Taking off from Jomo Kenyatta Airport. At 7:30 in the morning, the sun is bursting up over the horizon. A short flight that will take us to a new world, from the relative affluence and cosmopolitan flare of Nairobi to Juba, the capital of the newest country in the world. The Republic of South Sudan will celebrate its second full year as a country this July. The plane takes off east, straight into to the brilliance of the equatorial sun, then makes a 270-degree bank to the right. As we rise, we take in the vast expanse of Nairobi; glittering high rises next to sprawling slums. Mount Kenya appears to our north, until it passes out of sight, and the snow capped peak of Kilimanjaro, just over the Tanzanian border to the south, comes into view. The banked turn continues over the plains south of the city, where giraffe munch lazily on yellow acacia trees and lions nap in the shade. The steep turn continues, finally pointing us north, quickly passing from the southern to the northern hemisphere, and on towards South Sudan.
The history of Sudan is sadly defined by the evil twins of violence and poverty. Though clashes continue in the contested Abyei region, and inter-tribal violence claims many lives, South Sudan is enjoying a period of relative peace, hope and development.
The reason for this trip is to explore ways to provide surgical education services for South Sudan. This might seem an odd priority for a country just emerging from war, with deeply deficient basic infrastructure, but access to surgery is vital to the South Sudanese people. As South Sudan rebuilds its water supplies, electrical grids, and roads, the healthcare system also needs rebuilding. While healthcare in the poorest countries has rightfully focused on clean water, immunizations, and control of infectious disease, public health officials are growing increasingly aware that the complete lack of surgical services is harmful to the poor.
South Sudan’s grim health statistics reflect this: with the highest maternal mortality rate in the world, South Sudan is the most dangerous place on the planet to have a baby. Poor roads, lack of traffic law enforcement, and unsafe vehicles contribute to a high rate of severe trauma. Parts of South Sudan are not yet de-mined, and violent conflict continues. Trauma victims languish in depleted hospitals, life saving surgery completely unavailable.
In this setting, even the most basic anesthetic and surgical techniques can save thousands of lives. Spinal anesthetic can be safely administered for the cost of a needle and half a teaspoon of local anesthetic. Caesarian section can be done with only a scalpel and some soap, saving two lives for less than five dollars. How can we stand by when help is so cheap and easy to provide?
I’m travelling with Dr. Lewis Zirkle and Jeanne Dillner, two people responsible for reducing suffering and death for literally hundreds of thousands of the world’s poor. Lewis is the founder and Jeanne the CEO of SIGN International, a non-profit based in Richland, Washington. SIGN designs, manufactures, and distributes for free advanced surgical implants for the developing world. These elegantly simple devices, along with Dr. Zirkle’s tireless education of surgeons around the globe, have transformed trauma care in the poorest countries.
Studies conducted by the World Health Education have shown that the repair of a fractured femur (thigh bone) reduces suffering and death nearly as cost-effectively as an immunization program. As ministries of health and donor agencies wake up to this concept, more and more of the world’s poorest people are gaining access to life and limb saving surgery. We’re headed to South Sudan to meet with representatives from the World Bank and South Sudan Ministry of Health, to listen and learn how we can help educate a first generation of surgeons for South Sudan.
I have the best job in the world. I’m an orthopaedic surgeon at Kijabe Hospital, a small rural hospital in central Kenya. For reasons that are clear to me but hard to explain, Kijabe has become a center for surgical education in Africa. Though we only have one paved street, no banks, and only one local restaurant, somehow this muddy village has become a place for world-class medical education in Africa. The nursing school provides bright students the education to become excellent nurses. The award-winning nurse anesthetist program produces a steady stream of highly qualified anesthetists for Kenya and beyond. Certified programs train young African physicians to become family practitioners, general surgeons, orthopaedic surgeons, pediatric surgeons, and neurosurgeons. Once in a while I take this for granted, and then snap back to the unlikely reality that this little rural hospital is functioning as a major medical university.
Because these training programs already exist at Kijabe, we are perfectly positioned to extend training to surrounding countries. Kenya either shares a border or is very close to some of the most challenging environments in the world. Our neighbors include South Sudan, Somalia, Ethiopia, Central African Republic, DR Congo, Rwanda, and Burundi. My dream is to eventually have a “Kijabe School of Global Surgery”, providing training in the most essential surgeries.
The flight was uneventful, except for the fighter jet toppled off the edge of the runway as we land. As we flew over the southern part of the country, the defining geographical feature of South Sudan became evident: it’s flatness. Flat like Kansas. Flat dusty areas, scrub vegetation. Then greener, and greener, then puddles, then ponds, then, a river. The Nile. The land is so flat here, that sometimes the Nile is within its banks, other times it spreads out into separate channels and swampy areas. The word Sudan is derived from the word for swamp. In the rainy season, large parts of the country become impassable swamp. As we land, we can see beautiful thatch roofed traditional Sudanese homes across the countryside.
At the airport, we are jubilantly greeted by two very tall men in “SIGN International” T-shirts! They are Dr. James and Dr. Akau, the entire orthopaedic firepower of this country of 10 million people. Dr. Zirkle and I have just doubled the number of orthopaedic surgeons in the country. Don’t break your leg in Juba today, because we’re all having coffee together.
Next on the agenda is the 20-minute ride to our sleeping quarters. I’m braced for eye opening African scenes of poverty, bad roads, and chaos. But I’m shocked: perfectly smooth paved roads, shiny white SUV’s, and then, incongruously, a four wheel drive turbo-charged Porsche Cayenne. Uh oh, the international AID community is here.
It turns out Dr. James was a general in “The North’s” (Sudan’s) military. After independence, he was ousted, as he is a Christian in the Muslim north. So he’s now the deputy commander of the health corps, overseeing all the military hospitals in the ten states of South Sudan. His desire: to see an orthopaedic surgeon in each of the ten states. I asked a local doctor to describe his hospital, the premiere hospital of his country: “Irregular electricity. No water or sewage. Frustrating. Bad. Inhuman. A Hospital in Name only. No light at the end of the tunnel. The people have no faith in the healthcare system, and they are right. We have ex-freedom fighters driving Porsches, and we have no IV fluids in the hospital.”
Dr. Akau has returned to Juba from Norway, where he was in practice and where his wife and children remain. Why did you return to S. Sudan? “My colleagues thought I was crazy. Why would you go to hell? You live in Norway, it’s beautiful here. In Scandinavia, they value human life. Here, people die like flies. I came here with no expectation, that has helped. I thought, ‘I can put on an external fixator under a tree!’ Then I got here, and found there was no external fixator, only a tree.”
Our accommodations are a bit surreal. We drive through Juba, through a heavily guarded gate, with a banner-like sign proclaiming “SPLA Headquarters”, the Sudan Peoples’ Liberation Army. We’re told not to take photos, and driven past a dilapidated barracks, which we’re told is South Sudan’s military hospital. We continue through another secured gate, to a clean row of pre-fab buildings. A US military ambulance sits in the compound, and we learn these housing units are built by the US State Department. We’re shown to our rooms; clean brightly painted, free Wi-Fi, and freezing cold. I turn off the air conditioning. We’re escorted past an outdoor thatch roof bar with soccer on the flat screen TVs, to a small cafeteria, with fresh mango juice and coffee. I see some mountain bike shoes outside one of the doors and find there are two mountain bikers here. Weird.
We were told a story by one of the surgeons. A woman came to the hospital in labor. The baby was in breech position and she needed a C-section. The husband, a soldier, went to get money to pay for the operation. While he was gone, the labor progressed to the point where both the baby and the mother were in danger. Without a signed consent form, the surgeon went ahead and attempted an emergency C-section. The soldier returned to find his healthy new baby, but his wife had died. He left, returned with his weapon, and killed the surgical team.
The evil twins of violence and poverty. It can be overwhelming when viewed up close. Right now, I’m not sure what the plan forward might be. But I’ve found with some patience and collaboration, little threads can come together to form a fabric of healing. I would appreciate your prayers as I search for the way Kijabe can be a part of this.