Perspectives From the Field

HEAL Africa Hospital (HAH) is a 197-bed hospital in Goma on the eastern border of the Democratic Republic of Congo (DRC). It is regarded by the Congolese Government as one of only three tertiary referral hospitals in a country of 80 million people, where there is only 1 qualified surgeon per 1 million people. HEAL Africa Hospital is the preferred surgical provider for Medicin Sans Frontieres (MSF) in the North Kivu Province.

Congo had been in civil war for 40 years, particularly in the east of the country, but with peace initiatives over the past few years and the defeat of the M23 rebels in late 2014, patients have been enabled to safely travel further to seek medical help. This has exposed the poor state of surgical treatment that is occurring in DR Congo where 80% of the population live in rural areas.  This freedom to travel to seek assistance has also highlighted the enormous unmet surgical needs and workforce issues. 

Indicative of this is the increased number of patients referred to HAH with what the staff refers to as an 'Abdominal Catastrophe’. The following is a brief description of the treatment offered to just a few of the more than 40 cases like this that have been treated at HEAL Africa Hospital in the past 2 years. More often than not, these cases involve young women and children, underlining the fact that lack of surgical care isof maternal and child health concern as well as poor initial basic surgery. 

A 35-year old woman gave birth to a healthy baby via Caesarean section performed in a village clinic by an untrained person. Whether that person was a doctor, nurse or clinical officer/assistant is unknown. Soon after she was found to have urine leaking from her abdominal wound, as well as her vagina.  The operator performed 4 more procedures in the village, but the problem was still not corrected. At that stage an MSF doctor passing through the village noted the patient languishing in a room and referred her to HEAL Africa Hospital for further management. She had her young baby lying next to her but there was still urine leaking from her abdominal wound when she arrived at HAH. After stabilisation and imaging she was taken to the operating room. It became apparent that the original surgery had been performed badly and perhaps for a dubious indication. The baby had been delivered through the upper vagina which had been incised, suggesting that the woman’s cervix had been fully dilated when the Caesarean section took place. The bladder had been sutured to the vagina, hence the urine leak from the abdomen and vagina.

In another equally disturbing case, a 29-year old woman presented after a Caesarean section 4 months earlier followed by 5 subsequent laparotomies, but still had urine and faeces leaking from her vagina. Subsequent surgery at HAH found the ureter had been damaged, as had the bowel, but successful surgery resulted in a well mother with no fistula.

These cases are not only clinically challenging, but drain resources and funds in a resource-poor setting.

Both these patients survived to return to a reasonably normal existence. 

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 However a 22-year old who had a similar story and presented to HAH with gross sepsis as well as faeces exuding from her abdomen was not so fortunate. She is the only one of recent patients to succumb. Quite simply she was referred far too late after an initial Caesarean section and 4 subsequent laparotomies. Her husband had been left to care for their newborn, in addition to large hospital expenses, after what should have been a joyous occasion.    

It is easy to be critical of these situations and the poor surgery performed, however often young newly graduated Congolese doctors are sent to rural centres to staff a hospital or medical centre on their own. They have little to no practical experience. They are called on to operate but often have no significant training in ‘the basics’. Caesarean section to deliver a baby is often poorly performed and when complications ensue their attempts to correct the problems lead to even more problems and delays.   

Many patients with fistulae as a result of poor child birthing or sexual violence which is rampant in DRC are also sent to HAH. 

Clinical dilemmas like those outlined above underline the need for appropriate surgical and obstetrics/gynecology treatment. These ‘on the ground’ cases are occurring in parts of the world like DR Congo in 2016 ... not 50 years ago. In October 2016 three more cases of ‘abdominal catastrophe’ have been referred. They demonstrate that the data produced by the Lancet Commission Report on Global Surgery in 2015 and the delays identified in patients seeking, reaching and receiving surgical care are borne out by anecdotal stories from hospitals like HAH.

HAH has responded to these concerns and Congolese workforce deficiencies by commencing a surgical training programme in conjunction with the College of Surgeons of East, Central and Southern Africa (COSECSA) for some Congolese doctors coming from rural areas. These doctors are being trained in basic essential and emergency surgery to a 2-year COSECSA Membership level in-country at HAH, in a recognised programme with a defined curriculum. It is anticipated that theses Trainees will in time return to their respective villages and rural towns and perform effective surgery with less morbidity and mortality.

This COSECSA program at HAH commenced with 5 Trainees for the initial year of 2016. Such ventures however require both funds and commitment to a long term strategy.

The stories above illustrate that the provision of access to safe, affordable anaesthesia and surgical care is a matter of justice for those who do not have such access and literally for them a matter of life and death. The G4 Alliance can play a major role in bringing together key stake holders to advocate for this.