Service From the Heart -- Lessons From Mozambique

Zain Khalpey, BSc(Hons), MBBS(Hons), AFRCS

Disclosures

Service From the Heart -- Lessons From Mozambique

Ken was 5 years old and he had Tetralogy of Fallot, a constellation of congenital heart defects (Figure 1). He was a fisherman in a blue-tiled operating room, with sea secrets in his eyes. His legs hooked over the operating table and his little sandals fell to the floor. As he lay flat, he could not overcome his involuntary shivering. A tear fell down his cheek onto the syringe of fentanyl. He was soon asleep. In the newly furnished Heart Institute in Maputo, Mozambique, the Chain of Hope volunteer medical team, led by Professor Sir Magdi Yacoub, Professor of Paediatric and Adult Cardiac Surgery at the Royal Brompton and Harefield NHS Trusts in London, was about to perform the 4-hour operation to try to correct Ken's diseased heart.

Figure 1. Ken, Photograph: Lizzie Orcutt, June 2001.

I am a third year surgical Senior House Officer (surgical resident), doing a part time PhD in Cardiothoracic Surgery. I became involved in the Chain of Hope in 1999, when I delivered some children's books to the charity. The Chain of Hope (La Chaine de l'Espoir) was founded in France in 1988 as part of Medecins du Monde. In 1995, it became an independent charity and Prof. Yacoub established Chain of Hope, UK. The charity provides free heart treatment to children from war-torn, impoverished, and underdeveloped countries. Sometimes, children from these countries are flown to the United Kingdom for surgery; other times, teams of physicians are flown to the children. I was part of the Chain of Hope volunteer team mission to Maputo, Mozambique, where a multinational (Swiss, French, Portuguese, British) Heart Institute was being set up by Sir Yacoub, together with 4 European partners. The multidisciplinary team consisted of surgeons, a perfusionist, cardiologists, anesthetists, ITU nurses, intensivists, and physiotherapists, who volunteer their time and skills to help treat children (Figure 2).

Figure 2. The Chain of Hope team.

I became close to all of the team members. A Senior Intensive Care Nurse from Australia, John Ttikirou, was on his sixth mission. One day during a break together, he told me that, "despite the language barrier, the intimacy that develops between a nurse and a child make this an enriching and rewarding experience. Nothing can replace this feeling I have." Though late in the evening, and having missed most of his other breaks that day, his smile and energy never broke.

One of the main team players and coordinators of these missions is a Zimbabwean-born Consultant Cardiac Anaesthetist, Dr. Gavin Wright. The missions are a success because "what is more apparent in underdeveloped countries is that medicine, with its fundamentally altruistic and 'patient welfare first' philosophy remains." I appreciated this comment. Besides the required delicate balance between financial and professional considerations, we must also try to maintain an appropriate balance between the science of medicine and its humanism. Medicine is grounded in science much more now than ever before in history, and the core of medicine must remain as science in its clinical application. Nevertheless, science alone can never be enough. A solid exposure to real needs is necessary to ensure a humanistic approach of doctors to the care of their patients. Their attitudes and values must reflect a concern for human beings, their achievements, and their sense of dignity. A special relationship exists between doctors and their patients. The provision of a selfless service is an attribute of any profession, but this is especially true of medicine. I began to realize how easy it was to get "caught up in the system." Today, doctors in the United Kingdom practice in a different, more business-oriented environment. But this business model, in which healthcare becomes a commodity and doctors become factory workers who depart promptly when it is five o'clock, benefits no one. The attitude can never be "profits before patients," "money before medicine." Patients and doctors alike perceive that medicine is moving away from its principal focus on caring and they do not like it. As technology and economics intrude so prominently into the innermost sanctum of medicine, the essential transaction between doctor and patient is threatened as never before. Every day during ward rounds, patients feel shortchanged by the brevity and abruptness of their encounters with doctors. They see medicine being influenced by big business and turning to assembly-line, clock-punching methods. Patients want their doctors back.

In Mozambique, I felt like a doctor again. Medicine's response to commercialism must be the doctor's insistence on adhering to the altruistic canon of medical care. No laws, no regulations, no patient's bill of rights, no fine print in insurance policy, no watch dog agency; nothing can substitute for trustworthy doctors who care. All of this was evident in Mozambique.

Heart disease remains as lethal a predator in Mozambique as it is in other developing countries. Surgery in the developing world is usually performed against a backdrop of poverty, patients' low awareness of its possible benefits, and limited medical resources. Most patients live in rural areas, present to clinics with advanced disease, are malnourished, and cannot afford to pay even for low cost medicine. Diseases requiring surgery account for an estimated 10% to 15% of all admissions to hospitals in the developing world and are the cause of 20% of deaths in young adults.[1]

I felt that The Chain of Hope provided a channel to preserve medical professionalism, preventing a hollow mockery of the Hippocratic oath. The Chain of Hope offers an interim measure by bringing first world resources and expertise. This form of foreign aid and donations is not a simple solution to temporarily cushion the indigenous system. It serves as a catalyst for local doctors to identify what is wrong with their system and develop a basic and uniform cardiac surgical care service, in the end providing a center of excellence. A hospital for heart surgery with doctors like Professor Yacoub and Gavin Wright on the staff, albeit in a temporary capacity, is what heart patients in these areas need.

Consultant Cardiologist, Dr. Radley-Smith, another valued member of the team, makes sure that the preoperative assessment is performed meticulously because surgery is only granted to children whom she believes can be cured on a limited budget. Postoperative care is conducted by Dr Beatrice and Dr Anna Olga, Portuguese doctors who are French-trained cardiologists. The channels of communication are open all the time. There are many hidden emotional, personal, and financial costs for every member of the team that exceed the mission cost of GBP 40,000.

In life, when one makes a judgment or decision, it is subconsciously or consciously influenced by many things like color, creed, nationality, and materialism. All of these barriers appeared to be dissolved in Mozambique. Working together as a team with so many people from different backgrounds was simple and effective. There is an inevitable disconnect between the altruistic Hippocratic principles of healing the sick and the necessary commercial aspects of surgery. In Mozambique, a small group of people, lead by Professor Sir Magdi Yacoub, managed to virtually erase that (Figure 3).

Figure 3. Professor Yacoub with patient.

Professor Sir Magdi Yacoub is the kind of person who extracts the good from the debris in everyone he meets. His complete self-confidence eases the cold process of surgery that often frightens patients, especially when they are young and there is a language barrier. Patients need to be nurtured by a surgeon because of the traumatic nature of the situation. Professor Yacoub does not make himself the central figure, he is a true healer who does not bask in the attention of a job well done so patients always benefit. There is no search for the philosopher's stone in any operation that he performs and his tenderness and humanity in a profession I still view as technical and cold-blooded is awe inspiring. Professor Yacoub instills great confidence in the team and in patients.

One especially memorable patient was a 17-year-old boy, Anciento, who said after his ventricular septal defect operation, "I will wake up every morning and remind myself to live 'right now,' in the present. My goal is to enjoy my life, one day at a time, and to ride as many motorbikes as I can." The presurgery purple hue had vanished from his lips and they became a more natural color.

Often, physicians see a patient as a diseased entity: "the hernia" or "bed 9." However, that patient is a person with hopes, aspirations, and fears, which he or she trusts the doctor to consider. Physicians must become involved not only mentally but emotionally, philosophically, and spiritually. That this was possible to experience in Mozambique, despite a language barrier and other obstacles, was an eye opener for me. As Pliny said "Semper ex Africa aliquid novi." -- Out of Africa always something new.

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