Day 3: Dakar
It’s Tuesday. The cases for today include two children with ambiguous genitalia, which means their gender is indeterminate. In the States, there is every effort to determine a gender within days if not hours, and sometimes the diagnosis is made prenatally. These children are 5 months and 4 years old. This is not unusual in Africa. Most children are born in a village by a midwife with obviously little understanding of the medical condition. It is difficult to know what happens after that, how a gender is determined or by whom before the child is taken to a doctor. So when these children first present to a doctor, the family will present the child as either a boy or girl. The most common type of condition that results in indeterminate gender is one that is rarely seen in Africa because most babies with it perish within the first few weeks of life. (This is not the case in the United States, where these children do fine with a simple and inexpensive hormonal treatment.) The other causes of intersex are relatively rare and normally require an extensive endocrine and genetic workup. Unfortunately this is not possible in Senegal or most of sub-saharan Africa.
We had bad news this morning, which was that the biggest case later in the week had to cancel because the family could not afford the hospital charge of $1,200. This 6-year-old boy has bladder exstrophy, one of the most serious of congenital malformations where the open bladder and urethra are exposed, herniating through the abdominal wall. In addition, there are significant external genital, lower abdominal musculature and pelvic abnormalities. These kids are incontinent of urine. Reconstruction is very complicated. While there is no charge for the surgery itself, the costs add up from all the other items that make up a hospital bill. We bring almost all the medications, instruments, and disposables with us, provided by the NGO (five large bins worth!) so we don’t use the hospital’s resources.
Once I heard the news, I relayed it to the team and everyone said they would be happy to donate to do the surgery. There was no hesitation. I was really impressed that everyone had made not only a connection with this child, but all the children I think. The only problem was that the family had already left to go back to their village.
Today, we did six surgeries, most fairly complex. Total for two days is 14; the ward is starting to fill up.
Fran Schneck, MD