N° 0 • JULY 2009
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AFGHANISTAN Basic Life Support Course in Kabul – Emergency Cardiopulmonary Resuscitation (CPR)
Training for Critical Care Units
alcon 4 Falcon 4… cardiac arrest in Intensive Care Unit”. It was ten minutes before midnight, and someone was calling me on the radio. “Start the cardiac massage,” I replied as I ran towards the hospital. Latif, Fahim and Samiullah, just graduated from the Government School for Nurses at the University of Kabul, and were working the night shift. The school curriculum offers CPR training. Unfortunately, the quality of teaching is still very far from acceptable or satisfactory standards. This is understandable in a country devastated by thirty years of war. In all of its projects, EMERGENCY strives to provide intensive training for local staff through daily hands-on experiences with highly qualified doctors and nurses coming from other countries. This and other targeted activities provide local staff with current medical knowledge, and eventually lead to their autonomy. In the first months of 2008, Daria, Elena, Debbie and I, all international nurses at the EMERGENCY Hospital in Kabul, have established a Basic Life Support (BLS) course in an effort to accomplish these goals.
The ABC’s of resuscitation — Airway, Breathing and Circulation BLS encompasses all cardiopulmonary resuscitation procedures performed to rescue a patient who is unconscious, or suffering from cardiac arrest. Independently from the cause of cardiac arrest, the heart fails to contract and pump blood to the tissues. The lack of oxygen supply to the brain cells, known as cerebral anoxia, causes irreversible damage within 10 minutes of the onset of circulatory arrest. This implies that the time available to rescue a victim of cardiac arrest is extremely short before irreversible brain damage occurs. The goal of BLS is to maintain an “emergency oxygenation” through artificial breathing and cardiac massage, until more efficient means can be used to correct the factors that determined the arrest. The BLS procedures 2
are standardized and recognized as effective by several key international organizations that provide constant revisions and updates. To help with memorization, the BLS phases are schematized in three steps, indicated by the first three letters of the alphabet. A: Airway – Opening and control of the airway, removal of potential occlusions (foreign-body, food, blood), and insertion of a plastic tube to keep airway pervious. B: Breathing – Sustain breathing by ventilation with Ambu bag (if unavailable, proceed with mouth-to-mouth breathing). C: Circulation – Sustain cardio circulatory function by control of carotid pulse, and potential cardiac massage. At each step, a vital sign (airway, breathing, cardiac pulse) is checked and restored, if compromised.
Learning to save Minianne really means helping Gul Arifa BLS is of utmost importance in the training of health care staff. For this reason, it is periodically taught to newly hired staff at all of EMERGENCY’s hospitals. This latest course was designed specifically for nurses newly graduated from the University of Kabul, and working in the critical care areas (ER, intensive care, surgery room). It is divided in two sessions. The first session illustrates the guidelines of the Italian Resuscitation Council (IRC), while the second, besides reviewing previous material, allows students to practice the reanimation resuscitation of Minianne. Minianne is an inflatable manikin provided by the IRC. It is particularly
useful in the teaching of lifesaving maneuvers, since it allows effective simulation of cardiac massage and manual ventilation. During this session the nurses, divided into small groups, ask questions and practice until they feel confident with all the maneuvers. The hands-on nature of the class has guaranteed the expected results. In fact, the staff has acquired both physical and psychological confidence with instruments and maneuvers, and it is now ready to effectively cope with any emergency situation.
It is midnight. Out of breath, I reach the intensive care unit. I don white coat and shoe covers and I step inside. Latif is by Gul Arifa’s bed performing ventilation. Samiullah is standing on a step stool, ready to administer a cardiac massage. Fahim, the youngest, looks at me nervously as I come closer. Together we gaze at the monitor. Gul Arifa’s heart has resumed beating. We smile at each other. “Great! Well done!”.
NADIA DEPETRIS Translated by Ada Buvoli
AFGHANISTAN Six year old Quadratullah, Victim of a Landmine Explosion Arrives at our Hospital in Kabul
The Consequence of War
e arrived at two in the afternoon on 22 July in a car driven by his uncle. He had been carefully laid on a thin mattress, wrapped in a plastic cloth, with stained rags used to stop the bleeding from his wounds. Six year old Quadratullah is transferred to a stretcher by ER nurses. He doesn’t utter a single word and through teary, terrorized eyes watches all the people who are frantically racing around him. We remove the rags from his wounds. It is a devastating image. His left leg is gone, ending just under the knee with two bone fragments protruding from his flesh. The right leg is still okay, but wounded. His left hand is crushed, and the right hand is wounded. His back and pelvic area have deep wounds resulting from the explosion. We should be familiar with these scenes, but we’re not. Each time, the horror of these scenes doesn’t allow us to become accustomed to them. As soon as Quadratullah’s condition is stabilized, he is sent immediately to the operating room.
What remain behind are two apricots, and the tragedy of a morning that was supposed to be a celebration The boy’s father’s arm (Ajimir Aziz) is wounded. When we ask him what happened, he takes two apricots out of his pocket, and then breaks down crying. That morning he had gone with Quadratullah to gather some apricots in a small orchard near their home, in a village a couple of hours from Kabul. Quadratullah was so happy because his father was dedicating the whole day to him. It was their time to play, their moment to be together. Then he saw some ripe apricots on the ground. The boy turned to pick them up, meaning to take them to his mother and siblings. But, as he bent down to collect the fruit that’s when it happened. There was an explosion. It was instantaneous, like always. Ajimir extends the two apricots out to me. I face him, not knowing what to do. The nurses encourage me to take the fruit, he is offering them to me. I take them into my hands. I look down at them, and put them into my pocket - two apricots and Quadratullah’s life torn apart.
MARINE CASTELLANO Translated by Paolo Chiappetta
AFGHANISTAN In Ghazni, 120 miles south of Kabul, the local population asks for a new FAP (First Aid Post)
Restarting and expansion
n the summer of 2007, just after the re-opening of our hospitals in Afghanistan, we were contacted by the representatives of the Ghazni community from one of the areas most impacted by the war, and which runs along the road connecting Kabul to Kandahar. They made a request that we open a First Aid Post to be connected to our surgery center in Kabul where high standard, free medical assistance is provided to everyone in the area who is injured or wounded. We had to wait a few months before starting a new initiative and fulfilling this request since we had to be sure that the entire Afghanistan Program was back on track. In April, a delegation form EMERGENCY completed a first assessment of the city of Ghazni, capital of the province, to select an appropriate location for the new project. However, the local authorities had no appropriate building to offer, and to build a new hospital would take too long given the urgent needs of the population. The generosity of a wealthy individual provided the solution. The owner of a small supermarket donated the building, to be remodeled for the FAP. After a couple of months under construction tiling, windows and doors, painting, construction of lavatories, and the selection of the appropriate personnel the Ghazni FAP became operative on July 20th.
The official inauguration took place on August 10th at 2:00 PM. Many officials were present; the vice-governor of the Ghazni province, a member of the national parliament, the mayor of the city of Ghazni, the director of the Ghazni hospital, the community leader and many local citizens. Due to worsening security along the road connecting the capital with the south of the country, no one from EMERGENCY was able to participate in the opening ceremony. The distance from Kabul and Ghazni is about 120 miles, and is normally about a two hour drive. In recent months, with the increase in military conflict, the travel time has more than tripled to cover that area (the official delegation that came to Kabul to thank us for the new facility took seven hours), and the frequent attacks have made any travel extremely dangerous. In spite of the fact that the media and the international community seem to have forgotten, the war in Afghanistan continues, along with our commitment to mitĂgate, if only in part, the suffering of the victims.
RM Translated by Michele Isernia
AFGHANISTAN Amongst the Victims Many Children Are Admitted to the Lashkar-gah Hospital
A Flower in the Midst of War
he corridors of EMERGENCY’s hospital in Lashkar-gah remind us of the human cost and consequences of the war in Afghanistan. Over the past thirty years, more than one and a half million people have been killed, the majority being civilians. Our hospital is the only one in the region which provides completely free-ofcharge surgical interventions. For the most part, the patients suffer injuries sustained while caught in the middle of military combat, while stepping on one of the many landmines spread throughout the region, or as they become victims of violence associated with the drug trafficking trade. Others are wounded by air raids conducted by international forces. NATO asserts that troops do their utmost to take precautions to avoid civilian casualties. In the cases of civilian casualties, an investigation is conducted, and under the best of circumstances, civilians become eligible for compensation. Our patients come not only from the city, but from all over the region. In order to reach our hospital, they travel on damaged roads on a journey that can last days. Some arrive at the First Aid Post in Grishk thanks to an ambulance service which is open 24 hours a day. Many never arrive, partly because they die en route, and partly because after aerial bombing raids the Afghan army blocks the roads not allowing the injured to pass through. As in all of EMERGENCY’s hospitals, a red and white sign greets the public as they enter, “We inform that all medical and surgical assistance is free of charge for the patients”. The treatment is completely free, only a blood donation from the families of patients admitted to the hospital is requested. 6
For victims who are severely wounded, numerous blood transfusions are required, and the hospital’s blood bank needs to be continually replenished. Usually after making their donation, parents or siblings of patients often return a few hours later with friends and relatives to also give blood.
Gullandam, beautiful like a flower, in a Helmand that can no longer claim to be a garden Yesterday, an Afghan nurse presented us with paperwork that we had not seen before. The father of Gullandam, a young girl who was under our care for the past few days, asked us to complete the paperwork out as soon as possible. He is required to present the filled-out forms to officials in order to receive compensation for the explosion that destroyed his family’s home. We take all the paperwork, and of course will help. As soon as it is filled out with the relevant information regarding the young girl’s condition, we go with Paola back to D-Ward, the children’s ward, where we locate the girl’s father, and return the papers to him. Gullandam means beautiful like a flower, in Pashtun. She is in the garden playing amongst the other hospitalized children. At 6 years of age, she has already bravely faced the amputation of one leg, and many painful medical procedures to save the other. And sooner or later, she will have to be told that she has also lost her mother, and that she no longer has a home to return to.
NADIA DEPRETIS Translated by Roland Swan
SUDAN A Paediatric Centre in Darfur, Another Goal to Reach
Our Idea of Peace The Our Idea of Peace fundraising campaign to begin construction of another EMERGENCY health care centre, this time in Nyala, southern Darfur, for children under the age of 14, ended last October. The Centre in Nyala will further expand EMERGENCY’s Paediatric and Heart Surgery Program in Africa during 2009.
ver 1.5 million people live in Nyala, most of whom are refugees who fled the war. They live in camps surrounding the city. Following a request by the local Ministry of Health, EMERGENCY decided to build a paediatric centre to offer high standard free of charge medical care 24/7 to children under the age of 14. The Centre will address prevalent illnesses such as malnutrition, respiratory infections, malaria, and gastricgastrointestinal infections. It will implement immunization programs, and preventive efforts to combat diseases such as rheumatic fever, in addition to providing health and hygiene education for families. The Centre will provide screening for patients suffering from heart disease potentially requiring transfer to the Salam Cardiac Surgery Center in Khartoum to undergo heart surgery. Post-operative monitoring and care will also be guaranteed. The Centre in Nyala will be part of EMERGENCY’s Paediatric and Heart Surgery Regional Program, with the Salam Centre as its hub. Collaboration with the Sudanese authorities – both Federal and South Darfur – has been essential for this project.
The Paediatric Centre will be built on land offered by the South Darfur authorities, in collaboration with the local Ministry of Health. Last summer EMERGENCY carried out a feasibility study and assessed the estimated costs for the structure and start-up costs at 600,000 Euros. This total became the target amount for our text message fundraising campaign. The results coming in from the participating phone companies seem to confirm that we’ve reached the targeted amount. This is an important achievement since it will help us continue our mission in Sudan and the neighboring countries. As soon as we have the final results, we will publish the final tally of funds raised. In the meantime, we would like to thank everyone who has decided to participate in helping us build this paediatric centre, working together with us to concretely achieve Our Idea of Peace.
ROSSELLA MICCIO Translated by M.A. 7
SUDAN Fifteen Months after its Opening — An Update on the Salam Centre for Cardiac Surgery in Khartoum
A Comparison Between Goals and Results
hartoum, July 2008. The temperature outside is about 45° Celcius (113° Farenheit). The dry heat makes it a bit more tolerable, but it is certainly not advisable to dwell too long outside, even in the garden of the Salam Centre — a place that brings healing to the heart. This is a familiar place even to the patients of the Centre, who have organized a creative alternative to ‘outdoor activities’. Every afternoon, once clinical activities quiet down, a ‘parlor room’ is created alongside the large window which separates the patients’ wards from the outside world. The patients awaiting surgery, and the post-op patients who are able to mobilize, pull up some chairs near this large window, and spend the afternoon chatting there. Beyond the window, one can see the colorful seasonal flowers, the trees, the green lawn and bushes. Beyond, it is known that the Nile flows, and although it cannot be seen, it is “sensed”. 8
From this large window overlooking the garden, light comes in as gazes go out For all of those who have followed the progress, and believed in this hospital from the very start, from when it was only a ‘crazy’ idea, it has confirmed the transformation of a utopian dream into a reality - one rooted in the daily lives of hundreds of people. I am talking to Raul about this large window. As the architect, he designed the window with the intention of bringing light to the long corridor which faces the patients’ rooms. Now, the patients have chosen it as a place of gathering and relaxation. It has become a case, one could say, of unplanned consequences to calculated actions. This novel use was approved and appreciated by the designer himself, who for the time being does not delve too deeply into discussion about the ‘diverse nature’ or ‘outcome’ of intended purposes.
This space was transformed by the patients into an area for chatting, a simple act which lightens tensions, favors understanding, and fosters friendships. It is where we often stop to talk with the guests of the Salam Centre Barring complications, the average length of stay here in the hospital is about 10 days, which is sufficient time for people to get to know each other. It is amazing to see the behavioral transformation of the patients after just the first few days in the hospital. Initally, everyone looks lost, almost afraid. For many, the arrival to the Centre is like being left stranded on the moon. No relatives or ‘co-patients’, as they are called here, are allowed to visit except on the consented days and times. In the other local hospitals co-patients provide most of patient care, from food to laundry, from personal care to even medications. Here, on the other hand, clean pajamas and showers in the rooms, three free full meals per day, doctors and nurses, are all available 24/7. The omnipresent white faces of the khawala (‘white’ people) administer to everything. After a few days, patients memorize names, begin to feel comfortable, and even begin to trust the khawala. Children, in particular, are the ones who develop the most immediate rapport. And there are many children in our hospital, about 25% of the 937 patients hospitalized at Salam through the end of July 2008 have been younger than 15.
There is a long list of cases, difficulties and problems, and many solutions that have been researched and found The small group of teenagers who have been treated at the hospital since the beginning of July has truly been diverse. Wail, 14, arrived from Port Sudan. In addition to his young heart struggling from the damage of recurrent rheumatic heart disease, he suffers from kidney and lung problems, so we anxiously await definitive signs of healing. Enas, is an 11 year-old girl, who weighed just 17 kilos (37.5 lbs) when she was hospitalized. Our cooks prepared a special diet for her over several days to help her gain a body weight which she probably never had before…and at any rate, also to help her gain a few kilos before surgery. Osman “One” (to distinguish him from Osman “Two”), despite being only 10 years old, is a veteran of the Salam Centre. He has been with us since February, and has had treatment for his right ventricle. The right half of his heart wasn’t functioning. Blood taken from the right atrium through a cannula was channelled back with a pump to the pulmonary artery, to reach the lungs and to oxygenate. Now he is ready, well enough to go back home to the state of Sinnar, south of Khartoum. He will be accompanied by his grandfather, who was staying in the centre’s guesthouse during his grandson’s hospitalization. Then there is the trio from Darfur. Saddam, 15, of Genina, West Darfur, urgently hospitalized for a serious heart problem that was treated via replacement of the mitral valve and surgical repair of the tricuspid valve. Curly haired, darke eyed Osmad “Two”, 9, is shy and introverted, and was one of the last of the group to be operated on. After surgery he was received with a round of applause when he was transported from the operating room to the intensive care unit where some of his friends who had already undergone surgery the previous days were recuperating. Ali, the smallest of the group, and only nine years old, is from a small village near Al Fashir, North Darfur. He also needed a mitral valve replacement and surgical repair of the tricuspid valve.
Araghes the Ethiopian and Sarawit the Eritrean: distant is the world that would like to see them be enemies The unique atmosphere of the Salam Centre makes sure that not only do ethnic barriers disappear between the beds in the ward, but that also the linguistic difficulties due to the different nationalities be overcome. Proof is the story of Sarawit, a very young girl from Eritrea, hospitalized for a mitral stenosis, and Araghes, an Ethiopian child brought here thanks to the initiative of a group of Italian volunteers who collaborate with a hospital from the congregation of Mother Theresa of Calcutta in Addis Ababa. Araghes speaks only Amarico, hence she had difficulties comunicating with the foreign doctors and nurses, as well as with the Sudanese personnel. But, her problems are solved thanks to the help of Sarawit who, besides Tigrino, also spoke Araghe’s language, and she becomes her interpreter. They were apart only during surgery and immediately afterwards. We suggested that they become ambassadors of their respective governments, which have been at war for about ten years now. We may have been joking, but… their relationship is no longer a joke, it is real.
A lesson from our first balance sheet — something we ‘believed in’, is incredible After a little over a year since its opening a draft of the activity summary for the Salam Centre is available. Despite the continual necessity for precautions to be taken, and with the inevitable problems encountered, we are pleased with the initial results. Under the circumstances and given the difficulties, in 15 months time we have been able to progress from one to three open heart operations per day. About 30 patients are examined daily for triage. A third of these patients will then need a specialized visit with the cardiologist. Paradoxically, given the enormous distances in this country, news ‘by word of mouth’ has produced unexpected results. More than 43% of the Sudanese patients in our hospital do not live in Khartoum, but arrive from one of the 25 states that make up the federation. Even going beyond the Centre’s data and statistics, and the daily operational routines, the “life” of this hospital suggests a very comforting evaluation. From the examination rooms to the office administration, from the labs to the wards, from the kitchen to the laundry rooms, from the operating rooms to the pharmacy, one can clearly feel that the premises itself suggests the sense of being in a special place, in so many unique ways. More often than not, ‘Incredible!’ is the comment heard over and over by visitors to the Salam Centre for Cardiac Surgery, from the Sudanese, as well as from foreigners passing through Khartoum for work or vacation. For us this expression ’incredible’ reminds us of a daily effort, which began with an idea, went on to be built, fully equipped and furnished and ultimately completed with the search and assembly of personnel. It is an effort that continues on with a myriad of new and diverse problems (sanitary, logistical, technical) to be overcome each day. But, after a brief pause by the large window that overlooks the garden, and an exchange of a few words in bizarre, improvised “mixed” languages with the national staff and patients, we all become part of the incredible vision sensed by all visitors.
ROSSELLA MICCIO Translated by Rosalba Perna
SUDAN In Just Over Three Years More Than 56,000 Patients Have Been Treated in the Mayo Refugee Camp
First the Children
ince the EMERGENCY Paediatric Centre first opened its doors in December 2005, the camp has expanded and is now surrounded by new homes, at best made from mud and plastic sheeting. They belong to new refugees from Darfur, and to old residents driven away from areas that are increasingly urbanised - always a source of homelessness. From the hospital’s water tower, the grim view of the camp is a vast sea of shacks, extending as far as the eye can see, with dust and dirt everywhere. Although only a mere 12 km from dowtown Khartoum, we are very far from the skyscrapers dominating the heart of the city. Our Centre is situated in an area of the camp called Angola, which is populated by roughly fifty thousand people, fifty per cent are children. When it first opened three years ago, the Centre’s objective was to guarantee free medical treatment to the more immediate community in the area. Now, patients arrive from the rest of the refugee camp as well as far off neighbourhoods. In the Outpatient Ward, three nurses and two doctors work with a pharmacist, along with a lab technician who performs urgent blood tests -- all under the supervision of an international paediatric nurse. Mothers and children arrive at six o’clock in the morning and are seated under a protected outdoor veranda. As they await their turn, they are neat, poised and beautiful in their colourful clothing. Attilia, the international nurse, together with the local nurses carry out 10
a rapid triage to evaluate any urgent care cases. Patients with malnutrition, loss of consciousness, fever and severe respiratory problems are given high priority. It seems as if it were summer. There are clear skies and the temperature is a dry, 28 degrees Celsius. But, this is their winter, and illnesses such as bronchitis and asthma are common, just as in any outpatient ward in Italy during this time of year. Many are suffering the consequences of living under inhumane conditions in the camp. Malnutrition, conjunctivitis, and urinary tract infections are among the most common maladies. Diarrhoea is a consequence from drinking the water from the donkey tank. Water is sold and distributed house to house from a large tank transported by mule. It costs between 200 and 300 dinar depending on the vendor. Daily wages are roughly 1000 dinar.
An Urgent Transfer Leaves Us With More Questions Than Hope Every day our staff examines fifty children, and those requiring observation stay in the ward until closing time. “The Centre has to close at 4:00 PM due to security reasons”, explains Attilia. “At night the men get intoxicated on araki, a distilled alcohol with an extremely potent effect, and it is better not to stay around the area”. The more severe cases are transferred to the two city
hospitals, the Khartoum Hospital and the Bashir Hospital. Thanks to the working experience with the Mayo EMERGENCY Paediatric Centre, the government of Khartoum passed legislation that all care for paediatric emergency medical cases be provided free of charge. A mother brings in her child wrapped in a colourful cloth. As soon as she opens her little bundle, his emaciated face reveals that we are clearly faced with a very ill infant. “He’s not well, he hasn’t been eating for the past week”, she says. But the skeletal body, and lack of strength confirms evidence of long term malnutrition. At forty days old, the baby weighs only 2 kg. The infant is suffering from an infection, running a 40 degree fever, and does not even have the strength to cry. “After the operation, he stopped eating, and is becoming more and more lethargic”. The operation she refers to is the procedure performed by one of the twenty tribes living in the camp which believe that by cutting the uvula and palette of a newborn, regurgitation can be prevented. Every newborn undergoes the procedure. “Imagine a procedure of this sort, most likely performed in the middle of the street in a place like this, with instruments being washed in the camp’s water”, says Attilia, who periodically sees these cases. The ambulance is ready to go, and we immediately transport mother and child to the Khartoum Hospital. During the trip, Attilia asks me to try to stimulate the infant by stroking a pen along the bottom of his feet, while she keeps the oxygen mask ready for use.
No reaction, he keeps his eyes half closed, and does not even whimper. We arrive at Khartoum Hospital, a chaotic and dirty place where, even for Attilia who comes here often, it is difficult to orient oneself. In a large, half lit room, five doctors seated at their desks examine their young patients surrounded by a throng of mothers coming and going with their children. One female doctor quickly checks the baby and asks the mother and Attilia a few questions. He will be admitted and undergo an antibiotic and an intensive nutrition treatment.They assure us that “he will make it.” I ask myself how many more times will this little baby have to “make it” in order to survive life in Mayo Camp to reach age 5, and survive the infant mortality statistics of this country.
SIMONETTA GOLA Translated by Roland Swan
CENTRAL AFRICAN REPUBLIC
News in the Regional Programme for Paediatric Care and Cardiac Surgery
Good Morning Bangui Each day the staff at the Paediatric Centre in Bangui provides free specialized assistance to forty children. Thanks to periodic visits to the Centre by the international cardiologists, patients can be screened to determine whether they require surgery at the Salam Centre for Cardiac Surgery. The required post-operative follow-up care is also guaranteed.
t is Friday, 6 March 2009, 9:30 AM. “The promise has been kept,” declares Francois Bozizé, the President of the Central African Republic. Together with the Prime Minister, the President of the National Assembly, and the foreign ambassadors present in the country, Bozizé attended the inauguration of the Paediatric Centre in Bangui, a new development in EMERGENCY’s Paediatric Care and Cardiac Surgery Programme in Africa. The government of the Central African Republic had immediately provided aid and support for the project, granting EMERGENCY use of a centrally located plot of land near the Parliament buildings. This is where the Paediatric Centre would be built. Construction began in March 2008. The project was assigned to a Central African company that carried out the plans to perfection, respecting the deadlines and the predetermined budget. Finally, the Paediatric Centre was ready for its inaugural opening. With its red and white coloured external walls, its surface area covers 550 square meters. It includes an internal patio transformed into a play area with an imaginary grassy plains mural filled with toy crocodiles, rhinoceros, elephants… The Centre, which is open 24 hours a day, seven days a week, offers medical assistance to children up to 14 years of age. Immunisation and health and hygiene education programmes are also offered. During periodic evaluation missions, in the cardiology ward EMERGENCY’s international specialists come to screen and evaluate patients suffering from heart disease to determine those in need of transfer to the Salam Centre in Khartoum for treatment. After surgery, the patients are guaranteed postoperative check-ups at the Centre in Bangui.
In Bangui, Like Goderich and Khartoum: Malaria and Diarrhoea are the Most Common Diseases News of the opening of the Bangui Paediatric Centre spreads rapidly by word of mouth. In a scene similar to those in other EMERGENCY Pediatric Centres - such as in Khartoum, Sudan and in Goderich, Sierra Leone - from the early morning hours mothers and children crowd the entrance of the hospital, awaiting their turn to be examined. Each day, Paola a paediatric nurse, and Mariella a paediatrician, assisted by local doctors and nurses, examine forty children on average. With six beds in the Centre, the doctors are able to admit serious cases overnight, as needed. Just one day after its opening, the first patient was admitted. His name was Jonathan, who at 22 months was weighing in at only 7 kilos. He arrived suffering from dehydration due to severe persistent diarrhoea. As soon as he reached the Centre, doctors immediately initiated oral rehydration treatment, and proceeded with blood tests for Malaria, which came back positive. Together with his father who accompanied him, Jonathan will christen the clinic’s new toys with the hope of going back home soon.
PIETRO PARRINO Translated by Roland Swan
CAMBODIA Against Violence, Landmines and Accidents — Three Stories of Human Resistance
Cambodian Triptych A plastic surgeon details his encounter with a few patients he treated during his work at the Surgical Centre in Battambang bringing to awareness the difficulty of living the consequences of war, and facing new cruel realities.
hree girls — three stories from this ill – fated country’s history spanning half a century. The experiences of these three girls would be very unlikely to happen in Italy, but if they were to occur, the detrimental effects of the injuries sustained would be treated through an advanced health care system, and their lives would be supported by social and public assistance. In Cambodia these social infrastructures do not exist, at best there might be a fragile, and not always available family support system to help. Already faced with difficult lives, these three young women, having undergone physical surgical reconstruction and prosthetic rehabilitative training now find themselves facing the added burden of not having full use of their own bodies. EMERGENCY assisted them in their rehabilitation, and then when feasibly possible, in job placements, or by some small donations. But the biggest feats were overcome by their own courage, which was key to their recovery.
A disfigured face due to jealousy — Then surgery and a job towards a new life When I first saw Nhom Vun in the front garden of the emergency department, only half of her face was visible. Like most young Cambodian women, she had fine, gentle features. She kept the other half of her face oddly concealed with a towel which she uncovered as soon she entered the examining room. 14
What was revealed was a disfiguring two centimeter thick scar, banning any type of facial movement. Her eyelids were now non-existent due to the disabling scar, and the eye was wide open, with no protection of an eyelid, and already covered with sores. Her lower lip was fused to her chin, as was her upper lip to the side of her nose. She was only 19 years old. Three years ago, Nhom was raped and impregnated by a man in her village, who then decided to marry her. In the two years following the birth of her first child, there were two more births. And then, all of a sudden the man announced that he was going to Thailand to find work. Left alone, Nhom Vun found work in the rice fields. But once the harveting season ended, she had to find other work. She began to pack and sell sweets, and earn good wages compared to the average Cambodian salary. The husband, who had actually moved in with another woman in a nearby village, now revealed a renewed interest in Nhom, and her new prosperity. In order to prevent any type of reconciliation between the two, the jealous lover attacked Nhom by thrusting a bottle of acid over her face. At our initial consultation, I informed Nhom right away that one procedure would not be enough to restore a normal physical appearance, and that there would really be no hopes to totally erase all the effects resulting from the acid burns. I began the surgical intervention with the reconstruction of her eyelid, in order to try to avoid loss of the eye. Removing the scar tissue, I realised that some
that some of the muscles of the eyelid had been damaged, but still existent. So I began to reconstruct the eyelid with strips of tissue and cartilage from behind the ear. The few remaining muscles would allow movement of the eyelid, thus restore opening and closing of the eye. The second procedure began by removing the scar tissue over the lips, where I would have to proceed with a skin graft taken from the back of the undamaged ear. Her lips began to regain some mobility, even though she would need further corrective surgical intervention on her lower lip. Returning to Battambang this year, I encountered Nhom Vun in the hospital. She wasn’t there for a check-up, but as an employee. She was hired there as an orderly. EMERGENCY frequently employs its patients to help them socially reintegrate, especially those patients having undergone particularly traumatic experiences. The medical coordinators say that everyone is extremely happy with her work, and the patients really appreciate her. Every time we pass each other in the corridor, she shares with me the gift of a beaming smile. The reconstructed half of her face is not as graceful as the other [undamaged] half, but mobility is close to normal. I am happy to have been able to contribute to providing this young woman with the chance to a social life.
An accident at the beginning of a new life — Landmines don’t know when war has ended Den Srey Mao is 20 years old, and she has only been married for a few months to a man so tall and athletic that he does not seem Cambodian. Their families had given them a small parcel of land with a few animals (chickens, ducks and goats) as a wedding gift in order for them to begin their new lives together. They were farming vegetables on the land to sell at the market so that they could earn enough to buy a pig at the end of the year. One day while walking to it along the pathway which had undergone landmine clearance two years earlier, and which she had passed through countless times before, the young woman saw something strange on the ground. It was too late, she was unable to avoid stepping on it. It was a landmine which had been washed onto the path by heavy rains in the previous days. Dan Srey arrived at the hospital with traumatic amputation of both her
lower limbs, loss of an eye and various wounds to her face. The amputations were corrected by our orthopaedic surgeons in order to allow fitting of prosthetic limbs. I was responsible for the reconstruction of the orbital cavities. Two operations would be necessary: removal of scar tissue, and enlargening of the ocular cavitiy for fitting of a prosthetic eye. Three days before my departure Den Srey received her prosthetic eye, a necessary step in restoring her face with a certain degree of physical normalcy. While waiting for her leg stumps to heal so she can be fitted with prosthetic limbs, her husband takes her home - where another new beginning awaits them.
Two wigs for Proeung Even hair becomes a form of treatment Proeung Sreyrotha was 16 years old when I met her last year. She was harvesting rice when she got too close to the fanbelt of a threshing machine. Her entire scalp was ripped from her skull - from her eyebrows to her cervical vertebrae. In the West, depending on how intact the affected skin is, we treat these cases by surgically reattaching the ripped scalp, and through microsurgical anastomosis, re-establish the blood circulation to the damaged skin. However, in Cambodia, the proper surgical apparatus for microsurgery is unavailable. So in order to treat Proueng’s condition, she had to undergo several skin graft surgeries to the damaged area, a method no longer practiced in Europe for over 40 years. After 6 operations and much painful medication, we finally managed to cover Proeung’s skull with a layer of hairless tissue. Some time later, in a very moving and emotional ceremony of sorts, we presented her with two gifts. We gave her two wigs - one with short and the other with long hair - so that she can continue to carry out her life as a normal young girl.
PAOLO SANTONI-RUGIU Translated by Roland Swan
INTERNATIONAL Human Rights
Worldwide Malnutrition Malnutrition and undernutrition are some of the effects of a global imbalance that has caused recent alarm in the political world (under pressure from the speculative push to finance raw material and consumer markets) especially among those where access to basic food resources has been undermined.
hen the cost of bread rises excessively, revolts break out for tortillas in Mexico, and mud cookies are baked in Haiti, then we know that we are facing the disastrous effects of a global financial manoeuvre that threatens the health and even the lives of a large portion of the global population. Even now, according to the Health World Organization, half of all human beings – about 3 billion people – suffer from some form of malnutrition, a word with various, but always worrisome, meanings. In fact, this term is used to indicate an imbalance in the absorption of nutrients and other factors necessary for a healthy life; this could be undernutrition – lack of proteins vitamins or minerals, or overnutrition. In developing countries, one person in five suffers from the worst form of malnutrition: hunger.
Grains produced for livestock feed rather than human consumption It is well known that malnutrition is due mainly to unequal access to food resources rather than to insufficient food production. In fact, current agricultural production could easily nourish the entire world population. The problem is certainly underestimated, considering that a large portion of food resources is diverted to animal feed instead of being utilized as food for the hungry. Agricultural strategies adopted in recent years have resulted in complete failure. Public and private institutions have actively promoted large-scale cattle ranching in developing countries for production of meat and milk, without considering that farmed animals consume more calories than they produce in the form of meat, milk and eggs. When the quarrel about biofuels and conversion of crops for their production had not yet started, it was already evident that cereals were produced and introduced in the market in large part to raise cattle rather than to satisfy human nutritional necessities. Official statistics, from FAO (the Food and Agriculture Organization of the United Nations) and WHO (the World Health Organization) in particular, clearly point out that a shift in cereal production for human consumption to animal feed has forced developing countries to import grains at high cost, greatly worsening the problem of malnutrition. In fact, in developing countries, staple foods are mainly cereals and legumes, which provide the majority of carbohydrates and proteins necessary for survival. In a paradox, this diet that could be adopted in industrialized countries with great health advantages, is now overlooked even in its traditional countries of origin. Those who can afford it prefer a more occidental diet, where the majority of the protein requirement derives from meat.
Food subsidies help donor countries and undermine local economies Non-governmental international organizations that fight world hunger are in ferment to counter the steady increase in basic food prices. Oxfam and CARE, for example, are running worldwide campaigns to raise awareness and increase political pressure. In fact, the forecasts of their experts indicate that predicted Eastern and Western African tragedies could be avoided by immediate action on the part of governments of wealthy countries. “Food aids can save many lives”, says Ariane Arpa, responsible for the Spanish Intermón Oxfam, “Unfortunately, the interests of Western governments, tied with those of powerful agricultural groups and packaging/ shipping companies, frequently cause aid to arrive too late, at very high prices, often destabilizing weak local economies”. The humanitarian organization Oxfam has posted suggestions to remedy these issues at www.oxfam.org. In summary the suggestions are: increase donor as well as local governments investment in small-scale agriculture (especially in sub-Saharan African countries), cut incentives for biofuel production, and convince the USA and EU to review their emergency food aid policies and focus assistance on countries suffering the most serious consequences.
ANGELO MIOTTO Translated by Ada Buvoli
EMERGENCY Director Carlo Garbagnati Editorial Office Simonetta Gola Collaborators on this issue Marco Antonsich (MA), Ada Buvoli, Marina Castellano, Paolo Chiappetta, Graziella B. Costanzo, Nadia Depretis, Maureen Cairns, Robert Dvorak, Janet Garcia, Anna Gilmore, Simonetta Gola, Michele Isernia, Rossella Miccio (RM), Angelo Miotto, Rosalba Perna, Dada Pisconti, Paolo Santoni-Rugiu, Roland Swan. Images Emergency’s Archive, Piergiorgio Casotti, Cosimo Maffone, Samuele Pellecchia, Naoki Tomasini. Graphic and pagination Angela Fittipaldi, Guido Scarabottolo.
Every year war and poverty destroy the lives of millions of people. In contemporary conflicts, 90% of the victims are civilians. Since 1994, over three million patients have been treated in EMERGENCY’s clinics, hospitals and rehabilitation centres located in war-torn areas. EMERGENCY is an independent, neutral and non-governmental organisation that provides free medical and surgical care to the victims of war, landmines and poverty worldwide. All EMERGENCY hospitals, clinics and rehabilitation centres are designed, built and managed by international personnel committed to professionally train national staff.
For more information contact: EMERGENCY ITALY via Meravigli 12/14, 20123 Milano Tel. 02 881881 Fax 02 86316336 E-mail firstname.lastname@example.org http www.emergency.it via dell’Arco del Monte 99/a, 00186 Roma Tel. 06 688151 Fax 06 68815230 E-mail email@example.com http www.emergency.it EMERGENCY USA 4910 Massachusetts Avenue NW, Suite 300 Washington, DC 20016 – T +1 888 501 EUSA firstname.lastname@example.org - www.emergencyusa.org
The articles featured in this issue were translated from articles that appeared in EMERGENCY’s magazine, issues 48, 49 and 50:
Training for Critical Care Units, September 2008 (48): 2-3 The Consequence of War, September 2008 (48): 4 Restarting and Expansion, September 2008 (48): 5 A Comparison between Goals and Results, September 2008 (48): 8 Worldwide Malnutrition, September 2008 (48): 14-15 Our Idea of Peace, December 2008 (49): 12 Good Morning Bangui, March 2009 (50): 2-3
EMERGENCY UK PO Box 62437, London, E14 1GA T +44 (0) 333 340 6411 email@example.com - www.emergencyuk.org
A Flower in the Midst of War, March 2009 (50): 9
Data Protection Notice — ITALY
Data Protection Notice — USA
Data Protection Notice — UK
EMERGENCY – Life Support for Civilian War Victims ONG ONLUS, with registered offices at Via Meravigli 12/14, 20123 Milan, Italy, in its capacity as owner of the data processing, will process your personal data manually and in electronic form for the purposes of informing on its institutional activity and for administrative reasons as a result of your donations to the organization. The provision of your personal data is not mandatory. However, the failure to provide such data or the subsequent withdrawal of the authorization to process your personal data will prevent us from processing your data for the purposes indicated above. Your personal data may be disclosed to third parties, also in foreign countries and outside the European Union, only in connection with the purposes indicated above. You will be entitled to exercise the rights granted by Article 7 of Legislative Decree No. 196/2003 by addressing your request to EMERGENCY ITALY, Via Meravigli 12/14, 20123 Milan, Italy, ATTN: Ms. Mariangela Borella.
EMERGENCY USA – Life Support for Civilian Victims of War and Poverty, with registered offices at 4910 Massachusetts Avenue NW, Suite 300, Washington, DC 20016, USA, in its capacity as owner of the data processing, will process your personal data manually and in electronic form for the purposes of informing on its institutional activity and for administrative reasons as a result of your donations to the organization. The provision of your personal data is not mandatory. However, the failure to provide such data or the subsequent withdrawal of the authorization to process your personal data will prevent us from processing your data for the purposes indicated above. Your personal data may be disclosed to third parties, also in foreign countries and outside the European Union, only in connection with the purposes indicated above. You will be entitled to exercise the rights granted to you by law by addressing your request to EMERGENCY USA, 4910 Massachusetts Avenue NW, Suite 300, Washington, DC 20016, USA, ATTN: Ms. Graziella B. Costanzo.
EMERGENCY UK, with registered offices at Flat 58, St. David’s Square, E14 3B London, U.K., in its capacity as owner of the data processing, will process your personal data manually and in electronic form for the purposes of informing on its institutional activity and for administrative reasons as a result of your donations to the organization. The provision of your personal data is not mandatory. However, the failure to provide such data or the subsequent withdrawal of the authorization to process your personal data will prevent us from processing your data for the purposes indicated above. Your personal data may be disclosed to third parties, also in foreign countries and outside the European Union, only in connection with the purposes indicated above. You will be entitled to exercise the rights granted to you by law by addressing your request to EMERGENCY UK, P.O. Box 62437, London, E14 1GA, ATTN: Mr. Gianluca Cantalupi.
First the Children, March 2009 (50): 10-11 Cambodian Triptych, March 2009 (50): 14-15
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Articles describing ongoing medical humanitarian efforts of EMERGENCY as