Notes, Sources, and Photos for A Surgeon in the Village

Below are notes and sources for A Surgeon in the Village. My goal in writing this book was to craft a narrative about complex global health topics without slowing the reader's progress with footnotes and too many digressions.

That said, the book is based on hundreds of hours of interviews with Dilan Ellegala, Carin Hoek, Emmanuel Mayegga, Emanuel Nuwas, Hayte  Samo, Naftali and Haika Naman, and the many other characters that populate the book's pages. These interviews were done in the United States and during five trips to Tanzania between 2010 and 2015. Other sources include academic papers, books, journals, diaries, medical records, and photographs.

I was present during many moments described in the book after the year 2010 when I first met Dilan Ellegala in Charleston, South Carolina. Since much of this story happens before that time, I’ve reconstructed scenes and dialogue as best as fallible memories allow. When possible, I’ve confirmed dialogue with both participants. In some cases, particularly when Tanzanian characters tried to speak English for my benefit, I condensed and edited dialogue to capture the conversation’s gist. I witnessed numerous brain surgeries in Haydom and the United States, including Dilan’s  successful standstill in Lynchburg, Virginia.

To protect the privacy of patients in both Tanzania and the United States, I’ve changed names and identifying details in several instances. A few characters’ names have been shortened or changed for similar reasons. Because notes, recordings, and citations upon which this story is based are voluminous, I’ve selected the most pertinent ones below. I’ve also included a few interesting digressions that weren’t included in the book.

The Call

Ohayoda is pronounced oh-hi-oooda! Listen to a  recording of distant Ohayoda (mp3).

Information about the background of ohayoda came from Naftali Naman, Herman Malleyeck, Paolo Kangaga, and Amani Paul. 

In 2011, Amani Paul started a newspaper called Oyahooda. (The word can be spelled several ways.)

According to Paul, a government official decided that the name, a Datoga word, might inflame ethnic tensions. The official reportedly demanded that it be changed. Henceforth, it became Mbio xa Jamii, roughly “Community Trumpet.”

(Photo: Amani Paul and his newspaper, Ohayoda. Photo/Bartelme)

PART I: See One

Chapter 1

I observed Dilan Ellegala (pronounced Ella-ghalla) perform the suck, spread, suck technique during the standstill operation in Lynchburg, Virginia. The patient’s identifying characteristics in Boston have been changed.

For a history and more scientific description of cardiac standstill procedures, see James M. Wright et al., “Cardiac Standstill and Circulatory Flow Arrest in Surgical Treatment of Intracranial Aneurysms: A Historical review,” Journal of Neurosurgery, vol. 36 (April 2014).

For information about mortality and complication rates of standstills, see “Cardiac Standstill for Cerebral Aneurysms in 103 Patients: An Update on the Experience at the Barrow Neurological Institute,” Francisco A. Ponce et al., Journal of Neurosurgery, vol. 114 (March 2011).

For information about the Yasargil-type clips and their more recent iterations, see “A Brief History of Aneurysm Clips,” Deon F. Louw et al., Neurosurgical Focus (2011). For extensive descriptions about aneurysms and their treatments, see The Brain Aneurysm by Robert F. Spetzler and Vini G. Khurana, AuthorHouse (2006). Edward J. Sylvester writes about Spetzler and the standstill operation in The Healing Blade, Simon & Schuster (1993). 

Spetzler has done more than five thousand aneurisms and is known for doing a standstill on a musician named Pam Reynolds. Watch an interview with Pam Reynolds.

During the operation, Reynolds was clinically dead for about an hour, but when she woke up, she said that she felt as she had popped out of her body and hovered over Spetzler and his team. She described sounds and tools that she couldn’t have heard or seen. Some doctors claimed that this was evidence of life after death. See Michael Sabom’s Light & Death: One Doctor’s Fascinating Account of Near-Death Experiences, Zondervan Publishing House (1998).

Descriptions about the pain of aneurysm ruptures often sound like hyperbole, but emergency doctors are trained to recognize a potential aneurysm when they hear someone say, “It feels like the worst headache of my life.” In 1974, the musician Quincy Jones was working on his album Mellow Madness when he felt “as if someone had blown through the back of my head with a shotgun.”

In 1988, then-Senator Joe Biden gave a campaign speech. “As soon as I stood up to take the podium, a pain shot up the back of my neck . . . My head felt like it was about to explode.” They were lucky. According to the Brain Aneurysm Foundation, half a million people worldwide die every year from ruptured aneurysms.

Chapter 2

For a discussion about how our brains process odors, see Janny Scott, “The Biomechanics of the Sense of Smell,” Los Angeles Times (Sept. 8, 1988).

Our sense of smell actually begins its evolution the first time we breathe. See Michael A. Patterson, Samuel Lagier, and Alan Carleton, “Odor Representations in the Olfactory Bulb Evolve After the First Breath and Persist as an Odor Afterimage,” Proceedings of the National Academy of Sciences (2013).

Dilan is very tall for a Sri Lankan. The mean height of an adult Sri Lankan male is five-foot-five.

Descriptions about the landscape between Arusha and Haydom were drawn from Dilan’s memory and my observations on a similar trip. For information about the area’s problems with bubonic plague, see Makundi H. Rhodes et al., “Potential Mammalian reservoirs in a Bubonic Plague Focus in Mbulu District, Northern Tanzania in 2007,” Mammalia (2008). 

For more about the geology of the storied region between Arusha and Haydom, see “Lake Manyara Watershed Assessment, Progress report December 2003” by the Africa Wildlife Foundation. In earlier decades, Olduvai Gorge was previously spelled as Oldupai, a Maasai word for sisal.

Haydom is pronounced several ways, most often like “Hi-dom” but also “Hay-dom.”

(Photo: View of bomas from Flying Medical Services plane en route to Haydom. Photo/Bartelme)

Chapter 3 

The guinea worm, fortunately, has been eradicated in Tanzania.

One of the seminal books on Africa’s history and the roots of its present challenges is John Iliffe’s Africans: The History of a Continent, Cambridge University Press (2007).

The Maji Maji rebellion is a fascinating moment in the history of both Tanzania and Germany. Some historians argue that Germany’s successful scorched-earth tactics in its African colonies fostered German imperialism and eventually the rise of Nazism. One problem with that hypothesis: The British and other European powers were often as bad or worse—even after World War II. See Caroline Elkins, Imperial Reckoning: The Untold Story of Britain’s Gulag in Kenya, Random House (2007). For more information about the Maji Maji rebellion, see Felicias Becker, “Traders, ‘Big Men’ and Prophets: Political Continuity and Crisis in the Maji Maji rebellion in Southeast Tanzania,” Journal of African History (2004).

For information about changing scientific views about serotonin, see Gary Greenburg, “The Psychiatric Drug Crisis,” New Yorker (Sept. 3, 2013). The reference to the German invasion near Mount Hanang comes from Bjorn Enes, The Haydom Adventure, published by the Friends of Haydom Foundation (2005).

Listen to the Haydom Lutheran Hospital Choir (mp3).

(Photo: Brown twisters rising from the plateau. Photo/Bartelme.)

(Photo: Entrance to Haydom Lutheran Hospital. Photo/Bartelme.)

Chapter 4

For an overview about the dearth of local neurosurgeons in Africa, see Adelola Adeloye, “Black African Neurosurgeons Practicing on the African Continent,” Journal of the National Medical Association (2001). 

Descriptions about patient conditions come from medical records in Haydom, as well as observations from Jenny Edwards and Dilan.

The American Association of Neurological Surgeons pegged the number of American brain surgeons at 3,700 in 2012, according to its 2012 statement to the Institute of Health. Average pay for an American neurosurgeon is more than $609,000, according to Doximity, a compensation tracking company. Becker’s Hospital review said the average annual salary was $767,627 in 2010. The New England Journal of Medicine pegged median salaries at $625,300 that year. 

For an in-depth look at the impact of malnutrition in Haydom, see Estomih R. Mduma et al., “The Etiology, risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Study: Description of the Tanzanian Site,” Clinical Infectious Diseases, vol. 59 (November 2014). Data on physician ratios come from the World Bank.

For a thorough examination of the East African famine in 2005, see Kristin D. Phillips, “Hunger, Healing, and Citizenship in Central Tanzania,” African Studies Review, vol. 52 (April 2009).

For data on CT and MRI scanners, see the Centers for Disease Control’s roster: Japan has the most of any country—more than twelve thousand units for its 127 million people.

Chapter 5

The Glasgow Coma Scale is scored from three to fifteen, with three the lowest score. Doctors calculate it by assigning points based on three parameters: eye response, verbal response, and motor response. A score of thirteen or higher is a mild brain injury, nine to twelve is moderate, and eight or less is considered severe.

For information about the skull’s weak points, see Noel T. Boaz and Russell L. Ciochon, “Headstrong Hominids,” Natural History Magazine (February 2004). For a look at our long history of trepanation, see Charles G. Goss, “A Hole in the Head,” Neuroscientist, vol. 5 (1999).

Researchers continue to debate how many neurons are in a brain. Until recently, scientists had a suspiciously round estimate of one hundred billion neurons. More recent research estimates put it at eighty-six billion. See Suzana Herculano-Houzel, “The Human Brain in Numbers: A Linearly Scaled-up Primate Brain,” Frontiers in Human Neuroscience, vol. 3 (Nov. 9, 2009).

Many books have been written about Harvey Cushing. One thorough treatment is Harvey Cushing: A Life in Surgery by Michael Bliss, Oxford University Press (2005).


(Photo: Rusty and broken Gigli saw that Dilan found. Photo provided by Ellegala )

Chapter 6

Robert Liston’s famous surgery with the triple mortality has been recounted in many places but is particularly well told by Atul Gawande in “Two Hundred Years of Surgery,” New England Journal of Medicine, vol. 366 (May 23, 2012).

Another engaging book about the history of surgery is Richard Hollingham’s Blood and Guts: A History of Surgery, Ebury Publishing (2009).

Bellevue’s “Prepare to meet your God” sign was described in The New York Times on Nov. 23, 1884, as well as Howard Markel’s excellent book on William Halsted’s struggles: An Anatomy of Addiction: Sigmund Freud, Wiliam Halsted, and the Miracle Drug Cocaine, Pantheon Books (2011). Gerald Imber’s Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted, Kaplan Publishing (2011), is another excellent source.

The description of surgery at Bellevue came from The Rise of Surgery: From Empiric Craft to Scientific Discipline by Owen H. Wangensteen and Sarah D. Wangensteen, University of Minnesota Press (1979). Donald Effler’s quote is from “The Best Hope of All,” Time (May 3, 1963). Effler’s obituary appeared in The New York Times on Sept. 4, 2004. 

Chapter 7

The origin of medical pimping is thought to have begun in the 1600s when a British physician got fed up with his drunken and lazy students and said, “Oh that I might see them pimped.” See “The Art of Pimping” by Allan S. Detsky, JAMA, vol. 301 (April 1, 2009).

Oystein Olsen wrote about the importance of trust in “The Impact of Global Health Initiatives on Trust in Health Care Provision Under Extreme resource Scarcity,” Health Research and Policy Systems, vol. 8 (May 2010).

Chapter 8

For information about Kandy’s warrior past, see John Gimlette, “Sri Lanka: In the Kingdom of Kandy,” Telegraph (Aug. 25, 2013). Information about King Buddhadasa came from multiple sources, including, “The King Who Treated a Snake” by Premasara Epasinghe, Sunday Observer (May 22, 2011).

The front-page article in the Brookings Register, “After 19 years, Long- distance Love Affair Has Happy Ending,” is a charming story about how Somisara Ellegala fell in love with Brookings during his Fulbright visit in 1956. The article features a photograph of the entire family.

Richard Furman’s To Be a Surgeon, Frederick Fell Publishers (1982), was a study in goal obsession. At its heart was a message that what you do in this minute helps shape your outcomes, for better or worse.

For a discussion about flashbulb memories, see Antonietta Curci and Tiziana Lanciano, “Features of Autobiographical Memory: Theoretical and Empirical Issues in the Measurement of Flashbulb Memory,” Journal of General Psychology (2009). 

David Eagleman discusses flashbulb memories in his book Incognito: The Secret Lives of the Brain, Pantheon Books (2011).


(Photo: Elegalla Family in S.D. Newspaper)

Chapter 9

Charles Bosk’s Forgive and Remember: Managing Medical Failure, University of Chicago Press (1979), remains an illuminating look at how surgeons tick.

Bosk’s focus on neurosurgeons and obsession of failure is in a chapter of Clinical Neurosurgery, Congress of Neurological Surgeons, vol. 35 (1979). He writes about how doctors train like professional athletes to ignore aches and pains: “In my more cynical moments, I think of residency, during which such work values are learned, as a vast training for impairment—a time when physicians learn to deny their own needs, are rewarded for doing so, and are rewarded as well, for pushing themselves well beyond any normally tolerated limits and for tolerating a near total estrangement from the world outside the hospital. All of this self-denial, of course, has consequences.”

Malcolm Gladwell, also citing Bosk, probes the neurosurgeon’s mind in “The Physical Genius,” New Yorker (Aug. 2, 1999).

Chapter 10

Johns Hopkins University has an excellent history of its founders, including William Halsted and William Osler. Visit: www.hopkinsmedicine.org/about/history/history5.html.

The descriptions of the brain’s subroutines and the biological mechanics of intuition are culled from David Eagleman’s Incognito.

Chapter 11

One of the best stories you can find in Harvard’s Countway Library of Medicine is about Phineas Gage. Gage was working on a railroad in Vermont one day in 1848 when an explosion launched a forty-three-inch tamping rod through his frontal cortex. Despite losing an eye and part of his brain, Gage survived but became impulsive and prone to bursts of profanity. This personality change led to a major breakthrough in neuroscience: The frontal cortex controlled emotions and judgment. Gage’s skull and tamping rod eventually ended up in Harvard’s anatomical museum a few floors above Dilan’s favorite spot in the old journal stacks.

Harvey Cushing worked in the old Peter Bent Brigham Hospital building, which is connected by “the Pike” to the sprawling modern Brigham and Women’s Hospital complex. The strains in Cushing’s marriage and possible bouts with depression are discussed in Bliss’s Harvey Cushing: A Life in Surgery.

The workplace case against the Brigham and Women’s Hospital was appealed to the U.S. First Circuit Court of Appeals, which sided against the hospital and Day. The ruling can be found here.

Chapter 12

Harvard surgeon Atul Gawande’s Complications: A Surgeon’s Notes on an Imperfect Science, Metropolitan Books (2002), is a probing look at the ethical tension inherent in any surgeon’s education.

In a letter to a friend, Jenny Edwards described in beautiful and haunting detail her trip with Dilan to Tanzania, along with the challenges she faced in the wards and in the suffering around her. She graciously shared the letter with me as well as other details about her Tanzanian experience.


(Photo: Neurosurgery department at Harvard Medical School. Photo/Bartelme)

Chapter 13

Before medical school, Dilan bought a book by Ken Iserson, Getting into Residency, Galen Printing Ltd. (2003), which discusses personality traits that certain specialties tend to attract.

Chapter 14

Frank Vertosick Jr.’s plank metaphor is found in his book When the Air Hits Your Brain: Tales from Neurosurgery, W. W. Norton (1996).

Chapter 15

Mayegga’s name is pronounced My-eh-guh. Emmanuel is a common first name in Haydom and has numerous spelling iterations.

To build Emmanuel Mayegga’s story, I spent many nights on the patio with him at Mama Naman’s, his home in Haydom, and in Dar es Salaam when he was in medical school. I noticed one night at Mama Naman’s that he was looking into the distance and seemed preoccupied. He told me: “I always sit here so I can see where I came from.”

For effects of cerebral malaria on the brain, see Richard Idro et al., “Cerebral Malaria: Mechanisms of Brain Injury and Strategies for Improved Neuro-Cognitive Outcome,” Pediatric Research, vol. 68 (October 2010). The World Health Organization says there are between 124 million and 283 million malaria cases a year and an estimated 584,000 deaths. Thanks to an international campaign, malaria mortality rates have fallen by forty- seven percent globally since 2000 and by fifty-four percent in Africa.

For statistics about Haydom Lutheran Hospital’s patient counts, I drew from “Haydom Final review,” a consultant’s report for the royal Norwegian Embassy published in 2012. In 2006, the hospital had roughly 11,000 inpatients, 64,000 outpatients, 3,222 deliveries, 111,120 outreach clinic exams, 61,000 immunizations, and about 3,300 minor and major operations.

Mayegga’s home place is a two-hour ride from Haydom. During a visit there, he showed me the ochre hieroglyphics he saw as a child and the rock where he sat and waited for the monkeys to invade. He gave me a lesson on how to catch dik-diks with sisal ropes, and pointed to rock cliffs in the distance where he found clay to make his pots. He brought along his wife, three children, father, and brother, which is how interviews sometimes happen in Tanzania. It was the first time he had been back to that area for ten years, and he was stunned to see how many new huts had been built. “There was nothing here when I was a child,” he said.


(Photo: Mayegga pointing out the ancient rock paintings hidden behind his old boma. Photo/Bartelme)


(Photo: Mayegga on the boulders by his family's boma, staring toward Haydom. Photo/Bartelme) 



(Photo: Mayegga outside his house in Haydom.)

Chapter 16

For more information on the “setting sun” phenomenon, see Mariana Boragina and Eyal Cohen, “An Infant with the ‘Setting-sun’ Eye Phenomenon,” Canadian Medical Association Journal, vol. 175 (Oct. 10, 2006).

For statistics on spina bifida, see  www.spinabifidaassociation.org. For the economic costs of hydrocephalus, see Chevis N. Shannon et al., “The Economic Impact of Ventriculoperitoneal Shunt Failure,” Journal of Neurosurgery: Pediatrics, vol. 8 (December, 2011).

Roughly five percent of those diagnosed with dementia and Alzheimer’s disease in fact have hydrocephalus, symptoms that often can be reversed through shunt surgery.

Benjamin Warf is another neurosurgeon who has done impressive work on hydrocephalus in Africa. Warf went to Uganda in 2000 to work in a new hospital built by CURE International, a Christian NGO. As in Haydom, the area had a large number of hydrocephalus cases. But Warf found that inserting shunts was impractical in a low-income area. Shunts require follow-up visits, and in remote places, finding and returning to a neurosurgeon was difficult. To solve this problem, Warf combined two procedures—one using endoscopy to reduce tissue inside the brain that produces cerebrospinal fluid, and another to make a small opening to allow fluid to escape. No shunts were needed. He eventually returned to the United States but began work in 2012 on a teaching program that trained twenty-four surgeons throughout Africa. Two years later, the surgeons had treated more than one thousand hydrocephalus cases using this process. See Benjamin Warf, “Pediatric Hydrocephalus in East Africa: Prevalence, Causes, Treatments, and Strategies for the Future,” World Neurosurgery, vol. 73 (April 2010).

Atul Gawande in Complications writes extensively about the morbidity and mortality conferences.

For more information about the Maji Maji rebellion, see Thomas Pakenham’s The Scramble for Africa: White Man’s Conquest of the Dark Continent from 1876 to 1912, HarperCollins (1992). Also, John Iliffe’s A Modern History of Tanganyika, Cambridge University Press (1979).

For more on the Canadian Wheat Complex, see John Stackhouse’s Out of Poverty, Random House (2000). Perhaps the most interesting account was written by George Monbiot in No Man’s Land: An Investigative Journey Through Kenya and Tanzania, MacMillan (1994). Monbiot writes about the importance of the bung’eda funeral rite, and how tombs were plowed under to make way for the wheat. 


(Photo: Dilan teaching Mayegga. Photo provided by Ellegala.)

Chapter 17

Naftali Naman told me that before Dilan arrived, he and Dr. Ole Halgrim Olsen sometimes drilled burr holes into the heads of people with subdural hematomas. Before the CT scan arrived, they simply had to guess whether they were drilling in the correct spot. If fluid came out, they knew they were right. Naman showed me a photo album of his two trips with Lucas to Norway.


(Photo: Naftali Naman and Lucas, the boy whose jaw was ripped off by a hyena, in Norway. Photo provided by Naman.)

Chapter 18 

This chapter was reconstructed from memories of several participants, including Dilan Ellegala, Emmanuel Mayegga, and Victor Musa. A photograph also was taken during the operation. It shows the nurses and clinicians gathering around Mayegga, with Dilan behind them and peering over their shoulders just before he leaves.

Chapter 19

Tanzania inhabited Jenny Edwards’s thoughts and dreams after she left. All of this would send her on paths she might otherwise not have chosen. She would eventually create and run a large university’s Morbidity and Mortality Conference to help others learn from their mistakes.

PART II: Do One

Chapter 20

Former BBC journalist Suzanne Franks’ book, Reporting Disasters: Famine, Aid, Politics and the Media, Hurst (2014), is a thorough expose of the famine in Ethiopia and its ripple effect on global health leaders and the public.

For statistics on the number of youth groups doing religious service projects, see Don Fanning’s paper “Short-Term Missions: A Trend That Is Growing Exponentially,” for Liberty University’s Center for Global Ministries (2009). For information about airfare trends and how they influenced Christian outreach work, see Robert Wuthnow’s authoritative book Boundless Faith: The Global Outreach of American Churches, University of California Press (2009).

For David Livermore’s discussion about short-term missions, see Serving with Eyes Wide Open: Doing Short-term Missions with Cultural Intelligence, Baker Books (2006). Emma’s name has been changed.

For statistics about the number and expenditures of short-term medical missions, see Jesse Maki et al., “Health Impact Assessment and Short-term Medical Missions: A Methods Study to Evaluate Quality of Care,” BMC Health Services Research (June 2008).


(Photo: Carin introduced to staff in Hayom.)

Chapter 21

For information about the Lena Ward’s origins, see Valentine Marc Nkwame, “Murdered Norwegian Girl Saves Local Children,” Arusha Times (April 13, 2002).

Elizabeth Molyneux describes her experience in Malawi in “Fighting Childhood Illness: Elizabeth Molyneux,” The Guardian (April 10, 2015). The Lancet profiled Molyneux and her husband in“Malcolm and Elizabeth Molyneux: Making Better Health in Malawi” by Clare Kapp, vol. 372 (November 2008).

Molyneux writes about her triage techniques in a paper: “Improved Triage and Emergency Care for Children reduce Inpatient Mortality in a resource-constrained Setting,” Bulletin of the World Health Organization, vol. 84 (April 2006).


(Photo: Inside the Lena ward. Photo/Bartelme)

Chapter 22

One of the most widely quoted scholars on short-term medical missions is Kurt Allen Ver Beek of Calvin University, whose 2007 paper, “Lessons from the Sapling: Review of Quantitative Research on Short- term Missions,” is a fascinating account of his work. His paper “The Impact of Short-term Missions: A Case Study of House Construction in Honduras,” appeared in Missiology, vol. 34 (October 2006).

The clubfoot technique used in Haydom is known as the Ponseti method. Because tissues of a newborn’s feet are supple, doctors can manipulate them with a series of new casts every few weeks without the need of reconstructive surgery.

Chapter 23

The first George Patton quote Dilan told me was, “L’audace, l’audace, toujours l’audace” (Audacity, audacity, always audacity), on a plane trip from Haydom to Dar es Salaam. The quote, in fact, came from the movie Patton, not the general himself. However, Dilan said it expressed the emotions that surgeons must deploy to survive long and particularly complex cases.

Chapter 24

In a Psychology Today article, “A Hunger for Certainty” (Oct. 25, 2009), David Rock describes how the brain is wired to seek certainty and avoid uncertainty as if it’s a form of pain. “A sense of uncertainty about the future generates a strong threat or ‘alert’ response in your limbic system. Your brain detects something is wrong, and your ability to focus on other issues diminishes.” When that craving for certainty is met, there’s a feeling of reward. Perhaps this helps explain the addictive nature of surgery.

T. Peter Kingham and Adam Kushner et al. documented the desperate shortage of surgeons in Sierra Leone in their paper “Quantifying Surgical Capacity in Sierra Leone,” Archives of Surgery, vol. 144 (February 2009). The authors identified ten practicing surgeons in that country of four million people.

The information about Haile Debas was drawn from interviews and several papers, including his report in Disease Control Priorities in Developing Countries, Second Edition, published by the World Bank (2006).

Brian Mullaney, cofounder of Smile Train, said the “biggest global health problem no one has ever heard of” to me in an interview as well as in “How to Save Millions of Lives Now,” The Daily News (August 12, 2013).

Life expectancy data for that year come from the World Health Organization.

A discussion about Haiti and its “republic of NGO” nickname can be found in The Nation, “The NGO republic of Haiti: How the International relief Effort After the 2010 Earthquake Excluded Haitians from Their Own recovery,” by Kathie Klarreich and Linda Polman (Oct. 31, 2012).

Chapter 25

David Eagleman describes his subroutine hypothesis in Incognito.

The End of Poverty, by Jeffrey Sachs, was published by the Penguin Press (2005). Dambisa Moyo’s book Dead Aid was published by Farrar, Straus and Giroux (2009). Moyo’s comments to Newsweek were made in “Dambisa Moyo’s ‘Dead Aid’ Says Stop Aid to Africa,” Lisa Miller (March 20, 2009). 

Dilan coauthored a paper on microbubbles with  the  catchy  title  “Imaging  Tumor  Angiogenesis  with  Contrast  Ultrasound  and vβ3,” Circulation, vol. 108 (June 30, 2003).

Chapter 26

According to the American Association of Neurological Surgeons, it costs a teaching hospital about $1.2 million to train a neurological resident over seven years. This can be found in the report to the Institute of Medicine entitled “Ensuring an Adequate Neurosurgical Workforce for the 21st Century” (Dec. 19, 2012). 

Chapter 27

Paul Farmer writes in “How We Can Save Millions of Lives,” The Washington Post (Nov. 17, 2011),“Ten million people—many of them young and most of them poor—will die around the world this year from diseases for which safe, effective and affordable treatments exist. In Haiti, these are known as ‘stupid deaths.’ What’s more, inadequate health services predominate precisely where the burden of disease is heaviest, keeping a billion souls from leading full lives in good health.” Farmer also describes his philosophy and work in Partner to the Poor, University of California Press (2010). Tracy Kidder’s book about Farmer, Mountains Beyond Mountains, Random House (2003), is as inspirational as Jonah Attebery described.

Jonah kept online journals about his trips to Uganda and Tanzania, writing eloquently about his disappointments and achievements. He graciously allowed me to borrow details from his reports.

Chapter 28

In April, 2010, four years after Dilan arrived in Haydom, World Neurosurgery published the findings in a paper, “Initial Audit of a Basic and Emergency Neurosurgical Training Program in rural Tanzania.” Its listed authors were Jonah E. Attebery, Emmanuel Mayegga, Robert G. Louis, Rachel Chard, Abednego Kinasha, and Dilantha B. Ellegala.

The study cited the cases performed: VP shunts; repair of myelomeningoceles; burr holes and craniotomies for trauma and biopsies. “Of 51 patients initially identified, 14 (27%) were confirmed deceased and 20 (39%) confirmed living. The remaining 17 (33%) were lost to follow-up. There were no significant differences in the mortality rates of patients receiving care from the American-trained neurosurgeon and those receiving care from the Tanzanian AMO trained and mentored by the American neurosurgeon.”

Descriptions of Petro and Mayegga’s office are drawn from photographs that Dilan snapped at the time.

Chapter 29

About this time, Carin and Mayegga worked on another interesting case: a girl who arrived with her skull fractured from a rabid hyena. Thinking her brain had been exposed directly to the rabies virus, they feared that her bite wounds would be fatal. Finally, Mayegga suggested that they put the rabies vaccine directly into her brain. Looking for teeth marks, they injected the vaccine into the girl’s open skull, then wheeled her into the operating theater, where Mayegga spent hours stitching her skull and face back together. Several months later, the girl walked into Lena Ward, her wounds completely healed. “Is this you? Is this you?” Mayegga repeated.

Chapter 30

Robert Hamilton kindly shared notes from his journals about the trip to and from Arusha with the East African neurosurgeons.

Paul Young was a master of getting people together on two continents.  In 2005, just before the scene in this chapter, Young and Moody Qureshi set up a meeting in Nairobi with the few other neurosurgeons in East Africa. “I was astounded to find that most had never met each other,” Young told me later. He asked each physician to describe their work. As they spoke, he scribbled their names on a blackboard. When they were finished, he wrote “East Africa Training” in the center and drew lines to each doctor’s name. Suddenly, he said, everyone realized that if they worked together for  a higher goal, they could move forward.

Chapter 31

Emanuel Nuwas (pronounced New-ahs) was kind enough to take me to his family’s boma in the village of Getanyamba where he grew up.

Chapter 32

After saying goodbye, Carin wondered why Dilan only shook her hand, but not because she was in love with him at the time. “Americans are just big huggers. And Dilan is a big hugger. It was a little odd.”

Chapter 33

The doctor deficit statistics are from American Association of Medical Colleges, “Center for Workforce Studies,” June 2010 analysis. An updated analysis in 2015 found the projected shortage to be between 46,100 and 90,400 physicians by 2025. Other estimates and discussions about historical factors can be found in The Coming Shortage of Surgeons by Thomas E. Williams Jr., Bhagwan Satiani, and E. Christopher Ellison, ABC Clio (2009).

For a prescient view about the incorrect forecast about the number of doctors, see “There’s a Shortage of Specialists: Is Anyone Listening?” by Richard A. Cooper, Academic Medicine, vol. 77 (2002).

Vikram Patel wrote about the British perspective in “Recruiting Doctors from Poor Countries: The Great Brain robbery?” Health Systems Trust (Nov. 21, 2003).

The Walter Mondale quote and 1974 Congressional report reference are from a Wall Street Journal commentary by E. Fuller Torrey: “How the U.S. Made the Ebola Crisis Worse” (Oct. 14, 2014). Torrey wrote: “The total number of Liberian doctors in America is about two-thirds the total now working in their homeland.”

One of the most thorough sources for the extent and impact of the shortage of doctors is the Milbank Memorial Fund’s report “Health Worker Shortages and Global Justice” by Paula O’Brien and Lawrence O. Gostin (2011). The report also describes the recruiting industry.

The costs of brain drain are richly described by Edward J. Mills et al., in “The Financial Cost of Doctors Emigrating from Sub-Saharan Africa: Human Capital Analysis,” BMJ, vol. 343 (Nov. 24, 2011). The Guardian exposed the ongoing brain-drain problem in Great Britain in “NHS Hires Up to 3,000 Foreign-trained Doctors in a Year to Plug Staff Shortage,” by Denis Campbell, Haroon Siddique, Ashley Kirk, and James Meikle (Jan. 28, 2015).

Chapter 34

The pilot’s name was changed. Two missionary aviation groups, Mission Aviation Fellowship and Flying Medical Service, work in the area, and both organizations do heroic work.

Pat Patten runs Flying Medical Service from a farm just outside Arusha and has uncommon wisdom and insights.

I asked him, “What is the single defining feature of this region?”

His answer: “People know they need one another.”


(Photo: Outside the Chinese-themed hotel in Arusha, where Dilan and Carin first knew they would be together. Photo/Annie Duryee.)

Chapter 35

I found Patrice Bura cutting some trees near his shamba in Tumatti. He showed me his scars and said that he sometimes still has headaches but was perfectly healthy.


(Photo: Patrice Bura (center) near Tumatti. Photo/Bartelme.)

Chapter 36

During a camping trip in Yaida Chini before the wedding, Carin and Dilan heard a melody in the distance. Moments later, several Hadza men appeared between the thorn bushes. The Hadza are among the last of the world’s true hunter-gatherer groups and speak a Khoisan click language. They sat by the fire until a honeyguide bird appeared. One of the Hadza men began to whistle, and the bird circled around him, chirping back. Suddenly, the man took a stick from the fire and signaled for everyone to follow. The bird flew to a tree where there was supposed to be some honey, but the man looked irritated and chirped angrily back at the bird, which promptly took off in another direction. The man followed and returned a few minutes later with a comb full of honey. It was an example of the symbiotic relationship the Hadza have with their environment.

Researchers in recent years have studied the Hadza’s diet, and more specifically, their fecal matter because of its rich bacterial diversity. For an interesting read an hour or so after you’ve eaten, see Jeff Leach’s work at humanfoodproject.com. In 2005, a wealthy family from the United Arab Emirates stirred international outrage when it tried to acquire the Yaidi Chini valley for a massive private helicopter hunting preserve. Human rights groups eventually beat back this incursion.


(Photo: Hadza elder. Photo/Bartelme.)

Chapter 37

Some of the hospital’s looming financial problems were described in, “Haydom Lutheran Hospital—Final Project review” by Ottar Mæstad and Aziza Mwisongo of the Chr. Michelsen Institute (CMI) Norway.

In 2011, Hlin Irene Sagen Grung, a master’s thesis student from Norway, made waves in Haydom with her thesis for the University of Adger, “Haydom Lutheran Hospital: A Sustainable Health-Providing Organization or a ‘White Elephant’?”

Chapter 38

A few days before the wedding, Angela and the other nurses threw Carin a “kitchen party.” They presented her with gifts and advice: a yellow kanga skirt (“No more pants and dressing like a man”), a homemade broom (“He’ll be happy and bright because the home is happy and bright”), a long wooden stick with a polished handle for making ugali (“You must feed your husband before you feed yourself, but make a little extra food for yourself because you’re so thin”). When they were done, everyone danced, with one of the nurses tapping on the side of a wooden sofa to keep the beat.


(Photo: The wedding on the airstrip. Photos provided by Dilan and Carin Ellegala.)

Chapter 39

The pulse oximetry study is called “Global Operating Theatre Distribution and Pulse Oximetry Supply: An Estimation from reported Data,” by Luke M. Funk et al., The Lancet, vol. 376 (Sept. 25, 2010).

Atul A. Gawande was a coauthor of that study as well as one that found that more than 234 million surgeries were done worldwide every year: “An Estimation of the Global Volume of Surgery: A Modeling Strategy Based on Available Data,” Thomas G. Weiser et al., The Lancet, vol. 372 (July 12, 2008). Gawande’s quote comes from a paper he wrote for The Lancet, “Global Surgery,” vol. 386 (April 26, 2015).

Paul Farmer’s and Jim Kim’s calls for action can be found in “Surgery and Global Health: A View from Beyond the Or,” World Journal of Surgery, vol. 32 (April 2008).

For the study on how medical equipment fares after it has been donated, see “Effectiveness of Medical Equipment Donations to Improve Health Systems: How Much Medical Equipment Is Broken in the Developing World?” by Lora Perry and Robert Malkin, Medical & Biological Engineering & Computing, vol. 49 (July 2011).

For more information about the study that compared short-term missions with other surgical platforms, see “Charitable Platforms in Global Surgery: A Systematic review of Their Effectiveness, Cost-Effectiveness, Sustainability, and role Training,” by Mark G. Shrime, Ambereen Sleemi, and Thulasiraj D. ravilla, World Journal of Surgery (Published online March 2014).

PART III: Teach One

Chapter 40

I confirmed President Jakaya Kikwete’s woman-in-basket story through personal interviews with the president and Mohamed Janabi.

Information about the number of doctors in Tanzania is from John Iliffe’s East African Doctors, Cambridge University Press (1998). Information about stunting and nutrition in Tanzania is from USAID. Information about Kikwete’s visit in 2008 was compiled from interviews with the president and the two hospital staffers who escorted him: Emmanuel Mighay and Isaack Malleyeck.


(Photo:: D Word meets with President Kikwete. Photo/Bartelme)


(Photo: Mayetta and a friend, Daniel Anania, at the International Medical and Technological Institute in Dar es Salaam. Photo/Bartelme.)

Chapter 41

Emanuel Nuwas and I visited Charles Petro’s hut to see how he was doing. Nuwas translated his story into English as we spoke.


(Photo: Nuwas and Charles Petro. Photo/Bartelme.)

Chapter 42

Hayte (Hi-yeh-te) Samo told me the bulk of his story in Dar es Salaam when he was doing his advanced surgical training. Among Hayte’s other accomplishments: He worked with a filmmaker to do the first ever Datoga-language film, Ukimwi Datoga! (Datoga let’s beware of AIDS!). Hayte played the lead role of a herder who goes to town, gets drunk, has sex with a prostitute, and brings AIDs back to his community. With Herman Malleyeck, I also traveled to Hayte’s home place, where among other things mentioned, I saw the two trees where he went to school.


(Photo: Hayte went to classes under this tree. Photo/Bartelme.)

Chapter 43

Data on stroke deaths come from the World Health Organization. Data on stroke prevalence in South Carolina are from the South Carolina Department of Health and Environmental Control. Leonard Rodwell told me the story of his wife’s aneurysm.

Information about the prevalence of lawsuits filed against neurosurgeons can be found in “Malpractice risk According to Physician Specialty,” Anupam B. Jena, Seth Seabury, Darius Lakdawalla, and Amitabh Chandra, New England Journal of Medicine, vol. 365 (Aug. 18, 2011).

Chapter 44

Jane Word’s artwork was featured in “House on Folly Captures Spirit of the Area in a Big Way,” by Wevonneda Minis, (Charleston) Post and Courier (Sept. 7, 2013).

Chapter 45

The National Museum of Quackery closed in 1984. Other notable neurosurgeons who attended the meeting included roger Hartl, a neurosurgeon for the New York Giants who gained national attention for reassembling the spine of a firefighter in the Bronx who fell five stories out of a burning building. Hartl had done medical missions in Tanzania. Mike Haglund of Duke University had done impressive work in Uganda. Kevin Lillehei of the University of Colorado made a detour to St. Louis on his way back from a teaching trip to Haydom.

Chapter 46

Sunil 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. He was born in Dar es Salaam, which has a large population of Indian immigrants, and moved to Zambia when he was five. In Dar es Salaam, he told me about a monkey in his backyard in Zambia that he named Chiku. They played jokes on each other and taunted each other until one day his family said they were moving to the United States. Chiku bolted, never to be seen again. Patel eventually majored in physics at Clemson University and then went to MUSC for his MD.


(Photo: Dilan greets Hayte Samo in 2010 just after Sala. Photo/Bartelme.)

Chapter 47

I was in the bar with Dilan when he got the call from President Kikwete. His expression was a mix of amusement and confusion. “It took me a minute to figure out that it was really him.”

The scene in the president’s private residence is based on recollections of Dilan and D Word, as well as photographs taken by the president’s photographer.

Watch a video about Madaktari Africa at this time.

Chapter 48

As described in Incognito, the neuroscientist David Eagleman studied perceptions of time by having people go on a theme park ride that drops people from a great height. He then asked them to estimate the length of time they took to fall. People routinely said the drop was longer than it actually took.

Robert Lutton’s Toxic Charity was published by HarperCollins (2011). Lupton’s reference to “beggars” can be found in The Mennonite (June 16, 2009).

The study analyzing short-term medical missions and other models appeared in the World Journal of Surgery, “Charitable Platforms in Global Surgery: A Systematic review of Their Effectiveness, Cost-Effectiveness, Sustainability, and role Training,” Mark G. Shrime, Ambereen Leemi, and Thulasiraj D. Ravilla, vol. 39 (2015).

For more information about the Rwanda model, see “The Human resources for Health Program in Rwanda—A New Partnership,” New England Journal of Medicine, Agnes Binagwaho et al., vol. 369 (Nov. 21, 2013).

For information about the number of people who die every year from surgically treatable diseases, see “Global Burden of Surgical Disease: An Estimation from the Provider Perspective,” Mark G. Shrime, Stephen W. Bickler, Blake C. Alkire, and Charlie Mock, The Lancet, vol. 3 (April 27, 2015).

A landmark study on the shortage of surgeons appeared in “Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development,” by Mark Shrime et al., The Lancet, vol. 386 (Aug. 8, 2015).

In May 2015, the World Health Assembly passed an international resolution to strengthen surgical care across the globe.

Maarten Hoek, Carin’s brother, and James Kenning, also were present the night Dilan and D Word met Nuwas in Arusha.

Chapter 49

Life Without Care: Losing Haydom Hospital was produced by Michal Venera. His work can be found at: https://vimeo.com/64373112

Chapter 50

The Nyaturu boy, Paolo, was discharged a few days after Mayegga performed surgery.


(Photo:: Mayegga and Nuwas head to the surgical theaters in October 2013, after Mayegga mentions that he smashed his thumb. Photo/Bartelme.)

Chapter 51

In addition to Nuwas and Hayte, other Tanzanian specialists arriving in Haydom included two obstetricians, Yuda Munyaw and Paschal Mdoe, another surgeon, Daudi Lotto, and for the first time in the Lena Ward, a Tanzanian pediatrician, Judah Gideon.

Chapter 52

For information about the study comparing more intensive bedside teaching with the rotation of visiting doctors, see “Neurosurgical Capacity Building in the Developing World through Focused Training,” Journal of Neurosurgery (2014). Its authors include Dilantha Ellegala, Lauren Simpson, Emmanuel Mayegga, Emanuel Nuwas, Hayte Samo, Naftali Naman, D Word, and Joyce Nicholas.

Shannon Frazier did well after her surgery. Eighteen months later, she told me: “I felt as if I was given a second chance at life.”


(Photo: Dilan Ellegala and team at Centra Health in Lynchburg, Virginia, do the state's first standstill operation. Photo/Bartelme.)

Epilogue

For more information about deforestation’s link to Ebola, see “How Palm Oil, Fruit Bats and Deforestation Could Be Linked to Ebola Epidemic,” by Kevin Grandia, Ecowatch (Jan. 20, 2015).

For statistics about Liberia’s health care worker shortage, see “Implementing Liberia’s Poverty Reduction Strategy,” by Lawrence Sherman et al., Archives of Surgery, vol. 146 (2011). For more on the decisions humanitarian workers faced, see “With Aid Doctors Gone, Ebola Fight Grows Harder,” by Sheri Fink, The New York Times (Aug. 16, 2014).

“Essential Surgery” is the first volume of Disease Control Priorities, Third Edition (DCP3), published by the World Bank Group (March 2015). It identifies forty-four essential surgical procedures that should be available in low- and middle-income countries.

Information about the future economic consequences of the surgeon gap is in The Lancet paper “Global Burden of Surgical Disease: An Estimation from the Provider Perspective.”

For a discussion about how to speed up the training of doctors, see “Should It Really Take 14 Years to Become a Doctor?” by Brian Palmer, Slate (March 13, 2014).

In May 2015, doctors from Zambia, Malawi, and Europe began work on two pilot studies to see if clinical officers could be trained to do basic surgeries, a program called Clinical Officer Surgical Training-Africa (COST-Africa).

For more information about Madaktari Africa, visit www.madaktari.org.