Surgery and Healing in the Developing World - Dartmouth-Hitchcock

6
38 Surgery and Healing in the Developing World
department. Insofar as possible, in deference to the culture, sexes are strictly separated.
Most of the common textbooks, but not journals, are available. Only a
couple nursing stations have sinks, above which hang wet cloth towels “to dry one’s
hands” (preferable to drip dry, it would seem). Monitors, as we think of them, do
not exist, nor is there a ventilator in the hospital ... not even in the OR! A brace
and limb shop, reputed to be the best around, fashions prostheses which look
amazingly authentic.
Oriented to the customs and mores ... never do anything with the left hand;
do not wear shorts; do not display affection in public; don’t drink unboiled water;
don’t buy watermelon along the road ... it’s injected with nonpotable water to
increase weight. The work week is Saturday through Wednesday; ‘church day’
(day of worship) is Thursday for us, Friday for Muslims.
6/17: Rounds with staff at 0830 hours. Nurses, having considerable autonomy
and authority as a result of keen clinical expertise and physician staff shortage,
round first, provide necessary care and chart. Medics complete all history/physical
records. Most impressive protocols have been developed, with ‘routines’ for just
about everything encountered regularly (i.e., prepartum, postpartum, malaria,
typhoid, etc.). We identify patients by bed number. The women’s ward is much
busier, owing to the large volume of complicated obstetrics. The large majority of
routine deliveries occur in the village. Hepatitis B positivity runs about 25%.
Village practitioners, qualified or not, love to administer injections, of course
with used (not necessarily sterile) needles. Most patients are tested upon admission
for HBV and HIV (not common yet), and if positive, flagged at the bedside by a
prominent poster. We double-glove, naturally with recycled gloves, routinely. Only
polio and diphtheria cases are isolated. The deadly falciparum malaria predominates
in this region. Measles, malaria, malnutrition, pneumonia and diarrheal
diseases constitute the major killers. Mattresses are made of coconut husks, rubberized
and covered with a plastic for easier cleansing.
Saw a woman come in labor, prolonged and septic as a result of ‘stick abortion’,
a form of partial birth abortion in which a green stick is poked vigorously
into the head of the term fetus. Islamic faith teaches that abortion is sin. Yet, if
prenatal ultrasound, available in the village but not in the hospital, documents a
female fetus, abortion is justified as ‘menstrual regulation’. Come to think of it,
hypocrisy exists here just like back home!
We work in not only the poorest district in Bangladesh, but also the least
literate (20% for male, less than 10% for female). Suicide is common, customarily
by ‘rice poison’. Opium use is increasing. Virtually all men smoke. Nobody is
covered by health insurance. When a patient does not pay, a ‘relief committee’
comprised of a Hindu, Moslem and Christian (all nationals) meets to arrive at a
fair settlement. Sometimes a ‘broker’ represents the family’s case, for a fee of course.
A hospital bed costs $1.25 per day, with medications and food additional.
With Tibet just 20 miles to the east of the compound, the ethnic, linguistic,
cultural and religious admix is most complex and confounding. Here, in
Bangladesh, the Indo-European and Tibeto-Chinese persuasions collide. Religious
faiths include Islam, Buddhism, Hinduism and Christianity, but at a practical
level most are animists or spiritists. That is, a great deal of energy is expended to
placate the unseen, but exceedingly powerful, world. In the surrounding community,
largely Muslim, rumors abound: ‘Christians are evil.’ ‘The hospital gives
Christians good medicine, but gives Muslims bad medicine.’ ‘The shots given