We are now into the final phases of our work in Ethiopia. I have reported on the welcomes, the tough decisions, the high points, and the heartbreak. The last couple of weeks have really been dominated by the goodbyes to the patients we have grown so close to over the last couple of months. One doesn’t do this work for the thanks (we do it for the free flights..) but it’s overwhelming to be part of a team that sends these kids and adults back to their communities with a very different outlook from when they arrived. There are tears on both sides as we say goodbye to another of our friends each day. The strongest relationships that have been made are between the patients themselves, many of whom have spent their lives at the extreme end of human suffering. They came to a place where they met others in the same predicament, and have seen each other through the trauma of major reconstructive facial surgery, celebrating in the successes, and helping each other through the inevitable low points during the long post-operative period.
Karima is 16 years old and from Southern Ethiopia. When she came to us the left side of her mouth was almost inverted so that the gums and teeth were apparent through the cheek. She is the youngest of six and had spent her entire life behind the walls of the home. She came with her older sister, Foziya, who is not only very beautiful but very confident as well. The love between them is obvious but whilst Foziya led the show, Karima hid in the shadows behind her. I was in theatre as 4 surgeons, 2 anaesthetists, and 4 theatre nurses laboured together for 9 hours correcting her defect. Two months later and Karima is a very different girl: the swelling has gone down she can smile; she joins in the joking with the other girls; she’s confident enough to get her hair done, and we even find her and her sister putting lipstick on together one day. These seem like small things but this is the first time in her life she can take part in the normality of the everyday rituals we take for granted. I hope the UK-based surgical team that gave up their time can see these photos.
Leaza is about 14 years old and from Somalia. It is difficult to pin her age. She again has spent a life behind closed doors and so is more mentally immature than her body suggests. I remember exposing her defect two months ago, the first bad noma defect that I had encountered. I reported on the visceral effect that it had on me at the time. She had a talent for shyness that I had never encountered before. Whilst you knew Karima was around but retiring, Leaza had the ability to disappear in plain sight. Although in your immediate proximity she was able to hold herself in such a way as to evade your salience and avoid notice. You would call out to the other children to go and find her, only to realise she was standing in front of you. Again in two months we’ve seen an incredible transformation. She is now the scamp of the group and again joining in with the other children. She now has the confidence to chase me around the garden whipping me with her muslin.
In the last blog I reported on the developments of baby Dewal that came to us. He continues to get stronger each day. 6 weeks ago he didn’t have the strength to stand; now he has realised the joys of walking and running and can’t stop. He’s constantly exploring the world around him and has a smile strapped across his face, again a new novelty. He’s gone from 7.1kg to 8.8kg in a few weeks. Whilst his mother is being cared for in hospital his father has found a new role. A few weeks ago he didn’t have a clue what to do with the child, it doesn’t fall to the man in South Sudan. Today he cradles the happy baby, they sing together, and he is beside himself with laughter as he struggles to change the nappy. In terms of improvement baby Dewal has to be up there with many of our patients.
Whilst I report on these successes it must be said that working in this environment is not always easy. I think the biggest barrier we have faced has been communication. The operations which have been performed are complex, and whilst we counsel our patients all that we can, it’s not always possible to relay as much information as we would like. Our patients speak a variety of languages and dialects and whilst we try and use translators when we can, they are not always available. Our patients have so many questions that they don’t know how to ask. When events occur that they can’t comprehend they create myths to make sense of them. These myths are cultivated behind a smoke screen of linguistic difference, smoldering away without our knowledge. The results are frustration and sometimes anger. We’ve always managed this but it’s distressing for all parties when the power of speech and communication is taken away. As such we rely on the trust of our patients to let us do what we think is right for them, and to gain that trust we use the techniques that have been used for millennia. Whilst the armoury of words we have is redundant, the body language and tactile messages we can send are as powerful as they are anywhere else in the world. I have found that, whilst so much can be so different between two people from different cultures, the way in which affection is presented remains ubiquitous. I have had the privilege of working with two great mentors in this respect, Julia and Sue, who truly are experts in compassion. Just by talking, laughing, and spending time in the presence of our patients they have been able to gain not only their trust but their love. There is no doubt in my mind that the holistic care we have been able to provide under their guidance has contributed a great deal to the successes that I report.
In plotting our escapes from the compound we have passed off some trips out as ‘pastoral exercises, critical to the healing of our patients.’ It’s not the first time that trips have been organised so the adults can get away.. The kids have absolutely loved it each time, just to get away from the compound, and away from the mental slavery of healing for just a few hours. Here’s a few photos of the highlights. The cats are from ‘Born Free’ nearby in Menagesha. All the lions and cheetahs are rescue animals who were being smuggled. The primary route is across Ethiopia and into Somalia for the boat trip over to the Arab states. A baby cheetah can be bought in Dubai for $2000. As is the case for smuggling and poaching across Africa, the cause is not the poachers who are desperately poor and looking for a way out of poverty, the fault lies with the rich who are far removed yet continue to demand the animals for monetary compensation.
The two months seem to have gone by quickly as is always the case when one is so absorbed in a situation where work and life have no boundaries. It’s a pleasure to get so caught up in a real life without the distractions of pop idol and advertisements. There have been times that I have struggled with the concept of Facing Africa, providing very high tech and expensive services for just a few, and offering surgery to people who may not be able to understand the concepts at play. But having seen the transformations that we have it is easy to understand why this surgical team continues to give up their time for free, give up their annual leave, and provide the service which they do. There are of course arguments for spending the same amount of money on simple and wider reaching public health measures, but whilst Facing Africa make all their own money for this particular condition one cannot disagree with their existence. Noma falls into a narrow category of conditions which have certain characteristics. For me it is very similar to the conditions caused by traumatic childbirth, known as fistula, the focus of work at my previous home in Sierra Leone, for the following reasons: it exclusively affects the poor who have no access to medical services; the condition is inherently stigmatising such that sufferers are isolated and suffer profound psychological trauma; it is rare enough that sufferers imagine they are the only ones in the world affected; the treatment is complex and cannot be provided by the health structures that exist with Africa. In light of these characteristics there is a niche for specialist NGOs to fill the gap, and their existence is supported by the suffering that exists and the sensitive way in which they address it. As such I will continue to support the work that Facing Africa do and encourage you to do the same via their website at www.facingafrica.org
The jobs I have done abroad have taught me a lot. Sierra Leone was my first lesson in clinical practice in the tropics, and the diploma in East Africa was an introduction in the approach to academia in Africa. Whilst I have developed a few of my clinical skills in Ethiopia, the overwhelming lesson has been one in humanity. The personalities of our patients are caricatures of both strength and suffering in equal measure and spending time with them has been a privilege. There a very few situations where doctors and nurses have the opportunity to spend this much time with their patients, walking with them through chapters of both terror and joy. They have taught us a lot about what really matters in the world, and to love each other despite the very superficial forces that tend to govern us in the world in which we normally live. In so many ways we couldn’t be more different from each other. The ways in which we perceive the world around us could not be more disparate. Whilst some of our upbringings have instilled arrogance, for others it has instilled a sense of persecution; whilst some have been taught to question, others have been taught to obey. But whether you have been fed by the silver spoon in a public school in Dorset, or spent your childhood being branded with the scarifications of the Sudanese Dinka, some things are preserved: the looks and touches which are shared between two people, one nervous to offer care, the other nervous to offer their trust; the humour which arises with the trivial miscommunications surrounding everyday life; and the need for people to spend time in each other’s company.
We are all trapped in certain ways by the circumstances of our birth and upbringing. We often sympathise with the ‘poverty trap’ of people who are born in rural sub-Saharan Africa. But as we watch their laughter and their games unfold we see that in many ways they enjoy more freedom than us. They are not trapped by smart phones or by advertisements, they are not trapped by the dreams that Simon Cowell has so carefully laid out for them, they are not trapped by an ingrained desire to consume at all costs. Whilst we are all trapped in different ways by our upbringings and the societies in which we live, sometimes we become so trapped that we forget to experience the people around us. But here we had found a place where we were free to experience one another’s humanity, without distraction, just facing each other, somewhere in the highlands of Ethiopia.