Team Leaders: Andrew Kingsnorth & Etienne Steiner.

Where is Moldova? Why Moldova? During our preparations each time that I began to introduce the topic of our proposed mission, these two questions dominated the discussion. Imagine a small land-locked country, aligned to the East by a sliver of land which is claimed by its breakaway neighbour Transdniestra (which itself is infiltrated by Russian ‘advisors’), to the West by its sister country Romania, and to the North, East and South by its big brother Ukraine – then you will have some idea as to why Moldova has an identity problem. Stalin isolated the country further by redrawing boundaries to the South, cutting Moldova off from the Black Sea and even the Danube river except for 480 metres of access at the Giurgiulesti terminal which is suitable for only small vessels.

At a Hernia Congress in Paris in the summer of 2010, I was delivering a lecture about Operation Hernia missions to serve the underprivileged in Africa and the use of ‘mosquito net mesh’ for hernia repair. After the talk Dr Steiner stood up boldly and asked me if I realised that levels of poverty seen in African also existed in Europe (at the time I was the President of the European Hernia Society [EHS]). He then invited Operation Hernia and the EHS to organise a mission to Soroca (the birth-place of his parents) in the north of Moldova under his guidance. I agreed – and thus Moldova became the first European country to be taught to use Affordable Indian Hernia Mesh, at virtually no cost for the mesh material. Lichtenstein hernia repair or incisional hernia repair with mesh would otherwise not have been possible in a country with a populationof 3.5m, which has the lowest income per capita in Europe ($1800), and where in 2005 20% of people lived in absolute poverty (less than $2.15/day). In terms of human development Moldova is rated as ‘medium’, being ranked as 111th out of 177 nations.

Our team consisted of myself and Dr Etienne Steiner, his wife Brigid an ultrasonographer, his anaesthetist Dr Bernard Pelissier, Russian language expert and master hernia surgeon Professor Giorgi Giorgobiani from Georgia, President of the Georgian Hernia Society, Professor Tamaz Gvenitadze, and President of the Ukrainian Hernia Society Professor Yaroslav Feleshtynsky. Preparations had been somewhat erratic, with some uncertainty about our reception at Customs in Chisinau airport loaded with medical supplies on Saturday 9th April . We need not have worried, the bags were stranded at Vienna airport (and delivered the next day).

After formal greetings with our hosts we headed north for 150km along practically deserted, liberally pot-holed roads to Soroca. Winter was lingering, the temperature was just hovering above freezing, making our journey feel even more of an adventure. The terrain was flat with some gentle hills stretching into the distance and the road was never far from the Dniestra river to the east. The soil was yet to burst into life at the beginning of Spring and thus large swathes were exposed and appeared dark and rich, in places covered with extensive vineyards and orchards. The rural communities through which we passed had a Slavic air, populated with small, rustic, single storey cottages with pitched roofs and gables painted in a variety of shades of distinctive greens and blues. Little livestock was visible; although rough horse-drawn farmcarts were a relatively common sight. That evening we were treated to a fabulous welcome Dinner by the Medical Director of the Soroca District hospital ? and each night thereafter another Dinner was hosted in a different venue, so that we became quite familiar with excellent Moldovan wines, vodka, customs and speeches .

The next day, Sunday 10th April was a day for orientation, rest and relaxation. We wandered around the town square with its unreconstructed Soviet-style monuments (still with intact hammer-and-sickle) , sparsely stocked shops, and local folk shopping, waiting for busses or just socialising in the bitterly cold wind, sleet and hail. Thick padded felt caps for the men and head-scarves and shawls were the order of the day ? and were our first purchase. We were taken to the Rudi monastery, founded in 1770 and situated in an isolated sylvan setting. It is undergoing reconstruction after lying dormant for many years after destruction during the communist era. The visit was like stepping back into a medieval time of self-sufficiency, living off the soil and religious duty. The winter is survived by eating fruit and vegetables pickled in jars stored underground – just like our great-grandmothers had been accustomed to survive. After a vegan lunch with the abbot we returned to Soroca via a woodcutters lodge where wild boars were raised for hunting and variety of other animals were stocked such as goats, beavers and bees in the summer hives.

The working week lasted from Monday to Thursday and culminated in a meeting with the Deputy Minister of Health in Chisinau on the Friday. We were thanked warmly for our efforts and informed that the Operation Hernia mission was the first humanitarian mission to Moldova. Further visits were encouraged. Our pilot visit had accomplished operations on over 20 patients. A few were simple inguinal hernias which enabled us to teach the local surgeons the Lichtenstein method. The majority were large, incisional hernias which had probably not been offered surgery by the local surgeons because of the known high failure rate with sutured repair. Four of the patients were doctors working in the hospital. Mosquito net mesh was used in all cases. The working conditions were basic. Equipment would not have looked out of place in a medical museum. Instruments were clumsy, blunt and worn. Rags sufficed as drapes.

A tour around the hospital revealed motivated and well-trained staff working with extremely limited resources to the best of their ability. Oxygen was delivered from cylinders, hot water was limited, the only CT scanner was to be found in Chisinau. I was invited to operate on a case of necrotising pancreatitis, and subsequently gave a lecture on management of acute pancreatitis.

It had been a privilege to work with our colleagues in their difficult circumstances. We have a duty to help those in our own backyard. We will go back to Moldova. Join me!

Andrew Kingsnorth

The Moldovan surgeons that made our trip possible were: Angela Rusnac (Medical Director of the Soroca District Hospital), Valeriu Petrovici (Vice-Medical Director of the Soroca District Hospital), Veaceslav Costin (Head of Department of Surgery), Vasile Voloceai (Surgeon), Alexandru Samsonov (Surgeon), Serghei Manchevici (Urologist), Veaceslav Neamtu (Head of Department of Anaesthesia).