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NOVEMBER / DECEMBER 2005

FEATURE

Special Feature: A mission in seeing at a short-term eye camp in rural Namibia

In this Special HMI World Feature, Jesse Maki, a second-year student at Harvard Medical School, describes her experience with a short-term medical mission in Namibia. Jesse is part of a group of HMS students involved with STMMConnect, an organization focused on developing quality assessment tools to help foster improvements in the evaluation and delivery of short-term medical missions around the world.

“Seatbelts on,” the pilot yelled back from the cockpit. “We’ll be on the ground in ten.”

I was sitting in a circle of doctors and Namibian health care workers on the bottom of a roaring military jet filled with slit lamps and boxes of donated surgical supplies as we careened over the Kalahari Desert. We were en route to Opuwo, in northern Namibia, where we would be holding an eye camp sponsored by SEE International, a California-based NGO that sends surgical eye missions all over the world. This mission was a cataract clinic, and we planned to perform 150 operations in five days. Of the two million Namibians spread over a country half the size of Alaska, only about 5,000 call Opuwo their home, but it is a city by any Namibian standard.

Craning my neck, I hoped to catch a glimpse of the runway and settle my nerves, but there was only fine, red sand as far as the eye could see. As we continued our descent I saw there was no runway. When we touched down, the sand billowed in big waves and slowly settled around the aircraft. Opuwo came into sight. It was, certainly, the furthest I had ever been from home.

Jesse meets a member of the Himba tribe.

The entire town was waiting for our arrival. We were taken quickly to the Kunene Regional Hospital, where a long line of men and women—many with canes or led by their young grandchildren—were waiting to be seen. They stared and whispered at first, but there was a kind of hope and excitement in the air. These patients were blind from cataracts, most bilaterally, and had come to this clinic so the doctors could restore their vision. The crowd was lively and expectant. Half were dressed in bright, beautiful gowns with petticoats. The others, though scarcely dressed at all, had skin dyed a magnificent crimson.

In its color and splendor, the scene could have been taken right from National Geographic as the two main tribes of the Kunene region—the Ovahimba and the Ovahererro—intermingled. These tribes had initially been one and the same, a nomadic cattle-herding people. During colonization, the Herrero assimilated the European dress and began to wear the long Victorian dresses favored by the wives of the early European missionaries. These are still worn today, with matching hats that are fastened to look as though horns point forward, to signify their interaction with the cattle. The Himba, however, whose name means “beggars,” did not take to the European culture; warfare drove them to highly isolated regions of the Namib Desert. There they clung to more traditional, tribal garb and to this day wrap animal skins around the waist, wear beautiful ornate bangles on their wrists, necks, and ankles, and perhaps most strikingly, cover their bodies with a mixture of ochre and animal fat so that their skin and hair shine red.

The beauty of the crowd was distracting, but we had a task at hand and much work to do before we could start operating. The OR, or theatre as it is called, consisted of a waiting area, where the local anesthetic was given, and four beds for the operations. The shelves were stacked quickly with intra-ocular lenses, suture kits, and OR drapes, and within two hours the first patients were called in.

It is an African custom that the entire family accompanies the patient to the hospital. Eight to twelve families share a room with single mattresses on the floor that are often covered with the blankets the family brings from home. The community outside comes in, and the hospital becomes a temporary home for the patients.

Scared and timid, the first patients donned their gowns and prepared to wash. This provoked quite an argument from many of the Himbas, who refused to wash the red from their skin, but after gentle prodding from the Namibian staff, all were ready for surgery. The theatre assumed a busy, efficient routine with Namibian Red Cross volunteers bringing patients in and out. It was time for me to begin my role in the mission.

Jesse interviews local ophthalmologist Helena Ndume.

During my first year at Harvard Medical School, I joined STMMConnect, a program sponsored through Harvard Medical International, and worked with other HMS students to develop a survey-based evaluation tool to assess the overall effects of short-term medical missions (STMMs). STMMs have become a common means of delivering health care to the developing world, and account for hundreds of volunteer hours and millions of dollars. Given this huge resource investment and the emphasis on quality improvement in the United States, it seems intuitive that there be a means to gauge the effectiveness of STMMs. However, there is a poverty of discussion or inquiry on this topic in the international development literature. Therefore we found it critical that concepts of quality improvement be disseminated to the sector of STMMs to aid missions in improving their overall performance. We pursued this goal through the development of an evaluation methodology, and this past summer other HMS students and I administered this methodology at missions being run in Namibia, Zimbabwe, Honduras, Guatemala, and Brazil.

We provided surveys to the mission’s director, participants, and patients, as well as the local doctor who hosts the mission. The surveys gather data on quality, cost, and impact, as well as less easily defined goals such as efficiency, education, and sustainability. The surveys ask targeted questions, like how easy it is to refer a patient to a local provider in case of a complication, whether there is an efficient training and communication system for mission participants, and what the impact of the mission is on the patient’s daily life. All of the data is entered into our website at www.stmmconnect.org and a focused report is generated. The ultimate goal is to help the mission participants objectively evaluate their performance and more effectively achieve their goals, with the end result of, we hope, a higher standard of care provided to patients.

Patients who underwent the operation were presented with photographs of themselves.

While the goal of STMMConnect is to provide a critical assessment of medical missions, it’s important to remember the meaning behind the experience of the mission and the value of working within another culture to provide health care. On the second day of the mission, after long hours of surgery, the doctors rounded the wards for the first time and removed the eye patches from patients who had been operated on the previous day. We took Polaroid photos of the patients and presented them as gifts, along with balloons and patches with the SEE International logo. The women in one room began to laugh and cry with the joy of being able to see again. “Praise to God, we can see!” they all sang together as they danced around the room, the skirts of their colorful dresses swaying from side to side. It was a beautiful display of gratitude, and everyone was deeply moved.

I felt lucky to be part of a group of dedicated physicians working to restore sight to the people of Namibia. The experience reaffirmed my dedication to provide STMMs with a methodology to continue to improve the care they provide.

For more information about STMMConnect, visit the website at www.stmmconnect.org. The March/April 2002 issue of HMI World examined short-term medical missions, with a focus on the experiences of Ben White, MD, then a second-year student at HMS