Yes's & No's

One of the more difficult things to wrap your head around about the work being done on the Africa Mercy is the "no's."

There are a number of reasons patients would be disqualified from receiving surgery on board. They're all very good reasons, formed over decades of experience.

That doesn't change the fact that it's hard to say no. It often hurts.

The seemingly endless lines are sobering - though I've never seen them in person, I have met many people throughout the country who ask, "I have a hernia, can you help? My uncle is blind, can you help? My mother can't walk, can you help?" I have also had to explain to patients, on occasion, that although we had tried our best, there was nothing more medically that we could do to help.

One of my friends (and current cabinmate) Maddy is part of the screening team - the ones who decide who to say yes to, and who we must turn away. They have, without a doubt, one of the hardest jobs here. There is a lot more involved in the screening process than meets the eye, however, as I've learned from Maddy this year.

The first (and most visible part) of the screening job is to select, from thousands upon thousands of hopefuls, the best candidates for our surgical programs. Here, in Senegal, the Ministry of Health is also involved in this process; local physicians in each region of the country are doing initial assessments before our screening teams arrive. Those who fit certain criteria are then asked to return when our screening team visits that region.

Risk vs Reward

There is a very specific list of surgeries and procedures we can perform on board, and a very specific list of factors that would immediately rule surgery out. It is not easy to rationalize these decisions when staring into the face of someone who is hurting. It's hard to think about the big picture when facing an individual in a difficult moment. The fact of the matter is, however, that charging into any kind of humanitarian work headstrong and reckless often causes more harm than good, despite the best of intentions. I don't think I can say that what we do is the best solution, but it is one carefully thought and developed in collaboration with local professionals, officials, and experts in this field. 

The goal, in essence: provide the greatest possible improvement in quality of life, for the greatest amount of people possible, with as little risk of harm as possible.

Easier said than done.

The most clear-cut factor we consider is a patient's age. Over the age of 70, the risks of most surgeries far outweigh any benefit that might be gained. Recovery tends to take longer, have more complications and setbacks, and (harsh though it may sound), younger patients will have more to gain from their improved quality of life after surgery. More years to make the most of their new mobility, restored dignity, or repaired vision. Life expectancy in Senegal is only 67 years. 

The list of surgeries we can offer our patients is limited, in part, for similar reasons. Some surgeries would be incredibly high-risk, with very poor odds of recovery, and would be genuinely unethical to attempt. Some we simply don't have time or space to fit in, with our limited schedule and resources. Sometimes we don't have a surgeon who is willing to serve with us who has the necessary training and experience for a certain procedure. 

The resources of our host countries are also taken under consideration. With more and more of an emphasis being placed on mentoring and capacity building, we want our surgical programs to mirror those which exist (or are at least feasible) within West Africa. It is no good teaching a surgeon laparoscopic surgical techniques if laparoscopy is (for the foreseeable future) unattainable in most African countries. 

The 'C' Word

Another challenging factor to consider is cancer.

Tumor removals, of various kinds, make up a large part of our surgical programs. We advertise widely about it in our screening announcements. 

Things get complicated if we believe a tumor to be malignant. In most cases, surgery alone is not an effective treatment against cancer. Radiation and/or chemotherapy is usually necessary, and, unfortunately, is hard to come by around these parts. Available - potentially - but expensive. This is a really good article by the BBC about the barriers facing cancer patients here in Senegal.

You'll notice I said 'most' cases. There are a few situations where we do consider surgery for patients with confirmed, cancerous tumors. If our imaging shows no metastases, if the cancer is very localized to one area, if it can be removed intact with wide margins, and if it's believed removing it will provide a reasonable extension of life...then and only then will we consider surgery for them. In almost every other case, as we cannot provide long-term, ongoing oncology care, it would be unethical to operate. We would be causing pain, trauma, and a lot of risk for little to no benefit.

The main case where we would do often go ahead with surgery is breast cancer. It turns out that surgery alone is a reasonably effective treatment for breast cancer, although, most of the data on the subject is decades old. Recruiting research candidates for something potentially life-threatening, when a certain treatment regimen is proven to be quite effective - again, kind of unethical. What research we do have (from the 90's) seems to indicate a 5-10% higher risk of the cancer returning when treated with cancer alone. Not ideal, but if it's the only option you can afford, I daresay it's better than the alternative. We can potentially extend life by 10 years or more with just surgery. Worth it. 

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Next blog I'm going to have my friend and cabinmate Maddy (a screening nurse) answer a few FAQ's. If you've got any questions about the screening team's responsibilities, or the patient selection process, please drop them in the comments below, or on facebook.

À la prochaine,
-D