Benin, a small West African country between Togo and Nigeria, has severe resource constraints and a population of 10 million with limited access to health care. Mercy Ships will be in Benin for 10 months providing a range of surgical specialities: plastic and general surgery, gynaecology (fistula repairs), ophthalmology, orthopaedics, limited neurosurgery (specifically encephalocele cases), and dental and maxillofacial surgeries.
I found the Mercy Ships set-up to be very welcoming, professional and well equipped. Long before the ship had arrived in the country patients had been screened for suitability.
Initial screening took place in both metropolitan areas and in isolated rural villages with teams from the ship travelling far into the interior. The ship offers elective surgery for only benign disease and only where the course of treatment can be completed over the course of the ship’s stay.
Prior to their arrival on the hospital wards, patients had been checked by an experienced rural Australian GP, who had arranged for their bloods tests, ECGs and radiology. Severe hypertensives were postponed and started on treatment. Time had been spent counselling the patients in their own language about what was being offered, and expectations and likely outcomes. Final surgical consent was obtained the night before surgery, often with an inked thumb print.
The hospital is well resourced with five operating theatres, a post-anaesthesia care unit or PACU, an intensive care unit with adjoining high dependency unit (with the ability to ventilate post-operative patients), four post-operative wards, full laboratory services including transfusion – you have to love warm, whole blood when the suction bottle has reached the seven-litre mark – and radiology, including CT, ultrasound and plain film. Post-operative physiotherapy and extended-duration hand therapy was available.
From an anaesthetic perspective the theatres had Mindray anaesthetic machines, circle systems with Iso and Sevo volatile agents, oxygen/air mix, end tidal agent monitoring and the capacity for invasive monitoring in selective cases. A range of fibre-optic scopes were available along with C-MAC and Air Trac. Ultrasound was easily accessible for regional anaesthesia. Every theatre had an anaesthetic consultant and trained anaesthetic assistant.
The surgical pathology over my stay was varied, the sub-speciality surgery being dependant on the specialist skills of the surgeon who was onboard the ship at the time. I did plastics lists with lots of burn contracture-release surgery, removal of massive facial neurofibroma, MaxFax cases of ameloblastomas the size of watermelons requiring awake fibre-optic intubation (AFOI), subtotal mandibulectomy and plate reconstruction, lots of hernia repairs, and lumps and bumps. There was a mix of adult and paediatric cases.
There were plenty of times that I wished I had paid more attention during fourth form French classes but translators were readily available throughout the patient journey. Local people were very multilingual and one could always communicate with patients in one of their own languages including at induction and emergence.
The surgical wards were a very communal affair. It would be common to be seeing a patient for the next day’s list, asking questions about their past anaesthetic exposure, allergy or surgical pathology only to have those questions answered by the patient in the next bed with advice from visitors across the room. One notable general surgical list had three adjacent patients with four hernias between them. Much discussion ensued as to who had the biggest hernia, the stonemason, the fisherman or the jailer-turned-security guard. In the end the ward decided the fisherman was the victor given that he was scheduled for a bilateral hernia repair, but no one believed his account of the size of the fish he caught. The stonemason clearly had the toughest hands – mine were pronounced to be like a young girl’s – and the security guard laughed that the very people he was paid to keep in, he was now paid to keep out! It was certainly a unique pre-admission clinic!
With help from Mercy Ships and through contacts with the World Federation of Societies of Anaesthesiologists (WFSA) – thank you Wayne Morriss – I was able to spend two days at two local university hospitals observing. I was made very welcome by the two professors who patiently showed me through their institutions and allowed me access to the theatre complex. In Benin, medicine is a seven-year fee-paying course, at the end of which most graduates endeavour to specialise as soon as possible.
There is no universal health care; patients pay for medical treatment. Consequently Obstetrics and Gynaecology is the most popular choice given the young population and high birth rate. Specialist training takes four years during which the registrars receive no salary for their work.
The anaesthetic workforce statistics reported to me were staggering. Consistent with most of sub-Saharan Africa, Benin, with 10 million people, has 22 medical anaesthetists, and not all of them are in clinical practice. There are 250 nurse anaesthetists who do the bulk of the clinical work. The nurse anaesthetist school in Cotonou has trained 200 of the 250 but has been closed for the last two years.
Part of the role of Mercy Ships in Benin is to assist with medical capacity-building and education as well as clinical care. Accordingly they are running courses in sterilisation techniques, promoting the WHO Surgical Safety Checklist – which is not widely used – and promoting the need for a surgical count at the end of surgery to ensure all swabs and instruments are accounted for—also not used in the theatres I observed. In addition local surgeons and anaesthetists spend time working along expatriate specialists in the theatres onboard the Africa Mercy.
While in this environment, as a husband and father it was hard not to wonder what life would be like for my loved ones should the place of their birth have been different. It was a privilege to be able to make a small contribution to the lives of some very vulnerable people.
By Dr Tony Diprose, published by NZ Anaesthesia December 2016
Video link : https://vimeo.com/171768893 The Mercy Ships response to Global Surgical Need (3 min)