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Welcome to a special episode of The Drive. For this week's episode, we're going to be rebroadcasting my conversation with Dr. Tom Katana, which was originally released in February of 2019. Prior to interviewing Tom, I had known about him for three years, but this interview was the first time I met Tom in person. And it's actually the first time in my life that I was ever nervous prior to meeting another human being.
And of course, this is incredibly ironic because when you meet Tom, and this, of course, will come across in the episode, he is quite simply the most humble person you can imagine. But I see in Tom what I consider to be the greatest of any qualities or characteristics in a person. And it really humbled me to meet him that day and to continue to get to know him better and better over the years since that time.
Since about the year 2000, Tom has been a missionary physician in Africa, initially working in Kenya. And then in about 2008, he moved to a region of South Sudan called the Nuba Hills or the Nuba Mountains, where he continues to take care of about three quarters of a million to a million people. At the time, he was the only physician in the area, and there's a single hospital there. It's hard to describe how few resources he has to run it. This is something he'll explain in the podcast. It's really nothing short of a miracle.
As an update to Tom's work, after several years of relative calm, Sudan is again besieged with conflict. This time there is fighting between factions of the government. This civil war has inflicted widespread damage across the Sudanese health system. However, even with all of this, Tom's hospital is still functioning and caring for the wounded. Not only that, but the hospital now has its own clinical training school, which has 19 physician assistant students and 30 midwife students.
In 2008, when the hospital was founded, there were 15 staff members, including Tom and a few expatriate Catholic nuns, and the local Nuba were not formally trained at the time. As of today, there were 270 staff and over 50 formally trained Nuba health workers, including nurses, pharmacists, laboratory technicians, and anesthetists. And the first woman doctor from the besieged area of the Nuba Mountains is now also working with Tom.
In my conversation with Tom, we talk about a lot of things. We cover some of the unimaginable suffering that he sees and how he himself copes with death and copes with being in a situation that I certainly don't think I could be in and I suspect many of you listening would relate to that. We talk about a crisis of purpose. I think it's easy to look at what Tom does and feel sorry for him or feel sorry for the people that he serves, but I must admit I came away from this interview actually feeling more sorry for us in a way.
And Tom so eloquently, without judgment, explains some of the differences between people with all the privilege in the world, like most of us listening to this, and the people that he serves. We also talk about the sense of community that exists in Nuba. And what you start to realize is that the way we die in this country and the way that we live in this country is so different from the way that people live and die in other parts of the world. It's not surprising that people there don't die from complications of type 2 diabetes, but instead they die from infectious diseases and trauma.
There's also a more subtle point here, which is that we are in many ways prisoners of our own world and our own mind and our own possessions. Tom's work is so important to me that I want to be sure anybody listening to this can get access to all the notes that we're going to put together on this topic. And as such, for this episode, the show notes will be free and available to everyone, including those who are not subscribers.
Lastly, and perhaps most importantly, if anyone is curious about how to support Tom and his amazing work, we will have a link at the top of the page of the show notes where you can give directly to the work Tom does. My wife and I have been giving to Tom for about six years now.
And I can say that it is unquestionably the highest ROI money that we contribute to any cause. In other words, for every dollar we give, we really have a sense of how it's being used and how it is changing lives. So without further delay, please enjoy or potentially re-enjoy my conversation with Dr. Tom Katanga.
Hey, Tom, thank you so much for making the time to come over here today. Sure, Peter. My pleasure. Yeah, there were a few people that would be giving up more that they deem important work than you. So I know I know your time is tight. How often do you come to the U.S.? Well, this is my first time out in more than three years. So last time I was in the U.S. was November 2015. I was here for about five days. I was in my hometown of Amsterdam, New York.
And it wasn't much of a trip. I was, you asked about malaria. I was sick as a dog of malaria. So I was like in bed with malaria the whole time. The last day I felt a bit better just in time to go back to Africa. So it's been, it's been a long time. It's been back. You grew up in upstate New York. Yep. Your pedigree is like the star, right? You went to Brown, you played football, you went to Duke medical school. Right. At what point did you realize you wanted to do something a little different to vis-a-vis working, you know, outside of the US, for example?
This desire to do, this kind of work really was planted when I was in college, when I was at Brown, and I always wanted to do some kind of mission work, and that term has several connotations, but I wanted to be a missionary. Whatever that meant, I wasn't quite sure what meant the time, but I just had this idea. I wanted to work in other cultures, in the society, do mission work.
But I was, as you, a mechanical engineering major, and that didn't really fit with doing machine work. This was in the 1980s, and most of the jobs then were in the defense industry. They were, you know, they were good jobs, but I didn't really want to do that kind of work. So I graduated college and kind of floating around for I was offered a job by GE, working with their kind of nuclear submarine program. It would have been a really good job, but I just wasn't interested in that kind of work. And number one day, it was kind of odd.
coming back from my great aunt's funeral. I was with my brother Felix, and the idea just kind of popped in my head. I should go into medicine because I could, if I do that, then I could do mission work and, you know, I'd like the sciences. I could stay in the sciences, do mission work, help people. Just kind of that general idea and ended up going to medical school and kind of kept that desire to mission work and that kind of evolved into wanting to work in Africa, work with people that don't have a lot of options for healthcare. You know, 15 years later ended up in Sudan.
So you started out in Kenya, is that right? Right. So when I finished at medical school, then I did five years in the US Navy. I didn't even scholarship for medical school, so I had to pay that time back. Then when did my residency, I did family practice in Tarot, Indiana. Now it was time to kind of be free and do what I want. So I thought, well, let me just go ahead and let me do this thing that's been kind of an itch for so many years.
So I teamed up with Catholic Medical Mission Board and I said, okay, we have an opening in Kenya at this mission hospital. Maybe go there. I said, okay, I'll go for one year. I'll see what goes. If I like it, maybe I'll stay longer. Otherwise, maybe I'll just come back and start a practice and went down to Kenya and fell in love with the place and decided to stay.
What was the first thing that you remember when you got there as far as how different this was from the way you had trained because you did your residence in the United States, right? Right. Do my residency in the U.S. and do family practice. And the program I went to was kind of geared towards rural health. So I thought, okay, if I want to do admission medicine, I've got to be doing more than just kind of outpatient office stuff. I need to do something a little more, a little more meat to it. So, you know, a little bit of obstetrics. We did a bit of surgery, mostly just these sections.
So when I first got there, I think what struck me was just the volume of patients. I mean, I was a resident and, you know, in clinic days, we'd see like five or six patients, you know, and get all every little detail down at each one.
And now I'm in this rural hospital in Kenya. And I mean, you're seeing 50, 60 patients, huge numbers. The clinic, the wards are full. You go to ward around. I was in charge of the adult ward. And at the time, I thought it was a huge number, like 30, 40 patients there. And I was responsible for all them. It's just this year volume of patients you had to go through every day in the variety of diseases. So not only the tropical stuff, which I didn't know much about. I mean, here's malaria, TB.
Lishmaniasis, all this kind of stuff I had no idea about. I had to learn about when I was there. I learned to thank God some more senior doctors there like I learned from. But just a volume of patients and the variety of diseases you've had to face.
So what year did you get to Kenya? I arrived in Kenya January 17th, 2000. That's so interesting. I arrived at NIH when I was in medical school on January 17th, 2000. No way. Being at NIH while I was in medical school was one of the more formative parts of my experience.
So how long before you went to Sudan and what led to that transition? I'm trying to think of my geography, right? Kenya is south of Sudan, correct? Sort of southeast of Sudan? Right, south in a bit east, exactly. Okay. And much more stable, right? I mean, Kenya's a relatively safe place to be. Right.
Sudan is not right. It's divided into these provinces. And the one that got all the attention was Darfur, which is the furthest West. Correct, exactly. And that basically was a war zone. I mean, a killing field, right? So Bashar was basically killing his own people there, wasn't he? Right. So to go from Kenya to Sudan, what were you thinking?
I think maybe the modus operandi of my life was always looking for, what's the opposite of greener pastures? I'm looking for browner pastures. When I was there in Kenya, this was, as I said, I got there in January 2000. The Civil War in Sudan was really raging at that time.
And I was in Kenya learning a ton of stuff, really enjoyed the work. And I kept hearing about Sudan, the civil war in Sudan, and how it's so terrible. And the conditions there were terrible. And there's such a lack of any kind of health services. I thought, man, I'd really like to get involved in that struggle just to go and work with the health of people there, just because health facilities were so limited. I thought, that's kind of the place I want to go to. So I had this general thought. This is 2000, I was in 1002.
Now, this was in June of 2002. I left my first posting, which was in a real place called Motomo's every two and a half years. I went up to Northern Kenya, a place called Turkana. It was at the Kakomo Mission Hospital, which is up in the Turkana Desert near the refugee camp. A woman named Deidre Burns, so Deidre was, I think, her first time up in Turkana.
And I was talking to her. She's an American. She was in a kind of short term mission there. She's a surgeon and a family practice doctor. She did both was doing primarily surgery. And she said, look, there's a bishop. I know it was a bishop back from Gassiz who was building a hospital in Sudan. I think he might be interested to go in there and that say, whoa, that's exactly what I've been thinking about doing, you know, for the past couple of years. It's back in 2002. So she said, look, he's got an office in Nairobi. He's living there in exile. Maybe you can make contact with his office because I was due to go to Nairobi and start working there.
Anyway, to make a long story short, I ended up working in Lairobi, linked up with his office, and we started kind of making plans for the hospital, and how would it run, and stuff, we would need all that kind of stuff. And then it took six years, but six years later, who funded the hospital? Is all funded through the Catholic Diocese. I see. So, as a Catholic Diocese of Elabade, Bishop Gasees was the Bishop of the Elabade Diocese, and he and his office were able to get funding through the church mechanism to fund the hospital.
So now it's 0809, and that's when you go. Right, so I went to the mountains, arrived there March 10th, 2008. Was they ever landed there in the mountains?
Tell the listener a little bit about where Nuba is. I mean, I know it's in the southern part of Sudan. It's to the east of Darfur, but it's pretty rugged country, isn't it? Right. So the New Moon Mountains is probably one of the most remote places in the world. It's a region which for many years, and Sudan was kind of kept off limits before when Sudan was kind of a colony. It was called the Anglo-Egyptian condominium, partly kind of administered by UK and by Britain and by Egypt.
They decided to kind of keep the new bus separate. They said, look, these people have a unique culture and our new people. They didn't really allow a lot of open tourism or people to go in there. It was kind of a closed area. So they really kind of have maintained this separateness and this isolation over, over centuries is difficult to reach. It's semi-arid. It's got, it's got this thing rainy season. It's got a dry season, but more hills. They aren't real high-moans, but sort of, you know, 3000 foot hills, that kind of, that kind of range.
My history is not great, but I sort of remember that basically Sudan was granted sort of, I forget the term, but when you're given your independence for lack of a better word, that would have been in the 50s, right? Right. 56. Okay. And then what was the religious sort of map of Sudan? And did that figure into how it was divided? And was that partly why Nuba was, was it religiously diverse? Was it mostly Muslim, mostly Christian?
Yeah, you know, Sudan is a very, it's a very interesting place. So you've got, it was one country up until 2011 when they divided North and South. Now, the religious makeup is in the North. So North of Nuba Mountains, it's primarily Muslim, almost all Muslim in the North. The South is primarily Christian. Nuba is right in the middle. And interestingly enough, Nuba is a mix. It's about, let's say, half Christian, half Muslim. And everybody's an animist, but half our Christian, half our Muslim.
And the Nuba are unique, I think a unique tribe in the world, where you have families which are mixed. You have Nuba Muslims and Nuba Christians, and there's no conflict amongst them. For instance, my wife is a Nuba. Her father, both her parents, when they were born, they were just followed the traditional religions.
Christianity and Islam had not been introduced to the area. Now, as they got older, her father became Muslim, the mother became Christian, they married. Her father is a polygamist, so two eyes, both wise are Christian, their oldest son is a Muslim, the rest of the children are Christian, and nobody's really bothered by this.
That's in Nuba. Now the country itself, this difference between Muslim and Christian was really a big issue in the previous Civil War. You know, we had sort of the Southern African people that were mostly Christian against the Northern Arab people that were all Muslim fighting each other. And there was very much a religious context to that previous Civil War.
and also in Nuba Mountains. The Nuba Mountains, the Nuba people join the Southerners. They're all African and Nuba. They join the Southerners fighting the Northern sort of Arab Muslim people in the North. And in the 1990s, there was a jihad against the Nuba people. So there was a real genocide in the 1990s against the Nuba. Who issued this jihad? The ideologue behind us is a guy who just died last year. His name is Hassan Al-Torabi.
And Tarabi was a member of the Muslim Brotherhood. Very bright guy went to Sorbonne in Paris and was kind of intellectual, but really kind of an evil genius, if I can use that word. He was a real ideologue in the Muslim Brotherhood, and he managed to convince some of the imams in the north
to sign off a font to allow jihad against the noobah. And many imams projected it. They say, well, you can't, you can't do that. It's, you know, even though he'd be killing Muslims within noobah. Right. Exactly. His response to this was, okay, you can have a jihad because the Christians are fair game in the jihad. And then the Muslims are apostates from the religion because they associate with Christians.
Some of them eat pork, some of them drink local beer. They're not real Muslims. Like this thing with the new bar very much communal, and to have Muslims and Christians together at functions, it was a nothing but to him. The fact we could have Christians and Muslims in the same family was a huge scandal to him. He just couldn't tolerate that kind of stuff. So he said, no, these guys are also a fair game because they're not real Muslims. So what year was that Fatwa issued?
That was in the, I think in the early 90s, it would have been 93. So Beshir was already in power, right? His coup was like late 80s, right? He took power in 89. Okay. And this guy, Turabi, helped him in this coup. He was kind of the brains behind the coup. And Turabi, I mean, he was, you know, he was kind of a power hungry guy. He said, okay, he figured if he helped Beshir get into power, but she was a military guy. And we thought, okay, if I helped Beshir get into power,
I'm much more intelligent than Bashir. I'll just kind of find a way to get rid of him and I'll take over. And Bashir said, look, I'm the one in power. You're not taking over. So he kind of always kept Tarabi at a distance. And he was always throwing in Tarabi in prison afterwards because Tarabi started speaking out against him, put him in a quote unquote prison and he'd be, you know, he'd be doing some luxury apartment in Khartoum. But they kind of were at odds with each other.
Turabi was the ideologue behind a lot of this moment. He's the one that invited Osama bin Laden to Sudan in the early 90s. So bin Laden lived in the early 90s. When bin Laden was exiled from Saudi Arabia, which is in the early 2000s. Right. Well, that was before then. He invited what's his name? He invited bin Laden to Khartoum. So he lived in Sudan for a while, and a lot of Kaida had a lot of training camps in the desert in the north of Sudan. I had totally forgotten that fact, that the chapter of Valkaida that I sort of forgotten.
So you basically have a bunch of incredibly evil people who are deciding to kill their own citizens effectively. You got there in 08, you said her 09. 08, so he arrived March 2008.
So historically, that was the interim peace period. So since they got independence in 1956, Sudan's been at civil war, various parts have been at civil war for almost the entire history. That's how many years, 62, 63 years, most of the history they've been at civil war.
So, this was one of the brief periods. Actually, it wasn't even priesthood, because Darfur started in 2003. Darfurry rebels started fighting against the government in 2003. So, the whole country was not at peace at the time, but the big war between the south and the north, the peace agreement was signed in 2005. So, when we arrived in 2008, the peace agreement was still in effect, and there was no active fighting.
And then we were kind of waiting for this referendum to take place. The way the piece of room was signed up was Southerners, so South Sudan would have the choice for self-determination. And that would be done by referendum. So that people actually have a vote, straight up vote. If the majority vote to succeed, they succeed. The majority vote to stay and stay as one country, they stay.
Now 2011 have the vote and 99.99% vote to succeed from the North. So South Sudan separates in the peace agreement. I'm sorry, is Nuba considered South or North in this cessation? Right. This is part of the problem because in the peace agreement, Nuba was separate. Okay. And what they said was, okay, South Sudan will have it for a referendum. The Numa Mountains was not included as part of South Sudan.
Nuba and Blue Nile were separate regions, and they said in these two regions, they're called the two areas, they'll have what's called a popular consultation, which was a very vague system where there'd be committees set up, they would go and they would talk to people in the villages and kind of get their opinions on things and see what they wanted to do. If they wanted to separate, stay, it was very vague. And I think it was purposely vague.
because the government knew it was kind of a bargaining chip for the north to allow the South Sudan to have this referendum. They said, OK, because they knew in the end they would keep the mountains because this thing was too vague, you know, and they would be able to manipulate it enough. They will keep the new one on their side. So South Sudan separates. There are elections in the mountains in 2011 in May, the candidate for Bashir's party, of course, who wins the governorship in the parliament. Just as a side note, before that election,
The guy's name is Ahmed Harun, who was running against the guy named Abdul Aziz. Anyway, Ahmed Harun was the candidate for Bashir's party, the National Congress party. And before the election, Bashir said, Ahmed Harun is our candidate, and he will win this election, whether by the ballot or by the bullet. So going into it, it doesn't look like it's going to be a free and fair election. Right. And Bashir at this point, does he already have basically a warrant out for his arrest? Right. So he's got the warrant for his arrest. That was, I think, 2009, I think.
Amad Haroun also is indicted by the ICC for crimes. He was one of the architects of the genocide, you know, Darfur. So Amad Haroun, who is our governor, is indicted by the ICC. Bashir is indicted by the ICC. He also was a defense minister, wasn't indicted by the ICC. So Amadhar wins. They go and say, okay, now our party is there in South court of instinct in the mountains.
There are still SPLA soldiers like southern soldiers living in this region. The Northern Army came and said, you know, did a force disarmament of these SPLA soldiers. And that's when violence broke out. So June 2011, June 6, 2011, civil war breaks out in Nuba Mountains against the government.
Now I've heard you speak about this in the past. It was overnight that most, most of the staff in your hospital left. So prior to that, leading up to that, the referendum and that the breakout of war, you've got this three year period where you're in the hospital, you're working there as far as new, but can be tranquil. This is the greatest tranquility you've seen. The staff is what it's you. It's what else.
Right. So at this time, we started the hospital, March 2008. We went there with about eight expatriates, including myself. So I was only a doctor. We had a few nurses, an esthetist, a lab person. We had those eight expatriates. They were mostly from, they're all from Kenya or Uganda.
Those eight expatriates, myself, we had 15 local staff, Nuba. And the Nuba, I think the most educated person had finished primary school. They were not nurses. They were just kind of local people that could read and write a bit of English and he could speak English. So they had to be taught everything. We first started, they couldn't weigh a patient. They couldn't take a temperature, let alone give an injection or start an IV. Anyway, with time, we got these guys trained up a bit. So they had some pretty good skills. A lot of that was done by these expatriate nurses.
Now we still kept ex-patients, but over time we added more and more on-the-job trained people. We kept adding more primary school graduates, or eventually we got a few secondary school people, started training them on the job. We didn't have any trained new nurses, new-but nurses, by the time the war started in 2011.
So now, War Stars June 6th to 11. By June 16th is 10 days into the fighting. Things are getting pretty hairy. There's a lot of fighting within Nuba, Arab embarments all the time, and the Diocese. And this is all from the North. The North is fighting within Nuba Mountains.
The resistance is posed by whom? Is it former southern who have not seceded or are trying to basically are the north and the south now fighting for Nuba? Right. So what happens is the South Sudan is totally separate. So within Nuba Mountains, you've got a lot of soldiers that were southern soldiers, SPLA soldiers, a lot of whom were Nuba, most of them were Nuba, but you also had other southern tribes.
and their mountains kind of left over from the previous conflict. They were there in the barracks. So all those kind of trapped SPLA soldiers are fighting the Sudan army. Now they call themselves, instead of SPLA, they're called SPLA North. So from that point forward, these guys are called SPLA North. They have kind of a new identity as a separate military force from the SPLA, which is a cell Sudan.
So, fighting is going on, Arab embarments. June 16th, the diocese says, look, we're having, we're setting a plane in and this plane is going to come in to evacuate anybody who wants to get out of there. Okay. Because then the plane was going to go to Uganda or to Sudan. The plane was flying into the mountains to pick up whoever wanted to get out and they would get out and leave. Now, this was a bit dicey because at this time, there were a few flights coming into the mountains, mostly getting people out.
But they have to change the airstrip. There are a few airstrips around, but they would give the location of the airstrip at the last moment and they would have a code name for it because if there were a lot of spies around and if the North found out they would come with their bombers and come and bomb the airstrip, they would try to bomb the plane on the ground or bomb the people that were trying to get in the plane to escape. So all this stuff was top secret.
So, you know, all of our expats that were there with us, they had all the knowledge. I mean, our nested test, our lab person, pharmacists, the nurses that were rewarding charges, the ones that were doing most of the work and doing the leadership, they all decided to leave. Now, did you all sit down together and have this sort of heart to heart, which is each of you had to make a very difficult decision, which is you feel committed to this work you're doing. But now your life is at exponentially greater danger.
Right. So, yeah, we met with everybody. We had a group talk and we met individually and said, look, this plane is coming in. This is the last plane that the diocese can send in. This is it. You know, once this plane comes and once it leaves, you might never get out of here. You know, because you have no idea what's going to happen the next day. You don't know if the sitting arm is going to overrun us.
And this is the last chance. How did you think about that? I mean, was there a moment when you thought maybe I should leave and go back to Kenya or go to Uganda or go somewhere else? I mean, what was that thought process like? Right. So, you know, I was encouraged to leave by some different people and say, look, why don't you come out? You stay in Kenya for a while, then when things blow over, then you can go back when it's safer.
I thought, and I thought, geez, you know, first, I mean, you have no idea. This is just total chaos. You have no idea what's going to happen. What I did know is that we were getting people wounded or by all the structures that are ever coming in all the time, you know. So I know if I leave, it's not like they can go somewhere else. There were no other hospital or surgical capability. Okay, there wasn't a single one. There was a small husband nearby or by a German group that could do some inpatient stuff and outpatient and some minor stuff. But really, if somebody needed a C-section or something more serious, they would just die.
Okay, and that says nothing of the casualties that are gonna start coming in as a result of this attack, right? So all these people that came in that were wounded would just would just die a miserable death and I knew that So for me it was a very easy decision. I thought you know, there's no way I can in good conscience leave this place and go out. It was a very very stark reality and
And to be honest with you, it was not a difficult decision. I think the sisters that were there, the two company sisters that stayed, the priest that stayed, we all were of the same mind. We all thought the same thing. Let's just stick it out. We're here as missionaries. Let's do what we're supposed to do and take care of the people the best we can and come what may. We have faith in God. We'll see what happens.
And it wasn't, you know, we didn't feel like it was some big thing. It was just like, well, now we can't go, you know, we got stuff to do here. And, you know, the other expats said, look, I've got a family, I've got this, I've got that. And we said, look, we're not going to hold anything against anybody. This has to be a very individual decision. If you guys want to go, we'll find a way to keep going. Don't worry about it. So we want to give them
full latitude to lead in peace and not feel they are abandoning people there. So I think everybody's pretty much at peace with the decision. The expats left. And I mean, sure enough, they left June 16th, the morning June 16th.
They left around six in the morning. They had to get out there early because they had to get this plan and just get out of the place. And we had to keep everything secret. So all of our staff didn't know these guys were leaving. We had to keep it a secret from everybody. And they have been left and then the staff came to work at 7.30. And so you had an anesthesiologist. It was one of the people that left. Right. So talk to me about 10 o'clock on that morning, the first time or whenever the first surgical case comes in, who's running anesthesia?
That was the biggest problem. So these guys leaver on six eight o'clock casuals you start rolling in people that were there's a bombing from one of the Sudan Air Force planes called in Antonov that has barrel bombs. They bombed in a location near us, maybe an hour, couple hours away. We hear these in the film, the heart of Nuba, right, which we'll talk about in a few minutes, but.
Right. So like two hours later, all these megal bodies are coming. Describe what this, I mean, so I did my training in Baltimore. In many ways, trauma was a feature of the training program because if you're training in surgery, you know, one of my mentors said, you know, to be able to train into a place like Hopkins is a great honor because you really get to understand surgical anatomy in trauma.
And it's penetrating trauma in the United States is mostly gunshot wound and stab wounds. But I have no idea what you were seeing. So what explained to me what things you actually saw, what types of injuries are you seeing? Right. So this was very stark because when Antonov bombs, there are huge shards of metal. I mean, weighing, you know, 10 pounds. I've got a bunch of the scraps. I have them as a souvenir, Megan Nuba. So imagine a scrap of metal waste, 10 pounds, red hot.
just going through your body. So it slices off legs, slices of arms, cuts through people with just massive tissue loss and massive trauma. So I'm here one young lady. She was 16. Her name was Urshelim, which means Jerusalem and the Arabic. And her arm was just totally mangled. I mean, just shattered. She came in. Her cousin came in. His whole hand was blown off by the Antonov shrapnel.
So, these guys, both in the amputations, the girl, we did a distorticulation in the shoulders. So, we had a couple of our on-the-job trained nurses there, and they had done some, they had been taught how to do spinal anesthetic by the anesthetist. So, you get this from someone else, they couldn't do GA. For the listener, GA general anesthetic, meaning they couldn't intubate and put the patient fully to sleep. Right. And I had never intubated a patient before. I remember when I was in the military, we intubated at intubate goats for as part of our ATLS training. I think if I remember, but I never done it either.
It's like, what the heck? It was so afraid. I'm like, what am I doing with these people? I remember reading the book. We have a book there, kind of based against Asia book. Cybering through the protocols, okay, first, give some ketamine, you knock them out with that. They go to sleep, give it a laboratory pain, you give it succinylcholine to paralyze them, intubate, and you give pankeronium. You have a hell of a anesthesia, put the tubings, blah, blah, decide to intubate. I'm like, okay, okay, let's do it.
So we took some guys back and I would go and get the drug, I had a nurse there, kind of on child, it's okay, get the ketamine, you would push it in, push the succinylcholine, I would intubate. And I guess I should explain for the perbs on listening this, because we use these terms so commonly. So intubation is
a very important step where if you screw this up you're gonna kill a person literally you will kill them but you have to put a breathing tube into the endotracheal space so this is now to allow a machine to breathe for someone while they're under anesthesia and. We do these things in medical school we did them in residency with a lot of our critical care training required that.
But I have to tell you, and I was not trained as an anesthesiologist, I never intubated somebody without being incredibly nervous because it's so easy to put that tube accidentally into the esophagus. And you think you're doing it right. And all of a sudden, you get the tube in, you hook it up to the ventilator, you think everything's going well.
And by the time you realize you're providing oxygen to their stomach instead of their lungs, it can be too late. And then, of course, the panic that ensues is often what kills the patient. Because you're getting nervous and then you can't do it, you're starting to shake.
You know, the problem is my, as I said before, my training was family practice. I did internal medicine, internship, you know, the family practice. I never intubated somebody. I never did anesthesia, medical school. That was not part of our training at all. So I was very green with this. Anyway, by the grace of God, men as you get the patient, intubated, connected to help. We have a really primitive structure called an OMV, Oxford miniature ventilator. It's got a set of bellows. It's like turn of this injury kind of stuff. Turn of the 20th century.
So, you know, intubating, so we have to get to manual ventilation for the patient. Throughout the whole surgery? Yeah, throughout the whole surgery. As long as our paralyze, you've got to ventilate manually. Usually with the hella thing, up to you manually ventilate for about 20 minutes, they can breathe in their own. And it's a bit of an art to try to keep them under enough where they can breathe in their own, but they're not in pain. So it's a big art to this kind of work, but it's all manual.
I just have to go off on a tangent for a moment, which perhaps only the people listening to this who have medical training will appreciate what you're saying. I'm guessing you don't have blood gases. No. Okay. So you can't measure a patient's PAO2 or PACO2. And yet your anesthetist has to figure out how to ventilate, which, again, means how much oxygen the person needs and how much CO2 you take off. And if you screw either of those two up, you will kill someone. Right.
And if you told me to walk into Mass General or NYU or pick your favorite hospital and said, Peter, we're going to do everything for you. We're going to intubate the patient. We're going to do this. All you have to do is be the guy that manually ventilates them.
I wouldn't be able to do that. I would overdo it or underdo it. There's no way you'd hit that sweet spot. You'd cause an alkalosis acid, and then to be able to not have the laboratory tools to know when you're off the rails. Those days, we didn't have a pulse ox. Now, at least we have a pulse oximeter, which can measure the perceived oxygen saturation blood. That's the saturation blood. That's the time we had no pulse ox.
Some of this stuff, maybe ignorance is bliss because you can't measure it. So you just hope and pray that things are going okay, but manage to get the guy into bed. I mean, you couldn't do veterinary medicine like this in the United States. Right. Yeah. You know, it was pretty hairy. We managed to get through and this one, we eventually got an anesthetist to come. This was after about a month or two.
Well, and in that month or two, what types of casualties did you see? Oh, I mean, everything abdominal trauma, lots of electron. We did a number of general anesthetics during that time. We had a baby that came in with an interception. This was the worst case. It was a nine month old baby.
who came in, who had an interception, which is kind of an intestinal obstruction. Explain what that looks like the telescoping part. Right. So an interception is when the intestine telescopes on itself and basically causes a blockage of the intestine. And then when the longer you delay, that intestine can die.
and the person will die, the baby will die from infection. And we made the diagnosis and I'm just like, oh God, you know, he's supposed to do with this kid. So anyway, we take the baby to the outbreak and we say, we got to try something. So I'm intubating an adult is hard. The baby is really, really hard. We managed to get the kid intubated. So I did intubated the baby, started on the ventilated telephone.
Went out scrubbed for the case came back. We opened the baby up that a bowel resection Put it back together close baby up and he'd be great. He's how old is the baby now? He's like baby. He's eight years old now eight nine years old. So he's he's cruising But that's kind of one of the many miracles and when we seen bits of shrapnel are going through people I mean, you're seeing liver lacerations. You're seeing bowel injuries right he manuma thoracies head trauma. I mean
Give me a sense of the mortality. There are some cases that obviously just can't be saved. Right. Well, you know, I'll tell you Peter, I think what happens, some of these people say, why do you have so many extremity traumas? Because they're the ones that make it in. They want to survive. Yeah. So, you know, the ones that get a really terrible trap in the chest, they bleed out in the field. Because we're, you know, we're six hours. Sometimes these patients come a day. We've had people with penetrating abdominal trauma, with multiple holes in their intestines, come three, four days afterwards and survive.
So imagine that. You're leaking feces into the abdomen for three or four days. So imagine how strong these people are. And they come and it's just a mess and you open them up and some of them pull through. You know, anemic dehydrated. They haven't eaten in several days and these guys can survive.
So some of it is the people are just tough as nails, but we get a lot of penetrating. I mean, kidneys get torn to shreds, liver lacks, massive kidney trauma, liver trauma. I met one guy had, we counted, he had 23 holes in his intestines that we had to, you know, resect here, resect there, stitch this one, just look forever. How did you learn surgery?
Right, so I trained in family practice, and when I went to Kenya, we were doing tons of tropical medicine, a lot of obstetrical care, a lot of C-sections, but I realized a lot of the disease burden in Africa was surgically related, a lot of it. A lot of it, of course, is tropical medicine. You can do all those things and say, well,
A good similar half of what we were seeing was surgically related, either just wound care, miscarriages, laparotomies, amputations, kind of the run-of-the-mill kind of surgical stuff. There's a lot of it, so I thought I really need to learn how to do this stuff, if I'm going to stay here long term.
So, luckily, where I've been, both rural Kenya and Nairobi, I met up with people that were willing to teach me things. So, it really was like doing another residency. I mean, I would, when I was in Nairobi, had a whole day in the operating room. And we would do tons of cases. And there was an American missionary doctor there named Mike Johnson. So, I'm like, we just sit there and teach me stuff. You know, I would do just like he did in residency. I would do the case. He would assist me and just kind of walk me through it.
There was a Kenyan surgeon there, Dr. Rucho was a fantastic, he was like a magician. He was not so hands-on, but if he was always there in the operating room, he would say, go ahead and start the case. I think I had a little bit of experience because he started the case, he had problems calling me. So I'd start open up, look around a bit, say, okay, I'm stuck, what do I do? He'd come in, look around, say, I'll do this, do that, I'll do this and that, and things would go ahead. Before you know it, you're doing thyroid and laparotomies and reciting bowel and stitching liver and taking kidneys out and doing amputations.
I mean, you know, how it is, you just kind of want you to learn a few, you have a few skills you can add the next case, the next one, the next one. And I mean, it took, I was there for seven and a half years in Kenya. It was like doing another residency. I mean, at some point, though, you have to be making mistakes that are harming patients because even in our, and I say that not being critical, right? But just saying like that's the nature of medicine. I mean, I think of every time I hurt somebody, even, you know, I remember once causing a hema pneumothorax in a patient when I put a central line in them.
It was my 500th central line. So at this point, you'd think I could do it blindfolded and yet to cause that complication, which in my case, I'm lucky enough to have an x-ray to see that I've caused this complication, you don't even, I mean, you're missing so many of the basic tools that could act as sort of a safety net. So what was that process like?
I think what I wanted to make sure of when I was in Kenya, I think those whole seven half years I was in Kenya, I always had either somebody assisting me in the case or somebody in the room or in the next room over. So I think I was pretty well covered during that time. And by the time I was finished seven half years, I felt pretty confident I go, well, am I going to do
and do surgery. I think it's this concept, you know, better than I do, about 10,000 hours, you know? And I think in residency, you have like a thousand cases, it's supposed like a thousand cases at least, like that's like a minimum. Yeah, maybe 1200 or something. Yeah. So I did, you know, by the time I finished my time in Kenya, I'd done it. But for you, it's harder because you're doing a breadth of cases that, like, even if you took something as broad as general surgery, I mean, you were still doing basically orthopedic surgery as well. And obstetrics. And obstetrics, a lot of urology.
There was a mix, and I think maybe the trade-off is the surgery in Africa is much broader but less depth. We don't have any laparoscopic stuff. Of course, we have many of these da Vinci things and all that and all this high-tech stuff. You trade-off kind of depth of surgery for breath. I felt after doing around 2,000 C-sections in over 1,000 other major cases, I felt okay. I think I can do
Whatever we're doing in Nairobi, I can do that, I think, safely in Sudan. Obviously, we have complications and other problems. There are a lot of limitations in terms of going into the case. You tend to do more laparotomies because you don't have a diagnosis. You don't have a CT scanner. No CT scanner. You don't exactly what's going on. To get a tissue diagnosis might take you six months. You say, go, hey, let's do laparotomy and see what that thing is. That's your CT scan in the end.
But that's about the best you can do. So I think what I always, what I try to do when I approach a case is, you know, the premium known known chariot, first do no harm. So if you think you'll make the patient worse by doing this, like, okay, I'm not an expert doing this case.
And sometimes I say, I'm not going to do it. You know, I won't, I won't do it. If I think I really cannot improve this patient's health, I think, okay, this is too much of a risk. Sometimes they look, I just, I'm not really comfortable doing this, but usually I'll feel, I say, okay, I think it's better. If we try to do this operation, I think we can, the patient can improve and we'll go ahead and it works. I mean, it only works out pretty well.
I was talking with my wife and my daughter a couple days ago and about how we were going to be speaking today. And they had so many questions. You know, we all watched the heart of Nuba together. And one of the questions my wife had was, how do you deal with exactly that type of situation you described, which is what we would consider quote unquote end of life here in the United States or palliative care.
what do you do in a situation where somebody comes in and your judgment says this person is not an operative candidate, but also by not operating, they need to be palliated. I mean, they're not going to, they're not, you know, they're going to walk home. How do you deal with that? And more importantly, I guess then medically how you deal with that, it's emotionally and how is that communicated to the community because you're still a foreigner, right? Right.
Right. I was still a foreigner and it will always be one. So I would say when we first started 10 years ago, people did not trust us. And it was incredibly nerve wracking, something we just got here. People did kind of have this because they've been, these people have been traumatized and oppressed for so many years. But I can trust some foreigner showing up saying is there to help them. So you got to prove yourself something and well, you know, it got into these operations. What if we have bad outcomes? You know, what happens?
So it was really nerve-wracking for all of us. And, you know, thank God, things went pretty well. We went ahead. So the issue with palliative care, you know, we try to just talk to the family, talk to the patients, say, look, I think we can't do much for you. And I said, if you go home, we'll take care of the pain and what are the things we can do. One good thing there is the people, their expectations are extremely low. And I'm not saying that negative, I'm saying a positive way. They don't expect
They don't really expect miracles. They want to be treated as a human. They want that human touch. They want to talk to us and they talk to you and say, okay, what can we do? If we tell them, look, we can't do much. They're not saying they're not like, they're not very demanding saying, no, you got to forget it.
Send me to Nairobi for a second opinion. They're very accepting. I think that's just because of their lives are very hard. They're not used to good outcomes. So I think first off, they're very accepting. So when you tell them, look, I think there's not much we can do. We often will talk to the relatives culturally. Usually relatives will say, well, just, you know,
They don't like telling the patient, which is very different from here in the US. So we just talk with relatives, and they're usually very accepting. They say, OK, we see a dumb chicken. We'll take them home. I'm comfortable there. They have some of their local
traditional things they might try with the person at home, but usually very accepting of negative outcomes or bad news. When you're kind of at the edge of survival all the time, when you get this kind of bad news, it's not so shocking to you. It's like, well, you know, it's what happens. People die, you know, when people have bad outcomes, bad things happen to you.
So it's not so unusual for them. You know in the US we're kind of anesthetized that everything has to be perfect and We're not supposed to die. We're supposed to you know have this kind of outlook on life It's it's a very different way of doing things So they're fairly easy in that respect they understand this stuff You know most people have some level of faith whether Christian or Muslim they can accept this stuff in a theological sense. Also, it's not so difficult
When you showed up, how primitive was the extent to which people were receiving, I don't know how to describe the type of care, but there must have been local traditions and shaman and stuff like that, right? And at some point, you're showing up and you're coming from a place of science as sort of simple as you describe your work in medicine. It is still grounded in the fundamental principles of Western medicine. You use antibiotics, for example. You wash your hands before you operate.
What was the landscape like as far as the other types of medicine being practiced? And are they still being practiced now? Yeah, they're still being practiced. So their scope of medicine, you have kind of the local level in the home. And what they'll do is almost any febrile illness. So kids got a fever, someone's got a fever. They burn the person so that everybody there, my wife included, they have burn marks. They look like cigarette burns.
They're not cigarettes, but they take a round thing, just put it in the fire and they burn on the back of the wrist, back of the neck and the elbows. There are certain points where they burn the person to try to release the whatever it is. The spirit or the spirit of evil humors that are causing the problem. When they see that kind of smoke and they see the fat under the skin burning, they feel relief, okay, the thing is gone now better.
So they burn, they cut, a lot of people have cut marks in their arms or to have them in where they think that'll also release things. They cut down to have caused some blood loss that'll release some of the problem. And that's usually done in the home, usually by the father or the mother or the grandparents will do that kind of thing. That's kind of the local treatment.
That is still still practice less so than when we came I would say I mean everybody all of our staff have burn marks from when they were kids now We still see patients come with the burn marks when it comes with them with a simple malaria They've been at home four days. They've been roasting the kids like why you know
just gives a chance. Anyway, so burning, cutting, that's one level. They do have some herbal remedies that don't seem that prevalent. They were there, I think, traditionally some people still use those. And I don't know, you know, someday they still swear by it if you use the name tree or this Kayla, this plant that they use for malaria, they still swear that thing works for that. A lot of kind of local fruits and vegetables they use for for GI problems or the things. And those seem to work okay.
And the third level is the, what's called the Kujur. Kujur is like a, like a shaman. And the Kujur is like the priest for the, for the village. The traditional legendary is ancestor, kind of ancestor worship. It's, it's communion with the, with the ancestors. So if you're sick, if you have a problem, whether it's physical, psychological, whatever,
You go to the Kujur, you have a little ceremony with the family, you all get together. Kujur will talk with your ancestors, and then kind of give a report back saying, well, your kid is sick because your goats wandered on this guy's land and ate his crops. So you need to make up with this guy, you need to go and give him something, and then you pay the Kujur something, and then this thing is kind of lifted. Ciao, should get better.
Those three things are kind of traditional treatment. The couture is still very, very prevalent in the society, and they still often go to the couture, and they still will often delay treatment when they go to the couture. So how many people does your hospital serve? Catchment area is roughly a million, and they were from 70,000 to a million people, is in our catchment area. And the physical region is around the size of Austria somewhere in that range.
The people there, for example, how many of the people that you serve would understand what you meant if you were going to New York? Like, how big is their world? Well, it's interesting you've asked that. I mean, even the ones that have finished secondary school wouldn't have an idea. Like if they ended up here, or I mean, it would blow their mind.
Maybe I'll give you an example. My mother-in-law is probably in her 70s, so we went to talk to my wife. I was talking about writing a book. Actually, she started writing her book. We went to my mother-in-law, and we said, let's go and interview her mother as part of your book. I came right about her life. My wife didn't actually know a lot of facts about her mother. They don't have that. Mothers and daughters there are not like buddy-buddy. The girls are, once they get away from the breast, they start working, carrying water and firewood and everything else and cooking for the family.
So we went to talk to our mom and my wife asked her mother, her mother only speaks the tribal language. She doesn't speak Arabic or English or anything else. So we talked to, she's talking on the tribal language saying, do you know where Tom is from? And she said, she thought from it. She says, he's from Kenya.
And she said that. That's the furthest place she can imagine. Right, because she's heard of Kenya. So in her mind, anybody who's not from Numa Mountains must be from Kenya. Doesn't matter who you are, you know. So that's the outside world. And we say, well, no, he's from America. You ever heard of America? No, she never heard of it. Had no concept of America.
You know what an ocean is? No concept of an ocean. No concept of a lake. No concept of Africa. She didn't know she was in Africa. So what she knew was her local area, just a few of the villages there. She'd been to Cartoon One. My wife's mother has leprosy. We've treated her for leprosy and have amputated them. I think all of her fingers at one point or another.
She's really quite disabled. She got in the cartoon some years previously to get treatment there and ended up not getting treated. But besides that brief trip to cartoon, she'd never been out of that local area. A lot of my wife's siblings have never been out of this 15 square mile radius. You can't imagine the worldview. Presumably your wife also hadn't experienced things outside of that until she met you. And what was the first time she left or traveled with you? The first time, especially that you don't travel much.
Right, so the first time we traveled was after we married was just this past June. We went to Armenia. So that was really her first time out of rural Africa. She went to nursing school, but that wasn't South Sudan in a while, which is for South Sudanese. They call it a city, but it's a village. It's a big village.
So imagine we went from, we went from, uh, either of G camp down to Juba, which is the capital. I mean, Juba's more or less a city, but it's really not very nice. Then we fly from Juba to Dubai and we were in the Dubai airport. And I mean, which, which I was just there a month ago, even for someone who's from the United States, the Dubai airport is an overwhelming. Yeah. It's, I mean, it's, it's terrifyingly huge. It's a city. I mean, it's a, it's a major city. So we get there and her eyes are, you know, the size of saucers.
Has she seen that much electricity in one place? No. I mean, not even close. Not even close. Has she seen fresh water to that extent? No. I mean, I try to give she'd ever seen a tap. No, we had taps in the hospital. We have a pump that pumps water up and we have some taps in the hospital. But, you know, flush toilets were never seen before about all this stuff. Elevators. Elevators. So that was one of the things we get in there.
We're at the airport. We get in this, you know, push a button, this door opens, we get this thing and press the button and the thing goes up and we get off. She's like, what was that? So no concept in elevator. We got in the escalator and she's like falling over the place. We go to get off the escalator. She's like, what is the house? How's this thing moving?
I think when she was in there since going, wow, I think they had one set of stairs. There might have been a second floor, but just the concept of walking upstairs is something strange, a little moving staircase. So all these things were very new to her. Now we get to Armenia, and I mean, just being in a city. I mean, the caravan is a couple of Armenia, not like New York, but a very different experience for her. Now she came to the US for the first time just this past October, and I mean, she was in Times Square.
saw the ocean for the first time. She went to my brother lives in near Boston, a North Shore, Boston. So that was the first place she went. So the first place she went to Boston. And our hospital was getting an award by a group called Medicines for Humanity, which supports us. And they were giving us an award for the work that our outreach team is doing.
So nobody can make it. I couldn't go. My other staff couldn't go. So my wife went to accept the award on behalf of the staff. So she lands in Boston. And the first thing she does is goes to the Harvard Club to get this award. It was a very opulent place. It was my brother's place. He's up in Rockport, Massachusetts. He's the ocean for the first time.
She's a train for the first time. Goes to malls, to Walmart. She loved the dollar store. My family just went crazy with her. They had so much fun being with her, seeing all these things for the first time through her eyes. She has a very kind of infectious joy to her, and they really kind of tapped into that. It was really hard for her. The flip side of that is we can sit here and have this discussion, and of course, most of us would be thinking,
how amazing at all the things that they don't have. But I'll share with you a story that I suspect will resonate and you will understand it. This past Christmas, my daughter's school, each grade picks something they're going to do. And that grade decided that they were going to buy Christmas presents for all of the kids at the Sudanese Community Center in San Diego. And so they're basically all refugees.
And this was very interesting because we had already watched The Heart of Nubo, which was her first time even. She didn't know what Sudan was and she certainly didn't understand why there would be refugees leaving this place. So on the day that we take all the presents there and the kids have done an amazing job, right? They've bought like four or five presents for each and every kid there. And we spend the whole day there. So we go, it's my whole family. So it's me and my wife, three kids. And our youngest is like a year and a half old.
So there's another little kid there, a Sudanese girl, who's also about the same age. So the two of them are playing together. But you feel like you've got to sort of keep an eye on them because they can fall off the stairs or hurt themselves. So there's a woman that's holding the Sudanese girl. And she's sort of keeping an eye on our son as well. And so that gives us time to go and do these other things and see the other kids and do all the other stuff.
About four or five hours later when we're leaving, my wife goes over to the woman who's been holding this little Sudanese girl the whole time and says, what's your daughter's name? And she says, oh, I don't know. This is not my daughter. I don't even know whose kid this is, basically.
And we couldn't stop talking about that, right, which was talk about a different sense of community, right? There was nothing odd to this woman who was probably 20 to just say, hey, there's like this little 18-month-old running around. I'm gonna take care of her. And by the way, she's taking care of our kid, too. And so for as many things as they lack, they have something we don't have. That types in the Peter something,
You always hear about the negative side of places like Sudan. People think of Sudan, what are the images? War, poverty, disease, starving kids. The positive side is not shown and some things that always stick in my mind. One is we'll have patients that will come to us, that it's a seven or eight day walk to reach us. And on the way, like they'll start their journey and start walking.
Now, nighttime comes. In the society there, you can stop in somebody's hut and just kind of knock on the whatever or just show up and say, look, I've got a long journey. Would you mind if I kind of spend the night with you? I don't know where to stay.
So that family will take this person in total stranger, give him place to sleep, give him food, give him water for them to wash, take care of him that night, the next day he'll continue on his journey, next day he'll stop another total stranger's place. That stranger will take this person in, give him some food, hang out, this next day same thing until they reach the hospital. And this is the normal way of doing things there. The concept of community and what stuff belongs to you, what is a stranger, totally different than our outlook here.
So when you're there, like, well, jeez, who's really, really has it all? And who's doing the right thing? Which society is on the right track? It's really mind-blowing. Well, especially for you, because I guess it's one thing to know nothing that, but you've seen both worlds.
And I've read enough about you to know, I've seen enough interviews to know, I mean, correct me if I'm wrong, but you've described being more at home there than anywhere else, which I have to admit. You know, Tom, when I watch the videos of that, the first thought that comes to my mind is not, I wish I was there. I realize that probably just speaks to me being sort of a vapid, shallow person, but
If I'm going to be brutally honest, right? I don't look at that and think I want to be there. I think I would never want to give up my family. I would never want to give up my comfort, my safety, my whatever. You couldn't fake it. I mean, so it's obviously so genuine for you and any, you know, the other people like John who are serving as missionaries there.
I know that on some level, you'll say the answer is faith, but there must be more to it than simply your faith. Well, you know, some of it, Peter, I think is just, I think everybody is kind of geared a bit differently. So, you know, we grew up in a big family and, you know, my brothers could never, could never be there. But at the same time, I could not do what they're doing. So I think, I think all of us are really, we're kind of wired a bit differently even people in the same family. So I think I'm very comfortable there, but I couldn't maybe fit working in New York, you know.
But I think the good thing is, I don't attach a value to all this, because everybody has something to contribute. I really believe that. It's not just kind of blowing smoke. My thing is being there to a mountains. It's a part of the puzzle. Somebody else might be in New York. But you're doing a podcast. You're helping us in Nuba tremendously by helping get the message out.
If you're in Sudan doing the same work I'm doing, we don't have this, you know? So I think everybody has something to offer. And if we try to get in this thinking like, gosh, I'm not doing what he's doing. I should be doing what he's doing. I think we missed the point. We miss out on our shared abilities. You've got unbelievable talents and a brain twice the size of mine and you're using it.
in an area that you are comfortable with that is probably maximizing your abilities. I think it's good to be aware of what's going on in the world and everybody should think about their brothers and sisters elsewhere and contribute and do something to help other people. At the same time, don't spend too much time stressing that you're not doing enough. You're not doing anything. Do something, but it shouldn't be something which is agonizing, be painful. I think just the way I'm geared, that kind of life is a pretty comfortable fit for me.
You know, so I don't see it. Yeah, it's a sacrifice. It is. And I miss the family like crazy and I'm missing a lot and not being with my man. It's been more than three years. I've come here missing my parents, my nieces and nephews, my brothers, my sister. I do. I miss all that stuff. But I'm pretty comfortable in that, in that weird remote setting of a mountains.
So, I learned about you through my really dear friend Rick Gerson, his brother Mark Gerson, and ultimately met John, and I think they learned about you through a piece that Nick Christoff wrote in the New York Times in 2015.
How did Nick come to find you? Because that story, we're going to link to that story. The story is amazing, right? It leads off with about a 10 minute video that I watched over and over and over again. And I came home and I made my family watch it. And I sent it to my family back home.
There's a part in it that just says everything about it. First of all, I think Christoph did an amazing job framing the story, and he was there, which is in and of itself. I want to actually understand how someone actually gets there, because that strikes me as quite a challenge, logistically. But he ends the article with a story of a Muslim man who proclaims that you are Jesus Christ.
And I always, the title of the article, if I'm not mistaken, he's Jesus Christ, which coming from a Muslim man also speaks to the religious harmony that you've described. And for people like me who aren't especially religious, it makes you think, well, I guess that's what religion should be about, right? It shouldn't be about most of what we think of religion as, religion has its taboos here, but I think the point Christoph makes, and makes it beautifully is,
If you want to be critical of all of the religious hypocrisy, by all means do so, but you can't then fail to acknowledge the times when, in the name of religion, people are doing these incredible things. And the name of all religions, by the way, it's not just your religion. I mean, as you know, it's people of all faiths, there's many things.
But in many ways, I think that story brought amazing attention to your work that it breaks my heart to think are there other tombs out there, whose stories are not being told. So how did Kristoff find you or how did you just find each other? He has an interest in Sudan. I think he's had it for a number of years. And I think for him,
He saw this what Bashir was doing as such an egregious affront to humanity that he felt obligated to go and see firsthand what was happening. So he made a couple trips into the mountains. You could fly into Juba, then he got a flight up to the refugee camp in Ida, then managed to come into the mountains.
You know, you don't come in with official permission of the Sudan government. So you're sneaking into- Right. I'm basically sneaking in. You get a permit from the rebel government and they allow you to come in. And I think he just has an interest in that part of the world and really wanted to do something that shed light and the situation there against Bashir.
And he'd been at a new, I think, one previous time and heard about the hospital when they come and see us there and see what kind of work we were doing to see for himself and was there for a few days. He's a really intrepid traveler, an incredible journalist. I mean, he's unbelievable. And what I respect about him the most
as he can disagree with you, like, you know, whatever, religiously, politically, not agree with your beliefs, but he can realize what you're doing has benefit. It can look at it objectively and say, okay, you know, I don't believe in this religion, but I see what these guys are doing and highlight that.
You know, not many people are willing to do that. I thought it was very elegant how he framed that in that piece in the New York Times. And that video, though, it's only about 10 minutes, that was really my first introduction to you. God, it's about three and a half years ago now. Right. So the world's a better place. Certainly the Nuba Mountains are a better place because of Nicholas's work.
Right. And he tends to highlight people that are kind of not well-known. And there are others that are out there. And it's actually part of what we're trying to now with Aurora. Aurora's focus is on highlighting what they say is unsung heroes, but people that are kind of operating in the weeds that nobody knows about. So, China bit a spotlight on them, not so much for publicity, but to help them both in their work and to raise, by raising their profile, you raise the issues that they're involved with.
So, tell people a little bit about what the Aurora Prize is and what it means for you to now be, you're the 2018 recipient, is that right? 2017. 2017 recipient. So, what is the Aurora Prize? I know it's based on, I know a few things about it, so I'll fill in the little bits that I know.
It's a prize that has a finite life, correct? It was to begin in 2015 or 16, and it will run until about 2022, 23. And that duration, if I recall, is meant to commemorate the length of the Armenian genocide in 1911-ish, 1915. Well, it's 100 years onward. The genocide went on for about eight years, 1915 and 1923. So this is 100 years henceforth. Those eight years, those eight years that were surprisingly given out.
And it's a substantial prize. You were selected, and my understanding is, first of all, it takes an act of Congress to get you out of NUBA to be doing this other work, but it speaks to, I think, your understanding of how valuable this will be to the broader mission that you're serving. Right. What I saw was I'm very comfortable being in NUBA and doing the everyday medical work.
And I definitely want to go back to that environment longer term and get involved more with teaching the local people and when these guys, once these guys come back from medical school that we have out there really working with them to get their skills up. But I thought maybe using Aura as a vehicle, it was time to come out to kind of see what was out there with Aurora to try to expand the model that we have into the mountains.
So find a way to bridge the gap between, say, big donors or people that have resources and small organizations, small people on the ground that are kind of doing a lot of the grassroots work and doing it very efficiently. Because I think there are a lot of other people that are doing the work nobody knows about. And there should be a way to try to connect them to resources. So through Aurora,
That's one of my main goals. I wanted to come out and try to expand what we're doing. I felt that we're in New Way doing our thing, but maybe a little bit pigeonholed. How do we expand that and get outside of New Way, get into South Sudan, to Central African Republic, to Chad, to Niger, other places, which are really neglected parts of the world. Hopefully, there's some conflict zones. That was my main thinking coming out.
My time now, I've got three months out of the mountains. I'm traveling all over the place, speaking on behalf of Aurora, kind of doing some, basically, some promotion for them, but also meeting a lot of people and trying to formulate which direction we need to go in Aurora. So I'll be physically out for these three months. It'll be three months later in the year from September through November. Besides those two or three months periods, I'll be back into a mountains, do my usual work at the hospital.
What does more money solve in this problem? I remember recently Mark sent us an update about sort of where the dollars were going, and it was sort of hard to believe that so much could be done with so little. And I don't think the stats are, I think they're so overwhelming that it's almost hard to put it in context, but it's worth trying. For about a million dollars is an annual budget.
What have you been able to do in the past year? A million dollars is pretty generous. That's probably more than we'd need for the basic work, but let's save as a million dollars. We can see about 130,000 outpatients. 130,000 outpatients.
do close to 2,000 operations, see maybe 5,000, 6,000 inpatients. I mean, vaccinate tens of thousands of children. See, I'm not sure what numbers of maternity, anti-no-clinic patients, but a lot, several thousand maternity patients for that. A lot of that million dollars, I mean, most of that, gosh, I think it's,
The number that comes that I use is about 750,000, but somewhere between 750,000 a million. If I'm a conservative, if someone gave us a million bucks, we could easily run the hospital for a year and probably expand quite a bit of what we're already doing. That'd be a very generous amount of money for us for one year.
which is very interesting. Anyone listening to this who has some understanding of the economics of the US healthcare system would find everything you just said to be sort of comical because of just the costs here are so artificial and so inflated and so ridiculous.
Now, when you think about where those dollars go, I mean, how do you get these supplies? Where do these things come from? I remember once asking, I knew somebody who was, I think, on the board of Doctors Without Borders, and I said, hey, how come you guys aren't in Sudan? Because I remember once reading, you guys couldn't even get certain vaccines in antibiotics. You just physically couldn't get the supplies.
So you're really doing the work that nobody else can do here. Yeah. It's tricky. I mean, our number one problem, when people say, what's your biggest problem there? I always say logistics. It's the hardest thing because you don't have infrastructure. Infrastructure is not there. And if we want anything, you want chemotherapy drugs, you want antibiotics, you want a rule of gauze, you've got to buy that in Irobi. Irobi is two countries away at South Sudan and Kenya.
So it's got to come from Nairobi, like this past ship and the drugs came from Nairobi by a truck up to actually through Uganda, up to the border with South Sudan, where they just harassed the heck out of the drivers and all kinds of people. You have to bribe the guards? You've got to bribe the guards and they give you a hard time and they don't want you going through and they say, no, they're always changing the rules.
See, I know there's a duty. You've got to have all this paperwork. I mean, just reams a paperwork to get this stuff through. So we've got some people that are in Juba don't actually work for us, but work for the church that help us through all this process to get this truck through. Now, from there, there are, I don't know, 30 or 40 checkpoints from the border of Uganda and South Sudan up to the refugee camp in Ida. And it takes a few weeks. It takes about three weeks to get up there, just because of the checkpoints and the delays and everything else. You can take three weeks to get up to this refugee camp in Ida.
Then from there, it's offloaded. We've got to go and pick it up. We've got to find a way to get it from Ida up to our place. Not you personally. No, not me personally, but we've got to get some trucks or something to go down there and pick it up or find someone that can carry it up, carry it for us. That's about six
That's about six hours. It's not really a road. It's a dirt track. I mean, there are roads there, these terrible dirt tracks you get from heat up to where we are. That's about six hours in the best day, just during the dry season. It's already season, which runs from about June through October. You can't go with the trucks. You can't really even go with a, like a land cruiser.
Usually, we don't move at all. If you really had to get in or out at that time, you've got to go with a quad bike. That can usually get you in or out, but sometimes even then, if it's a heavy rainfall, if it's a flash flooding, these dry riverbeds fills up with water, you've got to wait. Maybe at the way today, a few hours. In the hospital, on any given day, how much do you have in terms of IV fluids, gauze, antibiotics,
Soap. Right. I mean, things that we just, we can't even imagine not taking for granted in an American hospital. Right. I mean, if we have, if this truck makes it through, because we make it fairly generous order, just because we know it's so difficult to get stuff out there, if that stuff makes it all through, we're in pretty good shape for how long? For a year. So we try to make it one full year on that supply that gets sent in.
The problem comes because sometimes you order stuff in a row B and it's not in stock and you just can't, you can't order one off things. There's no system against stuff up to us. That's really hard. If you can't load everything on that truck for this one go, we're a bit stuck. We've got to really be creative trying to get these other small things up. Is there like a chief logistics officer that is in charge of the ordering and the procurement and the management of this product? Because that sounds like a, I mean, that's a bottleneck.
Yeah, it's a terrible job. So John Fielder through F Commission health care has a woman who's in his office, he's got an office, small office in Nairobi, got a few staff. So she did all of our procurement. So we sent her the list of things we needed. I mean, it's, it's, it's a lot of items, a lot. So she has to go out and source all this stuff and get it in Nairobi.
from a few different vendors, get the trucks or less stuff, get it through. We've got a couple of people in Juba that help us with logistics and not employees of ours, but they're just helping us out, just kind of random people and they can help shepherd that stuff through. But it's really, really difficult. It's a lot of work for those people.
What does the pattern of mortality look like in Nuba? My guess is infant mortality must still be quite high. How much of that is due to challenges with prenatal care versus the actual deliveries and postnatal care? I think a lot of the neonatal deaths are just from difficult deliveries. Maybe it's fixated, maybe it's born, is it still born or dies soon after birth?
And there are very few deliveries done. I mean, 99% of women there are still liver at home. To deliver in a clinic with maybe a trip from a birth attendant is rare, let alone in a hospital. So I think a lot of it is just due to most of those people probably would end up with a C-section if they were at a hospital in the US or even in Kenya. If they had access to care or they would have the C-section. We have one place to in C-sections. There are actually two now that do C-sections. How many babies do you deliver in a typical year?
I think there are maybe three or four hundred in our hospital somewhere around there. I became of the exact number. So it's really, it's not, it's a very small number compared to the number of deliveries. So the vast majority of women still deliver at home and
But you're doing presumably more of the high-risk ones. If a child is breached, can you deliver a breached baby at home? The risk would be enormous. Some make it out, but a lot of those babies are going to die because they get stuck, they get fixated, and maybe dies.
I mean, when we do our anti-natal clinic, these women will come and the midwife there fills the card out for them. So, okay, they've had 10 deliveries and four living children. You know, this one died at birth, this one died from diarrhea, this one died from fever, you know, this kind of thing. And what about the mothers? What is the maternal mortality like?
I don't know. That's something I really wish I could have a grip on. Because you hear occasionally, you know, it's not that often we hear about it. But what's my hero? He had this woman died from, she bled to death, you know, after giving birth to the baby at some remote village. There's not really, it's so remote and people are so spread out. There's not really a system to collect that kind of information.
So I don't really know. It's got to happen because we have a lot of women that we end up doing C-sections on that would have died without that. How many times a baby is stuck? Well, it's already septic and we have to do a C-section or something. And this is nothing of preeclampsia and all of the other things that would just show up even under the most normal circumstance.
Right. And getting one with the clamps is not uncommon. So if you get clamps at home, especially young, you know, most of them are primitives that are very young, they're not going to survive when they start convulsing. And to get to us is a chore. It's really hard to reach us.
What are the patterns of diseases like there? I mean, when we're watching, and again, I keep mentioning this because it's just such an important film, The Heart of Nuba, you see these things that you're doing, Tom, that just, I mean, they blow my mind. And maybe because I know enough about medicine that I can watch what you're doing and appreciate the partial nephrectomies you're doing on kids with tumors in their kidneys.
Like, how did you even learn to do that operation? Even within the realm of surgery, that's not a trivial operation to do on a child that size.
Yeah, I'd done some of the rectumies before, totally rectumies on tumors or for trauma or for whatever. So, I mean, remove the whole kidney. So, I wasn't so worried about that, but I was worried about was the other kidney. It's harder to take part of the kidney out because you have to be able to preserve the blood flow to the part that remains. Right. And, you know, they could complete it. So, if it was just, say a tumor was partially involved in the kidney and say you're doing the operation and you can't stop the bleeding, your backup is just to take the whole thing out, but you couldn't do that in this case.
Because this child had one kidney that had to fully come out and then there was a partial, so you basically, this kid would die if you couldn't save half of the remaining kidney. Right, exactly. So it was a lower, the tumor was in the lower pole of the kidney. So I had to take out half the kidney.
So there's a visiting, actually a visiting as a friend of mine who was visiting. He's a family practice doctor, Corey Chapman was there and we were talking about this case and going back and forth and he said, let's look on YouTube if there's something, because I read reading about it and everything I was reading was talking about all these fancy things. There's some kind of a slush, like an ice slush that you have to bathe the kidney in to get the metabolism way down so you can do the operation. Just different things we didn't have.
So we looked on YouTube and I'm just want to think about it now I wonder how we did it because normally we can't watch YouTube there because we have internet we have a satellite dish internet but the speed is very very slow. So don't we can't watch any videos because it's just too slow but for some reason we're able to see this video.
And it was this group of Polish surgeons that were doing the partial refractive made. And with a fairly low tech approach. So we watched that. So, okay, I think I think I can do it following what these guys are advising. We kind of followed their system, managed to put these sort of buttresses on the lower pole, the kidney to kind of staunch the bleeding. And it worked. And the child did it very well. That was held by YouTube. I think that really helped us out in that case. Like the Khan Academy of Surgery. That's right.
How long do you just spend rounding? I mean, how many inpatient beds do you have in this hospital? Yes, 435 beds. And what's your typical capacity? I mean, your typical utilization, how many patients are in there? I mean, it's about 100% occupancy. It's a bit less now than it was saying the peak of the fighting, and the peak of the fighting, it was crazy to be 500 people there, 550. So there were several children's wars, several to a bed. We have wounded all over the place. I mean, not even in beds, just wherever we could fit them.
It looks like when you see movies in war zones and you see the tents that are serving as hospitals and you just see amputation, nose completely missing, sort of the most gruesome things, that's what it looks like you're in. I mean, you are literally in a war zone. I'm thinking back to residency.
If we had to round on 20 patients in the morning, we were moaning and groaning like it was going to be the end of the, oh my God, I'm not going to have time for breakfast today before the OR. I've got round on 24 patients. Yeah. So you're rounding on 300 patients? I mean, I don't even know how you do that. And now probably 300 those days was more. I mean, I remember one time we had this measles epidemic and just on children's ward, we had 225 patients. So 100 normal cases, malaria is
about obstructions. You don't have vaccines, I'm guessing, is that the reason they can't all get the measles? Well, the first three years of the fighting, we didn't have them. So the usual provider stopped providing them, the usual big organization that provides them stopped providing the vaccines. Why? Just logistically, couldn't get them in. Logistically, and we were in rebel-held territory, and a lot of these people, like these big organizations, don't want to violate the sovereignty of the host government by providing something as simple as vaccines. This is just how it is, which we really shocked me.
The sovereignty of a government that kills its own people needs to be respected. It's the theater of the absurd. It's crazy. So Yami Ronz would just, they would take hours and we'd start at seven thirty in the morning and two o'clock I'd be finishing up and just try to get through all those people. But then you're being interrupted every hour by some trauma that comes in because...
Right. There's stuff coming in. There's stuff. There's other emergencies. I mean, the other stuff was still coming. I mean, somebody comes into a woman, comes in and was having a miscarriage bleeding. We have to break into a C-section on somebody who can't deliver. So all this stuff was still going on. It was, it was pretty crazy. I mean, it was, it really had to just go as fast as you could. And it was a lot of just putting out fires and we weren't, we weren't able to spend a lot of time with these patients. Obviously it was really gotta go pretty rapid fire through all those cases. It was exhausting. Psychologically, it was, it was rough.
One of the other questions my daughter wanted me to ask you is, what's the most afraid you've ever been there? She was sort of taken aback. And we told her before the movie. I said, look, Olivia, this isn't a Disney movie. You're going to see people getting killed. You're going to see bombs dropping on innocent people. And it's not a movie. It's real. So are there times when you are just afraid for your own safety?
Yeah, I think every time they bombed the hospital twice and they bombed our local region kind of within a half kilometer several times. So the first time the area was bombed. We were at church and the church was just outdoors. It's not really church. It's kind of outdoors thing.
We were finishing up and the catechist was up there talking to people, and we heard they were playing overhead. We were used to it because every day they were playing came overhead, but we'd never been, our immediate vicinity had never been bombed. So we just got all the aprons of our heads going to bombs somewhere. And is that because you had this belief that said, even these people as wicked as they are, wouldn't actually bomb a hospital? Because there's some sort of view of, we'll respect at least one sanctity of life. So that was the bit in the back of our minds, and we had them bomb again. This was a couple years into it.
All right, we had them in bomb directly. They weren't commercial flights. So anytime you heard an airplane, it was going to bomb somewhere. And then we hear the airplane, then invariably a few hours later, Wounded would show up. They bombed somewhere and people were wounded in the wounded show up. This day was a bit different. We heard the airplane overhead and the mask was over and kind of standing there. Also, when somebody says, everybody get down.
So we just dive on the ground. It was lying flat. And I heard the airplane drone overhead, you know, this Antonov sound, then I heard the pitch change is sort of high pitched, like a whirring sound, almost like a jet engine noise. And then boom, this incredibly loud explosion felt like it was two feet away. I mean, it was like half a kilometer away. It wasn't right. But it was so loud. And
a circle again, then I realized that what that worrying sound was, was a sound of the bomb falling through the air. So then now, so now I know what that sounds like. Then it's happened six and bomb six times. You kept hearing this thing comes around again, bombs. And you're lying there.
terrified thinking, you just, you feel like you want to burrow yourself into the ground and disappear. You know, we're just lying flat, exposed, thinking what, you know, what happens? And the thinking is not even so much being killed, but what if, what if my, you know, what if my leg is blown off or my arm gets blown off? You have no control over this. You're totally at the, at the mercy of these people and you feel like you're, you feel like you're just in like a hunted animal. That's the, that's what I felt like. I feel like I'm a hunted animal. And at that time, since we hadn't been bombed,
We didn't have the foxholes dug around. So immediately after that, we dug foxholes all over the hospital grounds. That's what you see in the film. There's actually one point when you're being interviewed and the bombs start coming and you guys have to jump into these foxholes. Right. Then another time we were bomb those in the hospital and just down on the floor of the hospital, you know, you're thinking, well,
You know, we just, you're just thinking this, this might be it. This thing might, because you can't tell where it's going to fall. You hear that worrying sound and we hear that worrying sound. You don't know if that's going to fall on top of you. It's going to fall right next to you and just then shatter your body. You have no idea. So it's really, it's really terrifying. I mean, there's no way to describe it. And I mean,
You know, when you see this stuff that's happening in Syria, people living in these cities, I mean, you can imagine what that is like and the kids that are in that situation. That's something to never, never outgrow that fear and that feeling of being bombed. You really, you feel like you're a hunted animal. I think it's the closest thing I can, not that I've ever been hunted around an animal, but you just feel like, I remember thinking to myself,
We were down, this is after, this is a few bombings later, we're down in the foxhole, and there was a Sukhoi 24 jet going overhead. Sukhoi 24 is a supersonic jet bomber, you know, bombing villages, you know, huts. What are these people doing?
And we're thinking to these guys, I say, how can they bomb us? Don't they know there are people down here? That's what I felt. You know, like it was some exercise where they made a mistake. And of course, they know exactly there are people down there. That's what they're bombing, you know. But I really hope someday I will meet these pilots.
Not that I don't even feel any animosity towards them. They feel like it's never strange. You don't feel anger. You don't feel animosity towards these people. Just kind of wonderment. Like, what are they doing? Like, why are they doing this? So I would love to meet these guys someday and say, what, what were you thinking? You know, what, what did they tell you before you did your mission? You know, I was a flight surgeon in the Navy. So I know you have a briefing before the pilots fly out. They discussed the mission today. Everyone to fly here. We're going to bomb this target. This is our objective. What were you told in the briefing room?
And they say, okay, today guys are going to the Bible hospital. There are a bunch of siblings there. I mean, presumably if you're trying to put your psychology hat on, you have to believe that they are being told that the people that they are bombing are somehow a threat to them or their sovereignty or supporting rebel. I mean, you'd have to concoct a story that's so orthogonal to the truth. Right. Maybe that might be it because, I mean, after one of the times the hospital's bombed, one of our staff
heard a radio broadcast from Elevated, which is a city in the north. And the way they portrayed it on this radio was they admitted they bombed the hospital. They said, we bombed an American church hospital in Kouta, which is the capital, the rebel held territory. Hospital taking care of the rebel soldiers. That's how it's portrayed. So your American hospital in America, of course, is a great enemy. It's a Christian hospital. Therefore, they're no good.
And it's taking care of rebels. So you're justified in this act. And my guess would be that's what these guys were fed. Who knows if the pilots were true believers? I know work with a lot of pilots in the US military and they would not go along with the mission. They said, you're going to the Obama hospital with civilians. They wouldn't do it. They say, look, man, we're not doing this. I know these guys, they were not these guys, they loved the fly and they loved the country, but they were not interested in.
killing civilians. And I still hope someday I can meet these guys and just have a talk with them. And just to know what they were thinking and what went on in their brains, like whether they know this, how they feel about it. I'm just interested in what they would say.
How do you cope with what I could only imagine is stress and anxiety aren't the right words, but just sort of the gravity of it. When you describe a day in your life, getting up at 5.30 in the morning, making rounds at 7, operating, if you said, Peter, you got to go do this for a month.
First of all, I could provide no assistance to you. That's the unfortunate reality of it. Despite my medical training, I could put IVs in patients, and I don't think I could provide any benefit, but let's assume I could even magically provide benefit.
I can't imagine how physically but more so emotionally exhausted I would be at the end of 30 days. Even thinking back to my training where you'd have every other night call but on one of the nights in between you didn't get to go home and so you've been in the hospital for three and a half days and it's been one trauma after another.
Like even that feeling is just as physically tired as you are there's something different going on which is just an emotional depletion, right?
So to imagine that you're now eight, no more, you're coming up to 11 years into this, and this is just in Sudan. I don't understand how you can do that. I think you hit the nail on the head. I think probably the emotional trauma and upset is probably worse than the physical degradation your body takes by just always being on call. Even when you're not called at night, it's hard to sleep. There's a lot of kind of fear and worry about things.
But there's always that less so now because they're not bombing, but there's always that sense of worry about being physical danger. But even when you're out of that, when the physical, the risk of physical danger is not there, it's just the psychological thought of always being responsible for the patients and not having a psychological rest. I can't refer these people somewhere. There are other colleagues we can talk to or get an advice on or have somebody else see these patients. It is very draining.
I don't know. I just, you know, a couple things is one, of course, is I do draw on my faith all the time. And I think that does help me keep centered a lot. You know, I go to church every day and that's, I think helps put things in a bit of perspective.
That's just how it is. And besides that, I think you see the people there. They see the strength and resilience of the people. You say, well, OK, if they can put up this environment and keep functioning, keep going ahead, let me just try to keep taking care of them as best I can. So I definitely get a lot of strength from the people there and their attitudes.
They've been this for their whole lives and they're not giving up. They're pushing ahead with things. So let me see if I can also just keep going. It's not easy by any stretch, both physically and mentally and emotionally. It's very, very draining, but I don't know. It's weird. I mean, you get up in the morning and you
You know, I had this huge number of patients to get through and you kind of say, man, I'm sure I can. So I'm tired already. I kind of see the first view. And then you before you know it, you're finished with the Children's Ward. Take a deep breath. Okay, I got through all the children. Now we go to the female ward. You get through there, you pick up pace a bit, you get to the male ward, you go through them, see the maternity patients.
Now it's one o'clock, okay, I finished the rounds. We go to clinic, go to clinic and there's a big line of people. How many patients would you see in clinic typically? Maybe 40, 50. Again, I don't even know what that means. I mean, I think most US physicians would have a hard time seeing that many patients in a week in clinic.
Do you have any blood tests you can do? Can you do CBCs or UAs even? What's the extent to your diagnostic toolkit? Until recently, you had nothing. Now you have an ultrasound. We've had the ultrasound from the beginning. We've had it the whole time. That's hugely helpful.
You don't have an X-ray machine. X-ray we do now. Okay. So we just got that about a year ago. So you can do a chest X-ray at least if you want some assistance with does this person have pneumonia or a pneumothorax or something like that. Right. So prior to a year ago, we didn't have the X-ray now we do. It's been a help. Lab has been difficult. We can do a urine, we can do a hemoglobin. Sometimes we can do a CBC, but the machine always seems to be broken. We'll get in the machine, work it for a while, then it just stops working. You can't do a CBC.
Chemistry tests, we can sometimes do a creatinine, but then that machine breaks, and you can't do a creatinine. Sometimes you can do ALT, ST machine breaks, can't do anything. But with those things matter, in other words, if someone's listening to this and says, well, gosh, if it's $50,000 to buy a new lab piece of laboratory equipment,
Can we have one of those brought in with next year's supplies? Would that make life easier for the care you guys provide? It would help. Just saw this chemistry analyzer called a piccolo, which is supposed to be built for these remote locations. It's pretty doctor-proof. You have this thing that's pretty hardy. You slip in a disc, you put a drop of blood on it, and it gives you results. Our guys in the lab could do that.
Not, our lives, our guys in the lab can do the other tests, but the machines are just very sensitive. Yeah, it's less about the human. It's more about the, you need a robust machine, a very robust machine. So this is kind of a thing. And that's about 14 grand. If we had one of those and some of the discs, which have the reagents kind of embedded in them. So if you had a year's supply of test strips or reagent discs and then the machine. Right.
You could do a CBC and a Chem 7 or a metabolic panel of some sort. Right. Yeah, that would definitely help. We're pretty limited. We can do a peripheral blood film, so taking blood, you know, guys can do the film. We can look at that. So you're a pathologist now, too. Yeah, and a very dermatologist. I'm terrible at it, but I can pick up like a chronic leukemia, chronic monologous, chronic lymphocytic or an acute leukemia.
Those are, if it's pretty obvious, we can pick those up. But a lot of blood films, I'm baffled. And when you have a child that has leukemia, I assume you send them to Kenya? It's impossible. Why? It's too far, it's too expensive, it's too difficult, like just the administrative stuff to get them there and the chance in Kenya
of them being, I mean, maybe at a higher end hospital, they could get decent care, but they just can't do it. So what do you, can you treat with chemotherapy, a child? Not with leukemia. If a child is leukemia, we often will give steroids to try to, you know, target them a bit. Yeah, for leukemias. For chronic leukemias, these are, again, are usually adults. If it's a chronic levocytic leukemia, we'll treat them with cyclophosphamide. We don't have tablets, we'll give periodic injections, and that can kind of wiggle them a bit.
CML, chronic myelisigalchemia, we don't have treatment for. I would like to have at least some hydroxyurea, which is kind of an older drug for it. You don't just drug GleeVac. It's about to say GleeVac would cure most cases of CML. I mean, it's a very expensive drug in the United States, of course. That's the problem. So with GleeVac, I was so excited like a month or two ago. I'm really thinking that GleeVac is now in generic. Oh my God, maybe we can buy GleeVac because we get a few a year. We're going to get a huge number of CML patients. We get a few.
I think, man, we wouldn't need a huge amount, you know, so to look it up and it's okay, Glee back is going on generic. So the price went from 8,000 a month to 7,000 a month. Yeah, this is another one of these ridiculous systems, you know, problems, which is a lot of times when drugs go from being branded to generic, there's virtually no change in price. Right. We just can't do that. You know, there are a lot of things that are just beyond our scope of being on the pay for it.
That's something that to me is, it's really difficult to consider. We can be as critical as we want of the US healthcare system for all of its buffoonery. But in large part, it's because we can be buffoons. It's because we have infinite resources, though we don't. But in the short term, we have infinite resources. And so we never have to ask the question of what are we optimizing for, and how do we triage expenses?
On the other hand, you're faced with that decision every single day. You would look at a patient with CML and say, we're not going to spend $80,000 a year to save this person's life, because as much as we believe every life is equal, we sort of know that $80,000 can save a hundred lives in another way. Are you the one that has to make that decision by yourself?
Yeah, it's agonizing. It's absolutely agonizing. That's just one example of many. I've got a woman that comes all the time with CML, and she's got a huge spleen that hurts. She's anemic, and she's got a bunch of kids. I've got to talk to her in clinic and try to figure something out with her. She walks, I don't know how long before she walks to reach us.
I mean, it's absolutely agonizing. I cannot send her anywhere. There's just this totally impossible, just can't do it. We wouldn't need mountains of glee vac. A small amount would be enough to at least get her through a year. There are few people that have CML. It's a few. It's not a huge number. If someone's listening to this and they say, I'm going to tell you a story in a moment called the Starfish story, but I want to save one starfish. I'll tell you the story.
Logistically, would it even be possible for someone to provide one year's worth of glee back to a patient in your hospital? Is that something that they could do through the African mission? How would someone even logistically go about providing specific or project-based funding to your mission?
If they get the drug, so they had access to the physical drug here in the US, maybe if they sent it to say the Catholic Medical Mission Board, which is my sponsoring lay sending agency, and they also help us a lot with logistics and with the overall managing the hospital, they might be able to find a way to get it down to us, at least get it to Juba, and then we could figure out a way to get it up to us.
they can get the physical drug. There was a program when I was on Armenia at the time before last, we met some guys and there was this, there's supposed to be some playback program that you can register, like the patient can register and they can get drugs at either low cost or no cost. So I went through all this thing, counted the person and she said, okay, all you have to do is take, fill out these forms, have the patient go to cartoon and get the drugs.
That's absolutely impossible. We can't get the car to them. That's the other side of the enemy lines, and you just can't reach there. Which gets back to your point of providing the money is half the battle, but the logistics of actually getting it in there. I mean, just spitballing, you can't have these things airdropped or airlifted in because the enemy fighters will obliterate anything that's trying to
It's not like you can fly the Cessna in there to get this stuff in there. There's been no non-bombing aircraft in our airspace since November 2011. So even foundations like the Gates Foundations, which do a ton of great stuff in Africa, I mean, Sudan's basically off limits. So they were able to provide money for a bunch of GleeVac. One of the problems, and one of the problems I've decided to go with Aurora, is a lot of these funds are kind of unassailable.
Like I'm an individual or even a small organization has trying to apply to one of these big organizations to just get through that application process to get funds and then to account for it and do monitoring evaluation and follow up. It's a very daunting task. You need people who
are trained in this area of writing proposals and monitoring evaluation, all this sort of stuff to really follow through with all this. It's very difficult to access some of these big funds and big organizations. A lot of these bigger groups are set up to do that kind of work, and their administrative size has grown exponentially because in order to get this funding, you need a big administrative staff to apply for the funds and follow up and accountability and accounting and all that kind of
Right. And you've got tons of extra time, I'm sure, to do that, right? I just can't do it. I just can't do it. Unless it can be made fairly simple, or something's OK. If I got the drug, I'll send it to Catholic Medical Mission Board, and then the Catholic Medical Mission Board will send it down, and we get the drug, at least as far as Juba. And we can try to figure out a way to get it up. But it's just, there's a problem with access and just getting through the administrative things you have to do to get some of this stuff.
There are several different levels of difficulty. Going back to the state of disease as you see, if a person makes it out of their young life, if a person's your age or my age.
What are they going to die from? Middle-aged people, we have a lot of cirrhosis, liver cancers, and that's... There's a huge... Is it hepatitis-based? Hepatitis B, yeah. Huge, like we do, we screen all of our pregnant women for Hep B. Do you guys have a Hep B vaccination program? We do, we do. The reason we started screening the pregnant women is just to get an idea about the basic rate, and it's about close to 20%.
Hepatitis B positive, just in general populations, are people who are not sick. They're pregnant with children. So what we're doing is we encourage the mother when the baby's born, we give the baby Hepatitis B vaccine immediately after birth, and we hope with that that we'll stop, prevent this baby from getting Hepatitis B as they get older and prevent all the complications from that.
would haven't really scaled up to the point where we have so many heavy positive people. And can you only vaccinate the women who are coming in for deliveries? Or are you able to get the vaccine into the community for the women who are still delivering at home? No, we haven't reached that point yet. So you're only scratching the surface and because the majority of these birds are outside of your hospital. Right, exactly. I mean, eventually we like to have kind of been wise to these places and have the testing capability to test all these people where hepatitis B or
If people delivered in these clinics, you say, look, we can't do the testing, but we just give the vaccine. We'll assume the kid has heptide as being given the vaccine because they have to get heptide anyway as part of the pentavalent series. So after that first shot, we continue with pentavalent, which is DPT, diptosis tetanus, heptide as B, and marvelous influenza B. I've heard that kids actually can get diphtheria in Africa. Yeah. Has there been a case of diphtheria in the United States since the 40s?
No, I think that I think I don't even know what to fury is. I mean like I mean sounds stupid to say that but I remember learning about it in medical school and I know we all get the vaccine for it. What what is the disease? What is it? How does it manifest? We've only had from what I remember one case and I think she had the theories was it was in an adult.
but it's a coronary bacterium etheriai and it's a bacterial infection. It affects the throat and it looks almost like a thick scab that forms in the throat. They kind of die from airway problems. You know, they just think it's thick and they can't lay swallow, they can't really breathe well and they can die from airway problems. It's a horrible, really a terrible disease.
And you mentioned your mother-in-law has leprosy. Again, I've never seen that in my life. It's a bacteria as well. Is it in the tuberculosis family or something like that? Exactly. It's like a bacterium leproy. It's a like a bacterium. And it's transmitted by respiratory droplets.
Oh, it's not by touch. I thought leprosy was sort of contagious through touch. Yeah, that's that's that's a wives tale. Yeah, it's really transmitted by respiratory droplets and it should be prolonged close contact. So somewhat similar to TB. It's not a real it's a very slow growing organism, but prolonged close contact. Respiratory droplets, you can affect it is affects the nerves and the skin. And by that nerve infection, people lose sensation. They
They get cuts or wounds. They don't take care of things. They burn themselves. They don't pay attention to what gets infected. Bone gets infected and you have to amputate the digit. Are these people prior to your arrival that were kind of outcast and they would be not touched or anything like that?
Yeah, there was definitely discrimination against them. They didn't have like separate places where they would make them outcast, but people would kind of avoid them. Like my mother-in-law still, I think a lot of it was the people themselves would kind of withdraw due to shame and due to the fear of us giving it to somebody else. Like my mother-in-law
Kind of withdrew she stays by herself. She doesn't eat with the other family they keep telling look come and eat with us is okay, but she will not come and eat with other people. She was insist to kind of buy herself. She does it herself. She's kind of self isolation from society. She's put herself out. So she'll talk to you and chat interact with you. But then with eating with more social interactions, she'll kind of pull back and eat by herself.
And how prevalent is tuberculosis? Very, very prevalent. And for our place, our HIV rate is quite low, which is what? It's less than much less than 1%, maybe point something, maybe 0.1%. And is that an artifact of where you are geographically? Or is that as part of the benefit of some of the aid relief that made its way in the early part of 2000s?
Yeah, I think the main reason is our isolation. Is there drug use there? Prostitution, I mean, which I assume would be the two most dominant modes of transmission. Prostitution is not really part of that society. I mean, drug use is unheard of. It's all through, like with most of Africa's through heterosexual transmission.
And I think just the starting to get a little bit of a toehold in Nuba, but still our rate is very low. I'm worried that if if peace comes and the place opens up and we've got more movement of people in and out, the race is going to skyrocket. That's what happened in South Sudan. The night is there because we have a lot of STDs. Gunnery is very common.
syphilis. Do you see tertiary syphilis and really advanced cases or? I don't think so, but maybe some of the stuff we're saying is just undiagnosed tertiary syphilis. I don't know. I don't think we see it. What I see as syphilis is we have, we do a VDRL test and we have a lot of VDRL positives, which are not, you know, it's not a very accurate test. You have a lot of false positives. We have a lot of VDRL or RPR positive people. We do that screening. We're just screening now with the pregnant mothers for VDRL and we have a lot of positivity.
We don't see the shankers or the secondary civilist. That's really, really rare, but the behavioral positives are very common. So we talked about liver cancer. Do you see heart disease? No, heart failure. So in the older population, we'll see a fair bit of heart failure. Somebody may be in their 60s, 70s, that's in heart failure.
And it's like bacterial or I remember there was some bacteria like shagas, something or other that when we can heart muscle, is it that type of a heart failure? Yeah. No, we don't have shagas disease in our area. It's just old age. But do you think it's atherosclerotic in origin? I don't think so. I've ever seen anybody that could say, I think this person had an MI, just not a single one in 10 and a half years. Some is hypertension, just kind of untreated hypertension and we'll let people come in with blood pressure of 250 over 180.
Really? Yeah. How prevalent is obesity overweight type 2 diabetes? Obesity about 0.00% almost not existent. An occasional person is a bit overweight, but really, really rare. And how often do you see type 2 diabetes? We'll see it. Not so prevalent, but it's definitely there. Let me see, older people come in and just new diagnosis of diabetes. Maybe somebody's 40s or 50s.
Do you ever see fatty liver? Like when you're operating on a patient, do you ever see that the liver is fatty? No.
No, I think no, never. I can't remember a single case when I've seen fatty liver. What kind of cancers? I mean, you do so much cancer surgery, especially in children, but they're cancers. We don't see that much here. Right. What types of cancers do the people in Nuba get versus basically not get? I mean, in the United States, of course, you'd have lung, breast, colon, prostate are the lion's share of cancers followed by pancreas. So those are the big five. How prevalent are those cancers in Nuba?
Not so. I mean, like, if we go to kids first, our Berkus lymphoma is fairly common. That's an EBV related, if I recall, right? Epstein-Barr virus is... Epstein-Barr virus. And you only, you really just see that in Larry, a holo endemic region. So we're in that. It's called a Berkut zone. And that's a great cancer, because it's curable with just cyclophosphamide. Six courses, cyclophosphamide, and you cure a cancer. It's great.
for his satisfying, but it's rare to have a cancer you can cure, obviously. For adults, liver cancer is probably probably most common, and that's I think I'll have a cellular carcinoma and probably all related to hepatitis B positivity. They drink a fair bit. There's a local, a local beer that make them sorghum.
But the alcohol content is not very, very high. It's fully weak. It's a happy related cancer liver. We have a fair bit of cancer, the cervix. So for females, probably cancer, the cervix is the most common. And can you screen for HPV? You're the local gynecologist as well. Right. Can you do a pap smear?
No. Perhaps it would be a little bit impractical because we have to do the swab and get that sent off and do it high level, you know, get it off to a pathologist or is there any way. I mean, again, if someone were listening to this and said, Oh, my God, like, if I could have an impact on eradicating cervical cancer for these women.
Right. Is that even feasible to have the equipment there to after you do the swab assess for HPV? No. For cancer cervix, two approaches. One would be this Gardasil, the HPV vaccine, were made available either at very low cost or just giving us part of, I think it's actually just her today as part of WHO package.
So they could be integrated into the system where HPV is given to young girls, even young boys. But then we're back to the logistics problem. Right. Even if the WHO or any of the foundations came along and said, we want to provide HPV vaccination unmasked to Africa, you're still somewhat excluded, right?
we give other vaccines if they can be lumped into your annual supplies right and just do it to get stuff out there but if you do it in one big push yeah get it out there it's gotta be all cold chain it's really it's really hard but it's doable get this stuff out there one big push that will make a huge difference so start with that
to treat cancer the service, treat earlier versions, they call it a C and treat technique. I've not done it, but it's not, I prefer probably a YouTube video on it. There probably is, I think, I think there is actually, you paint the cervix with something, I can't emphasize that in some substance, and you look for irregularities in the cervix.
And then you freeze it. You have the little liquid nitrogen cylinder with some probes, put that in the cervix, and you freeze it, make a nice ball of the cervix, then you kill those precancerous cells, and hopefully those people will not go on to develop invasive cancerous cervix. You would need some personnel for that, because that would be pretty labor intensive, because that's more of a preventive medicine thing. We'd come in and examine them.
because you're not treating people with the cancers. You got to get the precancerous lesions. Because you have to screen them, do a lot of these screening things. We paint the cervix with some substance look and see. You don't even, probably you don't even need a culposcope. It's something even more simple than that. I know they're doing it in Uganda and they have this equipment.
So that might be cavity in between thing before Gardasil becomes available. At least we do a screening of young women, check the cervix, see what it looks like when you paint this stuff, and then treat with liquid nitrogen. We don't have the equipment. I think that stuff is there, nor the knowledge to do it.
What about breast cancer? How prevalent is that? It's definitely there. The problem with breast cancer is by the time we diagnose it, we only diagnose so we can feel a lump. No one's getting a mammogram. Right. No mammograms or we don't do other stuff, the diagnosis of MRIs where we have. So women present with a palpable mass that they're feeling and they show up. Right. So usually they come with a palpable mass and they already have a nose and think silo.
So you do in that situation you still do modified radical mastectomies we do we use you a modified radical mastectomy and then follow with Adrian my sin so go fossil my chemo and do that sort of every month for about six cycles and I mean it's still the results are pretty dismal I mean usually they they get a couple years but two years on two and a half years on they come back and they've got another lump they got lump in the axilla there's another tumor in the chest and
