On a medical mission in a developing nation, I found I could acclimate quickly to many things with surprising ease: heat, mosquitoes, odors, lack of medical supplies. These blend quickly into the background. But I never got used to death, even if I tried to pretend differently.
Our team knew we couldn’t save everyone, and we were only visitors to Uganda. One patient, a teenage girl, sustained injuries from rape so devastating it was uncertain that we had the resources to treat her. This is the story of how the team, especially the women on the team, drew a moral line and simply refused to give up on her.
My group was spending a week at the Mbarara National Referral Hospital in Uganda, ready to help dozens of girls and women who suffered from vaginal fistulas — injuries sustained during childbirth, which left them leaking urine and sometimes feces, making outcasts of them and destroying their chances for normal life. Nicholas Kristof, the New York Times columnist, has written eloquently about how simple repairs can transform the future for these patients.
We took over the staffing of three of the four operating rooms at the hospital, planning to use two rooms for fistula repairs and a third for emergency C-sections. But starting on Monday morning that week, we learned quickly that plans and good intentions aren’t always enough to avert tragedy.
The first bad news came from the postpartum ward, where a new mother had died overnight from a hemorrhage. There simply wasn’t blood available to save her.
Then, the first C-section of the morning produced a stillborn infant. So did the second one. The third and fourth C-section patients gave birth to preterm baby girls, but there were no NICU ventilators to keep them alive. Two of our lay volunteers, Nina and Lauren, stifled tears as they cradled the babies, who gasped weakly for air and then turned blue and cold.
On the positive side, we successfully finished ten vaginal procedures in the course of that day. I’m always stunned by how little equipment we actually need for these cases — no oxygen or EKG leads. Some alcohol prep, a spinal needle, and a large bottle of preservative-free bupivacaine allowed us to anesthetize each patient without even using any sedation.
Music from Michael Jackson and Paul Simon played in the background from my iPad as the gynecologist and I moved efficiently through our elective schedule. But during the breaks, the stress and heartache of the OB team couldn’t be ignored.
Death happens earlier here, everyone agreed. Kim, our high-energy, experienced OB nurse from my San Jose hospital, circulated constantly among the three ORs, making sure things ran smoothly. If she was feeling the strain, she didn’t let on. But Monica and Ruxandra, two OB residents volunteering from Santa Clara, looked visibly weary. It had been a rough day for the OB team.
Near sunset, we started filtering back to our hotel, still in scrubs, to unwind over local drinks. The young women in the group, the two OB residents and the two lay volunteers, were clearly shaken up by the day’s events. We all realized, if we’d never known it before, that women in Uganda are second-class citizens as they are in many underdeveloped nations, especially in their lack of access to medical care. We told each other that tomorrow would be better.
But Tuesday morning, we learned that another young woman had died during the night from septic complications following a crude village abortion procedure. And we found out about a girl of 18 who had spent the night crumpled and unconscious near the labor ward, overlooked among the many patients and families who crowded the hospital corridors and grounds.
Let me explain a little about Mbarara. Though it is the second largest town in Uganda, the population is only 80,000. The university hospital doesn’t begin to match an American’s mental image of the hospitals at Stanford or UCLA. It’s impossible to say how many beds there are, as cots and stretchers fill up all available space. Families come from hundreds of miles seeking help, but there is no organized intake process. It can easily happen that a patient will lie unattended in a corner if there is no family member to demand attention.
That was the case with this teenage girl, who I’ll call “Veronica.” If Gordon, the obstetrician on our mission team, hadn’t noticed her, she would almost certainly be dead. He asked a translator who she was and what had happened. She had been gang-raped in town and then left for dead. Bystanders had brought her to the hospital. Badly beaten and unable to move, she had already spent hours without fluids or any other emergency care.
Word about Veronica spread quickly throughout the hospital. The violence of her attack shocked the native Ugandans as well as the Americans, since Mbarara is normally a peaceful place. “This is something that happens in Congo, not Uganda,” they said.
The extent of the traumatic injuries to Veronica — to her vagina, rectum, and bladder — was horrifying. The problem was that we had a full operating schedule already, with another ten vaginal fistulas to repair. Nina and Lauren, the volunteers, wouldn’t give up on her though. “But what about Veronica?” they persisted. We agreed to operate on Veronica at the end of the day.
Suddenly Veronica’s survival became our mission within the mission. Fortunately, a representative from Cook Medical was able to provide round-the-clock IV antibiotics, pain medications, meals, and special nursing care for her. We took careful photos of her injuries and filed a police report. The team scrambled to put together instrumentation for her surgery, anticipating a colorectal repair.
Late in the afternoon, Veronica’s case started. Spinal anesthesia was the only option and, as you might guess, her blood pressure hovered dangerously low as we resuscitated her with IV fluids. I was working with two remarkable anesthesia residents, Andrew from Mbarara University and Bushra, a young woman from Massachusetts General Hospital (MGH) who was part of a separate ENT mission team. The news of Veronica’s attack had reached the MGH team too, and she wanted to be there to help.
As I watched our mission team repair Veronica’s many lacerations and the terrible damage to her pelvic organs, I realized the powerful impact that her case had made on us all. We could not walk away from her. We believed that violence against women was not OK and couldn’t be ignored. Though we couldn’t save everyone, and we had been battered by so many deaths, in healing Veronica we had a chance to make ourselves whole again.
This is how morality starts, I thought, when a group of people decides to act.
My thoughts were punctuated by the sound of a baby’s cry. A C-section in the OR next door had yielded a vigorously kicking, wailing baby. “A screamer,” said Nina in delight, cradling the newborn. Everyone was thrilled at the birth of a healthy infant, at last. Cry all you like, we told the baby.
Veronica survived. She stayed in the hospital for two weeks, and her family arrived to take her home.
We returned to San Francisco. As our flight landed, the clicks and beeps of smartphones started up, and conversations began. Taking a last look and saying goodbye to the women of our mission team, I realized how normal they seemed, and yet how extraordinary they were in their sense of sisterhood with one Ugandan teenager and their determination to see her safely through her ordeal. What courage under fire, I thought. They make our world a safer place. Of such stuff are civilizations made.
Editor’s note: Dr. Chow reports that Veronica has physically recovered from her injuries, and that two men have been arrested in the case. Nina, the volunteer mentioned in the article, continues to follow up on Veronica’s health and the prosecution of the suspects.
Dr. Chow is a frequent contributor to CSA Online First. Currently he is in private practice with Group Anesthesia Services (GAS) and is the Chair for the Department of Anesthesia at Good Samaritan Hospital, San Jose. He also holds an adjunct community faculty position at Stanford School of Medicine. The medical mission was supported and organized by Dr. Tom Margolis of the Medlend Foundation.