Perera handed the carton to the child’s wailing mother. It was only then that the irony hit him: a child who had starved to death conveyed in a Plumpy’nut box. “I couldn’t believe this had just happened,” he recalls. When the child’s mother walked out of the medical compound, he followed her, then watched in silence as she buried her child. “I felt that I couldn’t stop witnessing what was happening,” he says. “My presence there was saying, ‘This is not okay.’”
It is not okay, Perera says, that striking disparities in health care still exist in an increasingly globalized world, and that children die every day from preventable conditions like measles and malnutrition. He continues to volunteer with Doctors Without Borders—at this writing, he’s on a six-month mission in Central African Republic—not just to try to even out those disparities, but also to bear witness and let his patients know, by his presence, that it is definitely not okay.
Restoring Health And Dignity: Saifuddin Mama
It was early June, and in the coastal Vietnamese city of Da Nang, the temperature had climbed to 90 degrees Fahrenheit. Factor in the 90-percent humidity, and it felt like 122 degrees in Maternity Hospital for the City, which lacks many things we take for granted, including air conditioning. As he had every day since his arrival nearly a week earlier, Saifuddin Mama, head of minimally invasive gynecology and robotics at Cooper University Hospital, had sweated through his surgical scrubs. But he couldn’t complain. Compared to conditions he’d encountered in Rwanda, Eritrea and Ghana, Vietnam offered decent equipment and an organized system of medicine that made his missions there relatively easy.
That day, Mama had operated on a 14-year-old girl who suffered from urogenital tract anomalies. Because she had no egress for menstrual blood, her abdomen had swelled painfully. The procedure reconstructed much of her lower anatomy, putting an end to the pain, but Mama couldn’t save her fertility. “It’s a balancing act,” he says. “You do what you can.”
One of Mama’s specialties is the repair of obstetric fistulas, tissue damaged during childbirth. In the West, they’re rare and are generally repaired not long after they occur, but in sub-Saharan Africa, for women without access to surgery, they’re often permanent. At their worst, they cause women to leak urine and/or feces continually; the women are often stigmatized, shunned by friends and family. While not every advanced fistula is reparable, many are, and those repairs are life altering. “When patients first come to us, they’re sad, they make no eye contact,” Mama says. “After a successful surgery, they rejoice.”