Arrivals, departures, and the long haul

I was 16 years old when the peace of my childhood was shattered by the outbreak of war in my city. As I fled with my family beneath bombs and bullets, we had to jump over bodies, and we heard the cries of many in our community as they lay dying. If anyone in the world knows their final words, it could only be because we witnessed them. Likewise, many people in the Democratic Republic of Congo have witnessed events, both beautiful and uplifting, as well as horrifying, that remain hidden from much of the world. Global attention has recently focused on some of these events as witnessed by international organizations responding to the ongoing Ebola outbreak in eastern DRC. Alongside them, I share a lesser known story of two Congolese physicians fighting for life in dire conditions.

Dr. Ghislain Muhindo Mayao, a physician in Beni, which is near the epicenter of the Ebola outbreak and in the thick of the ongoing war in eastern DRC, wrote to me last fall about a research project I am working on with Congolese doctors. We knew each other from medical school, where we lived in adjacent rooms of the same dormitory. Aside from the repulsive stench of the toilets which separated our rooms, the first thing one noticed when arriving to our hallway was the room on the other side of mine. It was previously bombed during a fight between two foreign countries in our city, and not yet repaired. The shell of the room was open to the sweltering heat outside and torrential equatorial rainstorms that flooded our space, a constant reminder of the war we had so far survived. We learned from some professors who were born before independence from Belgian colonization, and one who was an Ebola survivor himself. They enhanced our training through their lived experience of disease and practicing medicine in time of war. For those of us who have been lucky enough to find jobs as doctors in Congo, we have witnessed the profound consequences of war on our patients over the years.

Dr. Mayao was a physician and entrepreneur, and for the past three years he cared for patients in a small hospital that he and his family founded. He was a perfectionist and was respected by his patients and community. He also responded to the current Ebola outbreak doing case detection and surveillance. Passionate about confronting social problems in Congo and finding solutions to them, he posted a photo on Facebook last year of villagers near his city mourning over a pile of massacred cadavers with this caption:

What I wouldn’t give to be 5 years old again. Not because we don’t have problems at that age, no. But simply because as a child, we have the right to cry and see problems taken care of by our parents. But there, even deeply wounded, I am asked to assume them and to assure. Is that what makes us adults?

On December 26, 2018, Dr. Mayao travelled from Beni to Butembo, a city 33 miles away. It is about a one-and-a-half-hour journey on an unpaved dirt road. His grandmother was sick, and he had asked a former medical school classmate in Butembo to transport her from her village near Butembo to his hospital. She had a heart problem and needed a kind of medicine called a beta blocker, a basic cardiac medication nearly ubiquitous elsewhere in the world. But despite the arrival in Butembo of massive investments from international agencies for health interventions, her doctors could not provide this to her. Dr. Mayao went that day to Butembo to bring this medication, carvedilol, to his grandmother. He arrived in Butembo by 5pm, spent an hour with his friend and his grandmother, and left by taxi at about 6pm with one other passenger.

Close to 7:00pm, his car was ambushed by an armed group, and he was shot in the lower back. The car was not drivable after the attack, and due to the dangers on the road, they had to wait for a tow truck in a convoy to safely rescue them. It took almost three hours for him to reach the nearest hospital, which was just three miles away. On arrival, he was already in hemorrhagic shock, with only a palpable carotid pulse. Dr. Miriko Samson Wasingya, whose own family was displaced recently due to war, was the sole doctor at the 40-bed hospital that day. The hospital had been full, swelling to over 60 patients during this Ebola epidemic, and Dr. Wasingya works there without supplemental oxygen for his patients, a blood bank, or reliable electricity. Dr. Wasingya had just successfully finished a caesarian section on a mother that evening.

He and his team sprung to action to receive Dr. Mayao. Without access to banked blood and with only a makeshift lab, they quickly mobilized to find blood donors in the community while Dr. Mayao’s blood type was determined, and they managed to give him intravenous fluids and transfuse him with whole blood, appropriately. They worked as rapidly and as best as they could in the conditions they were faced with. Dr. Mayao was barely able to speak and mostly incoherent, but diagnosed himself, telling Dr. Wasingya he had a hemoperitoneum, or blood in the abdomen, and that he could remove a kidney if that was an organ hit by the bullet.

He was taken to the operating room at 10pm for exploratory laparotomy. His bowel was perforated by the bullet, but more importantly, his inferior vena cava was as well, which is a central vein bringing blood back to the heart from the lower part of the body. A traumatic injury to the inferior vena cava is like turning on a faucet of blood. For Dr. Mayao, this resulted in massive hemorrhage. Dr. Wasingya found what seemed to be all of his fellow physician’s blood in his abdomen. He repaired the injuries, and at about 1am, as he was closing the abdomen with his final sutures, Dr. Mayao went into cardiac arrest. Despite several attempts to resuscitate him, with CPR and mouth to mouth resuscitation (due to lack of even bag-masks for ventilation), Dr. Mayao passed. The following day, an outpouring of Dr. Mayao’s former patients came to the hospital to mourn his death. Dr. Mayao would have turned 36 years old last month.

The operating room in Kabasha, DRC where Dr. Wasingya treated Dr. Mayao. Photo credit Dr. Miriko Samson Wasingya

Speaking to Dr. Wasingya, he replayed all of his decisions and actions again and again in his head over the following week, and was beside himself, as any physician in his position would understand. Caring for a fellow doctor is never easy and brings us to feel closer to our own mortality, especially when the outcome is not good. Thankfully Dr. Wasingya had built significant resilience from having worked for five years continuously in this isolated hospital with limited resources to care for his patients (a population of 18,000 people). He said he no longer felt afraid of cases that came to his care for which he did not have adequate medication or materials to treat, as he did as a younger doctor. He worked calmly and steadfast throughout his care of Dr. Mayao. He had seen and treated injuries such as Dr. Mayao’s before, and successfully, at times under the glow of a cell phone due to lack of electricity for lights. In this case, his patient arrived too late given the rudimentary materials he had to work with.

When I asked Dr. Osee Malinyota, Dr. Mayao’s friend and colleague in Butembo who was caring for his grandmother, what could we do to further advance Dr. Mayao’s vision for health in Congo, he said that by improving the life and work conditions of physicians in DRC, availability of materials to work with, and opportunities for continuing medical education for physicians, we could improve the care of patients.

How can we all participate in realizing the dreams of this physician, who managed to survive massacres in his city and the frontlines of Ebola, but was at last taken from his patients and community by a war that has been ongoing since 1996? No one is an island, and in times of emergency, we all benefit from solidarity and support of others. Can we think of new approaches to public health interventions that unleash the full potential of health workers who are in the community before we assume they do not exist? It is my belief that there are many Dr. Mayaos and Dr. Wasingyas in Congo.

A few months prior to his death, Dr. Mayao wrote,

“I go! I come! But in the end, an arrival is nothing but a new departure. Let’s move forward!”

His first mile to arrive at a hospital for treatment ultimately became his last mile, and his final departure from this world. Dr. Wasingya and his team in his small hospital remain on the front lines of disease and war in DRC. He is a part of the community he serves. These conditions are not new to him, nor to the health workers in the region. They have lived through Ebola, and they have lived through war, at times simultaneously (such as in Isiro in 2012). They are resilient, and they are survivors. They are there for the long haul. They have heard the cries of children as young as 5 years old who have seen people massacred in far more brutal ways than Ebola can kill. They have seen seeds of disbelief planted in those children who then watch the blue helmets of the United Nations and white land rovers of international agencies drive by, while their cries remain unknown to the world. It is my hope that we give the best of ourselves as human beings to plant seeds of peace in our communities for the next generation rather than surround our children with global silence in response to their cries. Together, with the international community, and in honor of heroes such as Dr. Mayao and Dr. Wasingya, let’s find peace, and move forward.

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Ali N'Simbo, MD, MPH

Ali N'Simbo, MD, MPH

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Ali N’Simbo is a medical doctor from the Democratic Republic of Congo and was the first African on the Board of Directors of Doctors Without Borders USA.