"Bush Opthalmology"

Today I was welcomed into the world of bush medicine – and more specifically bush ophthalmology. In a small town called Mwami where surrounding villagers are very poor, there exists a fully functioning mission hospital called Mwami Adventist Hospital. This morning, Dr. Ang gave us a tour of the facility.

The pediatric ward, the largest ward of the hospital, was filled primarily with PMC (protein malnutrition) cases. As we walked into the unit, the charge nurse there cheerfully greeted us. “How is everything?” inquired Dr. Ang. “Oh, everything’s fine,” he replied. Almost as an afterthought, he added, “Besides the fact that two children died last night of PMC, everything is fine.” We entered a room where six malnutritioned children sat, accompanied by their concerned mothers. Signs of kwashiokor included a distended abdomen, edematous extremities, desquamating skin, anemia, and lethargy. Several of the children looked quite sickly. “This one looks infected,” commented Dr. Ang. The “infection” was in reference to the all-too-prevalent HIV/AIDS epidemic so rampant in sub-Saharan Africa, particularly in Zambia.

Statistics show that one in every four Zambians (especially women) in urban settings is infected – and 16% nationwide. This figure is likely grossly underestimated due to the taboo nature of the disease, denial, refusal to undergo testing, etc. Having heard these statistics in the comfort of the United States is so different from encountering the actual individuals here who are suffering the consequences of this deadly disease. One of the contributing factors to the spread of AIDS is the promiscuity and prevalence of prostitution in the cities. Driving around Lusaka at night, I remember we would hear cat calls from almost every street corner – from street walkers dressed up in hip-hugging outfits. Edward Martin – a tall, African-American bachelor – told me, “It’s difficult to be a single male out here. Sometimes I have to be very direct with the women who approach me. I definitely need a wife.” He mentioned that many Africans believe the myth that if an HIV-infected individual were to have sex with a virgin, he would automatically or miraculously be cured from his disease. Hence, there are an increasing number of rapes that have occurred at local elementary schools, sometimes by HIV-infected male school teachers. This news definitely saddens me.

Continuing on with my tour of the hospital, the other pediatric beds were filled with malaria patients, orthopedic fractures, etc. One boy had been in a coma for two days, but regained consciousness by the time with sam him this morning. His malaria smear was positive (2+), and he had presented to the hospital with seizures. Todd commented, “In the U.S. that boy would have been in the PICU – intubated and monitored closely. This is wild.” I agreed; this indeed was wild.

We continued to tour the male and female ward, the Ob/gyn ward, the HIV/AIDS clinic. Afterwards, Dr. Ang took us to the Eye Care Centre, about a ten minute walk away from the main hospital. Spending the day with Mr. Limwanya, the cataract surgeon, was a fantastic, eye-opening experience (no pun intended)!

There are two main buildings to the Eye Hospital – the first houses the reception area, a diagnostic room, a female ward, and a male ward; the second holds the operating theatre and the accountant’s office. There were about ten patients lined up, awaiting surgeries. Mr. Limwanya had brought these patients from a village 50 kilometres away. This morning’s line-up in pre-op clinic included: a presumed squamous cell carcinoma of the conjunctiva, several senile mature cataracts, a painful blind eye (s/p trauma two years prior), two glaucoma patients needing trabeculectomies, one pseudoexfolation syndrome case, a pterygium, and a six-year old female with congenital cataracts. After assessing their vision and examining them with the slit lamp we prepared to go into the operating theatre.

In the OR, Mr Limwanya and his assistant proceeded to set up everything – they assembled the operating microscope onto an old rickety operating table. The sterile linens and instruments were laid out methodically. A purple-tinted alcohol solution was poured out into the stainless steel basins.

Two autoclaving machines were conveniently situated near the entrance of the OR – both of which were used repeatedly to sterilize instruments immediately after each case so they could be used for subsequent patients.
The resources were indeed limited. The venue was primitive. There was no phacoemulsifier. There was no bovie for cautery. Instead, we used “fire” – a small bottle of fuel with a wick, lit with a match – to heat up a small metal tool, which was lightly touched to the bleeding vessels in the conjunctiva. Irrigation and aspiration was done manually with a bottle of normal saline hung from a metal stand with the tubing attached to a special cannula and syringe. The capsulorrhexis was performed with the “can opener” method. The lens was dislodged by hydrodissection and manually removed. Although in a primitive setting, the sight-saving surgeries were performed successfully and in a timely fashion. It was quite incredible.