Friday, February 23, 2007

Occam's Razor and the Silver Bullet Gambit

Entia non sunt multiplicanda praeter necessitatem (Entities should not be multiplied beyond necessity.) - William of Ockham, 14th C philosopher

It began in the early New Year when I traveled to England on family business. Within 48 hours of landing in cold, crowded Heathrow I had a nasty Upper Respiratory Tract Infection (URTI). Notwithstanding my brother and I discovering our recently deceased father’s stash of old and distinguished whiskies, and consuming a plentiful amount in his memory, I felt increasingly miserable and the cough got worse.

After ten days in wintry England I began my two day journey back to northern Uganda, feeling very sorry for myself, convinced my URTI was morphing into pneumonia and regretting not seeing a doctor before leaving. The first night back in Lira I spiked a temperature of 101F and alternately sweated and shivered the night away, resolving to find a doctor, have a chest x-ray, whatever other diagnostic procedure was available and start industrial strength antibiotics post haste. The following day I felt better and convinced myself my ‘chest-cold’ had been exacerbated by the long journey and the abrupt change in climate. That night I spiked another fever and all the alarm bells rang…well, at least with my wife who insisted I get a test for malaria in the morning.

At 8am we were in a small mission clinic in town, sat amongst a group of fifty or so patients, mainly women with babies or pregnant or both; the nurse told me, most probably had malaria. Eventually I took my turn to be stabbed in the finger by a young laboratory technician called Fred, who explained what he was doing and how he would reach a diagnosis. Half an hour later he emerged from the lab to announce “ Mzee (respectful title for elder male) you are a strong man, you have over 50 parasites to 100 WBC!”

My immediate reaction was in character, I was overwhelmed with self-pity. Malaria? Why me? How? I am so careful and have never had it before in my life. Etc etc. The next 36 hours is a bit of a fog. I know well enough the standard treatment protocol and always have a stock of Co-ArtemÒ (a combination of artemether and lumefantrine) in the fridge. I have used it on patients in the middle of no-where and it works like magic. Given that I had a weapons-grade dose of the disease, I embarked on a ‘take-no-prisoners’ counter-attack: a full course of 20/120 Co-ArtemÒ plus 100mgs of Doxycycline twice daily as insurance, analgesics and gallons of water. My wife nursed me diligently. My temperature see-sawed around 101F to 105F, I crawled to the shower, ached in places I did not know I could and was visited by very strange creatures which walked the bedroom walls . After 72 hours, I emerged from my bed an old man. It took a further week to nurture my appetite and get out and about.

“If you hear hoof beats behind you, look for horses not zebras” - Dr Jay Sanders, an old friend and mentor.

My purpose in recounting this story is not self-indulgence. It raises some very clear issues for me. The first is how easily I reached a [wrong] conclusion as to what ailed me. In my defense, I had strong circumstantial and symptomatic evidence to support my ‘diagnosis’. Though I don’t take prophylactic antimalarial medicine – it’s neither feasible nor affordable over years – I do take every other precaution, covering up in the evening, use insect repellents and always sleep under an Insecticide Treated Net (ITN). I am rarely bitten and have never before had malaria.

My initial symptoms where of an URTI and I contracted that in the UK. The cough and chest pain became the focus of my illness. It was 13 days from the time I left Uganda and 2 days after I returned before I suffered my first classic malaria rigor and by that time I had a very high level of parasites in my blood. The malaria is long gone but I still have a hacking cough. I had followed the age-old saw of medicine drawn from Occam’s premise, to suspect the obvious and commonplace – horses not zebras. I made two errors, I was living in a part of Africa where there are no horses only zebras and I had ignored another famous medical saw, Hickam’s Dictum, “a patient can have as many diseases as he damn well pleases.” I had both an URTI and malaria, a disease from each continent and one masking the other. It’s not a mistake I will make readily again.

No-one who lives in Africa can ignore malaria, and I have written about it on a number of occasions; now I have first-hand knowledge of the illness. It is not something I wish to repeat. But I was lucky, I had the education and resources to protect me and to be diagnosed and treated when prevention failed. For most of my neighbors in Lira and Uganda in general, there is scant help and many die. About 400 Ugandans die every day from malaria, mostly children under five and pregnant mothers. The data for other countries in sub-Saharan Africa are similar. Despite the efforts of international organizations, governments and non-government organizations (NGOs) nothing seems to be making a dent in the death toll, to the contrary, it is inexorably rising.

In 1998 the UN, WHO, a host of governments and NGOs launched a program, Roll Back Malaria (RBM), aimed at halving deaths from malaria by 2010 – almost 90% of these deaths are in sub-Saharan Africa. With less than three years to go the annual number of deaths worldwide from malaria is higher now than in 1998, rising from 5.5m in 1998 to a staggering 16m in 2004. If ever there was a failure of an international initiative, one that has been trumpeted around the world in every manner of global forum, and funded to the tune of hundreds of millions of dollars, the Roll Back Malaria is the classic example. It is a damp squib. Why? If Uganda is any example, the impending demise of RBM is a result of broken promises, ineptitude, misplaced reliance on ‘silver-bullet’ solutions and the defeat of science by soap opera. In theory Uganda has the three tools needed to curb malaria deaths—effective combination treatment based on artemisinin, ITNs and insecticides. A glance at each might throw some light on why Uganda is losing the fight.

The reality is that most Ugandans consider malaria like Americans view a common cold, hardly something you visit a physician for unless it gets really bad. The parallels between the US and Uganda in this regard are striking. Americans, with colds, rather than navigate the complexities and costs of a physician consult, will self-medicate or at most, seek the advice of a pharmacist. Ugandans do the latter. But they rarely have access to trained pharmacists and they have to pay out of pocket. They opt for the cheapest plan. This can be anything from traditional herbal medicine through dangerously ineffective but cheap combination therapies like chloroquine and fansidar, to effective but hugely painful intra-muscular quinine. Combination treatments based on artemisinin, that rescued me from who-knows-what, are being made available through the WHO and Global Fund but given the ineptitude of the Ugandan healthcare system, are only slowly permeating down to the ‘village’. As in all matters Ugandan though, there is always a way for those who can pay.

Talk to any member of the malaria prevention cognoscenti and they will wax lyrical about the ITN and its life saving properties. It is the ‘killer app’, the ‘silver bullet’ of modern malaria intervention, single-handedly able to reduce malaria deaths by over 60%. Despite what Sharon Stone and other glitterati would have us believe, ITNs have been around a long time and yet have not made a significant impact on malaria. Why? The ITN lobby insists it is a problem of supply, not enough are available. But there are more complex issues that the ‘silver bullet’ theorists downplay. ITNs cost more to distribute than to make and distribution is complex business, fraught with issues of local politics and economics. Then there are some banal practical facts: you cannot live 24/7 under an ITN, mosquitoes bite most in early evening and morning, when ordinary folks are up and about. They are hot to sleep under, particularly when there are eight people living in a small hut, and they are a fire hazard in huts where the only means of illumination is a candle or paraffin lamp. This is not a dismissal of ITNs, I swear by mine; rather a recognition that ITNs alone cannot beat malaria.

The third leg of the triad, vector control with insecticides, is the most contentious, mainly because it involves a dirty word, Dicophane or DDT. This is not the time or place for a history lesson on DDT, most readers are well aware of Silent Spring and the American experience with agricultural use of DDT. I have also expressed my bias in previous articles. For anyone who wants a serious scientific opinion on the issue, I recommend, “Balancing Risks on the Backs of the Poor” by Amir Attaran et al Nature.

The plain fact is that in terms of cost and effectiveness, DDT has no rival as an insecticide in vector control of insect-borne disease. Despite libraries of research, much conducted during and immediately after the time when DDT was used on a huge scale in the USA and elsewhere, there is no science to support the claim that DDT harms human health. Moreover, the strategy for DDT use in vector control, is to spray, small amounts of oil-based liquid inside selected homes and buildings once or twice a year in a tactic called Indoor Residual Spraying (IRS). To put this in perspective, back in the old days, US farmers would spray 1,100kgs of DDT on 100 hectares of cotton in four weeks. IRS would use this much to spray every building in northern Uganda in a year. It is not surprising therefore that the Stockholm Convention on Persistent Organic Pollutants (POPs) in 2004, exempted DDT for use in control of insect borne disease. Nor that in September 2006 the WHO announced their support for IRS using DDT in malaria control.

When, shortly after the WHO announcement, Uganda announced it would embark on IRS using DDT as the third leg of its RBM initiative, the reaction and rhetoric from activists, local and international, resembled a soap opera. Every well-worn cliché and threat was rolled out, ranging from the disastrous impact on agricultural exports to ‘recent studies that showed massive IQ loss in children whose mothers were exposed to DDT’. Even if tiny amounts of DDT from IRS, leached into agriculture it’s a stretch to see how this would destroy the nations principal exports, cut-flowers, tea and coffee. My favorite warning of agricultural Armageddon resulting from DDT use in Uganda came from the British American Tobacco company, delivered without a hint of irony!

As to IQ loss in children, I have not researched the study quoted, but I doubt that the damage, if any, could match the destruction of children’s brains inflicted by malaria every year here. As a small measure, my wife plans to fund a project for care of epilepsy patients ( there seems to be a correlation between infantile malaria and epilepsy) in Lira; there are an estimated 1,000 plus – in a population of less than100,000. No rational argument seems to sway the activists in Physicians for Social Responsibility (PSR) or the Pesticide Action Network (PAN), maybe because it threatens their funding and their salaries. But every day they succeed in delaying the implementation of IRS, they need to explain why hundreds of Ugandans must continue to die.

What Uganda needs is a coherent, well resourced and managed plan to ‘Roll Back Malaria’; by every measure, the current plan is not working and I am a recent victim. The Plan must include all three legs of the triad, effective treatment, nation-wide distribution and use of ITNs and IRS, using the best insecticide currently available, DDT. Over-reliance on ITNs will fail. As to the siren calls of PSR and PAN so concerned about our future but with no solutions for today, I have only one comment. Close down your expensive offices in malaria-free San Francisco, Washington DC and Nairobi and open them in Lira. Bring your families, leave behind your expensive malaria prophylaxis and designer insect repellants. Come and sleep under an ITN and work here for a couple of years. Then you will have a credible voice at the table.

Wednesday, February 21, 2007

Combat Stress and the Modern Warfighter

This is an article I wrote for a US Special Operations Forces (SOF) training program in 2001, shortly after the beginning of US military action in Afghanistan. Though much has happened in terms of military conflict since those heady days, I believe the the fundamental tenets of men in battle have not changed and that the themes I have drawn out in the article remain just as true today. I have therefore posted it as a blog, in almost its original form.


“What battles have in common is human: the behaviour of men struggling to reconcile their instinct for self-preservation, their sense of honour and the achievement of some aim over which other men are ready to kill them. The study of battle is therefore always the study of fear and usually of courage; always of leadership, usually of obedience; always of compulsion, sometimes of insubordination; always of anxiety, sometimes of elation or catharsis; always of uncertainty and doubt, misinformation and misapprehension, usually also of faith and sometimes of vision; always of violence, sometimes of cruelty, self-sacrifice, compassion; above all, it is always a study of solidarity and usually also of disintegration – for it is towards the disintegration of human groups that battle is intended.”- John Keegan, Face of Battle

“ Ninety-five percent of American casualties in wars throughout this century came from "close-combat" units -- aircrews, infantry and armor. So to protect these troops, America needs to take a closer look at how to prepare them for battle”.
This was how the eminently sensible and recently retired Commandant of the US Army War College, MG Robert Scales, began his address to a DOD conference on combat stress a couple of years ago. At the same meeting, Mark Bowden, the author of Blackhawk Down, told the group "stress seems too polite a term for what those men went through. I think 'terror' is a more correct terminology," he said. "I doubt that anything could fully prepare someone for being in that kind of a situation. … the word 'stress' seems too polite a term for it." Bowden explained. "(In combat,) you face a level of terror that no training exercise can really prepare you for.”

I confess to being disturbed by Bowden’s address. He seemed to suggest that all battle is so terrible no man can be adequately prepared; all will be in some way psychologically damaged by it and all will need expert help to fully recover. This is a message supported by a well-meaning industry of contemporary mental health experts. Implicit in this theory is that the modern warfighter, though generally physically stronger and healthier than his forefather, is not as psychologically robust or suited to the rigors of conflict. I do not accept this premise. My experience has been that many men who endured terrible battles never have felt the need to seek out mental healthcare. (Others, whose exposure to the stress of war has been minimal, have spent years on a couch.) I will accept that in many ways the tempo and intensity created by modern weapons systems and the scope for unfamiliar threats, particularly urban and counter-insurgency operations, are increasing the “friction’ of war and putting new and greater demands on our warfighters. But I am not convinced that urban conflict produces markedly greater incidence of combat stress than combat in other environments. It is the intensity of combat and the weapons used that most affects rates of stress casualties. I also know that many of the young men and women I have met in recent years, have shown just as much “fighting spirit” as their forefathers.

"I am content that the opinion that ‘the problem of the psychiatric casualty is much too serious to be left to doctors’ be attributed to me. Soldiers, unable to get bogged down in the morass of diagnosis and treatment, might be persuaded to concentrate on prevention in which doctors have achieved little success " - Maj Gen FW Richardson L/RAMC 1978

I have argued often that man is more important in war than technology and debated the costs and difficulties of recruiting, training and replacing military people as against machines. It is clear to me there is a deliberate shift in modern military healthcare towards the prevention of illness and injury and away from fixing broken bodies. This ethos should also extend to mental health, in peace and conflict. In the context of readiness we must examine more closely what can be done to prevent, or at least limit the worst psychological effects of armed conflict rather than plan for the inevitability of attempting to fix damaged minds and broken spirits.

I have reservations about the current doctrine, which leans heavily on the medical services and particularly on mental healthcare professionals. It argues from a basis that all will succumb. To suggest that the modern warfighter has no defenses against the psychological impact of conflict seems to set him or her up for failure. Moreover, there appears to be little understanding as to what point education and awareness cross into the realm of over-awareness and expectation of, or justification for failure. “Preventive” measures emphasize the psychological and emotional limitations of the individual warfighter and need for early recognition of breakdown. Its center of gravity and resources lie with the Critical Incident Response Team, a necessary and valuable tool but orientated to mitigation rather than prevention. I am not sure I would go as far as one WWII military physician who thought “ psychiatrists were incompetent to judge normal men because their experience is mainly with abnormal ones. I do, however, agree with Major General Richardson, this subject is first and foremost the province of the warfighter. It is an issue of leadership, selection and training and far too important to be left to health professionals of any hue. Having hopefully stirred up an entire medical MOS, I intend to risk their further derision by reverting to some old-fashioned concepts and language to reinforce my argument.

Courage is the essential quality of the warfighter. As it was at Midway and Mogadishu, so it is in Afghanistan and Iraq and other conflicts in the future. It enabled SOF sergeants to storm bunkers in Afghanistan and will permit the young E3 to face up to an angry crowd in Kabul tomorrow. Courage manifests itself in two forms, physical and moral. We tend to emphasize the physical but the moral is often more important, particularly for leaders, yet it is rare a commodity. Many of the criticisms voiced by junior officers and enlisted about their senior leadership tin recent years, concern the need for moral courage. “Moral courage is the most valuable and usually the most absent characteristic in men” – General George Patton.

Physical courage is present in most men and women and it can be enhanced and eroded by a host of external factors. In the final analysis, courage comes down to the power of individual mind over body. Churchill’s personal physician, Lord Moran, in his famous thesis on the First World War defines it as “ a moral quality, it is not a chance gift of nature like an aptitude for games. It is a cold choice between two alternatives; it is a fixed resolve not to quit, an act of renunciation, which must be made not once, but many times by the power of will. Courage is will power” .

In attempting to depict and understand what causes men to succumb to the stress of conflict, there few who have described it more succinctly than Moran “men only have a certain amount of courage in the bank and that the call on the bank may only be a daily drain or it might a sudden draught which threatens to close the account” The key questions are what factors cause this daily or sudden drain and how can the effects be prevented or mitigated.

“Fear is the common bond between fighting men”. – Richard Holmes. The Firing Line
The major drain on a man’s bank of courage is fear; it manifests itself in many forms and is a perfectly natural and defensive reaction to threat or danger. I would argue that Bowden’s use of the word terror is hyperbole. Terror connotes a state beyond control. I don’t think that those he wrote about were ever at point where they lost self-control. In conflict, fear varies in proportion to real or imagined danger. Most warfighters overcome fear by effort of will and the support of others. Recognizing, understanding and controlling individual fear is an essential part of combat stress reduction. Education and training to achieve this is a subtle and difficult challenge. It is however, not the province of mental healthcare professionals, often with no combat experience, to lecture to warfighters about fear in the abstract. This task is a key leadership responsibility and cannot be abrogated to or assumed by the medics. Certain circumstances magnify fear and increase the drain on the bank. I would put the following factors on my list:

Failure. In nearly all men and women, the fear of failing is a deep instinctive force. In some, this fear that they will fail in combat and let their friends down is a real and disabling stress that must be managed by the leader. For many, the fear of failing will drive them to actions that they would not otherwise consider and has driven men to great acts of heroism. The interplay between courage and fear of failure is complex but they appear essential elements of the “fighting spirit”.

The Unknown. The downside of the human imagination is that it is difficult to control. For the warfighter it is at times an essential tool, enabling him to out-think the enemy. At others, it can plague him with doubts and fears to the point of breakdown. This is particularly so when he or she is faced with something new. Fear of the unknown is most marked when a warfighter is alone and especially at night – modern conflict relies increasingly on warfighters operating alone and at night. This requires psychologically robust individuals who are, above all else, well trained.
“What a man has not seen, he always expects will be greater than it really is” - Onasander 1st Century AD

The Unexpected
It is of first importance that the soldier high or low should not have to encounter in war things which seen for the first time set him in terror or perplexity. – Clausewitz
Surprise is a principal of war. Although good training will lessen the chance of a warfighter being presented with something he has not expected, it is highly unlikely that he will never be surprised. History is replete with examples of what happens when warfighters meet the unexpected: their will crumbles. The key lies deeper than learning the enemy’s weapons and tactics. It requires inculcating upon individual warfighters the need to act on their initiative when faced with something unforeseen. This is a principle that SOF have long adhered to and probably what sets them apart from the average warfighter.
Anyone who has been in combat will tell you it is a very noisy affair. War is about destroying the enemy’s will. Noise is very effective in that it limits the ability to think or act. Even at the battle of Agincourt fought between the English and French in the early 15th Century, before the days of gunpowder, the sound of 5000 arrows every ten seconds and the shrieks of dying horses and men were terrible. Being on the receiving end of a dozen modern 155mm artillery rounds is stunning.
Widespread death and destruction in many cases does not affect the individual warfighter as much as the loss of one member of his immediate group. There is little that can be done to prepare the warfighter except meeting and talking with people who have endured and survived. The physical effects of combat serve to increase the drain on the bank of courage. Fatigue, thirst, hunger, disease and above all the climate can reduce the physical state of a warfighter so quickly his “fighting spirit” is broken. Providing logistic support for the warfighter to insulate him or her from the worst is a vital task, but in the final analysis some degree of “combat acclimatization” is essential.

In the face of these challenges, preventing or at least mitigating the worst effects of combat - the draining of the bank of courage - seems more than a little daunting. I offer only three issues for discussion though I know there are many more.

"His majesty made you a major because he believed that you would know when not to obey his orders."- Prince Frederick Charles
Trust is the basic building block of leadership and vital tool in overcoming the stress of combat. It is a two-way contract, the leader trusts his subordinates and they in turn trust him; it will not succeed in the long-term as a one-way function. It is most powerful when a leader shows complete trust in his or her subordinates. The strength of the German Wehrmacht in WWII lay in the concept of Auftragstaktik. It epitomizes the precept of trusting subordinates. In simple terms it provided leaders at every level with a “commander’s intent”(what had to be achieved and broadly, how) and relied on individual initiative to deal with the unexpected as it arose.
This very successful way of fighting requires an ethos of risk-taking and devolution of responsibility. It is an essential skill in the very complex environment of Counter-Insuregency Operations where often decisions of tactical and even strategic impact have to be taken at the squad level – what the British call “the Corporal’s War”. The contemporary US military is in general a politicized, risk-averse organization, shaped by doctrinaire field manuals on every conceivable subject and, through the medium of modern IT, over-controlled from the top down. It is highly unlikely that the freethinking, risk-taking, confident young E3 or lieutenant will blossom in this environment. SOF, who pride themselves in the practice of freethinking must strive to maintain independence of thought and action at every level.

“Training had come to an end. There had been twenty-two months of it, more or less continuous. The men were as hardened physically as it was possible for humans to be”. 'Band of Brothers', Stephen Ambrose

There are two generally accepted verities in combat stress management. First, although personnel selection methods can weed out those manifestly unsuited for combat, selection is notoriously unreliable. Second, even the best prepared, equipped and motivated warfighters will eventually ‘empty their bank of courage” if they are subjected to enough stress. (Studies carried out in WWII showed that after 90 days of continuous combat even the best fighters began to deteriorate rapidly). Training therefore has two vital functions in combat stress reduction. It acts as a continuous selection system to further weed out the unsuitable; and it prepares the remainder, mentally and physically, for the demands of combat. But training is only of any value if it is realistic. Within the limits of reasonable safety, it must be both physically and psychologically demanding. It must train and test the individual but also, perhaps more importantly it must test the group or team. Good training will always impact the team and make it stronger. Lack of training and poor preparedness will bring disaster. In his book Band of Brothers Stephen Ambrose describes how the men of Easy Company the 506th, who jumped behind Omaha Beach on DDay were at their peak and almost invincible. In their twenty-two months of training their battalion had gone through 5000 enlisted soldiers to produce 1500 fit for battle. Compare them to the US Army only eight years later in Korea. T. R. Fehrenbach writes, “ the Army of 1950 was physically untrained for combat tasks, emotionally unprepared for its stresses. They had to learn in the hardest school there was, that it was a soldier’s lot to suffer and that his destiny may be to die. They were learning something that they had not been told: that in the world are tigers”. Whatever else the current operations in Afghanistan produces in terms of attrition of the enemy, it is the finest training available.

“They knew and trusted each other…they made the best friends they had ever had or would ever have. They were prepared to die for each other, more importantly, they were prepared to kill for each other”. - Band of Brothers

History shows that the strongest motivation for enduring combat is the bond formed among the members of a squad or the crew of a weapon system or aircraft. Simply put, warfighters fight because of the other members of their small unit. Most warfighters value honor and reputation more than their lives, because life among comrades whom a
warfighter has failed seems lonely and worthless. The cohesion found in small teams provides shelter from the horrors of battle and enables warfighters to persevere in combat. The team provides the individual with security, the belief that that danger can be overcome, a coping mechanism to deal with the trauma of death and killing and a sense that what the team is doing has meaning. J. Glenn Gray, in his book 'The Warriors', described the real value of the team as both the essence of combat and the key to mitigating stress. “Soldiers have died more or less willingly, not for country or honor, or religious faith or other abstract good but because by fleeing their post and rescuing themselves they would expose their companions to great danger. Such loyalty to the group is the essence of fighting morale”.

I believe there is an urgent need to re-examine the way we deal with the stress of modern combat. The issue is not that contemporary operations will necessarily increase the incidence of stress, it is the way we are planning to deal with the issue. It is dangerous predicate our thinking on the expectation that the modern battlefield will be so overwhelming all will succumb and that the medics will be required to mend huge numbers of broken minds and shattered spirits. There is a clear role for the medic in managing combat stress but it should not be the first line of attack. I believe today’s warfighters are just as robust as their forefathers. With the right training and leadership they will equip themselves every bit as well. The key will be how much we trust them, how well we train them and above all, bonding them together in teams and taking every possible measure to keep them together.

Tuesday, February 20, 2007

A Modern Leper

As a middle-aged white man traveling in the eastern border region of Kenya, I am used to being stared at. Adult African men are usually polite and often friendly. Women tend to avert their eyes if you return their gaze; in groups they often giggle when you have passed them. Children in gaggles will regularly call out, muzungu! or kawajia! Swahili and Arabic respectively for white man. Somali kids frequently use the less friendly epithet, galadin! Meaning ‘white pagan’, sometimes it is accompanied by a few lumps of dried goat droppings.

I was therefore not surprised by the patient’s inability to take her eyes off my face when she walked into the examination room. I was, though, disturbed by a sudden look of fear. I was even more troubled when the nurse led her to a chair in the far corner of the room; the girl carefully spread out a plastic bag on the seat and sat on it. Her shoulders drooped; head bowed she stared at the floor. Michael, the surgeon whose clinic I was sitting in on, began to speak to the nurse in his usual quiet tone.

The nurse explained the girl was from a village over the border in Ethiopia. Most unusually she had arrived alone at the clinic the day before (young women in this part of the world seldom travel alone). The nurse had conducted a brief examination and extracted a full story from the young woman; although she was not on the surgical outpatient list Michael had agreed to see her. I sat mute as her story unfolded and Michael interpreted.

Her name was Athar and she was nineteen years old. Her tiny body, curled up on the seat seemed more like a twelve-year olds. In accordance with local tradition, shortly after the arrival of her first period her family had arranged her marriage. She was thirteen years old; her husband was in his twenties. Within a year she was pregnant and went into labor before her fourteenth birthday. Like the majority of pregnant women in Africa, she was to deliver the baby at home. Her mother-in law and other female family members would assist. If there were problems a traditional birth-attendant, with no formal obstetric training or medical equipment, could be called upon to help. The nearest medical facility was days away. Antenatal care was unheard of.

After two days of labor during which her relatives had told her to just keep pushing and her only sustenance was water, the traditional birth attendant was summoned and paid. For three more days Athar endured the excruciating agony of obstructed labor, growing weaker by the hour. On the sixth day the birth attendant laid her on the hut floor and sat on her belly and pressed and pressed. She remembers little more of her ordeal.

Over the ensuing days the terrible pain in Athar’s abdomen began slowly to subside but she was unable to get out of bed. He mother-in law finally told her baby had died. One morning she woke to find to her horror that her mattress wet, she was dribbling urine and she could not control it. The women of her family examined her, held a brief discussion, carried her from the house and laid her on her wet mattress in a hut next to the chicken coop. She was told never to enter the house again.

The months and years that followed were almost too awful and sad to relate. Her incontinence made her clothes and bed permanently wet and despite all her efforts, she began to smell, constantly and terribly. Her husband sent her back to her family he didn’t want her anymore. They too rejected her and banished her to an outhouse. Her childhood friends deserted her and she was soon completely alone, even the village children threw stones at her and held their noses. This was to be Athar’s existence for the next five years; she was an outcast, a modern day leper.

A weaker person might have succumbed to the loneliness and the shame. But Athar was made of stronger stuff. She took odd jobs, mostly carrying heavy loads of wood, and built a hut on the edge of the village. She kept as clean as she could and raised a garden to feed and keep herself strong. She was reconciled to a life alone. One day an erstwhile friend spoke to her. She told of a hospital across the border in Kenya where doctors visited and helped women with her affliction. Now here she was, desperate to be ‘made clean again’.

Michael spoke to her softly for a little while; she raised her head, put back her shoulders and nodded in reply. Her face lit in a smile and I saw in her eyes the strength that had got her this far. Michael had told her he would help her; the first step was to examine her thoroughly in the operating theatre that afternoon. As she stood up to leave I realized the significance of the plastic bag on the chair, this was how she coped with life sitting in her own little puddle. Very carefully she folded in the edges and trapped the fluid to carry it away.

Athar suffers from Vesico-Vaginal Fistula, commonly known by the acronym VVF. She is one of an estimated 2 million young women in the developing world, mainly in Africa, who suffer from this painful and devastating consequence of complications in childbirth. The most usual cause and effect is that the young woman’s pelvis is too small to allow the passage of her baby’s head or the baby is badly positioned and she goes into prolonged obstructed labor. In the absence of trained medical assistance and resources (usually to perform a Caesarian Section) the labor ends disastrously, the baby dies and the mother’s birth canal is badly damaged. Prolonged pressure of the fetal head compresses the bladder against the bony sidewall of the pelvis. Crushed in this way over a period of days, the tissue dies creating an abnormal communication or fistula between bladder and vagina. Sometimes the fistula will be between vagina and rectum, or both, creating a constant leakage of urine or feces.

VVF seems to have been common throughout history, evidence of the affliction has been found in an Egyptian mummy. Once widespread in Europe and America, fistulas were eradicated by modern medical care early in the 20th century. They are still pervasive in the developing world, where malnutrition and stunted growth make obstructed labour more likely, where cultural practices lead to early marriages and early pregnancies and where health care is largely unavailable or extremely limited. It is estimated in Africa alone there are over three million deliveries annually where the mother survives and the complication occurs in about two to five cases per 1,000 surviving mothers; this means about 6,000 to 15,000 new VVF cases a year.

While VVF is devastating, it can be repaired. The surgery is relatively straightforward but each procedure costs about $300 and requires that surgeons be trained in the techniques. This raises two problems. The price is out of reach of most young women and must be performed at no cost, offering little incentive for surgeons to train and work in the specialty. Second, the scale of the problem, up to 15,000 new cases each year, and its distribution, in the under-served rural areas, necessitates a huge training bill, which cannot be met by most health ministries in Africa. As a result, much of the work in VVF in Africa is undertaken by outside organizations, particularly missionary hospitals and NGOs.

AMREF’s surgical outreach service (on which I was accompanying Michael when I met Athar) has provided VVF repair at no cost to the patient for over 20 years. Its service differs from other organizations in that it emphasizes taking specialist care to the remote rural hospitals – some 30 hospitals in Kenya, Somalia, Sudan, Tanzania and Uganda – rather than bringing the patients to specialist centres. AMREF’s current specialist surgeon, Dr Tom Raassen, performs hundreds of cases annually in rural hospitals and has a teaching programme in a number a of major hospitals throughout the region. His aim is to both alleviate the suffering of young women and to create national pools of surgical expertise.

As with most healthcare problems in Africa, the size of the task is beyond existing resources. Dr Ruth Kennedy of the Hamlin Fistula Hospital in Addis Ababa crystallized the debate “…There are more than 100 new fistula cases every day. At the rate we are going and if we have no more fistulas from today on, it would take 400 years to repair the ones that exist today." There must be more effort in prevention. We cannot solve the problem by concentrating all our efforts on fixing the broken.

In 2002 the UN Population Fund (UNFP) launched a two-year campaign to address VVF, through the provision of financial and technical support to train doctors and nurses and provide essential medial equipment. The programme is due to end this year; its impact has yet to be felt in this part of the world. I am convinced that a viable prevention programme must focus on:
• Eleveating poverty
• Educating women
• Educating communities to modify early marriage and end juvenile pregnancy
• Reproductive health education and providing family planning resources
• Building sustainable antenatal and obstetric care resources in rural areas
• Enhancing existing repair capability, particularly in rural areas

Later that same afternoon, Athar was wheeled into the operating theatre. A heft dose of Pethidine had given her a sloppy grin. She was uncomplaining as Michael undertook a detailed examination of the terrible damage to her body. He concluded that whereas the injury was repairable, she should be referred to an experienced specialist in VVF, Dr Tom Raassen, who would be visiting the following month. A few hours later, I watched as Michael explained to her what he had found and what should be done. She chewed on her bottom lip and shed a solitary tear as he told her she would have to wait another month for the surgical repair. A short while later I watched as she carried her little bundle of belongings out of the ward and into the dusty, hot street. What would she do alone in this border town, waiting another month for surgery? I will never get used to the bravery of African women.