The Price of Pain

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At the Alupe sub-district hospital in western Kenya, the patients wait on wooden benches or lean against the yellow and blue-painted concrete walls. Ants crawl out of a crack in the floor, up a wooden beam and onto the underside of the corrugated iron roof. In the midday heat, a mother jostles her crying son on her shoulder. "Next," shouts Tanga Audi, a consultant surgeon to the African Medical and Research Foundation (AMREF). Lucia Nasirumbi, 63, shuffles into the partially screened examination area and awkwardly lowers herself onto the table. Audi examines her ulcerated right leg and speaks to her in Swahili, explaining that the advanced stage of cancer means that the best thing is to amputate. The woman nods, but appears unsure. Audi turns to the window and sighs. "The loss of a limb is a very painful decision to make," he says. "The difficulty is not for the surgeon but for the patient to accept. There is no time to think, not a month, not even a day."

For the team from AMREF--Audi and anesthetist Alex Gikandi--time is a luxury. Over the next two hours they will see 46 patients. During their three-day surgical safari at Alupe, a former leprosy hospital set amid guava and mango trees not far from the Ugandan border, they will perform 28 operations, ranging from straightening malformed bones to removing a breast lump. Consultations may be brief by Western standards, but patients in rural Africa are lucky to see a doctor at all. According to the World Bank, there is just one doctor practicing for every 10,000 Kenyans. In the U.S. the ratio is 25 per 10,000, in Germany, 35.

Annual public and private health spending in Kenya totals just $8 a person compared to nearly $1,500 in the U.K or over $4,000 in America. The story in other African countries is similar, or worse. Nigeria spends $5 a person on health; Ethiopia just $3; while Tanzania, which has fewer than one hospital bed per 1,000 people, spends nine times more on servicing its national debt than it does on providing basic health care for its citizens.

Founded in 1957 by three Western surgeons, AMREF is a Nairobi-based non-governmental organization that provides health care to some of the most remote areas in eastern and southern Africa. As well as providing a flying doctor service for the region, it tries to fill the gaping holes in local health care by supplying medical skills where needed and by training local staff. "Often relatively simple operations can transform people's lives," says John Batten, AMREF's director general. The organization's efforts were recognized in September last year when it was awarded the $1 million Conrad N. Hilton Humanitarian Prize, the world's richest humanitarian award.

That money will go a long way toward helping Audi treat people like Joyce Khabetse, who hobbles to the examination table on crutches. The 20-year-old arrived 18 months ago. Her parents are both dead, and she had become a burden to her uncle, a farmer. She used to make clothes on a neighbor's sewing machine but her feet, congenitally malformed, stiffened so she could no longer work the pedal. "It will be easier when my foot is fixed," she says. "I would like to have my own sewing machine one day and make shirts."

And people like three-year-old Tom Dindi, who lies anesthetized in Alupe's operating theatre as Audi chisels into the boy's malformed tibia. Once it is broken the surgeon resets it, stitches the incision and uses two planks of wood and plaster of Paris to hold the bone in position. "In city hospitals they use stronger plaster," says Audi. "But if you don't have it, then you have to improvise." Medicines are also in short supply; often patients are prescribed a drug that they have to buy themselves at a chemist in Busia, 9 km down a dirt road. "It's a daily battle," concedes Jackton Kisivuli, the medical officer in charge of the hospital.

Over a quick lunch between operations, Audi talks with Kisivuli and other local staff members about challenges facing doctors in rural Africa. The patients who have come today arrived on the backs of bicycle taxis or in rattling old buses. But others stayed at home, unable to afford the fare, the patient's share of the operation's cost (between $3.50 and $7) or the time away from the fields. "Many people fear the bills so they tend to stay at home," says Bramwell Wafula, a nurse. "It's a hard decision, but in rural areas people know that if they take their child to hospital the family will starve."

Others believe that illnesses are caused by curses. "Some have to be brought here by force," says George Matete, who studies African sleeping sickness as head of the Kenya Trypanosomiasis Research Institute. "But even if you get them here, if they've been told by relatives that they are going to die they may just give up." On the final morning of his stay, Audi lectures local staff on forearm injuries, covering everything from fractures to telling a patient that a limb must be amputated. "You have to ask yourself, 'Is my patient able to understand and accept the outcome?'" Such concern for a patient's mental state is an integral part of medical practice the world over; in rural Africa it's a rare luxury.