Furthest Peoples First: M2H's Mission to Teach Mobile Surgical Care for Africa's Sick, Poor, and Remote

—G.G.

Preface

FOR MANY OF US, ACCESS TO BASIC MEDICAL AND SURGICAL CARE IS often taken for granted, since we have diverse and rich access to it in the United States and other developed countries. However, in the more remote regions of the world, this type of care is still often nonexistent. Because of this, I have spent most of my life working to bring these services to the forgotten people of this world.

Historically, the more advanced nations have pitched in to help prevent the spread of disease by donating vaccines and medications. While this practice treats some of the people who need it, it is limited in scope. It also creates a dependency in the developing nations where such donated services are quickly acclimated within the developing nations’ economies and then still more are demanded, creating a neocolonial dependency within the beneficiaries of these charitable short-term aid programs that become long-term entitlements. Hospitals and clinics donated and erected over time by wealthier nations have been limited to the more populated areas, and people in need located in harder to reach, more remote places have been ignored. And even with these donations, millions of deaths in the most desolate areas of the world can be attributed to a lack of basic surgical care.

In 2014 I founded Mission to Heal (M2H), a Washington, DC–based nonprofit to address this dilemma on a global scale. Adhering to our motto of Furthest Peoples First, M2H’s goal is to operate on the fringe of what many would consider civilization—in regions that lack electricity, potable water, and proper medical care. Many of these target regions also experience severe drought, poverty, government instability, and civil war.

M2H seeks to bridge the healthcare gap by providing free surgical care to people for whom basic medical care is either scarce or entirely nonexistent, and during this process, we train local practitioners how to continue the healthcare legacy after our volunteers leave. Our model is one that crosses boundaries of culture, national or ethnic identities, and language to share knowledge and deliver sustainable care.

Initially, I treated and taught people in developing countries how to cure and prevent the spread of diseases. And wherever feasible, I brought modern medical and surgical skills to address an array of health issues ranging from spinal Tb osteomyelitis, hernias, and typhoid fever to skull and extremity fractures and Marjolin’s ulcers. I traveled to locations that had existing clinics or hospitals equipped with limited personnel and supplies, or I set up temporary remote base camps, which required transporting personnel and supplies on foot, horseback, boat, vehicle, or aircraft. While these efforts were effective in their own right, I knew we needed to do more if we were to reach people in the most remote regions of the world and to create a truly more sustainable and lasting impact for them after we left.

Beyond needing capital to build hospitals and clinics in remote areas, we also faced the issue of training staff and hoping they would continue to live and work in these regions. For example, once trained, local people are often reluctant to return to the remotest areas, and they seek out a better life in the larger cities. I also noticed that the farther I ventured into remote areas with my hands-on approach, I found few to no resources to rely on. Operating on a patient in the open air or in a tent or a makeshift building with boarded-up windows to keep the flies out is risky, since sterile conditions are a challenge under these circumstances.

When past efforts took us to Ecuador, the Philippines, Afghanistan, Mongolia, Nigeria, South and North Sudan, Eritrea, Somaliland, Congo, Mozambique, Central African Republic, Chad, Liberia, Ghana, and Malawi, we were limited not only to existing clinics with limited resources, but we were also equally limited by the reach of available transportation. I began to discuss an idea with the new M2H board of directors, suggesting the development of mobile surgical units (MSUs) that could navigate the most challenging terrain so we could reach those who were too poor, too sick, or too remote to receive the medical and surgical care they needed. Instead of hoping that the afflicted patients might find their way to an operating room somewhere, we could bring the operating rooms to them.

After sharing my ideas with the board, my next step was to find someone who could build the MSUs at a price that might fit our budget. I decided to work with someone in the private sector who could adapt our prototype more rapidly and at a potentially lower cost than what the local governments (i.e., the mendicant government agencies of the developing world in places such as Nigeria, Congo, and Afghanistan, which often have limited capacity for wise use of these first-world facilities and are universally known for their graft potential), the UN, or multilateral NGO agencies would likely charge. I approached Bliss Mobil in the Netherlands (purveyors of state-of-the-art truck-mounted living spaces) to create MSUs similar to those built by the US military. During our conversations, I conveyed that these mobile operating rooms would need to be able to visit various otherwise unreachable mission destinations with all the needed surgical supplies and equipment on board.

Bliss Mobil’s design team (Marleen Hoex, Eduard Hagen, Gijs van de Looy, and Peter van der Wouw) was phenomenal in creating the prototypes. Soon after, plans were laid out for two fixed operating tables to simulate our mobile surgical gurneys, with space around them to conduct operations and accommodate all the necessary ancillary equipment while allowing for maintaining sterile working conditions in often unfriendly environments.

We specified that these self-contained operating rooms should be able to be transported by truck, train, ship, or plane. It was also important that each MSU be comprised of two sea container–sized modules, and along with the two operating tables, have solar- and diesel-generated power, HVAC and water purification systems, a shower and toilet, a food prep area, and staff sleeping quarters.

M2H MSU support unit rounds the bend in convoy across the White Nile River en route to Moyo, Uganda. Mobile Surgical Unit (MSU-II), Module A and Module B mounted on a pair of MAN KAT Is.¹

The designers helped identify the best type of carrier vehicle for this purpose: the MAN KAT, which met all our specifications of size, choice, and cost. The MAN KAT also held one huge advantage over any other options: It was already a major supplier of this type of vehicle to developing countries. Since the designers were used to working with MAN KATs, we deemed them the supplier of choice.

It was exhilarating to see years of planning come to fruition in 2017 when the MSU-II modules A and B were created. My dream of bringing advanced surgery and medical services to the poorest and remotest people on the planet was about to be realized! I was honored by the Republic of Ghana, the Queen Mother, and by Auntie Anna with a chieftain’s title on January 19, 2017.² The honors and privileges the title brought (free passage between and into the nations of Africa’s commonwealth and the respect and recognition of royal personages from Ghana’s fellow African nations) made gaining an audience in front of Africa’s indigenous organizations increasingly more possible. As Fred Graham-Yooll so aptly stated in my last book, Ebenezer, What better and more secure source of funds could there be than funding by Africans themselves? And what could be better than if they were asking for the support directly? . . . Just imagine African organizations working together to bring the miracle of modern medicine to all their countries with making life longer, more rewarding, and pleasant.

I was inspired to write Furthest Peoples First not only to share our latest mission work in Africa (which was part of a joint medical and educational project of M2H and local partners in the various countries we worked in that took place from January through November of 2019), but also to inspire and invite others to join us on upcoming missions. For decades I have carried out these trips on my own. And now, after creating M2H, a nonprofit global medical missions agency, I am ready to institutionalize this work so it will continue sustainably with future generations.

In this book we will follow M2H’s 2019 transects of Africa with two of our MSUs in which we provided medical and surgical care to the people of Somaliland, Ethiopia, Kenya, and Uganda. Our mission had three purposes: 1) to heal patients, 2) to train local health professionals to indigenize care, and 3) to offer medical students, surgical residents, and volunteers the opportunity for a transformational learning experience by participating in a medical mission in Africa.

During the African transects, local health workers, clinical officers (COs), and midwives were trained to task by the M2H team and African Diaspora doctors. These healthcare professionals were also updated on current health policies and objectives. I led the transects and traveled with 14 volunteers, 87 team members, and two MSUs. During our missions, we performed over 800 surgical procedures in four countries with the assistance of the state-of-the-art MSUs. These mobile miracle machines with multiterrain capabilities helped make medical treatment more accessible throughout the transects.

Piloting the M2H MSU up the Western Scarp of the Great Rift Valley after crossing the White Nile on a small ferry on approach to Moyo, ten kilometers from the border of the Congo. The MSU convoy returned from Moyo after our mission was aborted by an Ebola scare.

These latest missions are the start of a larger plan: M2H plans to return to these remote areas in subsequent transects to continue to raise the level of healthcare there. We also plan to expand our reach by placing more MSUs in various regions of Africa and other parts of the world.

Thank you for taking this journey with me. As you will see in the pages ahead, each day of our missions is an adventure in healing, perseverance, patience, compassion, and flexibility. Despite the best-laid plans, we were often tasked to surrender them to allow for something even greater to manifest in their place. I am grateful to the amazing team at M2H and to all of our supporters. Because of you, our work can continue to reach the furthest peoples first for generations to come.

Glenn W. Geelhoed, MD, AB, BS, DTMH, MA, MPH, MA, MPhil, ScD, EdD, FACS Derwood, MD, December 2019

1 MAN signifies the company that made the vehicle, and KAT is the model. Specially made for NATO, its NATO name is the English version, Cat.

2 This day fell on my birthday, Ghana’s 60th inaugural day as the first independent nation in all Africa to come out of colonialism, and the US presidential inauguration. My chieftain name, Nana Kojo Katabre, means benevolent healer, born on a Monday, who heals us and brings us peace.

PART ONE

First Transect of Africa: January 19– March 23, 2019

The river may be wide, but it can be crossed.

—CÔTE D’IVOIRE PROVERB

CHAPTER 1

Gentlemen, Start Your Engines!

JANUARY 19 IS A DAY OFTEN CELEBRATED BY MY INITIATING A NEW year abroad. On January 19, 2019, we arrived from wintry Washington, DC, into balmy Hargeisa, Somaliland. Each year on my pocket calendar this date is marked Ebenezer, commemorating my birthday and another mission milestone.³

I brought three students with me: Ashley Carter, Ismail Hussain, and Daniel Vryhof. I was in good company. Ashley is a premed student from the US whose mother is from the Afar region of Somaliland, who was looking forward to participating in her first M2H mission. Somaliland expatriate Ismail is a friend, fellow runner, and had been my driver since the days of my early trips to his home country. Dan has attended multiple M2H missions and is my protégé from Calvin College and George Washington University (GWU) Medical School. He is now an emergency medicine resident, finishing up in the Grand Rapids, Michigan, Spectrum Hospital System—the very hospital where I was born.

After long flights, we were excited to finally arrive and were eager to begin our work. We received a royal reception from the equivalent of the Somaliland Queen Mother, Woman of Firsts, Edna Adan Ismail. To my great surprise, I learned that Dick Bransford would also be arriving. He had made annual trips to teach Dr. Shokri (one of the earliest graduates of the Edna Adan University Medical School) how to do hydrocephalic shunts and other pediatric surgical cases, and remembered me from some of my earliest lectures there. Dr. Shokri had the privilege of visiting the weeklong American College of Surgery Clinical Congress and was the new surgical doctor at Edna Adan Hospital. She was Edna’s prime protégée, just as Dr. Sabra Aquil, a Yemeni refugee, became mine.

Sabra would be serving as my chief resident, and I’d heard such good things about her that I’d hoped she would be able to continue on with us as we moved from Hargeisa to Ethiopia. Dr. Shokri was also interested in joining us. And an additional three surgeon hopefuls at Hargeisa Group Hospital (HGH) were next in line—Doctors Emma Afnan, Adnan Abdullah, and Ismail. This Dr. Ismail was a male trainee, separate from the student Ismail and Edna Adan Ismail, who did not go by her last (paternal) name.

Edna Adan Ismail, the founder of the Edna Adan Hospital and University, and Dick were my nominees for the Medical Mission Hall of Fame at the University of Toledo. We’d all been inducted into that prestigious organization, and we were now together in Hargeisa. If that weren’t enough to have me brimming with pride, my former GWU medical student protégée Gail Rosseau would be arriving later in the week to teach neurosurgery techniques to select students.

I was thrilled to be there again and could hardly wait to get started. It turns out, I wasn’t the only eager one. Rumor had spread of an American surgeon (myself) who was coming to teach and operate in Hargeisa. As a result, some of the hospital wards and clinics where I would be screening patients were already filling up as I was meeting with the clinic doctors.

Edna Adan is the daughter of the former head of the Somaliland state⁴ and is a celebrity in these parts. But she is so much more than that. She is also a pioneer, as she was the first woman to receive an advanced education in this region. At an early age, she knew she wanted to be involved in healthcare and went to school in Djibouti where she decided to go into nursing.

Edna later married the president of Somaliland. As the first lady, she struggled with her own infertility issues, about which she was quite open. She made great use of her maternal desires, translating them into the achievements in nursing that made her known as Midwife of Somaliland—and the subtitle of her book Edna Adan—Woman of Firsts.

As the Midwife of Somaliland, she garnered universal acclaim. Anywhere we went, Edna was treated like royalty, and as the Queen Mother and a former minister of several departments (among them Interior and Health), she had many loyal followers and even more mendicants. We visited at least three entities in Hargeisa where she had held office, and we met her successors in each of them.

Potholes and chador-covered dark hulks loomed up in the headlights as she drove us through the city streets in her big diesel SUV, which dwarfed many of the other vehicles on the road. I realized she was the only female driver on the streets. Although not illegal, Western expressions of independence, such as driving by women, were not common in Somaliland. Apart from being daughter of and wife to heads of state, her driving is an extraordinary achievement in its own right.

Rolling Thunder

The next morning, as rolling thunder opened the day and minarets sent out competing muezzin calls, I prepped to meet with the minister of health, do rounds at the hospital, and visit an outpatient clinic with Dr. Shokri. A person would never need an alarm clock in Hargeisa, given the minarets of a score of nearby mosques. At 5:00 a.m. every day, a stentorian voice boomed out, Allahu Akbar! This seemed to be a signal of sorts for the rest of the competition to chime right in, and it reminded me of the famous Indianapolis call, Gentlemen, start your engines!

Edna continued to be a marvelous hostess, escorting us around town to visit officials and HGH. She even introduced me to a Turkish delegation of diplomats and took me to the Ministry of Health (MOH) so I could present a packet of information I had prepared for my licensure, which included some of my credentials along with some content about M2H and our MSUs.

This was perhaps the first time Ashley had ever seen women in full chadors or with the hijab (head covers) on—like the three principal women I would be working with, Dr. Shokri, Dr. Sabra Aquil, and Dr. Emma Afnan, each of whom would be operating with me at HGH and Edna Adan Hospital (EAH). When we arrived, they were busy celebrating the successful survival of triplet births.

At breakfast, I spoke with a woman named Rachel, whom I had initially assumed was one of the trainees at EAH. I learned she was actually a student at the Harvard School of Public Health and was in her last few weeks in Hargeisa. She was swathed in a hijab headdress (as was Ashley) and passed as one of the Somaliland folk until she spoke. I learned she would be working with us as part of her experience before returning to Boston the following week.

After breakfast, we packed up and went with Edna to HGH. We were introduced to the head of the hospital, who was wearing a suit and tie. From his appearance I deduced he was an administrator and not someone who directly took care of patients. There were a few such physicians around, all looking curiously at me. We were all seated in a mahogany-paneled boardroom, and after Edna introduced me, the staff asked what I would like to do while I was there. I said I was there to help and serve them, rather than take over any care they were obliged to give, and I showed them photos of the special MSUs that were on their way. As we were talking, I learned the new wing of the hospital had just been finished so we could hold our surgical mission there.

After the meeting, we toured the hospital, including the women’s surgical ward, which was separate from the men’s due to a strict cultural mandate. We met a woman with gallstones whose interest was piqued when Dan unpacked his ultrasound probe, hooked it to his cell phone, and showed an image of her gallbladder stacked with layers of stones. While touring the male surgical ward, we saw a patient being dressed with bandages. I noticed a large area of skin loss over his right shoulder and neck, and I knew right away it was from a viper bite with the venom causing defibrination and tissue necrosis. It was ripe and ready for a skin graft. When I mentioned this, I was told, We do not do skin grafting here. We have no such device, so we will just continue to dress him.

As I pondered the situation, they stated it would be a matter of years before they might have skin grafting capabilities. Unfortunately, our Zimmer Biomet dermatome—a device for slicing a predetermined thin layer of the epidermis—the so-called split-thickness skin graft—had been confiscated in Ghana as something valuable that might be used later for political bartering.

Here was a man who could be out of the hospital and harm’s way within the week, if only so much as a single dermatome existed in the entire nation. I knew we needed to procure one, despite the politicians’ sequestering it on the other side of the continent. It would be a high priority for our next visits.

During our tour, we saw crowds of people with congenital, long-neglected problems, like clubfeet or scoliosis or clefts, hobbling on sticks to support themselves. All could be treated—like the man with the snake bite—if only the hospital staff had the necessary supplies and know-how to address these very conditions.

Our delegation got coverall gowns, shoes, hats, and masks, and we entered the OR as several procedures were in progress. Two of the cases were thyroidectomies with the primitive support of a few instruments. A grizzled male surgeon greeted me as a senior elder and pointed out something obvious like, I am doing this but have no cautery. What he did have, however, was an anesthetist, and since they are Certified Registered Nurse Anesthetists (CRNAs) who can do endotracheal intubation, I noted we would be able to work with them on bigger cases that required general anesthesia.

After the tour, I was invited to return the next day to do whatever operations I wanted to. I reminded my hosts that I was there to assist them in whatever they were already planning to do. They listed a series of procedures for conditions they would be correcting, such as clubfoot, scoliosis, and a number of orthopedic cases. I pointed out that we would have a neurosurgeon coming, along with Dr. Dick Bransford and his son, who was an orthopedist. I stated that we would screen cases, and for the simpler ones, such as lumps and bumps, hernias, and other standard operations, we might just list them and do them in the MSU OR when it arrived.

Someone in the group asked why we didn’t donate or leave the MSUs behind after we left. The superb facilities of the MSUs, which many consider to be miracle machines, do not mean these machines take care of the patients. I explained that as a training unit, the MSU must be mobile and travel into needy areas, especially to those in harm’s way.

And, it would not be feasible to donate the MSUs for two reasons: First, we don’t have an unlimited supply of funding, and we must be judicious with how and where we use our equipment and supplies.

And second, our intent is to train local people to do the work in their own clinics after we leave so they can introduce new and effective lifesaving procedures to their own patients with existing supplies, rather than relying on us to support them.

Our First Working Day

On January 21, 2019, we began our first day working in the clinics of HGH’s outpatient clinic. We began to train Dr. Amal, one of the surgical trainees identified by Dr. Aquil, and Dr. Shokri to assist with the patients we screened and selected. At breakfast, Dan received a call about a 17-year-old boy who was in extremis with a pericardial effusion and not responding well to treatment. Dan cut his breakfast short to go evaluate him, while I went to the official HGH boardroom. The administrative officers insisted I stay put with Ashley, as some rather curious patients were clamoring to come in and drop their X-rays in front of me on the boardroom table—they wanted to be the lucky first ones to be seen by the visiting professor from America. This group seemed to be marked by affluence (or influence) and were typically first-order relatives or friends, selected by hospital administrators or other insiders related to them to be the first to be screened, often for problems that were trivial or already resolving.

After I had explained that I was not setting up a solo practice in HGH and that I was there to teach the trainees how to more effectively use their existing skills, they assigned Adnan Abdullah to me. Adnan is a tall fellow and was the only trainee from Hargeisa. As their senior registrar,⁵ he understood I would be helping him and others during our visit. I mentioned I had seen a patient with a snake bite and skin loss on the ward who should have a split-thickness skin graft and that we would try to do it for him while we were there. We then went to the outpatient clinic. While we were there, we met with a number of patients, all of them presenting serious conditions.

Every surgeon at this hospital performs every surgical practice, including urology, thoracic, gynecology, and orthopedics. Dr. Ismail, a small but active young registrar who had learned surgery in Dahlin, China, was keen on my teaching him. Dr. Sabra Aquil, an alert young woman in a hijab who teaches general surgery at the university, was most interested in learning tropical medicine from me. She presented a fellow who was dying of an unknown colitis and stated that a number of drugs had been used with no effect. She asked if I could demonstrate the first prostatectomy she had ever seen, let alone done, the next day, since we had clinic scheduled for Monday, Wednesday, and Friday, and OR scheduled for Tuesday and Thursday— and for which we already had eight cases lined up. I appreciated her enthusiasm and told her I would very much like to make that happen.

The first patient we screened came in drooling and unable to swallow anything but water. He was emaciated with enlarged nodes in his neck.

I looked at his chest X-ray and was instantly humbled. Even in this day of heavy-duty scanning and advanced treatment options, some diseases are just plain untreatable, regardless of where you find yourself in the world.

He had Stage IV esophageal cancer and did not need to undergo any invasive treatments or diagnostic testing. A gastric feeding tube might have kept him alive for a little longer, but it would have been a miserable existence. At this stage, I explained, only comfort care should be offered. I gave the family some medication to help him live out the final few weeks of his life at home with his loved ones more comfortably than he could in a hospital connected to tubes and machines.

Another patient presented with a right ureteral stone and hydronephrosis. We gave him analgesics and encouraged him to drink lots of water to see if he could pass the stone. A basketing of this stone would have been done in the first world, but no such cystoscopy could be done there. We saw two patients with enlarged, obstructive prostates, one of whom we would operate on the next day. Soon after, five women with fully veiled head covers shuffled in the queue behind a man with calcifications in his testes. Given the open space we were working in and the long queue we were presented with, we discussed the cases in front of others. While these women were not allowed to be seen without their head covers or to touch those in line, full public discussions of their private parts were open to all who crowded in. There was no Health Insurance Portability and Accountability Act (HIPAA) here.

I also examined a woman with a breast tumor. She had Stage III breast cancer, and she would need a toilet mastectomy for local control of the fungating tumor during her final weeks. I advised her to start Tamoxifen, a cheap and benign endocrine therapy. Then I screened a seven-year-old boy who, after a fall, had an alleged foreign body in his right knee, which was already in a 160-degree contracture a month later. Dan got out his phone and performed an ultrasound. He found no puncture site, nor any foreign body. Since we had an orthopedist coming later in the week, I decided to defer to him on whether we should tap out the joint effusion and splint him to overcome the contracture risk.

We screened four hyperthyroid patients that day, one of whom had lost over 15 kilos and had seen a local practitioner, who did a fine needle aspiration. Ever since the procedure, the patient had suffered from florid thyrotoxicosis. She was also tachycardic and needed beta blockers and antithyroid medication right away. An operation at that time, without medical preparation, would be lethal, so we needed to get her under normal metabolic slowdown first, which I noted in our charts.

I noticed one patient had a Marjolin’s ulcer from a long-ago healed scar that had degenerated into squamous carcinoma. I decided he would be a good candidate for an operation in the MSU. We also saw a woman with a big, solid mass in her pelvis that occurred after an operation for a myomectomy to ensure her fertility (which did not work, as she is now barren). After her, four women with gallstones appeared, one in full chador. Dan exercised his probe over her gallbladder and then showed her the results on his phone. I reflected on the irony of this woman, veiled from the gaze of any man, yet being shown her inner details from a device that could see right through her clothes, skin, and superficial modesty.

After the screenings, we planned to return to the OR at 7:30 a.m. the next day. Later, we would attend (and some of us would present) a series