One Brain at a Time - Chapter 4
A chorus of hope: Will a doctor's mission take hold here and in Africa?
The Post and Courier
Wednesday, July 28, 2010
Here's where ideas come from: Somewhere inside your brain, a signal shoots through a neuron at 200 mph toward a sac of molecules. Bam! When the signal hits that sac, it pushes the molecules out of the neuron, like a gust punching through an unlatched door. These molecules are on a mission now and fasten quickly to a nearby neuron, which sends the signal toward other neurons, over and over, until you think of a good place to get pizza or remember a funny joke or daydream as a choir sings softly in Swahili deep in the African bush.
It's late April 2010, end of the rainy season in Tanzania, and the choir sounds like velvet inside Haydom Lutheran Hospital's circular chapel. Outside, patients in brightly colored wraps and dusty sandals wait quietly to be seen by the hospital's staff. Inside, Dilan Ellegala, a neurosurgeon from Charleston, nods off in a hard-back chair as the singers cast their spell.
Ellegala is groggy from the flight to Africa, 7,900 miles from his home on Folly Beach, seven time zones from his wife, Carin, and newborn daughter, Else. He wears a blue long-sleeve shirt with the button-down collar undone. He feels himself relaxing, matching the easy pace of the Tanzanians around him, reconnecting with the place where it all started.
It was here four years ago in Haydom where Ellegala came up with the idea to train local Tanzanian medical technicians to do brain surgery, teach a man to fish. It was here on the edge of the Rift Valley where Ellegala spent six months training one of these technicians, Emmanuel Mayegga, to insert shunts and remove tumors. It was in this dusty village surrounded by fields of maize and sunflowers that Mayegga did so well that he trained a Tanzanian doctor, Emmanuel Nuwas, to do basic brain surgery, and that this encouraged Nuwas to train yet another young doctor. All this in a remote bush village in a country that previously had just three native neurosurgeons for 40 million people.
Brain surgeons know that neurons can atrophy over time, especially if not pressed into action, and when this happens, passion can turn into depression, movement into paralysis. So since his first trip to Haydom, Ellegala has been building a nonprofit to teach more Tanzanians brain surgery and expand this concept to other medical specialties, keep those neurons firing.
Funny how electrochemical impulses and molecules in a person's brain can fire neurons in the heads of others. Top neurosurgeons from Cornell, Harvard, Duke and five other noted teaching hospitals in America and Europe have signed up to help. At a dock party on Folly Beach, Ellegala met Doyle Word, a 6-foot-4 retired CEO looking for a new challenge. Want to be executive director of a nonprofit? Sure, Word said, and within months skillfully negotiated agreements with the Tanzanian government to expand brain surgery training to hospitals in Dar es Salaam and Mwanza, the country's two largest population centers. Ellegala's wife came up with a new and catchier name for the nonprofit, Madaktari Africa, playing on the plural Swahili word for doctor.
Yes, four years later, as he listens to the choir, Ellegala knows that his "teach forward" idea is growing beyond him. Nearly 500 volunteer doctors and medical students, including 25 from the Medical University of South Carolina, have traveled to Tanzania to train local health care workers, instead of just treating the ill and injured.
Ellegala has told his story to department chairs and top administrators at MUSC. They could block the neurons right there, tell him to focus on your cerebrovascular practice. Stick to Charleston! They do the opposite instead, parlaying Ellegala's work into plans for a new global health center. The center will coordinate MUSC's growing overseas research and clinical programs, put MUSC on the international map.
In a few days, Ellegala and Word will even speak at the World Economic Forum in Dar es Salaam, a gathering of African presidents and business leaders. One of their pitches: It's more effective in the long run to build human capacity -- make better doctors and nurses -- than throw billions of dollars at specific diseases.
They learn that the president of Tanzania may want to chat.
The student of his student
But right now Ellegala wants to find out how Dr. Nuwas is doing. After the chapel service, Ellegala strolls onto the hospital grounds and spots Nuwas, who wears a bright white doctor's jacket over a gray pinstriped shirt. Ellegala grins and gives Nuwas a bear hug. Next to Nuwas is Dr. Emanuel Hayte, the young medical school graduate Nuwas is training.
They walk to the hospital's radiology room and sit at a computer. Nuwas points to CT scans and quietly tells Ellegala how he recently removed a brain tumor the size of a Texas grapefruit.
Ellegala's eyes light up. This is no ordinary medical procedure; to get at the tumor, Nuwas had to blindly weave around fragile blood vessels, like a pilot flying low through a mountain range at night. It requires confidence and intense concentration.
"This is as complex a brain surgery as you'll find anywhere in the world!" Ellegala says, shaking Nuwas' hand.
It's a triumph for Nuwas, but also for Ellegala. "This is what it's about," Ellegala says, transferring knowledge, one person at a time, over and over, until the day Tanzania's health care system doesn't need overseas doctors anymore.
Nuwas tells him the patient is doing well. Ellegala slaps Nuwas' hand again, as if his team just scored a winning basket. "What you're doing is beautiful! You're the second generation. This will be in the Journal of Neurosurgery one day!"
A radiologist from Belgium walks in. He's here for a few weeks, he says. Visiting doctors are indispensable at this hospital, as they are in many hospitals in developing countries. But they can be difficult guests, even when they're well-meaning. Ellegala sees it all the time, the German doctor who makes eye contact with him instead of Nuwas, or in this case, the cheerful Belgian who has no idea that Nuwas has the makings of a first-class surgeon but lectures him as if he were a medical student. Nuwas fiddles with a pink card; Ellegala smells trouble.
It comes the next morning when the Tanzanians don't show up for the morning meeting. Ellegala lets the visiting doctors talk for a few minutes, then breaks in. "Guys, look around the room. There's something wrong with this picture," he says. "There isn't a single Tanzanian here. We are failing our primary job here, and that's to train people."
After the meeting, Ellegala mutters, "Changing the mind-set; it's a constant battle."
Bringing it home
Two days later, Ellegala and Word climb into a small plane on Haydom's airstrip, site of Ellegala's wedding two years earlier. A Christian group operates the plane to ferry missionaries and researchers in and out of remote areas of Tanzania. The pilot says a prayer, then fires up the propellers. The plane rumbles down the grass runway and lifts off, vaulting over Haydom's boulder-strewn plateau toward Dar es Salaam. Ellegala's thoughts turn to South Carolina.
Tanzania, South Carolina, you want connections? Here's a few, he says. "You can have tropical medicine classes at MUSC, and people will come to MUSC for that reason." A top university needs these kinds of programs to remain competitive. "We'll get recruits and talent in South Carolina that we otherwise wouldn't have, and that benefits patients in South Carolina."
The plane flies over huts surrounded by circular thickets designed to ward off wild animals. Here's an idea that came straight out of Haydom, Ellegala continues. "Patients who live outside Haydom either can't travel to the hospital or are intimidated, so I remember one time coming back to the U.S. thinking the same is true in South Carolina. There's still a stigma in some areas about going to downtown Charleston." So, bam, he puts together a business model for neurosurgery outreach clinics in Murrells Inlet and Bluffton. "They're the most profitable clinics our department runs now."
The plane lands in Dar es Salaam, the largest city in a country where the average person makes a dollar or two a day. Word notices the taxi drivers here fill up after they get their passengers, a sign that the driver can afford gas only with a paying passenger. After the fill-up, the taxi heads downtown to a hotel. They meet Sunil Patel, co-chair of MUSC's neuroscience department in the lobby, along with a Tanzanian doctor who's worried he has an aneurysm.
The Tanzanian is the personal doctor for the country's president. He pulls out some CT scans. Ellegala and Patel hold them up to the afternoon light filtering through the lobby's windows and agree that he needs an angiogram, a test that uses dye to identify blood vessel problems. But this equipment, common in U.S. hospitals, isn't available in Tanzania. Kenya is the closest option, and Ellegala says he'll escort him there tomorrow. If it is an aneurysm, they may fly him to MUSC for surgery.
Ellegala's cell phone rings. A man's voice comes on the line, Jakaya Kikwete, president of Tanzania. "Please take care of my physician," he tells Ellegala.
Tanzania, South Carolina. You want connections? Here's one with a twist: two neurosurgeons from Charleston fly to Tanzania to help the country become less dependent on foreign doctors, then help the president's doctor fly to another country for tests and treatment. Ellegala dons a tan suit and gets ready to leave for Kenya.
"You already know the diagnosis, don't you?" Ellegala says to Patel with an admiring smile.
Patel answers with confidence, "I believe our friend is OK."
Ellegala is off to Kenya, but Patel is just getting started. "I get anxious when I haven't helped someone in a few days," Patel says. Corny? Not from Patel. He lives on five hours of sleeps, gets emotional when he talks about how patients surrender their bodies to doctors in an almost spiritual way. "I get nervous when I don't see blood," he jokes on a tour of the main hospital in Dar es Salaam. Patel has flown across the ocean for just a few days to meet with Tanzanian business and hospital leaders. This work is that important to him. "I see this as a place to train!" he tells the hospital's executive director. "I see it as a place where people become neurosurgeons!"
Patel wasn't always so enthusiastic. After he hired Ellegala in 2007, he feared that his new recruit's focus on global health would divert him from his work at MUSC. Patel had a department to run, after all, and when one of his neurosurgeons was in Africa, he and others in the department had to fill the gap. He wasn't convinced until he flew here in 2009 and met Nuwas.
"That's when it sank in for me," he says on a rooftop restaurant before he sets out on another business meeting. "There's no doubt this is a financial burden on MUSC right now. When you have neurosurgeons out of the country, it's lost revenue. But there's no doubt it's a positive for MUSC, as well."
An example? Patel says he often uses a single $40 suture to close a surgical opening, while other doctors and residents sometimes use 20. At $40 a pop, these extra sutures add up. But doctors who practice in Tanzania and places where resources are limited typically become more efficient and creative. "Ultimately, coming here makes them better doctors," he says.
The conversation shifts to Ellegala. Patel is a respected neurosurgeon but may be a better psychologist.
"He has a vision," Patel says, but sometimes he sees a streak of arrogance in his colleague. "Insecurity is usually the root of arrogance," and it's surprisingly common in neurosurgeons, who often feel a profound need to prove themselves. Ellegala must be mindful of this, he says. Visionaries can be frustrating to deal with; they know what needs to be done and get frustrated when others don't see what they see. He says Ellegala has burned through assistants at MUSC because of this. He expects too much sometimes, wants things done too quickly, but he'll learn. He says a songwriter is successful only when that song has been passed to others. "Right now, he's the one singing the song, though others are learning."
Meeting the president
It's an eventful week. Patel's diagnosis is correct; the angiogram shows the president's doctor is fine. Relieved, Ellegala heads back from Kenya to Dar es Salaam for the World Economic Forum. He and Word give a presentation and field questions from top business and government officials. And, yes, the president wants to meet.
They spend an hour and a half at the president's home. They make a pitch: Why not expand this training program throughout the country? Self-reliance is the goal, they say, success is having an exit strategy, not a permanent presence. And for a man running a country that once lived under the thumbs of colonial rulers and now depends on the charity of overseas donors and doctors, why wouldn't this tune be music to his ears? He tells them this project should be part of the country's long-term plans.
Later, Ellegala and Word fly back to Haydom and meet with the vice president and the governor of Dar es Salaam. They talk to fundraisers in Washington and e-mail news to leaders at MUSC. The neurons are firing now on two continents; the chorus grows louder.
A doctor is born
During this whirlwind, Ellegala's first brain surgery student in Tanzania, Mayegga, stops by the hotel for a visit.
There they are, teacher and student: Ellegala, the son of Sri Lankan immigrants, an ambitious adrenaline-junkie who spends more than a decade to become a vascular neurosurgeon, then risks everything to help a struggling country help itself. And Mayegga, born in the African bush, hunted by a python as a child, so poor he made charcoal to pay for his school clothes, became a medical clinician, a brain surgeon, and now a medical school student in Dar es Salaam - probably one of the few people in the world to learn brain surgery before getting a medical degree.
Ellegala listens to Mayegga talk about his future as a doctor, and somewhere in his brain, impulses speed through neurons, break free and transmit signals to others, creating a thought: Yes, there's nothing like saving someone's life, but there's something even more satisfying, a feeling that's almost eternal, when you teach someone to save lives and know they will teach these skills to others. After all, in Latin, the word for doctor isn't healer.