Witchcraft

In talks I have given about working here in West Africa, I have made the point that facial tumors tend to be viewed as something more than physical, that there is the presupposition that patients with these tumors suffer from some supernatural antecedent cause, be it demon possession, witchcraft, or the anger of God.

I have always, however, felt a little bit disingenuous making these sorts of statements, not because I didn't really believe that they were true, but because they were things I had heard from others who work here, and, as a result, were subject to the vagaries of hearsay. In making these statements, I was at risk of perpetuating an exaggeration.

On June 30, the Standard Times Press, one Freetown's newspapers, published a photograph of a child with a facial tumor. I'm reproducing the accompanying article verbatim.*

MYSTERY!
12-year-old turns pig

History will never end, at least for the residents of Makeni. It was on Monday, the 28th of June 2011, around 1:30pm, an alarm was raised by the residents of K_____ Street, Makeni, when onlooker witnessed the unusual event of a 12 year old boy, Kaddy Bangura, transforming himself into a pig at his residence.

Makeni it seems has now become infamous as a witchcraft town. This Reporter upon hearing the news went to the Makeni Police Station where Kaddy Bangura was taken to.

I was informed by the Information Police Officer at Makeni Police Station Sergeant Senessie that the boy is presently with the President of the Traditional Healers at Calaba Town.

Upon arrival, the President, Dr. Kabbah, took me to the room where the boy was housed in and was allowed to conduct an interview with him. Kaddy Bangura narrated his story about how having put faeces in his auntie's Foo-Foo she was about to eat, the "Auntie" made a "Karafilo" (a form of protection against evil) which resulted in his being powerless in enacting the transformation from a pig back to his human form, and was thereby left with a pig head and his human body.

The President of the Traditional Healers Association, Dr. Kabbah, noted that there is something going on in the Makeni area.

He admonished all that witchcraft does exist in Sierra Leone. Dr. Kabbah noted that Kaddy's condition now is such that no doctor on Earth can cure him.

*All identifying patient information has been changed to protect privacy; the picture itself is, for the same reason, not reproduced.

Unholy litanies

When every store in the market sells cigarettes, plastic baubles, t-shirts, household goods, and chinese bras, demand for your wares is exquisitely sensitive. Do enough people come past your door, for example? And are you able, through sheer force of personality, to lure enough of them into your store itself?

Also, do you look normal?

As unfortunate as it is, we've become pretty comfortable with the fact that appearance correlates with income. So it should come as no surprise that, when Amidu's face started swelling, the flow of traffic to his plate shop decreased. And, since plates were his livelihood, this became a problem: eventually, he had to close his shop. After all, there were enough plate-sellers without distorting (and pungent) ameloblastomas on their faces.

Sometimes it's a an unholy litany here. Ameloblastomas, lipomas, hemangiomas, neurofibromas, cystic hygromas—these are bread and butter of surgery for me here on the ship, repeated week after week. And, to a large degree (without getting into the potential for airway compromise, for metastasis, for malignant transformation), these are cosmetic masses. And so what, really, if you have a lump of fat the size of a small melon growing off the back of your neck, as one of my patients tomorrow has? Is it really important?

As a cancer surgeon, I occasionally find myself thinking the same way—these aren't cancers, after all. Isn't there more important surgery I could be doing? Until it hits me that this is more than just surgery. The cosmetic vs. "important", benign vs. malignant dichotomies are not just flawed—they're outright false.

Because every tumor in that litany is a person. And, though Amidu is still on the wards, there's a chance that when he leaves, business slowly return to his shop.

And that is important.

Freetown

Freetown begs description. But I'm going to try anyway.

To begin with, it is, hands down, beautiful. This is the fourth West African city I have worked in over the last three and a half years, and it is by far the most picturesque. Mountains rise directly from the Atlantic, and the town is built on their slopes. Tin roofs, of various shades of red and punctuated by minarets of white (and, in a nod to the fact that this country is still the eleventh-worst on the UN's Human Development Index, massive trash dumps), ascend toward the university, which holds pride of place at the top of the hill. The green-white-and-blue tricolor flies everywhere, due in part to the fact that Sierra Leone just celebrated its fiftieth year of independence. And the city is packed with people. Literally.

Although numbers are obviously hard to come by, Freetown is home to about 1.2 million people (making it approximately twice the size of Boston proper), who pile themselves into a city initially designed to far fewer. Freetown's population density (about 7,700 people per square mile) rivals that of Los Angeles; its infrastructure does not. Sewage is carried by ditches that edge every street—ditches dug to about the depth of your hip, but filled to your knee (as a crew member found out this weekend) with effluent. During dry weather, the ditches are visible; in the increasingly common rain storms that will carry this country through the monsoons of the summer, they become invisible. Walking requires a preternatural predictive ability, lest you end up in one of them.

The city houses West Africa's oldest university, a larger-than-life cotton tree under which Sierra Leone was founded three and a half centuries ago, and street vendors peddling everything from aluminum foil to Obama umbrellas, from cassava to pre-sliced pineapple to street-grilled meat skewers, from shoes to aphrodisiacs. It is a claustrophobic, energetic, sun-beaten, traffic-clogged, beach-fringed city pulsing with life. Count me impressed.

Docked in the port on the eastern end of town (and, unfortunately, about a two-hour, few-kilometer drive to almost any restaurant), the hospital is humming. In the two and a half days of operating I've had this week (Friday was a ship's holiday), I've done 4 mandibulectomies, one parotidectomy, and a couple of smaller cases

Granted, my time here isn't about numbers (or about Obama umbrellas). I will tell you about the patients themselves next week.



More pictures are here.