By the numbers
3Neurosurgeons in Tanzania4,388Neurosurgeons in U.S.2.4 millionPhysicians and heath care workers needed in low-income countriesWorld Health Organization, Tanzania government
HAYDOM, TANZANIA — A baby lies swaddled in green towels in a hospital on the edge of Tanzania's Rift Valley, her head bulging from hydrocephalus, her brain slowly self-destructing. Dilan Ellegala, an American neurosurgeon, stands nearby as two young doctors prepare to open the baby's skull.
One doctor is from Germany. Desperate to save babies like this one, she taught herself how to insert tubes into a brain and shunt the excess fluid to a child's abdomen. But her skills are limited, her technique raw. And even if today's operation is successful, what will happen to other sick babies here when she leaves in a few months?
The Tanzanian doctor? He's barely out of medical school and isn't trained to operate on someone's brain. This is the norm in East Africa: Only three Tanzanians out of the country's population of 45 million practice neurosurgery.
People with injured brains and spines either heal on their own or die, though for a time, Haydom Lutheran Hospital had found a way to stop many of these needless deaths.
Read Tony Bartelme's 2010 series of stories, One Brain At A Time.
In 2006, Ellegala spent six months here on a working vacation. Frustrated with the absence of Tanzanian surgeons, he taught a clinician named Emanuel Mayegga how to do brain surgery. Mayegga had the training equivalent of an American physician assistant, but he had a surgeon's hands and a quick mind. He learned how to remove tumors and treat head injuries. Then he taught what he knew to a Tanzanian doctor, who taught a third.
Together, these three Tanzanians saved hundreds of lives. And buoyed by their success, Ellegala, formerly of Charleston, created a nonprofit called Madaktari Africa, with the goal of curing a problem that some call the “neglected stepchild of global health.” From sub-Saharan Africa to South America, vast numbers of people die or live with debilitating injuries and diseases because of a severe shortage of surgeons and other medical specialists.
Over the next few years, Madaktari (Swahili for “doctors”) Africa evolved into a multi-faceted experiment in how to help others in poor countries.
Instead of setting up short-term medical missions — trips where doctors swoop in and treat as many patients as possible, then leave — Madaktari would focus on training people, then teaching them to train others. Ellegala hoped this “teach-first” approach would lead to a new generation of medical leaders in Tanzania and reduce its dependence on foreign doctors.
Working with doctors, students and nurses from the Medical University of South Carolina, Madaktari Africa set up cardiology, anesthesia and dialysis training programs. More than 500 volunteers from seven other U.S. and European universities traveled to Tanzania to teach. The president of Tanzania had become one of Madaktari's strongest supporters.
And yet, in late January, Ellegala is back in the operating room in Haydom with a baby suffering from hydrocephalus and no Tanzanian around with the skills to save her. Mayegga is gone, off to medical school in Dar es Salaam. And the two Tanzanian doctors Mayegga taught also left for additional medical instruction. Brain drain from rural to urban areas is a problem in the United States, but it's much worse in East Africa, where freshly minted surgeons can make enormous sums by practicing in cities or moving to wealthier countries. Had his teach-first approach really made an impact?
Ellegala scrubs his hands in an old sink outside the operating room as a nurse inside leans next to a tray of silver instruments, a clutter of scissors, retractors and forceps. Doors to the hall swing open and closed, vectors for infections and flies. A piece of clear medical tape keeps the window shut.
With no breeze or air conditioning, the room warms as the German pediatrician makes an incision on the right side of the baby's head. The Tanzanian doctor takes over and fumbles under the skin flap with his forceps. Ellegala knows that Mayegga could knock out this procedure in half an hour.
But will Mayegga and the other doctors ever return? If they don't, then isn't his teach-a-man-to-fish work a failure? What is the real meaning of “sustainable?” Will this baby make it?
Surgery in the bush
Tanzania is a kaleidoscope of languages and landscapes. It is 10 times the size of South Carolina and has 130 ethnic groups. Three-quarters of the population lives in rural areas where many live on the equivalent of one to two dollars a day by raising cattle or growing sunflower and maize. Cellphones keep people connected, and it's typical to see stick-wielding cattle herders with phones pressed to their ears. Ellegala fell in love with this place when he first traveled here in 2006.
Ellegala is a tall man with a shaved head and dark arching eyebrows. He was born in Sri Lanka but moved to South Dakota with his family when he was 5. Even at that young age, he wanted to be a doctor. In medical school he decided to specialize in neurosurgery because he loved the complexity of the brain and the challenge of fixing it when something went wrong.
Like most American neurosurgeons, he spent much of his young adulthood training toward this goal. In all it took 14 years of medical school, residency and fellowships, and when he emerged from this tunnel of education, he was fried. To clear his head, he decided to spend six months at Haydom Lutheran Hospital, partly to keep his skills sharp but mainly just to explore and unwind.
His plans changed as soon as he arrived. Norwegian missionaries built the hospital in the early 1950s, and it now served about a million people in a region that stretched from Rift Valley plateaus to the Serengeti game parks. Brain surgery was such a foreign concept here that it lacked even a simple saw to cut open a patient's skull, an implement that might cost $20 in a modern hospital.
Yet this mixture of dust, wood smoke and scarcity ignited something inside him. When he learned that the hospital didn't have a proper saw, he bought a wire saw from a farmer and used it instead. The operating room's lights were too dim so he donned a camper's headlamp to better see what he was doing. He used duct tape to hold appliances together, metal scraps from the hospital's garage to fuse broken spines.
The hospital's staff talked with excitement about how they finally had a neurosurgeon; no longer would they watch patients with treatable head injuries and minor brain tumors die. But amid this excitement, Ellegala wondered: What happens when I leave?
The country's three neurosurgeons in Dar es Salaam could do some cases, but that city was a bumpy, two-day bus ride away, and too expensive for most people anyway. And the situation was even worse elsewhere in East and Central Africa. At the time, 11 countries had no neurosurgeons at all.
A little swagger
On occasion, visiting doctors filled this gap, descending on hospitals and villages with teams of nurses and containers of tools. They treated as many patients as they could, then left after a week or two, often mixing in a safari or beach trip to the spice island of Zanzibar. Ellegala began to see that foreign doctors like himself were making the problem worse. Their presence saved a few lucky lives but perpetuated a culture of dependency.
In his mind it was a new form of colonialism. He noticed how American and European doctors and medical students dominated meetings while the Tanzanians huddled in the back, though one local clinician seemed different — Emanuel Mayegga.
Now in his early 40s, Mayegga had grown up in a mud hut a half hour from Haydom. He had worked his way through school by selling charcoal and doing other odd jobs. After Tanzania's equivalent of high school, he received about five years of training to work in health clinics and now had the title of assistant medical officer.
Ellegala saw something in Mayegga that the others lacked — a bit of a swagger; he walked with a little more determination, asked more questions. These were traits he often saw in American surgeons. After seeing him work with patients, Ellegala told him one day, “You can be a neurosurgeon.”
Mayegga balked, thinking that he might get in trouble with the government. But Ellegala reassured him; he would teach him what he needed to know and would be nearby in case he ran into trouble. For the next six months, he showed Mayegga how to treat people with head injuries, insert shunts into babies with hydrocephalus and do other basic brain surgeries. “He was a natural,” Ellegala recalled. “Within a few weeks, he was doing procedures on his own.”
Mayegga also had a knack for teaching, and eventually taught what he learned to a Tanzanian doctor, Emanuel Nuwas. Nuwas had just joined the hospital after getting his medical degree and also was a quick read.
Over the next few years, Ellegala and Sunil Patel, chairman of MUSC's neurosurgery department, traveled to Haydom and taught Nuwas ever-more complex procedures, including tumor removals that would challenge the most experienced Western neurosurgeons. Nuwas proved to be a teacher as well, and he and Mayegga would go on to instruct a third young Tanzanian doctor, Samo Hayte.
Better yet, when Ellegala and other researchers studied mortality rates of patients and other quality factors, they found their work comparable to formally trained neurosurgeons at other African hospitals. Ellegala knew that teaching brain surgery outside medical school channels was an educational short-cut, but the alternative was worse — certain death for many patients who would never have access to neurosurgical care.
Encouraged by these results, Ellegala founded Madaktari Africa to promote this teach-first philosophy across East Africa. It was a direct challenge to traditional medical missions, which have only grown in popularity in recent years as universities vie to offer students global experiences and religious groups look for new ways to evangelize.
Today an estimated 500 groups around the world run upward of 6,000 short-term medical missions a year. “I think it's in the nature of doctors to go in and give the patient the best care possible no matter what,” Ellegala said. “But this also sends a message to local doctors and nurses that they can't take care of their own, and that's shameful.”
Lunch with president
But running a nonprofit proved a challenge. Ellegala had full-time duties as a neurosurgeon, first at MUSC and then, 18 months ago, when he left Charleston to become medical director of the Centra Neuroscience Institute in Lynchburg, Va. He had a young family. With little time to spare, he turned to a former neighbor on Folly Beach for help, Doyle Word.
Word was a big man with curly hair and deep disdain for traditional missionary work. He grew up in northern Alabama, spent four years in the Air Force in Vietnam and eventually ran several international manufacturing companies. Word had just retired, was looking for something meaningful to do, and quickly accepted Ellegala's invitation to become Madaktari's executive director. Jovial and smart, Word soon forged new bonds with Tanzanian health ministers and other leaders, including Jakaya Kikwete, the country's president.
Together, Word and Ellegala put their teach-first philosophy into practice. Under a legal agreement with the government of Tanzania, Madaktari helped hundreds of volunteer doctors and nurses travel to four Tanzanian cities to teach for a few weeks or months. Beginning this fall, Ellegala's new employer, Centra Health, will pay for two experienced neurosurgery residents to teach brain surgery full-time in Haydom and Dar es Salaam.
Madaktari also stationed a doctor from Baylor University full-time in the southern Tanzania city of Mbeya to teach ultrasound and cardiology procedures, thanks to a $850,000 grant from the Henry M. Jackson Foundation for the Advancement of Military Medicine.
The grant also helped MUSC nephrologist David Ploth set up a dialysis training program The hospital in Mbeya had new and virtually unused dialysis units, but no one knew how to run them, Ploth said. Now the hospital has about three doctors and eight nurses to man the machines.
The Tanzanian government has embraced this teach-first strategy. During lunch in February at the Tanzanian State House, Kikwete told Word, “When you tell people that this is a nation of 45 million people and you have only three neurosurgeons, you can't believe it. First they think it's a joke. But it's reality.”
Over chicken, fish and ugali – a porridge-like dish of maize – Kikwete recalled the first time he heard that Ellegala had taught a non-MD brain surgery. “The traditional thinking is that can't be done by an assistant medical officer, that it's supposed to be done by an MD, but Dilan and his colleagues proved that it can be done by anybody. It is a big inspiration, definitely. Nothing is impossible.”
Ellegala grinned; he often used similar words about the uplifting power of education. But amid this support and presidential pomp, he had wondered whether teaching-focused programs were enough. “If you go online, you'll see a hundred or a thousand other NGOs also say 'sustainable' or 'teach a man to fish,'” he said to Word one late afternoon. These terms have become fundraising mantras. Was Madaktari's approach truly sustainable? After all, look what happened in Haydom.
The three people who had learned brain surgery — Mayegga, Nuwas and Hayte — were gone now. It was partly his fault. Ellegala had encouraged Mayegga to get his MD in Dar es Salaam, a process that would take five years. He left in 2008, and Nuwas followed in 2010 to do advanced surgery training in Moshi, a city at the foot of Mount Kilimanjaro.
Hayte also left for surgery training, in his case at the government's teaching hospital in Dar es Salaam. Once again, patients in Haydom with severe head injuries and tumors were out of luck. “If those guys don't come back,” Ellegala told Word, “then I think all we've done with Madaktari is for nothing. It's a failure.”
A sudden realization
In late January they met Nuwas at a hotel in Arusha. Bleary eyed from doing surgery calls until 5 a.m., Nuwas said his wife had just given birth to a daughter, and that among his people, that meant he would someday give away a calf and 20 liters of honey when she got married. The conversation shifted to Haydom, and he was glad to hear that Ellegala's employer, Centra Health, would put two neurosurgery teachers in Haydom.
Full-time teachers are more effective than doctors who visit now and then for a few weeks, he said. And beyond that, the hospital should create a specific curriculum to document how Tanzanians were gaining new neurosurgical skills, something that could be certified through the country's health ministry.
Ellegala grew excited, and afterward, he and Word talked about how Nuwas had become not just a skilled surgeon, but also a medical leader. “He's thinking about curriculum and certification. He's gone two steps beyond what I've thought about. Now that's success.”
Yes, Word replied, “you can't have an exit strategy if no one takes over.”
Leadership? Suddenly Ellegala thought about the missing ingredient in many programs that try to help the poor. Teaching a person how to fish wasn't enough. A truly sustainable approach means passing the torch to someone capable of continuing the journey and inspiring others to do the same.
“It's an epiphany for me too,” Ellegala said. So many nonprofits successfully raise money to build new clinics and schools but fail to cultivate leaders. For the first time, he saw clearly how Madaktari could provide a lasting way to improve a poor country's health care system. “We try to help create people locally who do what we do, carry on the knowledge and then become leaders beyond us.”
What of Haydom?
Ellegala and Word were heartened to hear that Nuwas would go back to Haydom. But what about the others?
One night in Dar es Salaam, Hayte took a break in his rounds at the government's main hospital. As a new surgeon, Hayte could make much more money in the city than in Haydom. “I do not have a single reason why I should return to Haydom,” he said, then reconsidered the statement. Haydom Lutheran Hospital had paid for his advanced training; he has deep connections to his people, the Datoga, a cattle-herding group that have lost land to foreign investors and other ethnic groups. Yes, in the end, he said he would go back to make a difference for his people.
And Mayegga? Low pay for rural doctors is a problem, he said one recent afternoon in the simple room he rents up a dirt road from his medical school. But other issues are just as important. He has three children — Godwin, Godlisten and Glory — and the schools in Haydom aren't as good as those in other cities. “What I have faced I don't want my child to face,” he said. “I have to pave the way for them, because if I don't do that, then you have not changed anything.”
But yes, when he finishes his studies later this year, he will look for good schools in and near Haydom, and he will return to the operating rooms there, one of the few people in the world to learn brain surgery first and then get his MD.
Time and mistakes
In Haydom Lutheran Hospital's operating room, Ellegala stands behind the German and Tanzanian doctors as they struggle to save the baby girl. With a scalpel, they whittle a hole in her skull, but the opening is too small. The sound of a metal blade scraping bone mingles with feeble beeps from a heart monitor.
As he had done with Mayegga, Ellegala lets them do the work, following the old surgeon's maxim, “See one, do one, teach one.” It takes time and mistakes to make a neurosurgeon. He steps in occasionally when they're about to do something harmful. When he does, his hands move quickly and with more force.
Another half hour passes, then another, and Ellegala knows that the length of this operation is tough on this young child. He also knows that with a shunt in her brain, she faces an uncertain future, but at least now, thanks to the inexperienced hands of the surgeons in front of him, she has a chance.
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