Unlike medicine in the United States where prior authorization and paper work to perform surgery was required on every patient by the insurance company before taking anyone to the operating room, in The Gambia the resident just pointed and told the patient when to show up in the operating room. There were no charts or dictating machines, no insurance or related paperwork, and no malpractice worries. There was also little properly functioning equipment. In the US, when a surgical instrument or clamp malfunctioned or was bent and wouldn’t work properly, it was discarded. I never gave a moment’s thought when I tossed it off the operating table as to where it wound up. But now I know. They all found their way to the Gambia. When I put my hand out for an instrument it was sure to malfunction, which presented interesting challenges at the operating table.
My first day in the operating room was an eye opener. There was a sign on the operating room door that anesthetics were in short supply and there was a visiting ‘Professor’ in town. All the elective surgeries other than our cases and emergencies were cancelled for the month so there would be enough anesthetic gases for our patient use.
We had lined up a full day of cases. Everyone miraculously was there hours ahead of time waiting patiently for surgery. As I stood at the scrub sink with the resident for the first case of the day and went to turn on the water to begin my typical five -minute routine surgical scrub, there was no water that came out of the sink! I looked at him and asked: “What do we do now?” The response was that this was common. We just put on our sterile gloves and performed the surgery. Sterile scrubbing was out.
(A waterless scrub sink)
He had chosen a laparoscopy as the first case and everyone was excited to see how the equipment worked.
(Preparing for our first laparoscopic procedure in the Gambia.)
The operating room was windowless without air conditioning. It was boiling hot and sweat dripped. We wore heavy cloth gowns rather than the light disposable paper ones I was used to. We managed to get the laparoscope into the abdomen with the fiber optics working, identified the pathology, and were ready to begin the rest of the procedure to correct the problem when the power went out and left us in the pitch black. “What do we do now?” I asked again. This was turning into as much of a learning experience for me as it was for him. He said: “We wait, the generators will come on”. Of course the anesthesia machine wouldn’t work either without electricity so the nurse anesthetist began to hand bag the patient. I waited in the pitch-blackness, in the overwhelming heat, for what I considered to be an appropriate time for the electricity to come on, which it never did. When I inquired if there was an ICU and what happened to all those patients without electricity, the response was: “This is Africa, man!”
All I could think of at this point was the first and most important dictum of medicine, which is “ To do no harm” to the patient. In this case we couldn’t help her, but I certainly wasn’t about to harm her. I took the opportunity to stress this point to the resident as we pulled the instruments out in total blackness. The first case was over! At least he had an equipment tutorial on a live patient. The rest of the cases went better that first day; an abdominal hysterectomy with removal of tubes and ovaries for a large pelvic abscess; a vaginal hysterectomy; circumcision repairs; a fistula correction. It was a full and satisfying day.
(Exhausted and exhilarated after the first successful day of surgery.)
Upon arrival back to the clinic a phone call had come in from a local man for me. When I called him back he identified himself as my landlord. I had agreed to pay a certain amount of rent for the month I was there. Rent and food were my own expense. He asked if I was the gynecologist who had come to help the women of his country. When I said I was, he told me no rent would be necessary! Mother Nature does indeed work in mysterious ways. I felt as if someone were watching over me. Whatever fears I might have had quickly began to dissipate.
BAFROW was all about empowering women to take control of their lives.
(Young women at the Bush clinic.)
Money from AJWS was used to build clinics in the bush country; set up ways for the women to have economic empowerment for themselves in the communities; learn how to bake and sell bread and vegetables;
(Economic empowerment)
end female genital mutilation; build clean, new outdoor toilets; bring in running water, dig wells and in general give women a sense of self worth, dignity, and joy in their lives. The fresh bread the women made and sold outside the clinic was spectacular. I gobbled it up and bought as much as I could carry with me back to the city.
(The bakers)
Part of the arrangement with BAFROW included spending time at their clinics in the bush that required overnights in the villages. My first overnight foray into the bush country was likewise an eye opener. We drove several long, hot hours from the city along the Gambia River far inland on dirt, pothole filled roads. It was actually easier driving over the death defying, high mountain rocky roads to Ouray in Colorado than along this road. The kids in the villages had never seen a white man before. They ran next to the van laughing, smiling, pointing and shouting ‘Toubab”, white man. Upon first entering the village we had to stop at the village chief’s hut for a welcoming and blessing before being able to see the women of his village.
(The Village Women)
I had been told to bring small gifts for the village chief as I did. There were midwives to be met. These women were the very same midwives who had performed the circumcisions and had now been converted by BAFROW not only to understand the harm being done but also to stop performing the procedure.
(Two former ‘midwives’ recently converted by BAFROW from doing female circumcisions)
Perhaps more than anything, this one act on the part of BAFROW made its very existence worthwhile. It was a slow and difficult process, however, since it was never easy to make a cultural sea change like this.
I paid visits to the local village school.
(English instruction)
The kids were absolutely wonderful, delightful and respectful, full of life and laughter as all kids are.
Some of the kids were mothers themselves.
(Children having children in the Gambia.)
They were being taught ABC’s so I was able to have minimal English conversation but meaningful for them. I gave everyone the opportunity to pose questions to me through interpreters. George W Bush had just paid a visit to neighboring Senegal and promised millions in aid to Africa to fight HIV. They all wanted to know when the money was coming, as if the Brinks truck would show up tomorrow. They also asked incredibly detailed questions about how genital warts were acquired and what could be done to prevent them. This, of course, immediately told me what a major gynecologic problem it was for the villagers.
The clinics for the women were most interesting. Invariably the first patient in line was the village chief himself. All that mattered to him was that there was a doctor in his village. He needed to be seen first despite the fact it was a woman’s clinic. He had massive bunions and undiagnosed Parkinson’s disease, neither one of which I could do much about other than education and a referral to the Banjul medical and surgical clinic.
During my first clinic day four of us were wedged into one tiny overheated room; my interpreter, the patient, the largest hairy spider I had ever seen in my life resting quietly on the ceiling, and me.
I kept my eye on it, but as the day wore on and I became involved with patient after patient I realized that it had disappeared when I took my eye off it. It was a bit unnerving since I had no idea where it went and the room wasn’t very big.
I fully understood after being at the clinics in the Bush why obstetrical infant and maternal mortality was amongst the highest in the world. Women would labor for days often unattended or attended by untrained ‘midwives’, in small windowless unsterile conditions and overwhelming heat to the point of fetal death, exhaustion, dehydration, and sepsis. They were miles and hours from help. Those that wer
e luckiest would be put on a small boat and sent down the Gambia River into Banjul, often with a dead baby inside of them for days, hemorrhaging and septic. By the time they would get to the hospital many of the women were dead or close to it. The hospital had ample antibiotics but almost no narcotic pain medication for surgical or obstetrical patients. These women often suffered alone in large wards in silence.
(Our postoperative ward patients covered with antibiotics but without pain medicine.)
The look of despair and death was etched in their faces. It was just a way of life. The challenges of having a healthy baby in the bush country were astounding.
I had travelled as deep into Gambia as time would allow, and it was time to turn back, to the city and eventually to home. Imagine my surprise and wonderment on my last day in the bush when at dusk I went for a stroll on the banks of the gently flowing Gambia River. It was a beautiful site despite the overwhelming heat and humidity, the amber moonlight glistening off the river, the clouds a beautiful pink and mauve, the birds chirping away endlessly discussing their day. I glanced one last time skyward to take in the moonlight again before turning back. Flying alone high in the sky was a stork, a most unusual delivery system as yet to be explored in depth by me. I had never seen one before, nor since, but it was truly a spiritual and serendipitous message for me – I took it to be a thank you from the heavens for the brief time I was allowed to spend in this beautiful country in the service of their women.
Far away from Western civilization, even far away from Banjul, the capital, these were inspiring and wonderful accomplishments in the villages as a result of the aid of BAFROW, supported by AJWS funds. I was proud to be a small part of it all and proud to be bringing health care to these women. I enjoyed the opportunity to lecture to the nursing students on various topics and to the British Medical Research Council.
(Lecturing in the Gambia.)
I was able to establish a reliable Pap smear system in the country and more importantly I trained the practitioners in cryosurgery, a safe, cheap and simple way to deal with abnormal precancerous conditions of the cervix and venereal warts.
I found the average Gambian outside of the hospital to be happy, smiling, and exceptionally friendly, more so than the average American. By our standards they had little money and few material possessions. Yet they smiled spontaneously, broke into song and dance for no apparent reason, and extended big open hands of greeting when passing on the street. It was a remarkably simplistic and easy way of life to get used to. I learned as much from them as they likely did from my presence.
I was asked on my return what I was most afraid of when in the Gambia. There were really only two things -mosquitoes and dogs. When in the Bush, mosquitos were rampant at sunset. They would come out at night so sleeping under a mosquito net was critical for me as it was for everyone, though most people could not afford the few dollars that a net cost. The first night I crawled into my net and found I had company inside the net – mosquitoes. So not too much I could do about that. I placed my trust in Lariam, but it didn’t make sleeping any easier. When in Banjul during the daytime I noticed packs of wild, flea-bitten and abscessed dogs roaming the streets.
It was easy to avoid them during day time but at night, when walking around in the pitch blackness as everyone did without street lights anywhere, the dogs couldn’t be seen and often were sleeping or laying in piles in the middle of the streets. I love dogs, but was deathly afraid of stepping on and into one of these piles of wild dogs at night. Everything else was easy! The folks at AJWS, and its financial supporters, are true angels!
Chapter 2 Background and Education.
A Cesarean section is the removal of a child from the uterus through an abdominal incision. The origin of the term itself has given rise to many a discussion. It has generally been asserted that Julius Caesar (100-44 B.C.) was brought into the world by this means. Likely this explanation is not correct since his mother, Julia, lived many years after her son’s birth. The following view may be more plausible. In the Roman law codified by Numa Pompilius (762-715 B.C.) it was ordered that the operation should be performed upon women dying in the last few weeks of pregnancy in the hope of saving the child. In fact, the earliest Cesarean sections were usually performed on women who had already died in an attempt to save the fetus.
Born by a Cesarean Section because my brother before me was breech, and born in the days when the dictum “once a Cesarean, always a Cesarean” held true because it was then thought that a vaginal delivery after Cesarean section was too risky for the mother due to potential scar rupture in the uterus, I was fully expected to be a girl named Ruth. For that reason I suppose I may have been a disappointment at birth. Most people who have a son would prefer their second child to be a girl. Of course I never saw it that way, but then I expect in some way it did lead to development of my gentler, softer side.
(Black’s Hospital, Lewistown, Pennsylvania, where I was born in 1949)
My Dad was a small town lawyer in Lewistown, Pennsylvania, known really for nothing special other than its proximity to State College, home of Penn State.
(The courthouse in Monument Square, Lewistown, Pennsylvania, with my Dad’s former law office adjacent.)
He graduated from high school in an even smaller town in Central Pennsylvania, Mount Union, a brick mill town. His mother died during childbirth. Raised in a patriarchal family by their father, a shoe storeowner, Dad and his three siblings never got to know their mother. They developed a strong family support system, as is often the case in large families missing one parent, and an even stronger work ethic. He was Lithuanian by heritage, from an eastern European Jewish family, some of whom emigrated to the United States and some to South Africa. Like my grandfather, many of these immigrants were small town merchants throughout the Eastern United States. Tall and handsome, my Dad excelled in high school and graduated at the age of 16 after a successful high school basketball career. In the early part of the 20th Century one didn’t need to go to college first to become a lawyer. When he graduated law school at age 19 he was too young to be admitted to the Pennsylvania Bar Association. He had little choice but then to attend college where he was again a top basketball player. His first job after law school was as a law clerk for a Federal Judge, followed by several years of law practice before he enlisted in the army during World War II in the Judge Advocate Division (JAG). He rose to the rank of Captain and became a rifle instructor, an excellent marksmen for a lefty converted to a righty, felt to be the correct thing to do in those days. He moved to my hometown of 12,000 people in Central Pennsylvania and practiced law for the next 50 years before retiring to Arizona where he died three years later. He was a kind, ethical, gentle spirit who rarely had flashes of anger, although when they flashed it was always memorable. I once made fun of his elderly sisters, who while visiting us couldn’t turn off one of the ‘modern’ sink faucets in the upstairs bathroom. They called for help when it was too late after the sink overflowed, dripping water onto and through the floor and ceiling into the lower level. I deserved the slap in the face that I got for making fun of them. It was an impressive sight for a young kid to finally see what angered Dad, and even more interesting to watch how my parents seemed to suggest that it was not a big deal.
My Mom was born in the coal country of Northeast Pennsylvania, Scranton. She was raised in an orthodox Jewish matriarchal family with five siblings. Her father, who was a local constable, died when she was a young teenager. The family didn’t have much money and all pulled together to help out. My Mom went to a State Teacher’s College in Pennsylvania. She later joined the Women’s Army Corp (WAC’s) during World War II, had basic training at Fort Oglethorpe in Georgia, and worked in Washington D.C. during the war. She was from the penmanship era, often writing long, beautiful letters to family in her very distinct handwriting. Although considered the Belle of the Ball, and a prized catch, Mom was ‘picky’ when it came to men. She held out for years until the right one came along. My parent
s met through a mutual friend just at the end of World War II while both were still in the Army, then married shortly thereafter at the ages of 37 and 35. My brother was born one year later, a breech, delivered by Cesarean section, and I arrived 21 months after.
Assume the Position: Memoirs of an Obstetrician Gynecologist Page 2