Dr. Sherif Emil is the director of general and thoracic surgery at the Montreal Children’s Hospital of the McGill University Health Centre. He went on a surgical mission to Rwanda in November and December, his first trip to the country. He blogged about the experience; this is an edited and condensed version of his dispatches.
I stand in an operating theatre in Kigali, Rwanda, getting ready to operate on my first patient. I am half a world away from my pediatric surgical practice in Montreal, sleep-deprived, surrounded by personnel I met just moments before. I have to remind myself that I am still in my comfort zone, the operating room.
My first patient is a seven-day-old boy with bowel obstruction who has never been fed. He needs an emergency operation but, even at the country’s main teaching hospital, we can’t get the most basic tests – electrolytes, simple imaging. I will still operate, though – 90 per cent of such babies die here, and this one actually has a chance.
The baby gets through surgery and is taken to the recovery room. The battle is won – with many more to come.
This is my first trip to Rwanda. I was born in Cairo and spent two years of my childhood in small towns in Nigeria, where both my parents had worked as physicians. In 1994, I was a surgical resident in Southern California working an average of 120 hours per week. Like many, I did not know where Rwanda was on the map when news of the genocide emerged. Now I am here, almost 20 years later, as part of a McGill University program to train surgical residents at the University Teaching Hospital in Kigali.
During approximately two hours of hospital rounds and patient discussions on my first day, I encounter more major pediatric surgical pathology than I would see in Montreal in two months: congenital anomalies, bowel obstructions, kidney tumours, unusual hernias – a museum of pediatric surgical disease. Sadly, resources are extremely limited, material as well as human. In Rwanda, there are no training programs for pediatric surgeons, and there are very few resources to support anything close to a modern pediatric surgical practice. The country of 12 million people does not have a single fully trained pediatric surgeon.
The operating rooms at the University Teaching Hospital in Kigali feature bad lighting and blunt instruments. The issue is money, money, money. There are no funds to buy new instruments, to provide and fix equipment. This is the rule rather than the exception throughout sub-Saharan Africa; I have encountered the same on past surgical missions in Kenya, Tanzania and Zambia. The most basic diagnostic and therapeutic interventions are often not available. As well, there is a significant brain drain, not just to the West but also to places within Africa like South Africa, where the standard of living is better for physicians.
Given the genocide that completely devastated the country 20 years ago, Rwanda is not doing exceptionally badly in comparison. When I walk the streets of Kigali, I cannot imagine that it has been 20 years since the genocide. Kigali feels like any other African city; in fact, it is quite a bit safer than most. The people are genuinely warm and welcoming. In 1994, Rwanda died. When I visit the Kigali Genocide Memorial Centre, I feel like I am in a place that has risen from the dead, a testament to forgiveness and reconciliation.
Back at the hospital, more cases. No congenital condition better depicts the gulf in neonatal surgical care and outcomes between sub-Saharan Africa and the developed world than gastroschisis, an anomaly where a baby is born with some of its intestines outside of its body.
In Canada, more than 96 per cent of these babies survive. In Kigali, no physician or surgeon has ever seen a baby with gastroschisis survive – not a single baby. The stricken infants are often brought to the hopsital too late and are sent home to die.
A newborn baby boy with gastroschisis arrives during my second week. I feel strongly that he could be the first survivor. He has been brought in immediately after birth, is in stable condition, and the intestines are in relatively good shape by gastroschisis standards. We make heroic attempts to save the baby, and transfer him to another hospital with slightly more neonatal resources to give him every chance. We succeed in closing his abdomen a few days after birth but, shortly after, he starts having trouble, and there simply isn’t the neonatal expertise required to save him. He dies a preventable death.
During my time here, I win many battles but I often lose the war. Unfortunately, it is these lost wars, not the triumphs, that a surgeon remembers most. I think of my daughter, and the anxiety my wife and I live through when she experiences relatively simple medical problems. As I sit across the Atlantic from my family awaiting my return trip home, I resolve to accomplish two very important tasks when I return. First, to give my wife and daughter the biggest and tightest hug I’ve ever given them, and then to kneel down on our knees and thank the Lord for what we have.
Read Dr. Emil’s blog at www.thechildren.com/dispatches.