In Mozambique, the vast majority of surgery is not done by surgeons, but by "technicians"—non-doctor clinicians who are trained to do a range of essential surgeries like cesarean sections, hernia repair, amputation and hysterectomies. While I was reporting on the technicians' work at the Chokwe District Hospital in November, one of my editors asked whether I'd be afraid to undergo surgery done by a technician.
I had ample opportunity to contemplate her question during a four-hour ride in one of Mozambique's notoriously dangerous minibuses, called chapas. As the rickety, overstuffed van barreled down a potholed, unlit road, I thought about how I'd watched technician Victor Muitiquile calmly sew up a stab wound by the light of a Nokia phone when the power went out. I remembered how Nilza Munambo, a technician specializing in maternal health, worked almost wordlessly with a scrub nurse; they anticipated one another's moves and needs throughout a bloody 45-minute-long cesarean section and tubal ligation. Sterile procedures were rigorously enforced. Thinking of their cool demeanors and steady hands, I decided that I wouldn't be afraid to go under a knife wielded by a technician.
What would scare me, though, are the basic necessities these technicians often do without. Let's start with electricity—while I was at the hospital, the power went out several times. The hospital got a generator a few months back, but it wasn't working yet. When I asked if I could observe surgery, the main concern was whether the hospital could spare a set of clean scrubs for me. Two people do all of the laundry for the 125-bed hospital—by hand. Water shortages are common and the blood banks are frequently empty. And, while there are always some antibiotics on hand, they aren't always the best ones for a given infection. "We adapt," Muitiquile told me. "But sometimes improvising isn't enough."
Ketamine is the anesthetic of choice in Mozambique, said John Rose, an American surgeon who has spent considerable time in the nation's rural hospitals, including the one in Chokwe. But the drug can cause seizures and Rose has had the harrowing experience of amputating the leg of a seizing patient. He also noted that surgery is done without a pulse oximiter—a device that monitors the oxygen levels in blood. This is a problem, he said, when patients under anesthesia can't breathe on their own—it's especially serious for patients with TB or sickle cell anemia which interferes with the blood's ability to carry blood. "How do we know if we're oxygenating sufficiently or too much? We don't," he wrote in an email. "It's all guesswork."
Amid these hardships, Rose said Mozambican technicians exemplify thrift and have "uncanny ways" of dealing with shortages. The technicians often close a hernia with a single stitch, while it's not uncommon for U.S. surgeons to use five. And, while U.S. surgical residents are often encouraged to think about how they would care for a patient in the absence of essential tools or specialist consultations, it's not an academic exercise for Mozambican surgical technicians, but an everyday reality.
One of the greatest needs, however, is for more trained health professionals, Munambo said. September and October are particularly grueling months in the maternity ward. That's because many local women are married to men who work in South African mines. Most only come home once a year, at Christmas. Sure enough, nine months later, the Chokwe hospital has a baby boom on its hands. There aren't nearly enough beds, so two or even three women are assigned to the same one. They take turns and whoever needs the bed most in any given moment gets it. On the worst days, there's just one nurse for each 12-hour-shift and she might deliver 10 babies. And that's not all she does—she gives medication to everyone on the ward and, in the event of a cesarean section, goes to the operating room to receive the baby. "The month of September is a race," Munambo said. "The nurses run from one end of the ward to the other."