Profile
Dr. Dilan Ellegala’s Brain Train
By Tony Bartelme
In this article…
A young brain surgeon goes to the African bush on
vacation and leaves with a new mission.
Deep in the Tanzanian bush, a young neurosurgeon
from America walked along the hedges of a grass airstrip.
Out of the corner of his eye, he noticed a tree shaking and
two arms pumping back and forth. It’s a farmer using a wire
saw, he thought. That might just work.
The doctor’s name was Dilan Ellegala, and he was out
stretching his legs after a long morning in a small hospital
just down the parched red-dirt road. Looming nearby was
Mount Haydom, where hyenas often sleep in the shade of
smooth brown boulders.
Using hand gestures and the few Swahili words
he knew, Ellegala bought the wire saw for about $15 in
Tanzanian shillings. He thanked the amused farmer and
headed back to the hospital, where one of his patients had a
severe head injury and needed a craniotomy soon.
Ellegala has dark eyebrows and a sharp nose that gives
him the focused a look of an eagle. His shaved head is a convenient teaching aid for a neurosurgeon, and he points to it
often when describing a particular procedure.
He was born in Sri Lanka but moved with his family to
South Dakota when he was five. He did his neurosurgeon
residency at the University of Virginia, and in late 2005
capped 14 years of medical training with a grueling vascular
neurosurgery fellowship at Harvard’s Brigham and Women’s
Hospital. But before starting his new job as director of
neurotrauma at Oregon Health and Science University, he
decided to take a six-month working vacation in Africa to
clear his head.
He followed a girlfriend at the time to Haydom,
Tanzania, where she planned to volunteer in the village’s
hospital. It was a strange place to take a vacation. Haydom
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sits on a mile-high plateau overlooking the Great Rift Valley,
home of the Hadza, one of few remaining hunter-gatherer
tribes left on earth.
Lutheran missionaries founded a hospital there in the
1950s when the area was filled with zebras, giraffes and
elephants. Its first patients were four men bitten by leopards. Over the decades, a village of 20,000 people sprung
up around the hospital’s gates. And, as Ellegala filled his
lungs with air full of wood smoke and dust, he felt a sense of
peace, “as if I had come home,” he recalled later.
But he was overwhelmed by what he saw in the village’s
hospital. Rain had been scarce for two years, and the wards
were filled with patients suffering from end-stage malnutrition. Many patients also had hydrocephalus, brain tumors and
traumatic brain injuries and were likely to die without surgery.
But he knew that doing brain surgery in the hospital
would be nothing like what he experienced at the University
of Virginia and Harvard. The hospital in Haydom lacked
brain shunts and other basic surgical tools and equipment.
Patients were ventilated by hand, and when an operation
ended, family members sometimes took over the patient
care duties, occasionally falling asleep.
In fact, neurosurgery remains largely a foreign concept in Tanzania and other developing countries in Africa.
Tanzania has only three native-born neurosurgeons for its
entire population of 40 million people. (The United States
has roughly 3,500.) Because of the lack of neurosurgery
expertise, thousands of people with easily treatable brain
diseases and conditions die every year.
The farmer who needed the craniotomy would become
another casualty of this shortage of expertise and equipment if Ellegala didn’t improvise. When he returned to
the hospital, he handed the wire saw—three thin strands
twisted around each other to create a jagged cutting edge—
to a staffer to sterilize it. He donned a camper’s headlamp
because the operating room’s lighting wasn’t bright enough.
Using a medical hand drill, he drilled two holes into the
patient’s head, inserted one end of the saw into a hole, drew
it through to the other and began
cutting. After he removed the skull,
he stopped the bleeding. “The word
went throughout the hospital,” said
Emmanuel Mighay, the nurse in
charge: “We have a neurosurgeon!”
During other operations over the
next few weeks, Ellegala used duct
tape to hold appliances together, cut
IV tubes into pieces to use as shunts
and prowled through the hospital’s
garage for metal scraps to fuse
patients’ spines.
He saved one patient’s life after
another, did what he came to do. Or
had he? A question lingered in his
mind amid the sweat and metallic
odor of blood in the hospital’s wards:
Who would take care of all these
patients when he left?
Many medical missions
Ellegala isn’t the only one asking
these questions. Every year, thousands of doctors travel to povertyriddled countries to treat patients,
sometimes fitting in a safari or beach
trip in the process.
Today, an estimated 500 groups
around the world run upwards of
6,000 short-term medical missions a
year.1 But Ellegala and some researchers and nonprofit leaders argue that
many medical missions perpetuate
a culture of dependence on overseas
doctors that in the long run harms
a developing country’s health care
system. Paraphrasing the ancient
Chinese proverb, Ellegala believes
that it’s better to teach a man to fish
than give him one.
“I think it’s in the nature of doctors to go in and give the patient the
best care possible no matter what,”
Ellegala said. “But this also sends a
message to local doctors and nurses
that they can’t take care of their own.
This has a devastating psychological
impact, and what we end up with is a
system in developing countries that
stops human potential from being
realized, and that’s shameful.”
Brian Mullaney, a marketing
executive, had a similar epiphany in
the late 1990s. At the time, he was a
board member with Operation Smile,
a nonprofit that sends medical teams
to poor countries to treat cleft deformities. During a mission in Vietnam,
he grew frustrated as his team turned
people away. “We would be able to
treat 100 people, but 400 would show
up, including some who had put their
children on their backs and hiked a
week to get there.”
When Mullaney returned from
the Vietnam mission, he asked his
board to shift Operation Smile’s focus
toward training local doctors. When
the board resisted, he and another
partner quit and formed another nonprofit, Smile Train, to “teach a man
to fish and empower local doctors
in developing countries.” In the past
decade, Smile Train has provided free
training to 60,000 medical professionals in more than 140 countries,
reduced cost-per-surgery by 90 percent, and dollar-per-dollar served 10
times as many children as traditional
mission groups, Mullaney said.
“These local doctors can do
these procedures, sometimes better
than the ones from overseas. We’ve
got to stop giving away handouts. We
have to move away from the colonial
mindset of the white American surgeon stepping off the plane and saying, ‘Hi, I’m here to help.’”
Brain training
Teaching doctors how to fix cleft
deformities is one thing, but brain
surgery?
During his first visit to Tanzania
in 2006, Ellegala took notice of one
of the hospital’s medical officers,
Emmanuel Mayegga, a tall man with
a round face and easy smile. Mayegga
was an “assistant medical officer,” the
Tanzanian equivalent of a physician’s
assistant. Ellegala saw he had a swagger and confident aura that he had
seen in other successful surgeons.
Indeed, Mayegga had already
come far. He was born about eight
miles from Haydom, so poor that his
parents didn’t keep track of his birth
date. (“Maybe 1968?” he would say
years later with a shrug and a smile.)
He grew up in a hut made of sticks
and mud and spent his days chasing monkeys from the family’s small
maize plot.
As he grew older, he made and
sold charcoal to buy his school uniform, and to get to school, he woke at
5 a.m. and ran on narrow roads for two
hours to get there in time. During famines, his family took blood from the
veins of cattle, cooked it until it coagulated and then ate it for dinner. As a
teen, he studied so hard by a kerosene
lamp that he woke the next morning
with his nostrils full of soot.
One morning soon after he
arrived in Haydom, Ellegala pulled
Mayegga aside: “Do you want to learn
brain surgery?”
“I’m not a neurosurgeon,”
Mayegga responded.
“You need to learn. What will happen when I’m gone. Think about it.”
Mayegga eventually agreed,
though at first he feared he might get
in trouble because he didn’t have a
medical degree. Ellegala told him not
to worry, that he would watch him
and step in if any problems cropped
up. “It was important to help him
expand the idea of what he thought
he could do. It’s something you have
to do with all medical students.”
Ellegala felt it also was critical to
change the perceptions of the hospital’s visiting doctors. The day before
one training session, Ellegala told
Mayegga the questions he would ask
and gave him the answers. The next
day, Ellegala fired off his questions,
starting with the Western medical
students. When they came up empty,
he turned to Mayegga who responded
with ease.
“The overseas doctors all looked
at him differently after that,” Ellegala
said. “I knew Mayegga would master
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Dr. Dilan Ellegala assists Dr. Emmanuel Nuwas in Haydom Lutheran Hospital's Spartan operating room last spring.
To reach villagers, Haydom Lutheran Hospital sends medical teams deep into the bush to vaccinate children and provide prenatal
counseling.
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Dr. Dilan Ellegala, a neurosurgeon from the Medical University of South Carolina, greets Dr. Emmanual Nuwas, a Tanzanian doctor
at Haydom Lutheran Hospital, last spring. Dr. Nuwas learned brain surgery techniques from Ellegala's first student, Emmanuel
Mayegga.
Coffin-makers line the road to Bugando Hospital in Mwanza, one of several hospitals where doctors with Madaktari are training
Tanzanians to do brain surgery and other medical specialties.
Photos by Tony Barteleme
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the material, but it was important to
get everyone on an equal footing.”
Ellegala started by teaching
Mayegga to organize trays of tools,
then had him assist in several operations. At one point, Ellegala asked
him to touch the brain. “It was really
astonishing,” Mayegga said. “It was
like porridge, pulsating and soft.”
A month after he began training Mayegga, Ellegala told him to
take the lead to insert a brain shunt.
It was a big day in the hospital, and
nurses and other members of the
hospital staff gathered around the
operating room. As Mayegga finished,
Ellegala stepped away and clapped his
hands for effect. “You’ve got yourself
a neurosurgeon now! I’m leaving!”
African wedding
When Ellegala returned to
the United States later in 2006, he
formed a not-for-profit organization
to train Tanzanian doctors and medical clinicians to do basic brain surgery, eventually naming it Madaktari
Africa, plural in Swahili for doctor.
Top neurosurgeons from Harvard,
Duke, and six other noted teaching
hospitals in America and Europe
signed up with his group. At the same
time, he took over as director of
neurotrauma at Oregon Health and
Science University in Portland and
was considered a rising star.
But his supervisor in Oregon
grew concerned about his focus on
Africa, and as Ellegala made plans
to return to Tanzania, he called
him into his office and ordered him
to cancel the trip. “He wanted me
to focus on my work in Portland.”
Furious, Ellegala quit on the spot,
putting his medical career in limbo
but feeling liberated all the same. “I
was following my passion.”
This second trip was particularly
important because two graduate students were studying how Mayegga’s
patients had fared. If they weren’t
doing well, Ellegala’s training experi-
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ment was a bust. The graduate students sent Ellegala an e-mail with
preliminary numbers on mortality, and
at first glance, Mayegga’s patients had
higher rates of mortality.
But when Ellegala returned to
Haydom and analyzed the graduate
students’ work, he noticed that some
patients with the makeshift IV shunts
had developed infections. Factor out
these shunt cases, and Mayegga’s
mortality and complication rates
were no worse than his or in a typical
African hospital with trained MDs.
During this trip, Ellegala also met
a Dutch pediatrician, Carin Hoek, who
planned to stay at the hospital for two
or three years. Hoek liked how Ellegala
handled other overseas doctors, how
during the morning meetings, he
asked them to sit in the back and the
Tanzanians in the front, and how he
called the Tanzanian medical officers
“doctor,” even though they didn’t have
medical degrees.
“The Tanzanians walked a little
taller because of him,” she said. The
two fell in love and were married on
the village’s airstrip, not far from
where Ellegala bought the $15 wire
saw for that first craniotomy.
About 5,000 villagers showed
up for the wedding: Tongue-clicking
Hadza; Datoga people with their
bright red cloths and tattooed faces;
Carin’s tall, pale white family members from Holland; Dilan’s brownskinned family from America by way
of Sri Lanka. Mayegga was Ellegala’s
best man.
Five goats were slaughtered and
roasted on spits. Mighay, the hospital’s nurse in charge, said it was the
biggest event in the village’s history.
People appreciated the work Ellegala
and Hoek were doing at the hospital
and how they tried to become part of
the village by eating their food and
speaking their language.
“We adopted them,” he said.
And when your children get married,
“you go to the wedding.”
Teach forward
Ellegala and Hoek later returned
to the United States, where Ellegala
took a position with the Medical
University of South Carolina in
Charleston. Leaders at the medical
university wanted him to set up a
cerebrovascular team and work on
global health issues, though like their
counterparts in Oregon, they were
nervous at first that he might be
spread too thin.
“When I first heard his story, I
thought, wow this is amazing,” said
Ray Greenberg, MUSC’s president.
“But you have to remember that he
is a relatively junior faculty member,
and one of the concerns you always
have when someone is getting started
in a career, especially something as
specialized as neurosurgery, is that
they stay very focused.”
But over time, Greenberg grew
more confident that Ellegala could
take his patients in South Carolina
and continue his work in Tanzania.
“I’m still amazed; I get e-mails from
him in Tanzania about things going
on here in Charleston. It’s as if he has
no downtime, but I guess that’s the
life of a neurosurgeon. They live on
four hours sleep.”
Greenberg and other leaders
at the medical university also saw
an opportunity to parlay Ellegala’s
work into the creation of a new
global health center to coordinate
the institution’s growing international research and clinical programs.
Ellegala was named the center’s
director. “I don’t know of any other
global health program that has this
‘teach forward’ concept as its guiding
value,” Ellegala said.
The train-versus-treat model is
likely to remain controversial in some
quarters, though. The Western model
of training neurosurgeons typically
requires 12 years of medical training or more, and some physicians
question whether it’s ethical to relax
these standards in developing coun-
tries. Roger Hartl, MD, chief of spinal
surgery at Weill Cornell Medical
College, has volunteered in Tanzania
for several years and has had heated
arguments with colleagues about the
issue.
“The question is: Why should you
have different standards in Africa than
here, and isn’t that unethical?’” Hartl
takes the opposite view: Superimposing
American standards on a developing
country isn’t practical, while teaching
life-saving neurosurgery procedures is
an effective approach that saves lives.
“People are dying in Africa, so in my
opinion, it would be unethical not to do
it,” he said.
Meanwhile, under Madaktari
Africa’s umbrella, more than 500
people from across the United States
have traveled to Tanzania to train
local health care workers there. The
group has forged close ties with
Tanzania’s leaders.
In fact, on a trip this spring,
Ellegala and Sunil Patel, MD, clinical chair of the Medical University
of South Carolina neurosciences
department, found themselves in the
lobby of a hotel in Dar es Salaam, the
country’s capital, holding CT scans
of a Tanzanian doctor who feared he
had an aneurysm. The physician also
happened to be the personal doctor
for the president of Tanzania.
Ellegala and Patel agreed that
the doctor needed an angiogram, but
the nearest hospital with the proper
equipment was in Kenya. As Ellegala
made arrangements to escort the
doctor to Kenya, his cell phone rang.
It was Jakaya Kikwete, president of
Tanzania. “Please take care of my
physician,” he told Ellegala.
It was a surreal experience: Two
neurosurgeons from South Carolina
fly to Tanzania to help the country
become less dependent on foreign
doctors, then help the president’s
doctor fly to another country for
tests and treatment.
The incident was symptomatic of
the country’s challenges, but it also
opened a few doors. The doctor’s
angiogram ruled out an aneurysm, and
he’s now working with the Madaktari
Africa group. A week later, Ellegala and
Doyle Word, Madaktari’s executive
director, sat down with Kikwete, the
president, who said he wants to incorporate the training approach in the
country’s long-term plan.
After meeting the Tanzanian
president last spring, Ellegala
flew back to Haydom. By chance,
he bumped into one of his former
patients, the same farmer he had
operated on with the wire saw four
years before.
The farmer said he was in fine
shape, thanked Ellegala for saving
his life, and told him about his sons
and daughters. It was a gratifying
moment, but not as much as his visit
with Emmanuel Mayegga, his first
Tanzanian brain surgery student.
Mayegga was now in medical
school, perhaps one of the few people
in the world who can claim to be a
brain surgeon before becoming an
MD. Ellegala asked how med school
was going, and they talked about how
Mayegga taught another doctor in
Haydom basic brain surgery, and how
that doctor is now teaching another.
Ellegala sat back and smiled: “It’s
one thing to save someone’s life,” he
said. “But it’s another thing to teach
someone to do that, and then have
them teach another person. That’s
how real change happens.”
Tony Bartelme is an award-winning
journalist and freelance writer based in
Charleston, S.C.
Reference
1.
Health impact assessment and shortterm medical missions: A methods
study to evaluate quality of care. www.
biomedcentral.com/1472-6963/8/121/ Last
accessed July 27, 2010.
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