Earlier this year, I had the opportunity to participate in my first pediatric surgery mission aboard the Africa Mercy, reportedly the largest nongovernmental hospital ship in the world. During my two weeks aboard the ship, which at the time was docked in Tamatave, Madagascar, I wrote a blog for the Montreal Children’s Hospital of the McGill University Health Centre, QC, called Dispatches from the Africa Mercy.1,2 The following is an edited version of these blog entries.
Dispatch # 1: The end of the earth
If there is such a place as the end of the earth, it is likely Madagascar. Leaving Montreal, QC, February 24 on a night of freezing rain, I arrive in Paris, France, a few minutes too late to catch my connecting flight to Madagascar. Air France gives me a choice of staying three days in Paris or connecting through three different airlines and two African cities to reach Antananarivo [the capital of Madagascar] almost two days later. Neither option is feasible. I settle on paying an extra fare to reach Tamatave, the port of the Africa Mercy, through a new route, Saint-Denis de la Réunion, a small French territory in the southern Indian Ocean. I arrive in Tamatave 36 hours after leaving Montreal, tired, sleepless, and jetlagged, only to find my luggage missing.
However, my fatigue immediately starts to dissipate upon first glimpse of the ship. As I climb the gangway, I think of the thousands of patients who have climbed these same steps to find hope and healing. I board to find a genuinely warm and welcoming environment. Everyone from the receptionist to the managing director approaches me with warmth and compassion, expressing their gratitude for my decision to join them. All of the staff and health care professionals I meet in my first few hours are resident volunteers on the ship and have been part of this venture for months and years. And they are thanking me for coming for two weeks, which is a truly humbling experience.
Within a few hours, I settle into my cabin, take a tour of the vessel, and complete the embarkation paperwork and emergency training. I already feel like part of this community of several hundred people from more than 40 countries, representing different professions, cultures, races, languages, and various denominations, all united by one purpose: serving the least among us.
Dispatch # 2: Can it get any better?
As I settle in for the night after my first day of work on the Africa Mercy, I find myself marveling at what can be achieved when good people commit to a mission, no matter how hard, no matter how challenging. Yesterday, I had a two-hour conversation over coffee with Gary Parker, MD, the chief medical officer of the Africa Mercy.
Gary is one of those people who strengthens your faith in humanity. A craniofacial surgeon originally from California, he and his family have called the Africa Mercy home for 29 years. His two children were raised on the ship and educated in the vessel’s fully accredited school. Dr. Parker has tackled some of the most difficult craniofacial problems in the world and is probably one of the world’s foremost experts on resection of aggressive tumors and mandibular reconstruction. Yet he exudes humility and expresses a genuine desire to continue to learn from others.
A few hours after meeting Gary, I jump into the operating room (OR) rather unexpectedly. I came here to perform elective operations, but in the late afternoon, my cabin phone rings. Major Christopher Elliott, MD, is on the line. Dr. Elliott is a U.S. Army Medical Corps surgeon, and chief of general surgery, Landstuhl Regional Medical Center, Germany, who is using 75 percent of his annual leave time to volunteer on the Africa Mercy, leaving a big family behind in Germany. We knew we would be here at the same time but were unable to connect before our arrival.
Chris calls to tell me about a little boy who had undergone a hernia repair several weeks earlier by another surgeon and who is back with a recurrent incarcerated hernia. I hurry to the ward to confirm Dr. Elliott’s impression. The child does not look well, and we rush him to the OR. My first procedure on the Africa Mercy is an emergency procedure, a great way to jump head-first into a new OR. All goes well. “Chris, there is no better place for two surgeons to first meet than in the OR,” I tell him.
I awake in the morning to a real treat. Don Stephens, the founder of Mercy Ships, is on board and flying out today. I had read so much about Mr. Stephens when I first learned of Mercy Ships and would recommend his book, Ships of Mercy, to anyone with a desire to see how one person’s dream can translate into something larger than life. I have a brief conversation with Don and take some pictures with him before he leaves the vessel.
The rest of the day is spent in the screening clinic, where I see 35 patients with pediatric surgical problems who were initially screened by nursing staff. These patients are from all parts of Madagascar and are temporarily housed in Tamatave, which is paid for by Mercy Ships. Mirjam Plomp, RN, a young Dutch nurse who has been screening patients throughout the country for more than three years, leads the screening team. Their diagnostic accuracy and appropriate patient selection makes my job easier, and the efficiency of the screening process is amazing. I thought I was going to see patients through the late evening, but we are done by 3:00 pm, and at that point we move on to other matters.
I return to my cabin before dinner for a few minutes of rest to find a very special gift—my luggage has arrived after three days in limbo. Everything is intact, including some surgical supplies I intend to use in my first elective operation tomorrow. Can it get any better?
Dispatch # 3: The heroes of Africa
At the end of the third consecutive operating day, I leave the port of Tamatave for the first time to have dinner at one of the local restaurants with Heuric Rakotomalala, MD, one of four practicing pediatric surgeons in Madagascar, a country of 24 million people.3 Dr. Rakotomalala has come to the Africa Mercy to operate with me for three days. In addition to providing me with a chance to collaborate with local surgeons and learn from them, our joint work has very special significance.
In late 2008, I arrived at Montreal Children’s Hospital with an ambitious dream, to integrate a low-income country rotation into our pediatric surgical training program. I felt it would give our fellows a unique perspective on pediatric surgical practice in resource-poor areas of the world and an appreciation of our own resources. With the help of Dan Poenaru, MD, FACS, FRCSC, who had established East Africa’s first pediatric surgical training program in Kijabe, Kenya, we succeeded in creating the rotation and sending Robert Baird, MD, CM, FACS, FRCSC, as our first fellow in 2010. The program then evolved into an exchange of fellows between the Montreal Children’s and Bethany Kids Kijabe Hospitals. Five of our fellows have gone to Kijabe, and we’ve hosted five of theirs.4 Dr. Rakotomalala was the first graduate of the Kijabe program. Working alongside him on the Africa Mercy in his home country is profoundly satisfying, the fruit of a unique collaboration between North and South.
Dr. Rakotomalala is one of the unsung heroes of Africa, striving to provide pediatric surgical care in the most difficult of circumstances with major deficiencies in equipment, personnel, funding, and resources. Before arriving on the Africa Mercy, he had traveled to several cities to provide care to children who were in need of his expertise. Dr. Rakotomalala’s trip back home takes two days on difficult, dangerous, winding roads through this vast country. His commitment to his profession, his patients, and his country are unquestionable.
In addition to his pediatric surgical care services, he adds a unique flavor to all our work, particularly ward rounds. The patients are proud to see one of their own among the surgical team. His ability to speak the Malagasy language helps break barriers. The nursing staff welcomes him warmly and is grateful for his presence. I am comforted having Dr. Rakotomalala with me in the most difficult and challenging cases. In a continent where children die by the thousands every day due to completely treatable surgical diseases and anomalies, Dr. Rakotomalala and other physicians like him are Africa’s best hope for improved pediatric surgical care. They are the heroes of Africa.
Dispatch # 4: The Power of Camaraderie
The only act in life that requires more trust than a patient surrendering himself or herself to a surgeon is a parent surrendering a child to a surgeon. Every time I take a child from his or her parents, whether it is for a minor procedure or a major intervention, I am cognizant of the awesome responsibility I am carrying, as is the entire surgical team. All of us who work in the OR—surgeons, anesthesiologists, nurses, and respiratory therapists—have pledged to do our best to be worthy of this responsibility. However, it also makes for a stressful environment. Emotions often run high, and the margin of tolerance can be quite narrow.
The OR on the Africa Mercy is not like any OR I have experienced. There is a clear understanding that surgery is at the heart of the Africa Mercy’s mission to serve the forgotten poor of Africa. A deep sense of camaraderie pervades every moment and every action in the OR. This atmosphere is not easy to maintain, since new volunteer surgeons, anesthesiologists, and nurses join and leave every week. Monday starts with a meeting of all OR personnel to welcome new members and Friday starts with the same to bid farewell to those departing. On Tuesday, half an hour is set aside before starting for all those aboard who want to join in devotion, prayer, and reflection. Before we bring in the first patient every morning, we have a group huddle to review all the patients and discuss any anticipated difficulties.
Keeping the same team intact for the entire week on the ship enhances the camaraderie. My three nurses are from the Netherlands, Germany, and New Zealand. They obviously hail from different cultural backgrounds and have different native tongues; however, together they create a wonderful atmosphere in the OR, an atmosphere not just of competence, but also one of pervasive warmth and care for the patient and for the team. By the end of my first day, I truly feel like I have worked with this team for years, like I am among friends. Here, at the bottom of the world, on a hospital ship, I feel like I am in a familiar environment.
My last case of the week on Friday was exceptionally challenging, a large lymphaticovenous malformation, giving the appearance of a large breast in a pre-teenage boy. He was being ostracized and teased. I proceed with trepidation, knowing it will be difficult and bloody, and the procedure goes exactly as anticipated. But as I successfully complete the operation and put in the last stitch, I look at the team of nurses who have worked so hard, who have skipped their meals and their breaks, who were so profoundly engaged during the most difficult moments of the operation, and I offer them a simple but heartfelt acknowledgement of their sacrifice and skill. I thank them for being who they are and for leaving the comfort of their homes and coming to this ship of mercy docked at the “end of the world” to take care of patients whose language they do not understand and whose culture they do not share—patients who had no other options. The personnel of the Africa Mercy OR have taught me many lessons in a single week, the most profound of which is the power of camaraderie.
Dispatch # 5: It takes a Mercy Ship
Today marks the sixth day after Polly’s operation. She is looking better and better, brighter and brighter. She is her mother’s child, but she is also the child of the Africa Mercy, a testimony to the power of this ship.
Polly is identified by Mercy Ships during one of their screenings far from Tamatave. I find out about her before arriving on the ship. Mirjam, the screening coordinator, sends me her pictures, hoping that a pediatric surgeon might be able to help.
I had opened the electronic file in my office at Montreal Children’s Hospital in a moment of disbelief. The baby had a rare tumor called a sacrococcygeal teratoma, larger than any I had ever seen. She was born in November 2015, and continues to grow and thrive despite this massive tumor on her back, approximately twice the size of her head. I ask Mirjam to get some imaging done, which is accomplished by the ship’s radiology technician, and sent to a radiology group in Canada for review. I receive the report days before I leave for Madagascar. I see no convincing reasons not to attempt removal of this tumor, which will eventually turn malignant and take her life.
Days later, I am face to face with Polly and her mother. I review the imaging and examine the baby. She is beautiful, and it hurts to see her mother struggling to hold her due to the mass, which is now even larger and essentially obliterates her buttocks and lower back. But it is still resectable. I discuss the operation and its potential complications with Polly’s mother. She has no questions. This is the day she has been waiting for since the baby’s birth.
The Africa Mercy operates at a high level of accountability and responsibility. The ship is not an acute care hospital. It does not manage major pediatric congenital anomalies early in life. No tumors like the one Polly had have been previously resected on the ship. The case therefore has to be reviewed by a hospital board to decide whether to take it on. The main concerns are whether this procedure can be done safely and whether the child has a high chance of disabilities that will be unmanageable after the ship’s departure. I point out that this child has already proven her desire to live. She was delivered vaginally without rupture or hemorrhage from the tumor and has thrived and grown despite it. A decision is made to proceed. Together with anesthesia and nursing, we plan every step.
On the day of the operation, I start by placing a subclavian central venous line for access. We proceed slowly and deliberately, one small step at a time. Three hours later, the tumor is out, and Polly has been stable the entire time. We extubate her and send her to the recovery room, where Polly’s mother will see her for the first time without the deformity.
That night, as I head to dinner, I experience the power of the Africa Mercy community. The food servers and cooks, who have nothing to do with the OR, ask me how the operation went. In response to my puzzled look, they tell me that their entire team prayed for her as she was heading into the OR. This experience is repeated throughout the evening as many residents of the Africa Mercy with whom I do not work and had not yet met approach me to ask about Polly and to reassure me that they will continue to pray for her recovery.
In the ensuing days, their prayers are answered. Polly is in a ward of 12 patients sharing a single, large room. The other patients and families rally around her. The nurses take impeccable care of her, attending to her almost hourly to keep the wound clean and dry. On the second day, the drain in Polly’s buttocks is removed. On the third day, her bladder catheter is removed, and her bladder starts to function normally. Today, her biggest challenge is to satisfy the wishes of all the nurses who want to cuddle her.
What does it take to see hundreds of patients like Polly safely through deforming diseases and severe anomalies? A case like Polly’s requires the following: screening throughout the host country, linking the patient with the appropriate surgeon, transporting the patient and mother to the port city, performing the necessary imaging, hosting the patient in the port city for several weeks pending the surgeon’s arrival, planning responsibly to perform the case safely, providing excellent nursing care, and having an entire community of 420 crew from 40 countries support the mission in faith and prayer. It takes a Mercy Ship.
Dispatch # 6: Jane
I sit at breakfast about to try a new fruit. I am not exactly sure what it is—maybe a Malagasy pear or apple. But my teeth hit solid rock. Jane White, RN, sitting across from me, shows me a sharp knife and tells me with a gentle smile, “That’s what these are for.” She splits the fruit into two and gives me a spoon. Sweet and sour all at once—passion fruit! Despite coming to Africa for medical missions since 1999, I obviously still have a lot to learn about this continent.
Jane has been my shadow since my arrival. A nurse from Northern Ireland, she is serving her second long haul on the ship. After the first stretch, she returned home. When she wanted to return to the ship and her hospital refused to grant her the leave she needed, she resigned and came back to the Africa Mercy. “This is where I need to be at this time,” she tells me without hesitation.
Jane is the team leader for the ward nurses—a team leader who is always there, always passionate. I first met her at screening, where she saw all the patients with me, not because she had to, but because she wanted to. That allowed her to know the patients who would be in my care from the first day. She will follow them, facilitate their recovery, decide their disposition, arrange their follow-up, and make sure they get home safely.
There is no such thing as outpatient surgery on the ship. Patients come from all over the country and are housed in the Hope Center, essentially a hotel run by Mercy Ships for patients to stay in while they’re waiting for surgery or recovering from an operation. Every patient stays at least one night on the ship before surgery and one night after surgery. Every morning, I round with Jane and check on all the patients. Jane and I make a plan for the day for each patient, and she sees it through. Every afternoon, when we’re finished in the OR, I round again with her to visit all the patients who will be having an operation the following day. We answer questions. We get consents. We provide reassurance. She gives me updates during the day, whenever needed. Knowing that Jane is there is knowing that everyone will get what they need through their full recovery—impeccable continuity of care.
Jane White is an Africa Mercy nurse and like her colleagues she is multi-talented and multi-gifted. She has decided to put these talents and gifts at the service of those who need her most.
The final dispatch: A vision of mercy
Dr. Chris Elliott, whom I mention earlier, and I are very different surgeons. He is a military general surgeon who has served in war zones and come face to face with raw violence. I am a pediatric surgeon who practices in the safe and protected environment of a children’s hospital. Despite these differences, we have found much in common, and today there is yet another shared experience. We are both quite emotional, conflicted, and ambivalent as we perform our last operations on the Africa Mercy. We both miss our families, but we both also yearn to spend more time in this healing environment, which is different from any we’ve experienced in our medical careers.
Over the last two weeks on the ship and in its hospital, we have lived with the crew through the high-highs and the low-lows—the triumphs and the losses—the wars won and the battles lost. We have seen them celebrate together and mourn together, and rally to each other’s side during the most difficult of moments.
In our OR hall meeting this morning, my voice cracks as I thank the team who supported me through operations on 30 children. They have done so much for me and have taught me so much. I came here to serve, but I have been served. I came here to give, but in fact, it is I who was on the receiving end. I came here to teach, but I have learned. I came here to heal, but I have experienced healing in the most profound of ways.
I tried to share the story of the Africa Mercy but I have only scratched the surface. You see, the real story of the Africa Mercy is not just about free surgical care provided to the poorest of Africa’s poor. It is not just about planting hope in the midst of despair. It is not just about capacity building in resource-poor countries. It is not even just about making a difference in the lives of tens of thousands, one life at a time, and one country at a time. The real story of the Africa Mercy is about mercy—a merciful community, diverse and always changing, that has chosen to show its love through its actions. And in a world where evil actions are not only done, but also often publicly celebrated, the people of the Africa Mercy remind us of what we, as humans, can accomplish when we are driven by mercy.
As I get ready to start my long trip home, I will cherish the vision of mercy I have experienced these last two weeks. And if I can apply that lesson in my own life— among my family, my patients, my colleagues—then I will succeed in keeping part of the Africa Mercy experience within me, until I join this loving community again at a new port in a new country.
- Mercy ships. The Africa Mercy. Available at: www.mercyships.org/who-we-are/our-ships/the-africa-mercy/. Accessed July 11, 2016.
- Emil S. Dispatches from the Africa Mercy. Montreal Children’s Hospital at McGill University Health Centre, QC. Blog. Available at: www.thechildren.com/news-and-events/latest-news/dispatches-africa-mercy-1-end-earth. Accessed July 21, 2016.
- WaterAid America Inc. Madagascar. Available at: www.wateraid.org/us/where-we-work/page/madagascar. Accessed July 11, 2016.
- Baird R, Poenaru D, Ganey M, Hansen E, Emil S. Partnership in fellowship: Comparative analysis of pediatric surgical training and evaluation of a fellow exchange between Canada and Kenya. J Pediatr Surg. June 2016 [Epub ahead of print].