I walk down the long corridor, narrowly dodging a child chasing a ball and grinning widely despite the tell-tale dressings from recent cleft lip and palate surgery. I pass the small pre-op waiting area, where a nervous husband stares straight ahead, silently uncomfortable in these sterile surroundings, desperately hoping that this might be the day that their years of shame resulting from his wife’s obstetric fistula might be over. The familiar sound of drums and singing wafts down the hall, and I realise they’re preparing for the daily singing and prayer time brought to each ward by the chaplaincy service. Finally, I come to ‘A’ ward, the gynaecology unit. I smile at the nurses already rounding with the visiting surgeon as I take my place amongst the blue scrubs. As usual, I’m struck by the strength and courage of the women in front of me, lying vulnerable and uncertain on the narrow beds, waiting and hoping. For me this is another ordinary day, but for them it is far from it.
I first heard of Mercy Ships from books as a child and wondered if one day my life would take me to see it in person. Mercy Ships, headquartered in the US, is a global, non-governmental organisation that has provided free surgical care to coastal developing nations via mobile hospital ships since 1978. Each year more than 1,000 people from over 40 nations volunteer with Mercy Ships, a service which has provided care to more than 70 different countries to date. In 2018, I finally realised I had the time, resources and experience to agree to a self-funded stint as one of the two Hospital Physicians on board the Africa Mercy. This refurbished ship, formerly a train ferry, is the world’s largest non-military hospital ship and spends 10 months of each year docked along the African coast. Many years of planning go in to each field service, and in countries where the ship has been before, the welcome back is palpable.
My field service was in Cameroon, a Central African nation known for soccer, coffee and colourful national parks. Yet due to a long history of multifactorial unrest there is a high level of poverty and poor access to medical care. Along with over 450 live-in staff, I joined more than 250 Cameroonian day crew on board. Being a recently-fellowed Infectious Diseases physician, I was unsure how I would use my skills in a more general hospitalist role, but I was excited for this new experience.
And so, after a month in France conjuring up a few fledgling language skills, I found myself flying in to Douala along with a small contingent of other new volunteers from around the world. I remember walking up the long gangplank with my soon-to-be colleagues, travel-tired but enthusiastic. We were greeted by the unfailingly convivial security Gurkhas at the entrance and stepped inside.
My mornings commenced in the dining room with a few hundred other residents. The volunteer chefs and catering team served us daily with both smiles and culinary variety, not an easy feat when floating for months at a time in a country with the usual governmental red tape and mostly seasonal food access. Mealtimes became an equalising gathering of everyone from engineers and electricians to ship officers, children, hairdressers, cleaners, administration staff, teachers, security Gurkhas, anaesthetists, surgeons, nurses, and of course, the Captain and his family.
After breakfast I would head down to the hospital, a well-used section of Deck 3 where our patients would spend days to months. Starboard-side were the operating theatres, Radiology department (with X-ray, CT and a small ultrasound machine), the laboratory and pharmacy; port-side were the hospital wards, intensive care and crew clinic. There was scope to do standard haematology and biochemistry panels, blood culture and other plate cultures, basic antibiotic susceptibility testing, and other rapid tests like HIV and syphilis screening. They also had the important capability of preparing histopathological slides from biopsy, which were then placed under a microscope and video-linked to British pathologists in real-time to determine whether tumours were benign or malignant. Uniquely, the laboratory also formed a ‘walking blood bank’. Any volunteers could register their blood type, on the understanding that they might then be called at any time of day or night to directly donate urgent whole blood to a patient in need. I once witnessed a nurse who, while caring for a patient with post-operative oropharyngeal bleeding, left her post to donate blood, before carefully delivering that blood to her patient and completing her shift.
Ward rounds were completed with the surgeons, who were a mix of international experts and local surgeons completing (or having already completed) on-ship training in specific surgical techniques. We would make our way down the cramped rows of beds, communicating via interpreters whilst carefully navigating around family members camped underneath each bed, and develop a plan for the day. I would then head down to a row of temporary tents on the dock housing the admissions, screening, and rehabilitation clinics. In conjunction with the other Hospital Physician and the ship’s Crew Physician, my job was to review each patient and provide pre-operative screening assessments. Many patients had travelled for hours or days to return to the ship, temporarily staying in the Hope Centre, a repurposed accommodation residence housing up to 200 pre- and post-operative patients and caregivers. Many were nervous and intimidated by this white ship full of foreigners towering in front of them but remained hopeful as they were finally sent up the gangplank.
Planned surgeries ranged across multiple specialties, from large tumour resections, maxillofacial reconstructions, and craniofacial surgeries for cleft face or Noma (a gangrenous infection of the nose and mouth) to hysterectomies, club foot repairs and herniorrhaphy. Many months before our arrival, the ‘advance’ team had spent days triaging thousands of patients, narrowing it down to five or six thousand who were booked for surgery. Even after this triage process, it was never certain whether the patients would be well enough or able to have the surgery once the day came, so it was often an anxious wait for both the patient and surgical team alike. For many patients, the fear would not leave their eyes until after their surgery, when they realised they would be able to return home with stories of transformation for their families and friends.
In addition to the surgeries and training, many other projects occurred simultaneously. Dentistry clinics were held off-site, as well as plastering and prosthetics clinics. Many capacity building courses were also provided, such as regional anaesthetic training, ultrasound courses and emergency surgical management skills programmes. Although I wasn’t involved in these, it was an important component of the ship’s activities, and was deeply appreciated by the local staff on and off the ship.
My afternoons were spent following up blood results and essentially performing a house doctor or junior medical officer role on the wards. I also shared the crew’s on-call roster, so would occasionally get a call to review a sick staff member or dispense some simple medication after hours. The ship had never had an Infectious Diseases doctor before my arrival, so I also did my best to contribute in this area. I helped work on a sepsis pathway to improve time-to-antibiotics, created antibiograms from recent microbiological data to help with empirical treatment guidelines, and assisted laboratory staff with their antimicrobial reporting. We created an ‘Ebola Initial Management Plan’, wading through the highly-charged complexity of infection control in the confines of a ship. There were also a number of sporadic infection control concerns (for example, a mumps case in the Hope Centre, some probable tuberculosis cases, a cluster of resistant Gram-negative sepsis readmissions), and I worked with the infection control nurse to manage these.
Once evening came, the crew mostly relaxed, with the exception of those with around-the-clock jobs such as the shift-working nurses, security, or hospitality staff. I particularly enjoyed spending this time on the upper decks, soaking in the view of Mt Cameroon at sunset on one side, the greasy dock area on the other. If not on-call, we could catch a shuttle then taxi into town to grab some local or expat-style food or ice-cream. This was a welcome chance to see some of the city and practice my fledgling French in this African-French context. When the in-country security situation would allow, weekend and evening trips outside of the hospital were also coveted. My most memorable long-weekend consisted of many hours bogged in a minivan at an unsettling angle, getting covered in mud while trying to pry ourselves out, ending up on the same side of the bog as we had started, and having to find emergency accommodation for our group overnight before making the long drive back to the ship the following morning. We never did reach our intended destination, a reminder of the rich unpredictability of Africa.
The social aspect of the ship was fantastic, as I found myself surrounded by incredibly altruistic and eclectic people from a variety of nations and cultures. The diversity did bring with it, however, the potential for significant miscommunication and clinical differences of opinion. This was compounded by spending long days in the belly of a ship with no windows on the ward level (as it was underwater) and socialising with the same colleagues in your ‘down time’. Luckily, there were some incredible senior staff and chaplains to help navigate these complexities.
The ship was well equipped, with everything from a ‘Starbucks’ café to a small bank, a shop with snacks and essentials, a school for the more than 40 children of the longer-term volunteers, a small gym, an upper deck pool, a lovingly-kept library, a computer lab, and many areas to sit and relax. Although being light years from a modern-day cruise ship, life was more than sustainable for those living long-term within the relatively cramped decks.
The ethos underpinning everyday life on the ship reflected the Christian origins of the organisation. There were daily prayers before shifts, as well as church services and worship meetings. Each patient was offered prayer on arrival, and the chaplains also acted as the hospital’s social workers. For the volunteers, while it was definitely common to have some type of Christian faith, it was not a requirement, and I knew many who quietly avoided the Christian activities without issue. There was also an acute awareness that many host countries have a different majority faith and they tried to respect this through their dress codes and conduct. No matter what religion, I think most staff and patients felt comfortable within the community.
I spent nearly three months on board the Africa Mercy. Some patients will forever stay with me. I remember a young girl with a cleft lip who desperately wanted to have it repaired to save her from the ridicule of others in her village. Unfortunately, she developed severe malaria and pneumonia on arrival, so we admitted her for treatment pre-operatively. While on the ward she was noted to have a large heart on chest X-ray, and a basic echocardiogram revealed a likely congenital cardiac abnormality that made it too dangerous for us to perform the surgery. I will always remember her father’s desperately confused face as we told him the news – that he must travel home, a home many days away, with a new potentially deadly diagnosis to face, most likely without specialist follow-up. For him it felt like there was no hope in sight.
In contrast, a one year old boy with a severe cleft lip and palate spent 10 months with us after presenting close to death from profound malnutrition. He was carefully fed by nasogastric tube until he had the strength for his initial surgery, then fed for many more months until he could survive a second surgery. He struggled through multiple complications including chest infections and a perianal abscess but survived these episodes with the stoicism of someone who has never known an easy life. His infectious smile, eventually-chubby arms, and indefatigable mother endeared everyone, and it was a sad but exultant day when they finally left the ship with a staff-and-patient guard of honour.
Another defining case during my time on the ship was a young female refugee who spent nearly six months with us. She endured multiple surgeries for a congenitally cleft skull and face, with complication after complication, including multi-resistant bacterial infections and refractory seizures. Eventually she stabilised, but it was too dangerous for her to have her skull replaced and she was left with a large bony defect. An African headdress/helmet was created for her so that she could be safely returned to the refugee camp and not be ostracised for her deformity. The change in her appearance was shadowed, however, by the positive change in her outlook on life. On arrival she had been quiet, almost mute, with her head down, relying on others to talk for her. Slowly she blossomed and developed relationships with the patients and staff who fought her battles alongside her daily. When she finally left, she did so with her head held high, a wealth of people who knew and loved her, and a new understanding of her own worth. While it was a tough case that taught the team many lessons, it was hard to see her situation as a failure.
A day in the life of a Hospital Physician on board a floating surgical hospital was an experience unlike any other. For anyone considering a similar role, it is important to think about the amount of time that is required, the self-funding requirement, and any specific expertise that can be offered. For me, it was an extraordinary and memorable experience, and I do truly miss being part of such a beautiful community of people. I will forever be grateful for the experience.