Friendship is a value based non-governmental organization which aims to help people in remote and unaddressed communities. Established by Runa Khan in 2002, Friendship works in the most remote and inaccessible islands and riverbanks of northern Bangladesh and the remote coastal belt in the south.
Monday, March 21, 2016
The Star: Mission of mercy: Toronto surgeons treat burn victims on remote Bangladesh island
On ever-shifting river islands, a group of women are shunned because of serious burns. A Toronto medical team flies in to help.
By MARINA JIMENEZForeign Affairs Writer
Mon., March 21, 2016
DAKATIA CHAR, DEWANGANJ, BANGLADESH—The day a white and pale blue floating hospital docked on the silty shores of this remote island, the women dared to hope their luck was about to change.
A team of foreign doctors, they had been told, would arrive to treat women and children disfigured by burns — fingers gnarled, faces deformed, legs and arms covered with ropy scars and burn contractures.
Women like Morsheda. The inside of her legs had been burned from groin to ankle after her sari caught fire two years ago while she was boiling water over a mud stove. Her husband used the incident as an excuse to divorce her, take custody of their child, and marry another woman.
“I am damaged. I’m not an important person in my own family,” says Morsheda, who guesses she is 26. She can no longer squat to wash clothes, pray or grind spices; her once-smooth brown legs are now mottled, white and painful with scar tissue. “I feel worthless in life.”
Morsheda and the other burn victims are the most vulnerable people living in one of the world’s most isolated communities — the ever-changing char islands in the Brahmaputra-Jamuna river system of Bangladesh.
The sedimentary islands are beautiful, with misty fields of rice, coriander, corn and bean stalks beside papaya trees and rickety thatched houses. But the chars, subject to constant erosion and flooding, are cut off from the rest of this country of 160 million and lack even basic necessities.
On the last day of the week-long medical mission to Dakatia Char, Dr. Toni Zhong walks across the char, or river island, as curious village children follow. (MELISSA RENWICK / TORONTO STAR) | ORDER THIS PHOTO
A local woman washes her food in the Brahamputra-Jamuna River in Dakatia Char, near Dewanganj, in northern Bangladesh. Three million people live in the chars in Gaibanda and Kurigam districts; many are displaced from their homes by catastrophic annual flooding. (MELISSA RENWICK / TORONTO STAR) | ORDER THIS PHOTO
Dr. Toni Zhong, director of Toronto’s University Health Network’s breast reconstruction program, examines 12-year-old Sumaiya, whose face was badly burned in a motorcycle accident. Dr. Zhong spent seven days here on a surgical mission with Women for Women, a charity based in Germany. (MELISSA RENWICK / TORONTO STAR) | ORDER THIS PHOTO
Dr. Toni Zhong meets with the surgical team aboard Emirates Friendship Hospitakl: Dr. Jennifer Klok (background), Inge Haselsteiner, a German anesthesiologist, and Antje Hube, also an anesthesiologist from Germany. (MELISSA RENWICK /TORONTO STAR) | ORDER THIS PHOTO
Dr. Zhong injects cortisone into the chest scar of 7-year-old Jami in an attempt to soften a burn scar known as a keloid. (MELISSA RENWICK / TORONTO STAR) | ORDER THIS PHOTO
Dr. Zhong and the team operate on Sharifa, 9, who was burned by an outdoor mud stove. Her parents had to be persuaded to bring her to the hospital. She would have died without treatment. (MELISSA RENWICK / TORONTO STAR) |ORDER THIS PHOTO
Dr. Marie-Christine Gailloud-Matthieu carries a patient into the recovery room aboard the Emirates Friendship Hospital. (MELISSA RENWICK / TORONTO STAR) | ORDER THIS PHOTO
Shabuli is comforted by her mother after surgery to reconstruct her neck and face and lower eye lid. Shabuli, 18, fell in a wok of boiling oil as a child, causing such severe facial and neck burns that she couldn’t move her neck or make proper eye contact. (MELISSA RENWICK / TORONTO STAR) | ORDER THIS PHOTO
A surgical assistant washes the instruments aboard the floating hospital, which has rudimentary facilities and lacks a modern ventilation system or a sterilization room. (MELISSA RENWICK / TORONTO STAR) | ORDER THIS PHOTO
Dr. Zhong comforts Mariam (centre), who is recovering after surgery in the patient shed which is constructed of corrugated iron and bamboo poles. (MELISSA RENWICK / TORONTO STAR) | ORDER THIS PHOTO
Dr. Zhong calls home to check in with her husband and two young children, a rare quiet moment during her mission. (MELISSA RENWICK / TORONTO STAR) | ORDER THIS PHOTO
Inside the patient shed, locals have misunderstood the doctors’ instructions to keep the young girl’s arm elevated and instead tied it to the ceiling. (MELISSA RENWICK / TORONTO STAR) | ORDER THIS PHOTO
Bengali women squat while cooking breakfast over open mud fires in a corner of the patient shelter. Women and young children often suffer from life altering burns as a result of these open fires. (MELISSA RENWICK / TORONTO STAR) |ORDER THIS PHOTO
On the last day of the week-long medical mission to Dakatia Char, Dr. Toni Zhong walks across the char, or river island, as curious village children follow. (MELISSA RENWICK / TORONTO STAR) | ORDER THIS PHOTO
A local woman washes her food in the Brahamputra-Jamuna River in Dakatia Char, near Dewanganj, in northern Bangladesh. Three million people live in the chars in Gaibanda and Kurigam districts; many are displaced from their homes by catastrophic annual flooding. (MELISSA RENWICK / TORONTO STAR) | ORDER THIS PHOTO
Every spring, when the snow melts in the Himalayas and flows south, the great Brahmaputra river rises, turning from a lifeblood into a killer. The char people, subsistence farmers, are forced to abandon their homes and move to new islands. Some move as many as 10 times in their lives, and disputes over land and dowries are common. Many children are put to work on the land, and women are married off in their teens .
“The chars are their world. It’s all they know,” says Dr. Rafi Siddique, the physician in charge of the floating hospital. “To be from the chars is to be poor and stigmatized.”
There are no government schools, electricity, police, roads or hospitals for the three million char dwellers. The only medical care comes from Friendship, one of Bangladesh’s largest charities, which runs the Emirates Friendship Hospital and another floating hospital, which dock for weeks at a time along the river.
“I am hoping the foreign doctors will do surgery and cure me,” says Morsheda. “I want to return to normal.”
Morsheda and dozens of other women and children wade barefoot into the river’s green-grey waters to watch the Cessna Caravan float plane land. It is bringing experts to this neglected corner of the world: Dr. Toni Zhong, director of the University Health Network’s breast reconstruction program, Dr. Jennifer Klok, her fellow, Sarah Linklater, an operating room nurse from Toronto General Hospital, Sabnam Mahmuda, a researcher and translator, two anesthesiologists from Germany and a plastic surgeon from Switzerland, Dr. Marie-Christine Gailloud-Matthieu.
Zhong and her team walk down a wobbly wooden gangplank into the hospital ship. They greet Siddique, who has screened more than 70 patients for treatment. Women in the chars are more likely to be burned than men because they do all the cooking over outdoor mud stoves — simple rings of hardened mud — and their saris catch fire.
Some have travelled for hours by boat and rickshaw from islands and villages up and down the river. They hold out their children, pointing to deformities and angry red scars.
As members of a German-based charity, Women for Women, Zhong and her fellow plastic surgeons trade their big-city careers once or twice a year to volunteer in countries like Bangladesh.
“I feel a great sense of responsibility to provide surgeries to the patients who have been waiting for days and travelled so far to get here,” says Zhong, 40, a compact, elegant woman with a surgeon’s slender fingers. “Plastic surgeons can make a real difference in people’s lives.”
Zhong is inspired by memories of her late father, a surgeon who worked in rural China during the Cultural Revolution. Sleeping in a tiny berth in a ship adjacent to the floating hospital with no toilet in her room and no email for a week is nothing compared with the daily lives of the char women, who scoop ash from the fire to brush their teeth with their fingers and use old rags as menstrual pads.
“In Canada, our prevention and acute burn care is so much more sophisticated so you don’t see the complexity and extent of these burn deformities and contractures,” says Zhong. “But at the same time, I want to do what is right and what is within our capacity to offer the patients.”
There isn’t much she can do, for example, for a girl with a keloid covering her chest, a raised scar so thick and red it has displaced her nipples. They inject it with cortisone cream to reduce inflammation and order a compression bandage. Without breasts, the mother is worried nobody will marry her, but the doctors are reassuring: “Your daughter is so beautiful, this is a small thing. Once the tissue is softer, we can come back and try to operate.”
The surgeons are limited by the rudimentary facilities on the ship, which, while scrubbed with bleach every morning, lacks a modern ventilation system, intensive care unit or a proper anesthesia machine.
“Omigosh, the breathing machine looks like something out of the dinosaur age,” says Linklater, the nurse. “It is like a MASH unit.”
With no stretchers or attendants, the doctors carry the patients in and out of surgery. Used syringes go into an empty water bottle and surgical instruments are sterilized in a broom closet sink then placed in what looks like a large cooking pot. Inge Haselsteiner, one of the anesthesiologists, has cobbled together an anesthesia machine by taping a patient vital signs monitor to an oxygen tank.
“Inge would win a Survivor reality show for doctors,” jokes Zhong.
The team unpacks more than 200 kilograms of medical supplies: bandages, anesthesia drugs, dressing pads, gauze, sutures, catheters, surgical gowns, gloves and drapes to cover the patients. And, of course the forceps, scissors, knives and bone cutters that are about to come to life in their hands.
A woman in Bhatikamari char, along the Brahmaputra-Jamuna River, where the Bangladesh charity Friendship runs a medical clinic, a school and a good governance project to help villagers resolve disputes peacefully and to improve the living standards of the farmers who live there. “We go to the places nobody else serves,” says Runa Khan, founder of Friendship charity. (MELISSA RENWICK)
Nine-year-old Sharifa was severely burned when her blue sari caught fire from a stove six weeks ago. Her parents covered the wound in banana leaves and borrowed money for a rickshaw ride to the hospital ship. Siddique had to persuade them that Sharifa — just 35 pounds and as delicate as a bird — was worth saving.
“When she first came in she was so malnourished, she stared at the ceiling and didn’t speak. Her jaw bones stuck out,” he said. “I told the family that if we were going to treat her burn, then they had to start feeding her better. Because she was a girl, they didn’t think it was worth it.”
Zhong, who has two young children, shakes her head, shocked by the infected wound that stretches down Sharifa’s right leg. She suffered third-degree burns, and the dead tissue will have to be scraped away. Zhong shaves the skin with a dermatome, a tool that resembles a high-tech, electric cheese slicer. The smell of charred flesh fills the room.
It is already above 30 C and the surgical team is sweating through their blue scrubs. They can’t turn on the archaic air conditioner for fear of further infection.
“Most cases here are reconstructive, but this is an emergency, life or death,” says Zhong. “Let’s get all hands on deck.”
They work quietly, removing the burnt skin and deftly preparing the wound for 15- by 20-centimetre skin grafts. They staple — not sew — the new skin in place to save time.
Ninety minutes later, they are done. “When you see that much blood loss, you think in terms of minutes, not hours,” says Zhong.
“Shob tikh asay. All is well.” Siddique smiles in relief.
Locals in Dakatia Char use sand bags to guard against flooding. The grey-green water of the Brahmaputra-Jamuna River is their lifeblood but also their hazard. Every year in the spring, as the snow melts on the Himalayas, the Brahmaputra rises and submerges entire villages. The char people are forced to abandon their homes and move to islands with their few possessions. Some move as many as 10 times in their lives. (MELISSA RENWICK)
Shabuli Shaik fell in a wok of boiling oil as a child, causing such severe facial and chin burns that she cannot move her neck. Her right lower eyelash line has been pulled down several centimetres, exposing the inside of the mucous membrane.
At 18, Shabuli has no marriage prospects and is an outcast in her own family, supported only by her mother. She has been forced to move to Dhaka to work as a tailor in a small shop and lives alone in a rented room.
“Very few things shock me. I have seen so much. But in my nine years, I’ve never encountered such a severe case as this,” says Zhong, noting that in Canada, Shabuli would have received years of care and multiple surgeries. “This is major surgery because it’s around the face where there are a lot of arteries and nerves. We have to be careful around the eye.”
Shabuli’s injuries make it difficult to sedate her. Antje Hube, the anesthesiologist, inserts a laryngeal mask airway, but it is too large, and won’t stay down. Shabuli’s oxygen saturation level drops to 60 per cent and then to 48. Hube decides to intubate, but inserting the plastic tube into her windpipe is difficult because of the girl’s neck contracture. If her brain doesn’t receive enough oxygen she could suffer brain damage; if she goes into a laryngeal spasm, Zhong would have to consider performing an emergency tracheotomy — which she hasn’t done since medical school — or abort the surgery.
It is a tense 45 minutes. Without an ultrasound machine as guide, Hube relies on years of experience and successfully inserts the tube.
An eyelid reconstruction, a face and neck lift all-in-one, in the midst of scar tissue: “This is the kind of thing you read about in textbooks,” says Klok.
She and Zhong perform an extensive scar release on Shabuli’s constricted neck, cutting into the tissue and opening up the wound site to prepare for a skin graft. With a purple marking pen, they outline the skin behind her ear which will be grafted underneath her right eye. Surgery lasts three and a half hours. They have to finish by dark, when the mosquitoes and no-see-ums invade the floating OR, attracted by the open wounds.
Dr. Toni Zhong (right), director of the University Health Network's breast reconstruction program and a University of Toronto associate professor, performs a surgery on a burn victim on the Emirates Friendship Hospital. (MELISSA RENWICK)
Shabuli’s mother wipes away tears as she looks nervously at her daughter’s swollen, bandaged face. It wasn’t the miracle transformation they had expected. But after a lifetime of looking down, Shabuli can move her neck and make eye contact. She chews the rice and egg that her mother feeds her by hand. “I am happy my eye is OK. I want to feel better,” she says.
Sharifa lies in the next bed. She has rebounded as only a child can. Smiling, she shyly accepts a Starburst candy and a pencil with a butterfly eraser from Zhong. “You have long beautiful legs and one day soon you’re going to run out of this hospital,” the surgeon tells her. The Swiss surgeon, Gailloud-Matthieu, gives her a finger puppet, which Sharifa carefully places under her pillow.
By week’s end, Zhong and the team have completed 60 surgeries — 40 under general anesthetic and 20 under local. They managed to restore a young girl’s nipple that had been displaced by a burn. Saving her breast is “good for her family, good for her culture and good for her life,” says Shimuli Akhter, the local nurse.
Most patients are recovering in the patient shed, a dirt-floor barracks-style shelter made of corrugated tin on the shore.
Morsheda lies in a bed in the corner, eating rice and curry, her clothes bundled in a burlap rice sack. Zhong had to operate on her twice, after part of the first skin graft didn’t take. Morsheda looks forward to the bandages coming off, and being able to move without pain. She is upbeat: “I will show my ex-husband I can do everything on my own.”
The doctors change dressings and make post-operative notes for Siddique. “Make sure you keep moving,” Klok tells one. Later, she observes: “I come here to remind myself how lucky we are in Canada. Plastic surgery is an elite world and people make a lot of money.”
Zhong agrees: “We are all human and we share so much even if our worlds are completely different. We have brought these women hope. And when I go back, I will be a better doctor, a better mother and a better person.”
She tears up when she says goodbye to Sharifa, worrying the little girl will feel abandoned just as she’s beginning to heal.
The next day, when the float plane arrives, children run down the beach, which is stained deep red in patches from betel nut spittle. The women’s colourful saris billow behind them, brightening the foggy grey landscape.
“This chapter is over and a new one will begin,” says Zhong. “We made promises we will be back, and we will keep those promises.”
The patients wave until the plane rises out of sight.
