Snails, spears and salvation

My African surgical adventures for 2022 are coming to an end, as I write in transit back to the UK. It has been my privilege to once again work alongside the dedicated team of Zambian and foreign workers who serve at Chitokoloki Mission Hospital, a 180-bed remote facility on the banks of the upper Zambezi. Chitokoloki has benefitted from many years of talented leadership and outside investment, drawn from a large base of Christian support. The Zambian government supports the salaries of an excellent Surgeon, Dr Felix Chibwe, a Medical Licentiate (the very capable Mr Zayson Maambo), a Junior Doctor, Clinical Officers, and a large number of nurses, midwives and physiotherapists. Their long-serving Medical Director, Dr David McAdam, was taking a well-deserved break back in Northern Ireland with his wife Lorraine, although it was good to catch up with other old friends who serve the hospital and mission station in a variety of roles. 

The long journey home began at dawn on Friday

 

I largely worked with Dr Chibwe and Mr Maambo, who cheerfully and competently deal with a huge diversity and volume of medical and surgical problems. Some disease processes are familiar to a UK doctor, and others are more specific to the environment. 

Schistosomiasis (or bilharzia) is rarely seen in the UK, but affects 200 million people worldwide and is second only to malaria as the most devastating parasitic disease in the world. Carried by snails that inhabit stagnant or slowly flowing water, when these tiny parasites enter the human body they take up residence in the blood system, preferentially settling in the urinary system but also lungs, spinal cord and brain. The numerous eggs they spawn can survive 10 years or more, and cause an immune reaction that results in local irritation and tissue damage that predisposes to cancer and causes various serious problems as well as 200,000 deaths per year. 

Guido4, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons

One of the sad consequences of schistosomiasis which I saw was inoperable bladder cancer. A young lady in her early 30s had travelled a long distance to obtain an answer for her abdominal pain. Through an ultrasound scan and then cystoscopy (telescope test into the bladder), we could diagnose a very large bladder tumour but not offer a cure. Even in high resource settings, such locally advanced squamous cell cancer would be difficult to treat, necessitating complex, major surgery to excise the bladder and recreate the lower urinary tract to empty urine via the abdominal wall. In our setting, such an undertaking was not practical – it would carry prohibitive risks, given our lack of experience (and blood products), and not likely lead to a sustained good quality of life. It was my sad responsibility to break this news to her via my nursing colleague Everisto who translated. I must say it was quite heart-breaking and I was touched by the quiet dignity and acceptance of this beautiful young woman. She understood that she was not long for this life, but we shared also our transforming hope that this life, as sad and disappointing as it can be, is not all there is. She understood too that through faith in Jesus Christ we can have a certain and sure hope of life beyond the grave, redeemed from brokenness, sickness, and death for an eternal life in glory. 

I spent my first few days at Chit tackling another of the serious consequences of schistosomiasis: portal hypertension. When schistosomal eggs lodge in liver tissue, they set up an immune response that ultimately leads to severe damage to the blood vessels. Venous blood ends up being squeezed through the liver at high pressure, leading to downstream engorgement of the veins which drain the gut. Such dilated veins include the ones which surround the lower end of the gullet, which are then called oesophageal varices. When varices are eroded, catastrophic bleeding can result and many patients lose their lives. One of the established treatments to prevent such events is to use an endoscope to apply small, tight elastic bands to these protrusions, which then shrivel up and the gullet flattens out for a period of time. With the help of a fantastic theatre team, particularly Kayombo, Katota and Jack, we were able to coax one of Chitokoloki’s temperamental endoscopes into performing this service on a number of patients. 

A view of the lower oesophagus in one of my patients with varices

 My clinical activities consisted of ward rounds, outpatient clinics and diverse theatre cases. A new injury for me was a self-inflicted spear wound! A little girl had been playing with one of the local fishing harpoons, miming battles with river creatures, when her aim was misjudged and the spear entered through the web space between her 4th and 5th toes. Such spears are barbed and thus not easily withdrawn. I was called up to help by Sister JR Elwood, Chitokoloki’s Chief Nurse and local legend. After tranquilising the youngster with ketamine, the spear was cut in two just above the entry point and pulled out through the exit wound. Following cleaning and dousing in antibiotics, she is recovering really well. 

 

More difficult cases included two (presumed) cancers, one large breast tumour and one very challenging stomach tumour. The lack of diagnostic facilities, particularly pathology of biopsy specimens, is very difficult and means sometimes recommending huge, mutilating procedures simply on the basis of clinical examination. So far these patients seem to be recovering well and I enjoyed these tests of surgical skill. 

One of the other privileges of the fortnight was the chance to participate in the spiritual teaching at the station. I was asked to preach on my first Sunday morning, and subsequently also led short messages for the twice-weekly staff devotions. Two of my messages described what we can learn from Jesus' famous parable of the Good Samaritan (Luke 10:25-37): the story of an outsider who demonstrated love to a neighbour that was bold, courageous, generous and undiscriminating. 

At one level, the parable tells us about the quality of care that we should have for all fellow travellers on life’s journey. This can inform how we use our talents, our resources, our time in all contexts including healthcare. However, the other major learning point from this parable is found in its context, and is perhaps the greater challenge. Jesus tells this parable to a religious lawyer who starting question is: “What must I do to inherit eternal life?” (Luke 10:25). 

Jesus’ answer blows apart the premise of his question; he is incapable of earning his own salvation. For the standard of the Jewish law was perfection: loving God and neighbour with all our hearts and minds, impossible to maintain in all circumstances and in all times. The unreachable standards of the law gave insight into God’s character but also made clear that salvation could never be attained by human effort alone. The apostle Paul wrote this summary (Romans 3:21-22, NIV): 

“But now apart from the law the righteousness of God has been made known, to which the Law and the Prophets testify. This righteousness is given through faith in Jesus Christ to all who believe.” 

And so it is that my salvation is not achieved through works, but through faith in Jesus Christ. My good works are merely an evidencing of this faith, as fruit of a living relationship rather than a personal grasping towards my own redemption. A joyful gratitude for life made new by Jesus has sustained the mission station at Chitokoloki for over one hundred years and I pray it will continue to be my motivation as life reassumes its familiar shape in Aberdeen.