Maranhao, Brazil March 2013
Brazil Report, 16-25 March 2013
Operation Hernia Team: Andrew Kingsnorth, Todd Heniford, Shambhu Yadav, James Brewer, Heidi Miller & Lorenzo Dimpel (anaesthetist). Brazilian coordinators: Flavio Malcher, Luis Soares.
Brazil is the engine of South America. A vast country with 200 million population, bordering all the other South American countries except Ecuador and Chile, and with extensive natural resources and protected habitats. Its topographical diversity includes not only the Amazon, the largest river in the world by volume, but also hills, mountains, plains, highlands and scrubland. Brazil has a highly advanced technological industry concentrated in Sao Paolo, manufactures & exports cars and aeroplanes, and is due to take delivery of a French nuclear submarine in 2015. A two million kilometre road system includes 184,000 of paved roads. Statistics for the various ethnic groups indicate that 48% are classified as white, 43% brown (multi-ethnic, or pardo), 8% black and 0.4% Ameri-Indian. These limited facts give a mere glimpse into the amazing cultural, scenic and human elements that make a trip to Brazil a thrilling experience.
Our destination was Maranhao State in the north east. It is the second poorest state in Brazil (after Amazonia) with 24% illiteracy and the highest levels of inequality. It features the spectacular sand-dunes of Lencois (Lencois Maranhenses National Park) and the Parnaiba river delta with stunning lagoons, deserted islands and beaches. The northeastern part of the state is heavily forested and is the eastern extension of the tropical moist forests of Amazonia.
From Rio de Janeiro we flew into the San Luis, the State capital of Maranhao, just 3 degrees south of the equator with a tropical monsoon climate, and a population of one million. The city is situated on an estuary of three rivers and has a vast deep water seaport, and the best preserved historical city centre of colonial Portuguese architecture of all Latin America. On account of its striking architecture it is known as “The Tiles City”.
In the last decade significant progress has been made to provide public services to deprived regions in Brazil. In Maranhao two recently built modern highways (BR-010, BR320) criss-cross the State, new schools have been constructed and over 30 new hospitals with approximately 50 beds are being built. Presently, the government is having difficulty in recruiting trained doctors to staff the hospitals in these remote areas. Our first destination was to one of these hospitals in the town of Coroata (population about 50,000), where we travelled overnight by road on a four and a half journey from San Luis to arrive in darkness, but ready for the first days work.
The home team was extremely well-organised. Cases had been prepared and worked up to include not only straightforward inguinal hernias, which we used to teach the local surgeons and residents, but also children and several incisional hernias. Our programme had been supported by the Minister of Health for the State and extra staff had been drafted in, including a locum anaesthetist from Rio who was able to handle several simultaneous spinal anaesthetics, and intravenous general anaesthetics, so that 21 cases were achieved on the first day.
The town’s hotel was situated just behind and over a petrol station. Early morning breakfast on the verandah of the hotel afforded exciting views of the town as it awoke amidst the noise of goats, motor cycles and mule-drawn carts going about their daily business. On the second day we worked until 9PM to complete another 19 cases and then set off for another night drive back to San Luis arriving at 3AM after a splendid midnight feast at a truck stop in Mirando do Norte
After this rather exhausting start to the mission, the next day consisted of a tour of the Old City, a traditional business lunch at a Senac restaurant, and in the evening a tour of the flood-lit city, the presidential palace and a visit to the Sarney museum of fine art, followed by a buffet dinner hosted by the State Minister of Health.
During the next two days Flavio had organised a Hernia Congress followed by a hands-on workshop in Hospital Tarquinio Lopes Filho to teach complex hernia surgery to consultant surgeons. Both days were very interactive. More than 100 surgeons attended. Each Operation Hernia member gave at least one lecture, and we demonstrated several complex techniques in the operating theatres. The dinner on the night after the congress took place in the beach restaurant of Cabana Del Sol where Lorenzo’s birthday was celebrated by a barber shop quartet (actually the waiters)!
The next day we headed for the second hospital in the town of Barrierinhas, a four hour drive to the east of San Luis. Here we had the luxury of staying in a beach hotel and took a trip up the Parnaiba river to see the dunes of Lencois. The operating consisted of two long days with four operating theatres active to complete another 50 cases. The support from the Brazilian team was amazing, with constant refreshments, and even time to celebrate another birthday- red pixie hats were donned in the operating theatre, balloons strewn around the coffee room before the a cake was cut and more songs sung!
This was a very well-structured and advanced mission which will be repeated in another region of Brazil in 2014