Into Africa

If you can bring the slightest help or hope, especially to underprivileged people, it’s a source of satisfaction and it keeps you going.¹
-- William Gunn, Canadian surgeon

No truer words than those above have ever been spoken. In the October 2008 issue of WOUNDS, you read of Dr. Tom Serena’s trip to Cambodia and Dr. Mary Jo Geyer’s trip to India and how that experience changed their lives. I want to add another to the list, because helping others in any way is the greatest calling one can experience. People with needs are everywhere—even in your own neighborhood—but traveling to the other side of the world to assist those in need adds a bit of mystery and excitement.

The Global Alliance program of the AAWC, founded by Dr. John Macdonald, has established program sites around the world for wound care practitioners to visit and share their knowledge. A very special addition to the program occurred in 2007 when the World Health Organization (WHO) asked Dr. Macdonald and the AAWC to help write guidelines for the treatment of patients with wounds and lymphedema in underserved countries. To be chosen among other AAWC members to write these guidelines was an honor. This became a monumental work of 11 chapters by 11 individuals. We were all incredibly excited, proud, and relieved when the WHO accepted our report in March 2008. Little did we know that the real work was just beginning. Shortly after the paper was accepted, Dr. Kingsley Asiedu, Director of the Neglected Disease Program for the WHO contacted Dr. Macdonald and suggested we show them that what we had written could actually be done! The WHO chose Ghana, West Africa as the location for our group to establish a viable, sustainable, comprehensive wound and lymphedema treatment program. This was no small task. Dr. Macdonald, Dr. Mary Jo Geyer, and I were chosen to take on this project.

What were we to do? None of us had ever been to Ghana. How do they treat wounds there? What types of bandages do they have there? What kind of wounds do they treat there? Who is treating the wounds? All of these questions had to be answered before we could establish a specific plan, although the general ideas, aims, and goals had been outlined in the 11-chapter white paper. Talking about a program like this is one thing; making it happen is another.

In order to get some of our questions answered, the WHO sent the three of us to Ghana in July 2008 for a site visit. During that trip, we visited hospitals and clinics, met physicians, nurses, and other healthcare providers involved in wound care, made rounds in the institutions, and most importantly, observed and learned from them. And, for good measure, the WHO wanted us to present three wound care seminars for the clinicians.

After preparing lectures, getting the required immunizations and visas in addition to packing to travel to a country hotter than Alabama in July, the three of us met in New York for the flight to Accra, Ghana. I can truthfully say that boarding that airplane in New York was one of the more difficult things I have done in a long time. I have flown around the world but never to a place that was so unknown, to attempt to do something that none of us were absolutely certain about with people who may or may not have wanted us to be there. Admittedly, after our arrival all of my fears and concerns were quickly erased.

During the 10-day visit, we visited the two largest hospitals in the country, Korle Bu Teaching Hospital in Accra, Ghana, and Komfo Anokye Teaching Hospital in Kumasi. We gave a seminar in each city, made ward rounds in each hospital, and learned many things from the healthcare providers there. Everyone seemed to appreciate our lectures. The people were so kind and anxious to learn. As I mentioned in my WOUNDS editorial (August 2008), one of the nurses said in a prayer, “Lord, your children are dying because of a lack of our knowledge.” We wanted to stay, talk, and answer questions indefinitely.

Every hospital there has a children’s ward. Many of the patients, especially wound patients, are children. Traumatic wounds of all causes are prevalent. Since cooking is still done over open fires, many of the injuries were burns. We saw patients with a devastating wound called a Buruli Ulcer. We learned that this disease is caused by Mycobacterium ulcerans, a relative of the TB and leprosy organisms. Once the organism gets in the skin, it secretes a toxin that kills the subcutaneous tissue and skin. It can destroy up to 15% of the total surface of the skin before it stops. About 60% of the patients with Buruli Ulcer are children. The treatments include antibiotics for eight weeks, debridement, excision, and skin grafting. Unfortunately, many late wound problems occur such as contractures, amputations, and malignancy. This is a devastating disease.

The swollen extremity is a major problem in Ghana. Filariasis, venous ulcers, and venous insufficiency are major causes of lymphedema and edema. In Ghana, compression therapy does not exist. Venous ulcers are treated with topical antimicrobials or antiseptics and bed rest. Lymphedema is treated by debulking operations and skin grafting, a treatment that we have not used in years. We were able to find some bandages that we could substitute for a short stretch compression bandage. Dr. Geyer and Dr. Macdonald showed the physicians and nurses how to clean and wrap a swollen leg. At least one patient’s debulking operation was cancelled because of treatment with these makeshift bandages.

After seeing the largest hospitals, they took us to the smaller hospitals and clinics. The need for healthcare workers and facilities is tremendous, but the people serving in these facilities are devoted to their work, and their countrymen and women. One physician in particular is Dr. Samuel Etufal. Dr. Etufal practiced in one of these small, remote hospitals for 10 years. He is a true man of God who cares for his people. The nurses told us many stories about Dr. Etufal and the care he provided his patients. Because the Buruli Ulcer was devastating his people, he did research on the disease and is now considered one of the world’s experts in the disease. We believe Dr. Etufal will be the obvious one to lead the forthcoming Ghanain Wound and Lymphedema Association because of his great interest in wound care and lymphedema management, but I am getting ahead of myself.

During our visit, the Ministers of Health, the Director of the WHO in Ghana, and others were our hosts. They were quite interested in our program and supportive of it. All were very gracious and seemed truly appreciative that we had come. Dr. Macdonald and I even had an unexpected interview explaining the wound and lymphedema program on 103.3 FM Accra, a local radio station in Ghana.

As our visit concluded, we didn’t want to leave because of the new friends we had made and knowing the work that had yet to be done. We reflected on the mission of our trip—to learn what was needed so that we could return to teach the Ghanian people what would help them the most. Rest was not easy because of the thoughts and conversations about the forthcoming work. Our true task remained at hand—to help our new friends establish a viable, sustainable, comprehensive wound and lymphedema treatment program, centers of excellence in the major hospitals, and training programs to educate healthcare workers at all levels of the healthcare system in the treatment of patients with wounds and lymphedema.      Over the next few months our team, with input from the WHO and the people in Ghana, decided on a plan to start two centers of excellence for wound and lymphedema management in Korle Bu Hospital in Accra and Komfo Anokye Teaching Hospital in Kumasi. Commitments from the hospitals would result in clinics being established to treat these patients. We were charged with designing an educational program to train the healthcare providers who would treat patients in these facilities. Not only did we need to cover the basics of wound care, but also how to effectively manage wounds with the products available to them, which was a priority. A bit of ingenuity was in order as each of us prepared our assigned lecture topic. The only difference for the next trip would be that Ms. Janice Young, RN, representing Kinetic Concepts Inc ([KCI] San Antonio, Tex), and my wife, Sheryl, would accompany us. KCI had offered a negative pressure wound therapy device and 1 year’s worth of disposable supplies to each wound center. Ms. Young would train the physicians and nurses in each center on the V.A.C. indications and usage, while Sheryl would assist with the training and help document the programs. Both were welcome additions to the team.

The WHO requested that we return in February 2009 to continue the program and help establish the wound care centers. The return trip was much easier. We knew the people, the hospitals, and exactly what we needed to do. The team spent 3 days in Kumasi and 3 days in Accra advising, recommending, and sharing with those chosen to attend the programs. Attendance was by invitation only this time. The hospitals decided which physicians, nurses, and other healthcare personnel should attend. There were about 30 people trained at each site. The training included lectures and hands-on activities. The lectures included the basics of treating diabetic foot ulcers, venous leg ulcers, burns, acute wounds, and lymphedema. The most fun for me was teaching them how to make bandages they did not have. Since they did not have non-adherent dressings, we showed them how to make Vaseline gauze (Vaseline + gauze). We showed them how to make an Unna paste boot for short stretch compression of the swollen limb using zinc oxide, calamine lotion, and gauze. We also discussed using the juice from the papaya fruit (papain) to debride wounds since there were no enzymatic debriding agents. Dr. Geyer demonstrated how to make an off-loading diabetic shoe from an old tire and foam rubber—this was great fun. The Ghanians even offered suggestions to me that I may try in my wound center. We all learned from each other. The hands-on afternoon involved teaching each participant to wrap a leg with an Unna paste boot, apply a negative pressure dressing, and how to do manual lymphatic drainage. Dr. Geyer even taught the participants to do the “lymphedema dance!” This was a “dance” or exercise designed to improve lymphatic fluid drainage, performed to the beat of African music, of course. There was no way wrapping a leg with an Unna boot or putting on a negative pressure dressing could top Dr. Geyer’s dance class! Each session was held 3 times each afternoon. Needless to say, we were exhausted at the end of those days.

We were privileged to visit an orphanage outside of Accra on our last day in Ghana. There are many state orphanages in Ghana but this one is sponsored by the Rafiki Foundation. Rafiki found and sustain Christian orphanages in 10 countries throughout Africa giving “double orphans” (children who lost both parents) a chance to get a classical education and learn a skill. At this particular orphanage the children are taught to make beautiful baskets to give them a vocational skill. Each of us on the team was privileged to purchase several baskets. We visited with the children and even saw a video of their choir presenting a concert. It was a moving experience. The visit affirmed that it is not just the patients suffering with wounds and lymphedema who are in need of the help we can provide.

All too soon our time was over, but the memories will last a lifetime. The people (unforgettable and gracious), the country (beautiful), the patients (grateful, numerous, and in need), the road trip from Accra to Kumasi and back (rough and long), and the orphanage (heartwarming), have all left a lasting impression on us. We felt we had accomplished our assigned task for the trip. Both hospitals committed to establishing clinics for the treatment of lymphedema and wound patients. The healthcare professionals to work in the clinics had been trained to the best of our ability in a 3-day period, but the task is just beginning. Follow-up visits will be important to provide additional education to those in the centers and train those in the smaller clinics and hospitals. Help is needed with documentation and outcomes measurements. We have since been offered an opportunity to apply modern wound care techniques in the treatment of the dreaded Buruli Ulcer in an attempt to improve the outcomes of these patients. The assistance we can provide is unlimited, but it is important for us to remember that any overseas endeavor is to help the people do it themselves not for us to come in and take over their programs. If you give a hungry man a fish, he will be satisfied for 1 day. If you teach a hungry man to fish, he will never be hungry again. This is truly a situation where we are to teach how to fish and neither give them the fish nor fish for them.

With the wonders of the Internet, we have kept in touch with all our new friends in Ghana. I am pleased and proud that the clinic in Kumasi is officially open and saw its first patients on March 19, 2009, about 3 weeks after our return.

It is not enough to do a good deed. One must be involved in it wholeheartedly. Each action should be performed with life and soul, with every limb, with all one’s vitality.
-- Abraham Joseph Heschel (1907–1972)

To read Dr. Macdonald’s thoughts on the trip, visit the Online Exclusives section of www.o-wm.com.

Terry Treadwell, MD, FACS
Senior Clinical Editor, WOUNDS
woundseditor@hmpglobal.com