From February through May 2011, Chris, and Danièle worked hard in Burundi getting the project off the ground. Barnabé Karorero who lives in Bujumbura was a great help finding us a house and a vehicle, clearing the shipments of material through customs and finding instant solutions to day to day bureaucratic and other problems that would otherwise have made it very difficult for us to work. Surgeons Dr. Reda Eissa, Dr. Jean-Claude Niyondiko and Dr. Antoine Nifasha allowed us to work in their hospitals, gave us operating time and, together with the nurses and other hospital personnel, made the work interesting and fun.
Just before leaving, we shipped 21 boxes of donated surgical material by air freight. We also purchased 7 boxes of orthopaedic equipment and implants from a company in New Delhi. And most importantly, we carried with us, in our luggage, the SIGN nail for treatment of fractured femurs and tibia, which we had obtained from Dr. Lewis Zirkle, orthopaedic surgeon and engineer who invented and developed the nail for use in poor countries. ( link: www.sign-post.org)
With all this material in our possession, we were able to put together many different trays of instruments and implants, each for a specific task. For example, there were two trays for fixation of small bone fractures, two for large bone fractures, two for intra-medullary nailing and so on. Each tray was wrapped and sterilized so as to be ready for use. The trays were stored in a reserve in the university hospital where we did most of our work, but we often carried them around in our rental car as we visited different hospitals.
We were based in the capital, Bujumbura, where we worked in three different hospitals but periodically, we visited other hospitals in the interior of the country as well as a center for handicapped children. At each center, we saw patients at the request of the resident doctor or surgeon and if we felt the patient could be helped by surgery we operated together with the resident surgeon within a short delay. Thus we were able to perform over 150 surgeries including 31 SIGN nails.
When we first started working at the university hospital in Bujumbura, we found many young patients, victims of road traffic accidents who had been lying around for weeks or months, sometimes in traction, sometimes just with a splint. Their broken femurs and tibias were healing in overlapped and poorly aligned position, their knees were getting stiff, their muscles wasting away. Some of them had open infected wounds that communicated with their fractures. These patients were well on their way to becoming permanently disabled yet had they received expert treatment soon after their injuries they could (in most instances) have made a full recovery and returned to their previous level of functioning.
Why were these patients left in such a state ? There are several reasons: the operating theatres are extremely poorly equipped to do orthopaedic surgery and lack almost everything that one would need to do quality work. The surgeons at the hospital are general surgeons and have variable but usually insufficient expertise in doing orthopaedic procedures. But the main reason is that the vast majority of the patients are poor, yet they are required to pay for every service they receive in the hospital, from dressings to drugs, intravenous fluids, sutures, X-rays; everything is added to the bill. The cost of orthopaedic surgery ($200-$500) is totally prohibitive for most of them. They may never have had more than the equivalent of $10 or $20 in their pockets at one time. For them to come up with this amount of money, they would have to call upon all the members of their extended family to contribute or perhaps to sell a piece of their land. This, they are very reluctant to do because their land is sacred to them and they depend on it for their family’s survival.
When we introduced ourselves to the administrators of the university hospital and made our intentions known, we were welcomed without hesitation. We were paired up with one of the surgeons who had a special interest in orthopaedics and they allowed us to operate three days a week. We were given the use of a small storage room where we could keep our sterile trays and other orthopaedic materials. It all seemed too good to be true. And it was. Because we soon ran up against the other major obstacle, the inefficiency of the operating theatre, due primarily to lack of motivation of the a minority of the staff who’s attitude seemed to be: “For what I’m being paid, why should I work any harder?”
In fact, the chronic underfunding of all hospitals by a government that seems to put a low priority on healthcare is at the root of the dysfunctional state that the public hospitals find themselves in.
We worked in two other hospital in Bujumbura, both of them private institutions; one catered to the poor and middle classes and the other to the rich. The former was our favourite because the staff were so hard working and devoted, although their salaries were even lower than in the university hospital.
Often on weekends, we would go to Bururi, about two hours drive away in the mountains, where an Egyptian team of doctors had been working for three years. There, we would operate cases that young orthopaedic doctor, Reda Eissa, had saved for us, since they needed surgical material that only we had. Then, in our time off, we would enjoy hiking in the mountains, the cooler weather and the company of our Egyptian hosts.
In addition, we made two trips to Ruyigi, also in the interior of the country where we worked at REMA hospital, a modern, clean and well equipped institution built three years ago with European donations. We were impressed with the efficiency and hard work of the staff, plus the hospital’s policy to treat everyone regardless of ability to pay. We hope to work more often there when we return in November.
During our four months in Burundi, we carried out a large number and variety of orthopaedic operations and procedures including treatment of clubfeet in babies, tendon repairs, treatment of non-union and mal-union of fractures, drainage and irrigation of infected joints, hip fracture surgery, operations for chronic osteomyelitis, open reduction of neglected elbow, hip and shoulder dislocations, repair of foot and hand injuries, treatment of gunshot injuries, joint injuries and fixation of long bone fractures with plates and screws or with intra-medullary nails. For the latter procedures, 31 in number, we used the SIGN nail. This nail was developed for use in poor countries because it requires no sophisticated equipment yet give excellent results. For each nail we inserted, we sent a report by internet to SIGN headquarters in Richland, WA who commented on our technique and responded to any questions we had. When we had used ten to twenty nails we were sent replacements free of charge.
Many of the fractures we treated were weeks or months old and already healing in poor positions. The operations were often challenging and difficult yet the results were gratifying. The SIGN nail in particular gave excellent results with a high healing rate and low incidence of infection.
We performed almost all the surgeries together with the local surgeon or surgeon-in-training. This gave us the opportunity to teach surgical technique. Wherever possible the African surgeon performed part or all of the surgery under surveillance. We considered this to be of the utmost importance since, at the end of our four months in the country, we would be leaving all our equipment for them to use.