Assume the Position: Memoirs of an Obstetrician Gynecologist (2 page)

     As a country the Gambia had perhaps the world’s worst statistics for both maternal obstetrical deaths and infant mortality and morbidity.  There were no Board Certified American Obstetrician and Gynecologists in the country. Almost all the women had been subjected to female genital circumcision (mutilation) shortly after puberty when they were dragged into the bush and brutally mutilated by midwives with unsterile cut glass while held down by their mothers.

The young girls would lie in the bush without any pain medication or antibiotics until scarring began.  They were brought back to civilization as women. Why did this happen?  Girls were there for the pleasure of their husbands and this guaranteed that for the men.  Once married a young girl would be cared for the rest of her life, so there was no escaping this horrid and brutal practice.  In my prior career I had never seen the results of a genital mutilation but I read about how to surgically repair the damage since I was reasonably certain it would be staring me in the face.

      There was 50 % unemployment.  Most men in Banjul stood on the street corners. Most women went to work in the fields doing the hard, backbreaking work. So this was a far cry from what I was used to, that is for sure.  Off I went with my huge box filled with donated materials, plastic speculums, boxes of lubrication, a microscope, and various medications I thought would be essential.

     I was met at the airport in Banjul by the lovely folks from BAFROW and was introduced to the nurse who would be with me in the clinics as my interpreter.  I was immediately struck by a unique smell heretofore unfamiliar to me.  When asked what it was I smelled, the response was ‘burning trash’.  There was one clinic in the city of Banjul at the one public hospital in the country, and several in the bush run by BAFROW, all of which I would visit during the month.  There was also an OB-GYN resident from Uganda working in the public hospital who would be attached to me by the hip.

(My Resident Physician)

He was indeed a young book smart guy.  But he had no supervision and was running wild in the hospital doing the best he could to keep up with the workload.  He was most eager to learn whatever he could from me during the month. And I was eager to impart as much knowledge as I could. This made us a great team.

     There was one TV station in the city which blinked on and off during the day because electricity would go out on average 20 times a day.  Unbeknownst to me, word got out over the TV that an American gynecologist would be in the city. The city hospital also had a unique system whereby women who had come in previously with gynecologic problems were put on a call list when help was in the country. I had no idea how they ‘called’ these women because there were few working phones but there they were, awaiting my arrival.

     My first day at the public clinic was astounding. 

(Waiting in line in the hot morning sun.)

When I arrived at 8 in the morning, amidst unbearable heat and humidity in July, there was a long line of women, over a hundred, hunkered down in the shade outside the hospital walls. I had no idea how long they had already been waiting. These were some of the blackest people I had ever seen.  The women were most beautiful with high cheekbones, lovely white teeth, dressed in beautiful dresses made of multicolored fabrics and African patterned cloths with beautiful brightly colored headdresses.  The women appeared to be wearing their Sunday finest, as we would say, that brought out the best colors and styles of all the beautiful birds in the Gambia. 

(One of many beautiful Gambian women.)

     When we set up ‘office’ at the hospital in a small room with an antechamber that could hold maybe 10 people, there was a mad rush to get into the antechamber and a fierce squabbling amongst the women who wanted to be the first to be seen.  Our exam room had a desk, several chairs, and a gurney with one sheet on it. There were no extra sheets to be found anywhere.

One per day would have to suffice.  My specula and lubricant came in handy. I sat the resident behind the desk with me off to the side.  The day began without end until well into the evening when all the women had been seen.  The lines continued every day thereafter on days when surgery was not scheduled.  100 % of the women had been ‘circumcised’.  So to begin with they were all surgical candidates, and if all I wanted to accomplish were to correct everyone’s anatomy and resultant problems there would not have been the time to do so.  There were so many other surgical problems facing us that it was overwhelming, with not enough hours in the day or the month.  I was distraught over how to choose who should have surgery and who not.  So I made the resident make the choices. I was unwilling to decide who was more needy than the next. The only stipulation to him was that short of circumcision corrections, every case that he chose should be different from the rest.  If I only had a month I felt this was the best way for him to learn. When I left he would be alone again, so he might as well see as much as he could and we should have as much surgical variety as possible.  He was particularly interested in laparoscopy, a procedure that he had never seen.  Laparoscopy is a highly technical procedure requiring specialized instrumentation and skills, a fiber optic light source and cables, and a myriad of unique instrumentation that had to be in perfect working order. There was one unsterile laparoscope in the hospital covered with dried blood. It had not been used in years and was far from being in perfect working order. So we spent time getting the equipment cleaned, sterilized, and in working order while instructing him and the operating room nurses how to use it. 

     The problems we saw on the first and every day thereafter ranged the gamut in gynecology.  Infertility was huge and a major issue for the women because if they weren’t able to procreate they couldn’t eat.  For many of these women who thought they were infertile, they weren’t infertile at all.  They might have had 3 or 4 children but if the other wives had produced more, in their minds by comparison they were infertile.  Scarring and painful difficult labor and deliveries were the result of poor or no maternity care and mutilating female circumcisions.  There were massive vesicovaginal fistulas, a complication of bad obstetrics that produced a communicating hole between the bladder and vagina so that urine constantly leaked into the vagina.  Many of these women were cast out of their homes to reside in the corner of the villages since the smell was overwhelming and their husbands wouldn’t come near them. Pelvic abscesses were rampant as was HIV.  If a woman’s husband died, his brother would become husband to them.  Thus everyone was more or less having sex with everyone else with all the problems that come along with that.

     Unlike medicine in the United States where prior authorization and paper work to perform surgery was required on every patient by the insurance company before taking anyone to the operating room, in The Gambia the resident just pointed and told the patient when to show up in the operating room.  There were no charts or dictating machines, no insurance or related paperwork, and no malpractice worries.  There was also little properly functioning equipment.  In the US, when a surgical instrument or clamp malfunctioned or was bent and wouldn’t work properly, it was discarded.  I never gave a moment’s thought when I tossed it off the operating table as to where it wound up.  But now I know.  They all found their way to the Gambia. When I put my hand out for an instrument it was sure to malfunction, which presented interesting challenges at the operating table.

     My first day in the operating room was an eye opener.  There was a sign on the operating room door that anesthetics were in short supply and there was a visiting ‘Professor’ in town. All the elective surgeries other than our cases and emergencies were cancelled for the month so there would be enough anesthetic gases for our patient use.