Dilan Ellegala returns to the tiny bush town of Haydom in the summer of 2007, Tanzania's dry season, when the sun scorches the fields of maize and sunflowers, and the air fills with clouds of fine red dust. Ellegala greets the staff of Haydom Lutheran Hospital like old friends, including the medical technician, Emmanuel Mayegga, the man he trained to do brain surgery during his first visit the year before.
Ellegala beams as he hears Mayegga describe his recent brain surgeries. He sees that Mayegga is especially excited about one case, a man brought to the hospital after being beaten on the head with a stick. The patient was unconscious, paralyzed, about to die from a brain hemorrhage, but Mayegga opened his skull and stopped the bleeding. A month later, the man was walking around with barely a headache. "I want to show you photos!"
Ellegala feels as if he's returned home, as if it's a celebration, but he's also worried about the results of a study, a thundercloud that could douse his plans to teach brain surgery in the bush.
A few months before, Ellegala dispatched two graduate students to examine how Mayegga's brain surgery patients were faring. At first glance, the numbers didn't look promising; Mayegga's patients died at a higher rate than those Ellegala treated on his visit the year before.
Maybe I need to fold the program now, Ellegala thinks before he dissects the graduate students' work. They're still in Haydom and give him breakdowns of their findings. He notices that several of Mayegga's patients died from infections. Then it hits him; it's the shunts.
Mayegga used cut-up IV tubes as brain shunts during these operations because regular shunts weren't available. It was Ellegala's idea to use these shunts -- the patients would have died without them -- and he used them himself in several procedures. Some of Ellegala's patients developed infections, but Mayegga did many more of these operations. Factor out the patients with the makeshift shunts, and Mayegga's patients did roughly the same as those in clinics elsewhere in Africa with trained specialists. The shunts and lack of good infection control procedures were the problems, not his student.
Ellegala breathes a sigh of relief. He knows he needs more evidence showing that you can teach non-physicians basic brain surgery, but this data is good enough to keep pushing forward. He strolls through the hospital's grounds with a lighter step, saying hello to the staff, asking about the latest news.
It has been especially busy in the children's ward, they say, and have you heard? A new pediatrician from Holland arrives in a few days.
Her name is Carin Hoek, a tall and athletic woman with short blonde hair, a lilting voice and an electric smile. Ellegala spots her as she leaves the morning reports.
"I'm really excited you're here," he says as professionally as possible as this woman, this bolt of lightning shocks his brain in a way he never felt before.
The electricity isn't mutual, though. In fact, Hoek is a tad put off by Ellegala and his entourage, all in their bright white coats, embroidered letters saying "Neurosurgery," very impressive. No, her mind is on her work in the children's ward; she plans to stay here for two or three years; the last thing she needs is a fling with a visiting American surgeon.
But then she watches him during the morning meeting. He's different than some of the other overseas doctors, more patient, a teacher. She smiles as he rearranges everyone in the room, asks the visiting doctors and medical students to move to the rear to make way for the Tanzanians. One morning, he puts a CT scan of someone's neck on the light board and asks the Tanzania clinical officers what they see.
"A liver," one guesses, and Hoek figures Ellegala will do what her professors did, drop the person down a notch, use pain as a motivator to learn, but instead Ellegala says, "Well, maybe ..." and continues teaching until everyone knows they're looking at a neck. That's it, she thinks, you don't lower people who have been at the bottom of a ladder for years, you raise them. Wonderful! But some visiting doctors aren't sure about this guy and even suggest he's lazy. One day a visiting orthopedist ask Ellegala about a patient with a tumor.
"What do we need to do with this patient?" the orthopedist says.
"Why don't you ask Dr. Mayegga?" Ellegala answers.
"Why are you here then! You are the specialist!"
Ha, by now, she knows such comments are an open door that Ellegala is only too happy to walk through, no, burst through: We're not running the hospital; the Tanzanians are. What happens when we leave? Look at Mayegga; he's learning neurosurgery now. If there's a problem, he knows I'm here. We need to train people like Mayegga, and then train them to train others. Do that and someday maybe we won't be needed here anymore!
She sees how the Tanzanians stand a little taller now. But just because he's a good teacher doesn't mean she's in love with him. She sees him leave Haydom in October with his team, she figures for good. Meanwhile, every bed in her ward has a child who needs help.
Lifeline or noose
Sunil Patel, clinical chair of the neuroscience department at the Medical University of South Carolina, vaguely remembers an e-mail from him years ago, maybe an inquiry about MUSC's program. Dilan Ellegala, unusual name. Now, Patel sees he's asking about a job in Charleston. Looks good on paper, he thinks. More than 20 studies and papers to his credit, done groundbreaking research in the use of microbubbles to assess brain blood flow. Looks like this guy thinks out of the box. Patel likes that in his people.
Patel is a compact man with glasses and an accent that's a blend of his Indian roots and three decades in South Carolina, part curry, part shrimp and grits. Tanzania? He was born there, in Dar es Salaam, which has a large population of Indian immigrants, moved to Zambia when he was 5, studied for hours in the mango trees in his backyard, sometimes with a monkey he named Chiku. He loved that monkey. They played jokes on each other, taunted each other, until that day his parents announced the family was moving to America. Chiku hears the news and bolts, never to be seen again, and even decades later, Patel gets misty-eyed when he tells the story. That's why his patients are so devoted to him; he's a softy, a listener in a medical specialty with a reputation for arrogance. He majored in physics at Clemson University, then went to MUSC for his MD.
Now, along with co-chair Peter Kalivas on the research side, Patel runs a department with ambitions to become one of the neuroscience greats. MUSC neuroscience? Number two in the nation for National Institutes of Health neuroscience funding, right up there with Columbia University, Johns Hopkins, Harvard.
You don't move forward by thinking inside the box. You get there by using lasers to stimulate brain circuits, inserting electrodes deep into the brain to cure depression, pioneering ways to remove tumors through the nostril. You do things that take a page out of Mary Shelley's "Frankenstein."
Swelling in the brain? It's a killer because the brain has nowhere to go. So when necessary, Patel and his colleagues might put a patient in a coma, remove a portion of the skull, implant it in the patient's abdomen to preserve it, wait for the swelling to go down and then reattach the skull. The brain is like an unexplored continent, he says: If it were the United States, we've only explored Manhattan.
Patel wants the best of the nation's best, and he asks a colleague, Dr. Ian Johnson, for his take. Johnson trained with Ellegala at a demanding neurosurgery program at Harvard. Ellegala is good, Johnson says, you need him here.
Patel invites Ellegala to Charleston for an interview. Ellegala tells Dr. Ray Greenberg, MUSC's president, about his work in Tanzania. Greenberg thinks, Wow, this is amazing, but wonders whether such a young neurosurgeon can juggle his responsibilities in Charleston with those in Africa.
Patel takes him to dinner, and they end up having drinks at the bar in Charleston Place. They click. He gets an offer from Colorado but his gut tells him that personal relationships are more important at MUSC than other places he's worked and trained. It's like that in Tanzania, he thinks. I can make a difference in both places.
Patel hears Ellegala's stories about Tanzania, about how a global health program could benefit doctors and medical students in South Carolina, as well as those in Tanzania. No neurosurgeon talks about global health. Interesting. The man has charisma, no doubt. Then again, Ellegala failed to make it at Oregon. But every new hire is a leap of faith, and Patel makes an offer, thinking, I will give him a rope and hold it tight; he can hang himself, or use it as a lifeline.
Wedding in the African bush
From Charleston, Ellegala sends e-mails to Carin Hoek, seven time zones away. He will return in December, he says, promise. She doesn't believe him. She gets more e-mails. Hmm. One asks her to meet him in Arusha, a town in the shadow of Mount Kilimanjaro. He needs to buy a car. Will she come and help him?
Hoek is a bit puzzled. Buy a car? Why does he need my help? Besides, Arusha isn't exactly around the corner. From Haydom, you take a bush plane or a backbreaking seven-hour drive on hard-packed dirt roads.
OK, she knows he's flirting, just like that bush pilot who's after her, and the mechanic, and that other doctor at the hospital. But she goes anyway because she needs a break from the hospital's grind. A few weeks later, she meets him at the airport, sees him grinning as he walks toward her. And here's another bolt of electricity, but this one hits her. They buy a Land Rover and drive back to Haydom, the neurons in their brains firing in tune. During an evening walk a few days later, he tells her what she's already thinking, "Do you realize I'm going to marry you?" A few days later, on the last day of 2007, he proposes.
The wedding will be on Haydom's grass airstrip, and about 5,000 guests will attend. Why so many? Curiosity about how white people get married perhaps, some villagers would say later with a laugh. No, it's deeper than that. The people in Haydom have witnessed the couple's dedication in their hospital, how they accept their ways, eat their food, learn their language. Because of this, they accept them as adopted son and daughter, and as Emmanuel Mighay, the hospital's nurse in charge and one of Ellegala's best friends, later points out: "When your son gets married, you go to the wedding."
Everyone is invited, and it seems like everyone comes. Tongue-clicking Hadza, Datoga people with their bright red cloths and tattooed faces. Hoek's tall pale white family members from Holland; Ellegala's brown-skinned family from America by way of Sri Lanka.
Five goats are slaughtered and roasted on spits.
Hoek's small plane touches down, and she marches down the long grass in her cream-colored dress, escorted by her father. Now that's an entrance.
She heads to the tent where Ellegala stands with his best man, Mayegga, both holding wooden staffs.
Women wave branches and trill yi, yi, yi! Men with spears dance traditional dances.
Ellegala and Hoek take their vows and kiss, and suddenly, as if on cue, a storm crashes through, soaking everyone, blowing down the tents, sending everyone scurrying for shelter, and in a place where water separates life from death, everyone agrees there is no better sign from above.
SUNDAY: A Doctor's Quest: Teaching brain surgery in the bushMONDAY: One Brain at a Time, part 2: Are medical missions doing more harm than good?TODAY: Ellegala creates a nonprofit to teach brain surgery in Africa, and finds love in the process.WEDNESDAY: Ellegala and MUSC team up to create an international model for health care training in developing countries.