Author: akingsnorth

Team members: Andrew Kingsnorth, Antonella De Rosa, John Hack, David Earle, Angleo Sorge, Alberto Meyer, Artur Seabra, Elaine Marinho, Luiz Alfredo, Sidney Chalub, Flavio Malcher.

Brazil is the fifth largest economy in the world, and is the world’s fifth most populous country, with an estimated population of 202,768,562 in 2014. The Brazilian health system consists of public and private components. The public subsector (the Unified Health System; Sistema Único de Saúde, SUS) was established in 1988 based on the principles of ‘health as a citizen’s right and the state’s duty.’ Since the creation of SUS access to health care has substantially improved, however regional disparities in healthcare still exist and are unacceptably large; the remote and poor regions of the north and northeast have reduced life expectancy compared to the south region, where life expectancy approaches that of rich countries.

The 2014 mission to Brazil was to the Amazonas state, in the northwest region. Most of the state is tropical rainforest with cities clustered along major waterways, accessible only by boat or plane. Manaus is the capital and the largest city, home to 45% of the states population.

The following three government hospitals were visited:

Hospital Geral de Manacapuru. The city of Manacapuru is located 80km west of Manaus with an estimated population of 92,996 in 2014. The hospital has three operating theatres but only performs emergency surgery. There are no elective surgical lists because of the lack of surgical expertise.

Hospital Universitário Getúlio Vargas, Universidade Federal do Amazonas. This is the University Teaching Hospital in Manaus, which is a busy, public hospital with five operating theaters. The hospital has the facilities and equiptment to perform laparoscopic surgery including laparoscopic hernia repair.

Hospital Regional Dr. Hamilton Cidade, Manicoré. Manicoré is a small town located in the south-east of the Amazonas state with a population of 52,200 in 2014. The hospital is well equipped with three operating theatres however no emergency or elective surgery is performed because of a lack of surgical expertise. At the time of our visit there were no doctors working in the hospital, which was run solely by nursing staff.

Eighty-nine hernias were repaired in 74 patients (female = 22, male = 52) with a median age of 44 years (range 2 – 83 years). Nine patients underwent more than one type of hernia repair, and there were 9 laparoscopic inguinal and ventral incisional hernia repairs. Local doctors were trained in hernia repair techniques, and an International Hernia Symposium was held at the University of the State of Amazonas, Manaus.

The humanitarian mission provided hernia surgery to the underserved population of Brazil and training to local doctors, building local sustainability. Practicing hernia surgeons from the host nation and the international surgeons were able to share ideas and learn from each other, a rewarding and invaluable experience for all team members.

Antonella De Rosa. September 2014

Phnom Penh, Cambodia, July/August 2014

Team Members: Trent Cross, Dominique Robert, Sarika Sharma, Almudena Ceballos Ruano, Cea-Cea Moller, Mohan Jayasundera

Cambodia is an amazing country that has suffered enormous tragedy during the reign of the Khmer Rouge in the mid to late 70’s. Genocide of over 3 million of its 15 million population and countless other atrocities have resulted in unimaginable suffering for the surviving population. The country has been in a state of rebuilding since 1980, with still a long way to go with over 20% still living below the poverty line. Few hospitals exist and those that do are largely private in nature expecting significant payment from the very poor population.

Hebron Medical Centre was the base for our team of 6, which included 4 surgeons, an anaesthetist and a theatre nurse. Hebron Medical Centre is an amazing hospital which started as a small house in 2007 and has progressed to a 70 bed hospital which has 3 operating theatres and sees over 40 visiting teams per year. It is a Korean missionary hospital and has many missionaries that stay on the grounds for years dedicating themselves to the people of Cambodia. The team worked well with the local staff and managed to treat over 60 patients performing 70 hernia operations on mostly children; some under 1 year of age. Other interesting cases included some recurrences in children and a complex re do inguinal hernia in an older gentleman which had previously been operated on 5 times. Both the patients and parents of the children where very happy and we left Phnom Penh planning to return in the near future. All patients we treated were well at the follow up clinic as arranged by our local coordinator Stephen Kim.

Socially we enjoyed very pleasant accommodation and were well taken care of by Hebron Medical Centre with our transport to and from the Hospital daily.  We had an amazing dinner with the hospital staff on the last night and tasted alot of the local cuisine. Most team members had planned a few days either side of the mission to see Phnom Penh, visit Ankgor Wat at Siem Reap and pay their respects at the Genocide Museum and mass burial site from during the reign of the Khmer Rouge.

Hernia International and I would personally like to thank Menaka Thomas from Samaana Yoga, Australia, and others who personally donated $1000 to support the mission. It was greatly appreciated and very generous. Hernia International is excited and dedicated to its long-term commitment to the Hebron Medical Centre and the Cambodian people.

Trent Cross August 2014

We are just back from our last mission of Hernia International Foundation and Surgeon in Action Foundation in Mongolia. The team was made up by Martin Kriz (surgeon) and Christian Andersson (urologist) from Sweden, Hugh McGregor (surgeon) from Australia, J. A. Pascual and T. Butrón (surgeons) and Faustino Santisteban (business) from Spain. This was the fifth mission in Mongolia.

 We all arrived on different flights on 14 and 15 June. Martin and Christian remained in Ulaan Bataar during the two weeks the mission lasted, as they went to the prison hospital. The rest of the group flew to the city of Khovd in the Northwest of Mongolia on Monday 16. We were met by the driver of the hospital where we were going to operate on the following days. We loaded all our equipment on a Russian van (the hospital ambulance) and we went to the city of Bayan Olgii 200 km north. The road went through the steppe and over some rivers, and we arrived after more than five hours and some incident as when the van stopped in the middle of a river we were crossing. We waited expectantly, and the driver could finally get us through.

 We had a picnic in the steppe with all that we had bought in the supermarket. Along the way we saw herds of sheep, goats yaks, camels, horses, cows and some yurta (Mongol tent). All that in the midst of a treeless landscape, pure steppe with mountains on the horizon. On arrival, we went to the hospital where we were introduced to the staff and then we saw the ten patients we would be operating the next day as well as the operating theatres. We ended our day with supper with the hospital director, two residents (Bota and Satu) and Sanchin in a Turkish restaurant.

Next day we started operating. We were able to get more instruments and so we could place two operating tables in one of the theatres. Thus we operated 12 patients. We had lunch and dinner at the hospital. Every day we did the rounds in the wards, and then we operated on three different tables. At the end of the day we saw the patients to be operated the next day. We were daily helped by the surgeons and residents of the hospital, and on Friday evening we gave two lectures.

On Saturday we went for an outing with some of the surgeons and anaesthiologists of the hospital. We went to a valley surrounded by mountains where the Mongols spend their summer. In the midst of that impressive landscape we were invited for dinner inside a Mongol tent. On Sunday morning Hugh operated on the last child. We then went round the city and had lunch with some surgeons and doctors of the hospital. Then we took our leave.

We came back again to Ulaan Bataar where we spent our second week. We arrived on Monday evening and we went to the hospital where we saw the patients we would be operating next day. The following days we followed the same pattern as in Bayan Olgii. At the end of the week we had operated more than one hundred patients.

In the evenings we walked around the city, we went to see a show of Mongolian folklore, and we had dinner in a Mongol restaurant. We hardly realized when the last day arrived. We had had a TV interview. Our mission was over, and we had come up to all our own expectations: 20 patients operated in the prison hospital, 52 patients in Bayan Olgii, and 29 in the second hospital of Ulaan Bataar. (101 patients, 29 of them children.)

Teresa Butron

Puente Piedre Hospital, Lima, Peru. June 2014

Team members: Dr Arun Baskara (Team Leader, surgeon from USA), Dr Ramon Soliva (surgeon from Spain), Mr Magdi Hanafy (surgeon from UK), Mr Michael Kelly (ST5 registrar from UK), Mr Shahab Khan (ST6 registrar from UK).

The Hernia International trip to Peru was wonderful and it was quite a humbling experience. We (Dr Ramon and myself) were received by Dr Jaime Herrera (who had made all the local arrangements to host the team) late in the night (or early morning) and his hospitality was amazing. We went to his home the next day and spent time with his family. It was so sweet when Dr Herrera’s little kid gave me and Dr Ramon a Father’s day card; I didn’t miss my daughters  on that day.

Our stay at the hostel was comfortable. We were assigned to stay at the 5^th floor. Though there were no elevators, the hotel personnel helped us to get the baggage to our rooms. They were very courteous and helpful. They brought breakfast to our rooms and it was a different experience.

We all were received at the Puente Piedra Hospital by the hospital Chief of Surgery, their CEO, and the surgeons working at the hospital. Every one of them were kind and again their hospitality was immaculate. The cases for the day were on a list and our team divided the cases among us on daily basis. The OR staff were kind, helpful and their enthusiasm in helping us amazed me. I wish I could have learnt more Spanish before landing in Peru. The flow of cases was good and I got the opportunity to teach the Surgical Residents. I could see that they are well ahead of the curve when it comes to hands on while doing the cases. Some of the cases were complex but doable. The lunch at the cafeteria was great and the hospital was kind to provide us lunch free of cost. The Chief of Surgery was there every day with us during lunch hours and made sure we were fed well.

Two weeks flew by in the blink of an eye. I felt a lump in the throat on the last day of our surgery when the thoughts of leaving that place crossed the mind. I appreciate Dr Herrera, Dr Miguel & Miguel (Two Surgeons), the Chief of Surgery and all other Surgeons, Staff, Students, Residents, hotel personnel for all their help and hospitality  which made our stay a pleasant and humbling experience; and thanks to our team as well.

I am looking forward to do more work in Peru during the coming years.

Thanks for arranging this trip, Hernia International.

Arun Baskara

Hernia International in Pakistan, March 2014

Team Members: Andrew Kingsnorth, Alan Cameron, Shambhu Yadav, Vernon Sivarajah, and Penny Howell (anaesthetist)

 As a destination for Hernia International, Pakistan’s reputation for terrorism, corruption, poverty, overpopulation and illiteracy did not seem promising. However my fears were allayed after attendance at a fundraising gala in Birmingham to support the Bewal International Hospital (BIH) in the Punjab – our host hospital. BIH is an extraordinary venture and based on £2m donations from Overseas Pakistanis mostly originating from the Bewal area. A modern, well-equipped facility has been built on the Pothohar plateau on which Bewal is situated. The plateau is fertile being situated between the Jhelum and Indus rivers which spread their muddy waters over the terrain in the monsoons. Wheat, barley and sorghum are grown in abundance. At this time of year the fields are a  green patchwork of terraced plots, which will be ready for harvest (manually) in just one month’s time. Shortly after the harvest the temperatures will rise to 40 degrees until the monsoons arrive in August. 

Our mission was meticulously organised by Atiq Rehman, an ex-patriot Pakistani who had relocated from Bewal about 30 years previously and who currently practices as a vascular surgeon in Dudley. Atiq had been largely responsible for the design, building, equipping and staffing of BIH during the last 3 years, and its coming on-stream as a community hospital, but with 2 operating theatres ready for use when the opportunity arose – enter Hernia International for a 5-day mission during 1-9 March!  

Bewal town is a typically chaotic, unplanned Asian town where street traders line the extravagantly potholed and undrained, metalled road on which traffic rules are absent and the main form of travel is tut-tut or a motorbike-for- four. In early March the mornings are bright and fresh (temperature about 5 degrees) and the atmosphere is bracing. We were housed in Atiq’s uncle’s spacious and vacant house about a mile from BIH. We had the luxury of a cook and housekeeper to energise us for the 10-hour working days. We had the choice of an invigorating walk to the hospital either through fields and past villagers’ houses and livestock, or through the town as it awakened and struggled to work, and children strolled happily to school.

Local members of staff supporting us included a theatre tech (Ashiq), and several nurses and a gynaecologist who doubled up as ward, OR and recovery staff. Surgeons doubled up as operator, scrub nurse and assistant. An exotic mix of supplies was brought by the team and provided by the hospital, all of which proved to be more than adequate for the 59 patients (with 66 hernias) that were treated. Several junior registrars from Rawalpindi Medical College attended during the week for hands-on tuition. Andrew lectured at the College and performed an operation on the Mother-of -all-hernias (4 hour job) at the Benazir Bhutto hospital.

The week was rounded off with a day spent in the capital city of Islamabad – a scenic, green and calm city planned and built in the 1960s, with a backdrop of the Margalla Hills National Park. After visiting the vast Faisal Mosque, we had lunch in a restaurant overlooking the panorama of the city below, before a tour of the Pakistan Monument at its imposing best, at dusk.

It was a great adventure, and no doubt we will be back.

Andrew Kingsnorth