WARNING: some of these pictures are graphic.
You know how people are always saying that you wouldn't want to have to get surgery in a developing country? Well, now I understand. And you really wouldn't.
Dr. Mercy took me and Jen to JUTH (Jos University Teaching Hospital) on Tuesday morning to observe surgery. That in itself should tell you a little about the differences between the standards of medical care in a place like Jos, Nigeria and the standards in the U.S. We weren't watching from some kind of observation room or behind a window. We were in scrubs, wandering among surgeons, nurses and medical students, able to get alarmingly close to the action. Incredible doesn't even come close to describing the experience.
We started our morning with a couple of colonoscopies. The room where they were performed lead directly outside; the door wasn't closed, but rather a curtain hung over the entrance, through which the next patient would walk when his or her name was called. The patients would come in and situate themselves on the bed, with only vague directions from the distracted medical staff, kicking off their sandals and swinging their legs up onto the green sheet covering the table (not changed between patients). They were only mildly sedated before the procedures began, and the grimaces on their faces made it plain that they were in definite discomfort. I was shocked when I noticed the water source in the room: a large black barrel, similar to the one in our bathroom in the guest flat, only bigger. Keep in mind, this is a teaching hospital, badly overcrowded and understaffed, in a city that's been without running water for six months and only a few hours of electricity every day, if even that. The light in this room consisted of narrow windows up high near the ceiling and a single light bulb hanging from the middle. The scope itself was soaked briefly in some sort of bleach or spirit solution between patients. I asked Jen if she knew anything about their sterilization procedures, and she told me that she mostly just didn't want to think about them.
From there, we followed the residents to the operating room (called the "theatre" here), where we had been invited to watch Dr. Mike operate on a 26-year-old man. This theatre, however, adjoined with another one, and we were able to walk freely back and forth between them, so we got to watch three different operations. No one made us scrub in or sign in, no one asked for any sort of ID, no one questioned whether or not we were supposed to be there, no one seemed to think there was anything strange about having us in the operating rooms. Most of the observing med students were wearing flip flops, and almost no one was wearing gloves, except for those with direct contact with the patients during the surgeries.
The first operation we saw was so crazy that it took us a while to figure out what, exactly, we were looking at. Without getting too graphic, it will suffice to say that people here commonly don't seek medical treatment until the situation is dire because they are too poor to afford it, and by then, there is often little that can be done to save them. In this case, the patient will most likely survive, but he had lived with his condition (which was probably TB, a disease that affects not only the lungs, but causes a host of other problems and can lead to severe swelling of any body part) for a decade. The surgeons were partway through the procedure when we walked in, and when we asked one of the other doctors what was happening, he explained to us what they were doing, and pulled out his camera phone to show us what it had looked like before the drainage began. I think this is hilarious, and we saw it frequently: doctors would whip out their camera phones before or during operations whenever they thought something was especially interesting and snap pictures.
The next operation we saw was abdominal surgery. The young man had been waiting on a bench outside, and walked himself into the operating room and lay down on the table. As the nurses and doctors prepared, some liquid spilled onto the floor; it was mopped over to the side of the room, where a trough funneled it to a drain that appeared to lead outside the building. After the patient was put under, a nurse stood by his side throughout the process, pumping air into his lungs manually. After cleaning and disinfecting the young man's abdomen, his body was covered by sheets, leaving a square right above his bellybutton visible. Dr. Mike made an incision about six inches long and pulled back the layers of skin and muscle tissue. I was pretty much in awe at this point until the sight became even more incredible and I realized that he was pulling out the intestines- and not just a small section, but the entire length of the upper and lower intestine, bit by bit, feeling as he went. At one point, he removed a small piece of tissue and continued to examine the intestines. Once he finished with that and had replaced everything in the body cavity, he inserted his whole hand and wrist inside the upper abdomen and appeared to be feeling around. When he removed his hand, his assistants removed the props that were keeping the incision open and called for sutures.
If I hadn't been wearing a mask, about 25 people in that theatre would have seen my jaw hanging the entire time. At the end, Jen and I turned to each other with the same look: WHAT just happened?? We rushed over to find Dr. Mike, who answered all of our questions in a casual tone, as if this were everyday conversation, as if he was not holding his hands up, his gloves covered in blood from pawing through someone else's insides. The patient, apparently, had been complaining of symptoms that his doctors could find no cause for. They had told him as much, that they believed there was nothing wrong with him, but he insisted. He requested and insisted on having the surgery, even though the doctors tried to talk him out of it, since they had little reason to believe that they would find anything, but he would not be dissuaded. So Dr. Mike had cut him open, looked, and as suspected, had found nothing. He removed a lymph node to have it analyzed in the lab to see if that would reveal anything further. The whole surgery had been
exploratory. Dr. Mike shook his head with the same half-depressed, half-bemused expression that I have seen so often here, as if to say: this would be funny if it wasn't so horrifying. There is no CT scan in Jos. There is no laparoscopic surgery. For some patients, it is simply cheaper and more feasible to pay for exploratory surgery than to make the trip to Lagos to get a CT scan. The diagnostic and other medical technology that we take for granted in the U.S. simply doesn't exist here, for the most part, because it's too expensive. (A lot of the instruments they do have here are old and used ones that have been donated from American clinics, such as Mayo.) At Overland this summer, we had a girl on one trip complaining of abdominal pain- her leaders took her to a clinic and the doctor ran a CT scan, just to be safe. It turned out to be constipation.
The JUTH campus itself looks like a mix of some sort of dilapidated high school and a refugee camp. Open-air corridors and walkways connect buildings with crumbling corners and peeling paint, while people camp and hang laundry in the open spaces between. The patients' families serve as care-givers while they are being treated, because there is not enough medical staff to cover everyone. Many have traveled long distances to get here, and once here, have no place to stay. So they set up tarps and blankets and pots and they make do. There are signs everywhere that say Cooking Prohibited Here; there is usually a woman stirring a pot over a small local stove less than ten feet away from the sign. An enormous hospital is being constructed here in Jos, and from the outside appears to be relatively modern and nice. It will be able to hold much larger numbers of patients than the current facilities combined and should ease the conditions like those found at JUTH, but there is no expected completion date, and it has been under construction for longer than I have been alive.
Patients are expected to pay up front, in cash, for medical services rendered, starting with 500 naira ($1 = 127 naira) for their hospital registration card and number, and they are charged per service. For example, one of the women we saw opted to have a colonoscopy because she could have just had a barium colonic, which would have revealed any potential problems on an x-ray, but if she had done that and they had found a problem, she would not have been able to afford both the colonic and the colonoscopy, which they would have needed to take a biopsy and make a diagnosis. (They didn't find the problem on the colonoscopy, either, so she remains undiagnosed.) Faith Alive is the only free clinic in Jos, and all of its services are free, including the patient registration card. It is obviously not exempt from the technology problem, however; it is in some ways even more tied by the lack of resources. They were donated an x-ray machine, but it has been held in port and prohibited for some reason by customs from entering the country since May of last year, so they have to send out for every x-ray they do, which takes about three days' turnaround and costs $10 per picture. Along those same lines, x-rays are the only tool they have to diagnose TB, because they lack the necessary lab equipment to analyze sputum samples. X-rays are very imprecise as a TB diagnostic test, but right now it's what they have to work with.
Aside from being the only clinic to offer free services to the poor, who would not otherwise be able to afford any care, Faith Alive has an arguably even greater benefit to offer its clients: a caring and committed staff, whose goal it is to provide holistic care to the community they serve. Doctors and counselors often offer to pray with their patients at the end of visits, and whether Muslim or Christian, every time I have witnessed this, the patient has accepted with a grateful look on his or her face; I've seen doctors and nurses dive into their own purses and pocketbooks to pull out cash for a patient who has no food or can't cover transportation costs to get to their appointments; the FANOL bank (Faith Alive Necessities of Life) offers food and clothing to those who need it; doctors and home-based care teams will go to people's homes to talk with families who have threatened to throw their children out because of their HIV status; the weekly support group meeting offers people not only a community who will not shun them, but a close-knit family and a place to sing and dance and celebrate, unbelievably. Imperfect and struggling though it may be at times, you don't have to be here long to grasp the truth that Faith Alive not only saves lives but changes them, as well.
