The Peter Attia Drive - #40 - Tom Catena, M.D.： The world's most important doctor – to nearly a million patients – saving countless lives in the war-torn and remote villages of Sudan

00:00:00.000 Hey everyone, welcome to the Peter Atiyah drive. I'm your host, Peter Atiyah. The drive

00:00:10.880 is a result of my hunger for optimizing performance, health, longevity, critical thinking, along

00:00:15.940 with a few other obsessions along the way. I've spent the last several years working

00:00:19.660 with some of the most successful top performing individuals in the world. And this podcast

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00:00:28.360 more fulfilling life. If you enjoy this podcast, you can find more information on today's episode

00:00:33.000 and other topics at peteratiyahmd.com. Hey everybody, welcome to this week's episode

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00:04:05.320 find value in the content I produce, please consider supporting us directly by signing up for a

00:04:11.020 monthly subscription. My guest this week is Dr. Tom Katana. Now I want to preface this by saying

00:04:16.640 something that, you know, on the one hand is a little bit embarrassing to admit, but I think it

00:04:20.100 also speaks to sort of the significance of Tom. I've been very privileged over my life to have met

00:04:25.700 many quote unquote important people, people who are very rich or people who are very famous or people

00:04:30.260 who have accomplished great things athletically or otherwise. For whatever reason, I've never been

00:04:35.640 nervous going into the first meeting with somebody who is quote unquote special. Not sure why, maybe

00:04:42.480 just deep down kind of get that we're all kind of the same. And just because one person's smarter or

00:04:47.340 runs faster or, you know, made more money, you know, in the end, it doesn't really matter that much.

00:04:51.600 And we're all the same, but I got to say, I've known about Tom for about three years. We've exchanged

00:04:56.960 emails in the past, but this interview was the first time I met Tom in person. And I only know

00:05:03.540 how to say this just bluntly. It's the first time in my life I've ever been nervous to meet a human

00:05:08.760 being, which of course is ironic when you meet Tom and this will come across in this episode because

00:05:14.300 he is quite simply the most humble human being you could ever meet. But I, I suppose I see in Tom,

00:05:21.600 what I consider to be the greatest of any qualities or characteristics of any human being. And so

00:05:26.280 it, it humbled me and intimidated me to meet him. Since about the year 2000, Tom has been a missionary

00:05:32.680 physician in Africa, initially working in Kenya. And then in about 2008, he moved to a region of

00:05:40.520 South Sudan called the Nuba Hills or Nuba mountains, where he continues to take care of about three

00:05:46.820 quarters of a million people. He's the only physician in the area. And there's a single

00:05:51.960 hospital there that he runs with a, it's hard to describe how few resources he has to run it.

00:05:58.800 And I don't want to get into that because the episode will cover that in detail, but I can only

00:06:02.980 say that it is nothing short of a miracle what he and his very limited staff are able to do.

00:06:09.000 His accolades are so numerous that I don't even think it's worth getting into them. I will say he is

00:06:13.080 the recipient of the Aurora prize for awakening humanity. This is a prize that awards $1 million

00:06:19.400 to the charities of Tom's choice. And needless to say, that is about as high an honor as anybody could

00:06:27.260 receive for the type of work that he does. He's been described by one Muslim man as Jesus Christ,

00:06:34.640 which I think also speaks to the impact that he has had on the community that he serves.

00:06:40.860 Now in this episode, we talk about a lot of things and obviously talking about kind of the

00:06:45.980 unimaginable suffering that he sees and how he himself copes with death and how he himself copes

00:06:52.920 with being in a situation that I don't think any of us can understand. And certainly no physician

00:06:57.640 can understand because none of us really practice medicine alone. And yet in many ways, that's what Tom

00:07:03.080 is doing. We talk about a crisis of purpose. So it's easy, I think, to look at what Tom does and

00:07:09.480 feel sorry for him or feel sorry for the people he serves. But I must admit, I came away from this

00:07:15.020 interview actually feeling more sorry for us. And Tom so eloquently without judgment explains some of

00:07:22.480 the differences between people with all the privilege in the world, like most of us listening

00:07:26.740 to this and the people that he serves and talk about the sense of community that exists in Nuba.

00:07:32.800 And what you start to realize is that the way that we die in this country and the way that we live in

00:07:39.140 this country is so different from the way that people live and die in that part of the world.

00:07:44.860 And it's not just on the obvious things. It's not surprising that people there don't die from

00:07:50.180 complications of type two diabetes, but they die from infectious diseases and trauma.

00:07:54.680 But there's a more subtle point here, which is we, in many ways, are prisoners of our own world,

00:08:03.100 our own minds, our own possessions, these things. And to see the way Tom describes the freedom from

00:08:08.020 that, it gives me hope that if someone like me can realign the way I think about these things that

00:08:14.100 in many ways enslave me, perhaps I could even capture a fraction of the satisfaction, the happiness,

00:08:20.040 the purpose that someone like Tom has. Tom's work is so important to me. And I want to be sure that

00:08:24.840 anybody listening to this can get access to all of the notes we're going to put together on this.

00:08:30.580 And so normally our show notes are only available to subscribers, but for this episode, they're

00:08:35.500 available to everyone. I don't want anyone to not be able to see this under any circumstance. So I

00:08:40.460 really do recommend that everybody take a moment and look at some of the videos that we link to.

00:08:44.840 If you don't make time for that, but you are still sort of interested, I can't recommend enough that

00:08:49.580 you watch the documentary, The Heart of Nuba, which is based on the work that Tom does there.

00:08:55.040 I think you'll come away from this episode understanding why I could feel so nervous

00:08:59.460 meeting Tom for the first time. And so without further delay, please enjoy my conversation with

00:09:04.480 Dr. Tom Katana. Hey, Tom, thank you so much for making the time to come over here today.

00:09:12.100 Sure, Peter. My pleasure. Glad to be here.

00:09:13.700 Yeah, there are a few people that would be giving up more that they deem important work than you. So I

00:09:18.600 know your time is tight. How often do you come to the US?

00:09:22.280 Well, this is my first time out in more than three years. So last time I was in the US was

00:09:27.320 November 2015. I was here for about five days. I was in my hometown of Amsterdam, New York.

00:09:33.420 And it wasn't much of a trip. You asked about malaria. I was sick as a dog with malaria. So I was

00:09:37.360 in bed with malaria the whole time. The last day I felt a bit better, just in time to go back to

00:09:41.960 Africa. So it's been a long time since I've been back.

00:09:45.100 You grew up in upstate New York. Your pedigree is like the star, right? You went to Brown,

00:09:50.340 you played football, you went to Duke Medical School. At what point did you realize you wanted

00:09:56.860 to do something a little different vis-a-vis working outside of the US, for example?

00:10:01.960 This desire to do this kind of work really was planted when I was in college, when I was at Brown.

00:10:07.480 And I always wanted to do some kind of mission work. And that term has several connotations,

00:10:12.000 but I wanted to be a missionary, whatever that meant. I wasn't quite sure what it meant at the

00:10:15.620 time, but I just had this idea. I wanted to work in other cultures, in a society, do mission work.

00:10:20.240 But I was, as you, a mechanical engineering major. And that didn't really fit with

00:10:24.000 doing mission work. This was in the 1980s. And most of the jobs then were in the defense industry.

00:10:31.160 They were good jobs, but I didn't really want to do that kind of work.

00:10:34.060 So I graduated college and kind of floating around for a while, I was offered a job by GE,

00:10:37.940 working with their kind of nuclear submarine program. It would have been a really good job,

00:10:42.000 but I just wasn't interested in that kind of work. And I remember one day, it was kind of odd. I was

00:10:47.100 coming back from my great aunt's funeral. I was with my brother Felix, and the idea just kind of

00:10:53.640 popped in my head. I should go into medicine because I could, if I do that, then I could do

00:10:57.780 mission work. And, you know, I like the sciences. I could stay in the sciences, do mission work,

00:11:01.720 help people, just kind of that general idea. And ended up going to medical school and

00:11:06.520 kind of kept that desired admission work. And that kind of evolved into wanting to work in Africa,

00:11:12.120 work with people that don't have a lot of options for healthcare. You know, 15 years later,

00:11:16.640 ended up in Sudan.

00:11:17.740 So you started out in Kenya, is that right?

00:11:19.300 Right. So, you know, when I finished at medical school, then I did five years in the U.S. Navy.

00:11:24.860 I did a Navy scholarship for medical school. So I had to pay that time back. Then went to my

00:11:29.180 residency. I did family practice in Terre Haute, Indiana. Now it was time to kind of be free and do what I

00:11:35.180 want. So I thought, well, let me just go and let me do this thing that's been kind of an itch for so

00:11:39.000 many years. So I teamed up with the Catholic Medical Mission Board and they said, okay,

00:11:43.880 we have an opening in Kenya at this mission hospital. Maybe go there. I said, okay, I'll go

00:11:48.200 for one year. I'll see how it goes. If I like it, maybe I'll stay longer. Otherwise, I'll just come

00:11:52.240 back and start a practice. And went down to Kenya and fell in love with the place and decided to stay.

00:11:57.680 What was the first thing that you remember when you got there as far as how different this was from

00:12:01.940 the way you had trained? Because you did your residency in the United States, right?

00:12:04.960 Right. I did my residency in the U.S. and I did family practice. And the program I went to was

00:12:09.700 kind of geared towards rural health. So I thought, okay, if I want to do admission medicine, I got to

00:12:15.060 be doing more than just kind of outpatient office stuff. I need to do something with a little more

00:12:18.620 meat to it. So, you know, a little bit of obstetrics. We did a bit of surgery, mostly just C-sections.

00:12:25.200 So when I first got there, I think what struck me was just the volume of patients. I mean,

00:12:30.380 I was a resident and, you know, on clinic days, we'd see like five or six patients, you know,

00:12:35.540 and get all every little detail down in each one. And now, I mean, in this rural hospital in Kenya,

00:12:41.080 and I mean, you're seeing 50, 60 patients, you know, huge numbers. The clinic, the wards are full.

00:12:47.500 You go do a ward round. I was in charge of the adult ward. And there were, you know, at the time,

00:12:52.800 I thought it was a huge, I mean, like 30, 40 patients there. And I was responsible for all them.

00:12:56.160 It's just this year volume of patients you had to go through every day in the variety of diseases.

00:13:01.600 So not only the tropical stuff, which I, I didn't know much about. I mean, here's malaria, TB,

00:13:07.020 Leishmaniasis, all this kind of stuff I had no idea about. I had to learn about when I was there,

00:13:11.940 you know, learned to, thank God, some couple more senior doctors there that I could learn from,

00:13:16.180 but just a volume of patients and the variety of diseases you've had to face.

00:13:19.960 So what year did you get to Kenya?

00:13:21.480 I arrived in Kenya, uh, January 17th, 2000.

00:13:25.660 That's so interesting. I, I arrived at NIH when I was in medical school on January 17th, 2000.

00:13:32.020 No way.

00:13:32.680 Yeah. Yeah. That was, uh, which was NIH being at NIH while I was in medical school was one of the

00:13:38.020 sort of more formative parts of my experience. So how long before you went to Sudan and what

00:13:43.640 led to that transition? I'm trying to think of my geography, right? Kenya is South of Sudan,

00:13:48.840 correct? Sort of South East of Sudan. South, right. South and a bit East. Exactly.

00:13:53.300 Okay. And, and much more stable, right? I mean, Kenya is a relatively safe place to be.

00:13:58.200 Right.

00:13:59.360 Sudan is not right. It's divided into these provinces. And my, the one that got all the

00:14:04.760 attention was Darfur, which is the furthest West. Correct. Exactly.

00:14:08.340 And that basically was a war zone. Right. I mean, a killing field, right? So Bashar was 0.80

00:14:13.280 basically killing his own people there, wasn't he? Right. So to go from Kenya to Sudan, what were 0.94

00:14:18.960 you thinking? I think maybe the modus operandi in my life was always looking for what's the

00:14:23.920 opposite of greener pastures. I'm looking for browner pastures. When I was there in Kenya, 1.00

00:14:28.840 this was, uh, as I said, I got there in January 2000, the civil war in Sudan was really raging at

00:14:34.000 that time. And I was in Kenya learning a ton of stuff, really enjoyed the work. And I kept hearing

00:14:39.340 about Sudan, the civil war in Sudan and how it's so terrible. And the conditions there were, were

00:14:44.960 terrible in the, you know, there's such a lack of, of any kind of health services. I thought, man,

00:14:49.280 I'd really like to get involved in that, in that struggle just to go and work with the, help the

00:14:54.280 people there just because it was so health facilities were so limited. I thought that's

00:14:57.700 kind of the place I want to go to. So I had this general thought, this is 2001, 2002. Now this

00:15:03.100 was in June of 2002. I left my first posting, which was in a rural place called Mutomo. I was there

00:15:08.680 for two and a half years. I went up to Northern Kenya, a place called Turkana. I was at the

00:15:12.700 Kakuma Mission Hospital, which is up in the Turkana desert near the refugee camp. A woman

00:15:17.840 named Deidre Byrne. So Didi was there, I think her first time up in Turkana. And I was talking

00:15:22.760 to her, she's an American, she was doing a kind of short term mission there. She's a surgeon

00:15:26.860 and a family practice doctor. She did both, but was doing primarily surgery. And she said,

00:15:30.720 look, there's a bishop I know. It was Bishop Makrim Gassiz, who was building a hospital in Sudan.

00:15:34.400 I think he might be interested in going there. And I said, whoa, that's exactly what I've been

00:15:38.060 thinking about doing for the past couple of years. It's back in 2002. So she said, look,

00:15:42.460 he's got an office in Nairobi. He's living there in exile. Maybe you can make contact with his office

00:15:46.420 because I was due to go to Nairobi and start working there. Anyway, to make a long story short,

00:15:50.200 I ended up working in Nairobi, linked up with his office. And we started kind of making plans for

00:15:55.740 the hospital and how would it run, the staff we would need, all that kind of stuff. And then it took

00:16:00.400 six years, but six years later.

00:16:01.780 Who funded the hospital?

00:16:02.900 It was all funded through the Catholic Diocese.

00:16:05.080 I see.

00:16:05.480 So it was the Catholic Diocese of El Abade. Bishop Gassiz was the bishop of the El Abade

00:16:08.720 Diocese. And he and his office were able to get funding through the church mechanism to fund

00:16:13.840 the hospital.

00:16:14.700 So now it's 08, 09, and that's when you go.

00:16:18.480 Right. So I went to Nuba Mountains, arrived there March 10th, 2008. It was the day I landed

00:16:24.120 there in Nuba Mountains.

00:16:25.180 Tell the listener a little bit about where Nuba is. I mean, I know it's in the southern part

00:16:29.320 of Sudan. It's to the east of Darfur, but it's a pretty rugged country, isn't it?

00:16:35.140 Right. So the Nuba Mountains is probably one of the most remote places in the world. It's a region

00:16:41.100 which for many years, and Sudan was kind of kept off limits before when Sudan was kind of a colony,

00:16:47.240 it was called the Anglo-Egyptian condominium, partly kind of administered by UK and by Britain

00:16:52.900 by Egypt. They decided to kind of keep the Nuba separate. They said, look, these people have a

00:16:58.120 unique culture and are unique people. They didn't really allow a lot of open tourism or people to

00:17:03.500 go in there. It was kind of a closed area. So they really kind of have maintained this separateness

00:17:08.620 and this isolation over centuries. It's difficult to reach. It's semi-arid. It's got this thing

00:17:15.520 rainy season. It's got a dry season, but more hills. They aren't real high mountains, but sort of

00:17:19.660 you know, 3,000 foot hills, that kind of range. My history is not great, but I sort of remember

00:17:24.720 that basically Sudan was granted sort of, I forget the term, but when you're given your independence,

00:17:30.720 for lack of a better word, that would have been in the 50s, right? Right. 56. Okay. And then what was

00:17:36.380 the religious sort of map of Sudan and did that figure into how it was divided? And was that partly

00:17:42.340 why Nuba was, was it religiously diverse? Was it mostly Muslim, mostly Christian? Yeah. You know,

00:17:48.960 Sudan is a, it's a very interesting place. So you've got, it was one country up until 2011 when

00:17:53.520 they divided the North and South. Now the religious makeup is in the North. So North of Nuba mountains, 0.97

00:17:59.260 it's primarily Muslim, almost all Muslim in the North. The South is primarily Christian. Nuba is 1.00

00:18:04.320 right in the middle. And interestingly enough, Nuba is a mix. It's about, let's say, half Christian,

00:18:10.480 half Muslim. And everybody's an animist, but half are Christian, half are Muslim. And the Nuba are unique.

00:18:16.180 I think a unique tribe in the world where you have families which are mixed. You have Nuba,

00:18:22.580 you have Nuba Muslims and Nuba Christians, and there's no conflict amongst them. For instance,

00:18:27.960 my wife is a Nuba. Her father, both her parents, when they were born, they were just followed the 0.89

00:18:33.120 traditional religions. The Christianity and Islam had not been introduced yet to the area. Now,

00:18:37.680 as they got older, her father became Muslim, mother became Christian, they married. Her father's a

00:18:42.900 polygamist. So two wives, both wives are Christian. Their oldest son is a Muslim. The rest of the 0.93

00:18:47.140 children are Christian. And nobody's really bothered by this. That's in Nuba. Now the country 1.00

00:18:52.240 itself, this difference between Muslim and Christian was really a big issue in the previous civil war.

00:18:59.740 You know, we had sort of the Southern African people that were mostly Christian against the

00:19:03.720 Northern Arab people that were all Muslim fighting each other. And there was very much a religious 0.99

00:19:08.080 context to that previous civil war. And also in Nuba mountains, the Nuba mountains, the Nuba people

00:19:13.660 joined the Southerners. They're all African in Nuba. They joined the Southerners fighting the Northern 1.00

00:19:18.120 sort of Arab Muslim people in the North. And in the 1990s, there was a jihad against the Nuba people.

00:19:24.980 So there was a real genocide in the 1990s against the Nuba.

00:19:28.380 Who issued this jihad?

00:19:29.620 The ideologue behind this is a guy who just died last year. His name is Hassan al-Tarabi.

00:19:35.900 And Tarabi was a member of the Muslim Brotherhood. Very bright guy. Went to Sorbonne in Paris and was

00:19:42.220 kind of intellectual, but really kind of an evil genius, if I can use that word. He was a real

00:19:48.000 ideologue in the Muslim Brotherhood. And he managed to convince some of the imams in the North

00:19:53.600 to sign off a fatwa to allow jihad against the Nuba. And many imams rejected it. They said,

00:19:59.060 you can't do that. 0.99

00:20:00.680 Even though he'd be killing Muslims within Nuba. 0.99

00:20:03.000 Right. Exactly. His response to this was, okay, you can have a jihad because the Christians are 1.00

00:20:07.580 fair game in the jihad. And then the Muslims are apostates from the religion because they 1.00

00:20:12.260 associate with Christians. Some of them eat pork. Some of them drink local beer. They're not real 1.00

00:20:16.840 Muslims. Like this thing with the Nuba are very much communal and to have Muslims and Christians

00:20:21.580 together at functions, it was anathema to him. The fact you could have Christians and Muslims in the 1.00

00:20:27.360 same family was a huge scandal to him. He just couldn't tolerate that kind of stuff. So he said,

00:20:31.940 no, these guys are also fair game because they're not real Muslims. 0.99

00:20:34.260 So what year was that fatwa issued?

00:20:36.180 That was in the, I think in the early nineties, it would have been 93.

00:20:41.040 So Bashir was already in power, right? His coup was like late eighties, right?

00:20:45.560 He took power in 89. And this guy Tarabi helped him in this coup. He was kind of the brains behind

00:20:52.060 the coup. And Tarabi, I mean, he was, you know, he was, he was kind of a power hungry guy. He said,

00:20:56.680 okay, he figured if he helped Bashir get into power, Bashir was a military guy. And he thought,

00:21:01.740 okay, if I help Bashir get into power, I'm much more intelligent than Bashir. I'll just kind of

00:21:05.580 find a way to get rid of him and I'll take over. And Bashir said, look, I'm the one in power. You're not,

00:21:09.580 you're not taking over. So he kind of always kept, uh, Tarabi at a distance. And there are always 0.99

00:21:13.460 these, he would always, he was always throwing Tarabi in prison afterwards because Tarabi started 1.00

00:21:16.340 speaking out against him. So we put him in a quote unquote prison and maybe, you know,

00:21:20.060 some luxury apartment in Khartoum, but they kind of were at odds with each other. But Tarabi was the 0.64

00:21:25.360 ideologue behind a lot of this movement. He's the one that invited Osama bin Laden to Sudan in the

00:21:30.520 early nineties. So bin Laden lived in. When bin Laden was exiled from Saudi Arabia, which was,

00:21:34.480 yeah, in the early two thousands. Right. Well, that was before then he invited, uh, what's his name?

00:21:38.440 He invited bin Laden to Khartoum. So he lived in Sudan for a while. And a lot of, you know,

00:21:43.220 Al Qaeda had a lot of training camps in the desert in the North of Sudan.

00:21:46.680 I had totally forgotten that fact that the chapter of Al Qaeda that I'd sort of forgotten.

00:21:52.080 So you basically have a bunch of incredibly evil people who are deciding to kill their own citizens

00:21:59.020 effectively. Right. You got there in 08, you said, or 09?

00:22:03.720 08. So he arrived March, 2008. So historically that was the interim peace period. So since they

00:22:10.420 got independence in 1956, Sudan has been at civil war, various parts have been at civil war for

00:22:15.860 almost the entire history. That's, that's 60, that's how many years? 62, 63 years. Most of the

00:22:22.260 history they've been at civil war. So this was one of the brief periods. Actually it wasn't even

00:22:26.460 priesthood because Darfur started in 2003. Darfur-y rebels started fighting against the government

00:22:30.860 2003. So this wasn't, the whole country was not a piece of the time, but the big war between the

00:22:35.280 South and North, the peace agreement was signed in 2005. So when we arrived in 2008, the peace

00:22:40.820 agreement was still in effect and there was no active fighting. And then we were kind of waiting

00:22:45.360 for this referendum to take place. Referendum, the way the peace agreement was signed up was

00:22:49.980 Southerners. So South Sudan would have the choice for self-determination and that would be done by 0.98

00:22:56.060 referendum. So the people actually have a vote, straight up vote. If the majority vote to secede,

00:23:00.560 they secede. The majority vote to stay and stay as one country, they stay. Now, 2011,

00:23:05.880 they have the vote and like 99.99% vote to secede from the North. So South Sudan separates.

00:23:12.340 In the peace agreement... I'm sorry, is Nuba considered South or North in this cessation?

00:23:16.700 Right. This is part of the problem because in the peace agreement, Nuba was separate.

00:23:19.620 Okay. And what they said was, okay, South Sudan will have a referendum. The Nuba mountains was not

00:23:23.680 included as part of South Sudan. Nuba and Blue Nile were separate regions. And they said in these two

00:23:29.160 regions, they're called the two areas, they'll have what's called a popular consultation,

00:23:35.020 which was a very vague system where there'd be committees set up. They would go and they would

00:23:40.220 talk to people in the villages and kind of get their opinions on things and see what they wanted

00:23:43.460 to do. If they wanted to separate, stay, it was very vague. And I think it was purposely vague

00:23:48.780 because the government knew it was kind of a bargaining chip for the North to allow South

00:23:54.580 Sudan to have this referendum. They said, okay, because they knew in the end they would keep

00:23:57.700 Nuba mountains because this thing was too vague, you know, and they would be able to manipulate it

00:24:01.420 enough. They'd be able to keep the Nuba on their side. So South Sudan separates. There are elections

00:24:06.640 in Nuba mountains in 2011 in May. The candidate for Bashir's party, of course, wins the governorship in the

00:24:13.020 parliament. Just as a side note, before that election, the guy's name is Ahmed Haroun, who was

00:24:19.400 running against the guy named Abdulaziz. Anyway, Ahmed Haroun was the candidate for Bashir's party,

00:24:24.280 National Congress Party. And before the election, Bashir said, Ahmed Haroun is our candidate and he

00:24:29.540 will win this election, whether by the ballot or by the bullet. So going into it, it doesn't look like

00:24:34.620 it's going to be a free and fair election. Right. And Bashir, at this point, does he already have

00:24:38.900 basically a warrant out for his arrest? Right. So he's got the warrant for his arrest. That was,

00:24:42.420 I think, 2009, I think. Ahmed Haroun also is indicted by the ICC for war crimes. He was one 0.99

00:24:49.220 of the architects of the genocide in Darfur. So Ahmed Haroun, who is our governor, is indicted by

00:24:56.460 the ICC. Bashir is indicted by the ICC. He also was a defense minister, was indicted by the ICC.

00:25:01.300 So Ahmed Haroun wins. They go and say, okay, now our party is there in South Kordofan State in the

00:25:06.140 mountains. There are still SPLA soldiers, like Southern soldiers living in this region. The Northern

00:25:12.100 Army came and said, you know, did a forced disarmament of these SPLA soldiers. And that's

00:25:16.940 when violence broke out. So June, 2011, June 6th, 2011, civil war breaks out in Nuba mountains

00:25:22.140 against the government. Now I've heard you speak about this in the past. It was overnight that most,

00:25:28.900 most of the staff in your hospital left. So prior to that, leading up to that, the referendum and

00:25:35.180 the breakout of war, you've got this three-year period where you're in the hospital, you're

00:25:41.680 working there. As far as Nuba can be tranquil, this is the greatest tranquility you've seen.

00:25:46.340 The staff is what? It's you. It's what else? Right. So at this time, you know, we started the

00:25:51.500 hospital, March 2008. We went there with about eight expatriates, including myself. So I was the only

00:25:56.480 doctor. We had a few nurses, an esthetist, a lab person. We had those eight expatriates. They were 0.92

00:26:03.340 mostly from, they're all from Kenya or Uganda. Those eight expatriates, myself, we had 15 local

00:26:09.680 staff, Nuba. And the Nuba, I think the most educated person had finished primary school.

00:26:16.020 They were not nurses. They were just kind of local people that could read and write a bit

00:26:18.780 of English and they could speak English. So they had to be taught everything. When we first started,

00:26:23.160 they couldn't weigh a patient. They couldn't take a temperature, let alone give an injection or start an

00:26:27.340 IB. Anyway, with time, we got these guys trained up a bit. So they had some pretty good skills.

00:26:33.340 A lot, most of that was done by these expatriate nurses. Now we still kept expatriates, but over 0.86

00:26:38.380 time we added more and more on the job trained people. We kept adding more primary school

00:26:42.840 graduates or eventually we got a few secondary school people, started training them on the job.

00:26:47.940 We didn't have any trained Nuba nurses by the time the war started in 2011. So now war starts June 6,

00:26:55.040 2011. By June 16th, this is 10 days into the fighting. Things are getting pretty hairy. There's a lot of

00:27:00.400 fighting within Nuba, Arab bombardments all the time. And the diocese-

00:27:05.220 And this is all from the north?

00:27:06.560 All from the north, right. Fighting within Nuba Mountains.

00:27:09.500 The resistance is posed by whom? Is it former Southern who have not seceded or are trying to

00:27:16.240 basically, are the North and the South now fighting for Nuba?

00:27:19.240 Right. So what happens is the South Sudan is totally separate, okay? So within Nuba Mountains,

00:27:24.060 you've got a lot of soldiers that were Southern soldiers, SPLA soldiers, a lot of whom were Nuba.

00:27:29.260 Most of them were Nuba, but you also had other Southern tribes in the Nuba Mountains kind of

00:27:33.240 left over from the previous conflict. And they were there in the barracks. So all those kind of trapped

00:27:38.900 SPLA soldiers are fighting the Sudan army. Now they call themselves, instead of SPLA,

00:27:44.580 they're called SPLA North, okay? So from that point forward, these guys are called SPLA North.

00:27:49.980 They have kind of a new identity as a separate military force from the SPLA, which is in South

00:27:54.220 Sudan. So fighting is going on, Arab bombardments. June 16th, the diocese says, look, we're having,

00:27:59.940 we're sending a plane in and this plane is going to come in to evacuate anybody who wants to get out

00:28:05.600 of there, okay?

00:28:06.880 And the plane was going to go to Uganda or to Sudan?

00:28:09.220 The plane was flying into Nuba Mountains.

00:28:11.200 Oh, okay.

00:28:12.060 To pick up whoever wanted to get out and they would get out and leave. Now, this was a bit

00:28:16.680 dicey because at this time there were a few flights coming into Nuba Mountains, mostly

00:28:20.840 getting people out, but they have to change the airstrip. There are a few airstrips around,

00:28:25.600 but they would give the location of the airstrip at the last moment and they would have like

00:28:29.020 a code name for it because if there were a lot of spies around and if the North found out,

00:28:33.360 they would come with their bombers and come and bomb the airstrip. They would try to bomb the

00:28:36.800 plane on the ground or bomb the people that were trying to get in the plane to escape. So all this stuff

00:28:40.740 was top secret. A plane comes in and they said, look, we come in, we land and we're taken

00:28:46.980 off in 10 minutes. You better be at the airstrip waiting, get your butts on the airplane. We 0.96

00:28:51.000 have to be out by in 10 minutes or else these guys will come and bomb.

00:28:53.120 And they do this at night, I'm assuming.

00:28:54.940 No, they did it early, early in the morning because you can't, you know, there's no lights

00:28:58.020 or anything for the planes to land. So it's all just by sight. So they would come early

00:29:02.180 in the morning, land and they would get out. So, you know, all of our expats that were

00:29:07.160 there with us, they had all the knowledge. I mean, our anesthetist, our lab person,

00:29:10.280 pharmacist, the nurses that were warding charges, the ones that were doing most of the work and

00:29:15.260 doing the leadership, they all decided to leave.

00:29:17.740 Now, did you all sit down together and have this sort of heart to heart, which is each of you had

00:29:23.180 to make a very difficult decision, which is you feel committed to this work you're doing,

00:29:26.820 but now your life is at exponentially greater danger.

00:29:30.660 Right. So yeah, we met with everybody. We had a group talk and we met individually and said,

00:29:34.680 look, this plane is coming in. This is the last plane that the diocese can send in. This is it.

00:29:40.100 You know, once, once this plane comes and once it leaves, you might never get out of here,

00:29:44.940 you know, cause you have no idea what's going to happen the next day. You don't know if the,

00:29:48.420 their sitting army is going to overrun us. And this is the last chance. 0.91

00:29:52.040 How did you think about that? I mean, was there a moment when you thought

00:29:55.500 maybe I should leave and go back to Kenya or go to Uganda or go somewhere else? I mean, what,

00:30:03.320 what was that thought process like?

00:30:05.120 Right. So, you know, I was encouraged to leave by some different people. I said, look,

00:30:09.060 why don't you come out? You stay in Kenya for a while. Then when things blow over, 0.86

00:30:12.880 then you can go back when it's safer. I thought, and I thought, geez, you know, first, I mean,

00:30:17.460 you have no idea. This is just total chaos. You have no idea what's going to happen.

00:30:20.280 What I did know is that we were getting people wounded or bowel destruction was ever coming in all the

00:30:25.840 time, you know? So I knew if I leave, it's not like they can go somewhere else. There were no other

00:30:31.380 hospital with surgical capability, okay? There wasn't a single one. There was another small

00:30:35.460 hospital nearby run by a German group that could do some inpatient stuff and outpatient and some

00:30:39.720 minor stuff. But really, if somebody needed a C-section or something more serious, they would just die,

00:30:45.600 okay? And that says nothing of the casualties that are going to start coming in as a result of this

00:30:50.100 attack. Right. So all these people that came in that were wounded would just die a miserable death.

00:30:54.840 And I knew that. So for me, it was a very easy decision. I thought, you know, there's no way

00:30:59.940 I can in good conscience leave this place and go out. It was a very, very stark reality. And to be

00:31:06.460 honest with you, it was not a difficult decision. I think the sisters that were there, the two

00:31:09.780 Kamboni sisters that stayed, the priest that stayed, we all were of the same mind. We all thought the

00:31:14.340 same thing. Let's just stick it out. We're here as missionaries. Let's do what we're supposed to do

00:31:18.720 and take care of the people the best we can and come what may. We have faith in God.

00:31:21.800 We'll see what happens. And it wasn't, you know, we didn't feel like it was some big thing. It was

00:31:26.980 just like, well, no, we can't go. You know, we got, we got stuff to do here. And, and the, you know,

00:31:31.700 the other expats said, look, I've got a family, I've got this, I've got that. And we said, look,

00:31:35.620 we are, we're not going to hold anything against anybody. This has to be a very individual decision.

00:31:39.800 If you guys want to go, we'll find a way to keep going. Don't worry about it. So we want to give

00:31:44.020 them full latitude to leave in peace and not feel they were abandoning people there. So I think

00:31:51.240 everybody's pretty much at peace with the decision. The expats left. And I mean, sure enough, they

00:31:56.520 left, uh, June 16th, the morning of June 16th, they left around six in the morning. They had to

00:32:02.480 get out there early because they had to get the, you know, get this plan and just get out of the

00:32:05.760 place. And we had to keep everything secret. So all of our staff didn't know these guys were

00:32:09.380 leaving. We had to keep it a secret from everybody and lay up and left. And then the staff came to work

00:32:13.840 at seven 30. And so you, you had an anesthesiologist. It was one of the people that left, right?

00:32:19.420 So talk to me about 10 o'clock on that morning, the first time or whenever the first surgical case

00:32:25.520 comes in, who's running anesthesia. That was the biggest problem. So these guys leave around six,

00:32:30.880 eight o'clock casualties start rolling in people that were, there's a, there's a bombing from one of

00:32:35.760 the Sudan air force planes called an Antonoff that has barrel bombs. They bombed in a location near

00:32:39.840 us, maybe an hour, a couple hours away. We hear these in the film, the heart of Nuba,

00:32:45.360 right? Which we'll talk about in a few minutes, but right. So like two hours later,

00:32:49.400 all these mangled bodies start coming. Yeah. Describe what this, I mean, so I did my training

00:32:53.920 in Baltimore. In many ways, trauma was a feature of the training program because if you're training

00:32:59.580 in surgery, you know, one of my mentors said, you know, to be able to train at a place like Hopkins

00:33:04.280 is a great honor because you really get to understand surgical anatomy in trauma and it's

00:33:09.200 penetrating trauma in the United States is mostly gunshot wound and stab wounds. But I have no idea

00:33:14.560 what you were seeing. So what, explain to me what things you actually saw, what types of injuries

00:33:21.940 are you seeing? Right. So this was very start because when Antonoff bombs, there are huge shards

00:33:28.000 of, of metal. I mean, weighing, you know, 10 pounds, I've got a bunch of the scraps. I have them as a

00:33:33.180 souvenir, Mac and Nuba. So imagine a scrap of metal, it weighs 10 pounds, red hot, just going

00:33:39.280 through your body. So it, it slices off legs, slices up arms, cuts through people with just

00:33:45.560 massive tissue loss and massive trauma. So I remember one young lady, she was 16. Her name

00:33:51.720 was Urshalim, which means Jerusalem in the Arabic. And her arm was just totally mangled. I mean,

00:33:57.600 just shattered. She came in, her cousin came in, his hand was, his whole hand was blown off by the

00:34:02.620 Antonoff shrapnel. So these guys both in the amputations, the girl, we did a disarticulation

00:34:08.020 on the shoulders. So we had a couple of our on the job trained nurses there and they had done some, 1.00

00:34:13.760 they'd been taught how to do spinal anesthetic by the anesthetist. So they had some spinals, 0.99

00:34:17.400 they couldn't do GA. For the listener, GA general anesthetic, meaning they couldn't intubate and put the

00:34:21.700 patient fully to sleep. Right. And I, I had never intubated a patient before. I remember when I was in the

00:34:25.740 military, we intubated at intubate goats for as part of our ATLS training, I think, if I remember,

00:34:30.960 but I'd never done it either. It's like, what the heck? So I'm, and I was so afraid. I'm like,

00:34:34.820 God, what do I do with these people? You know? So I remember reading the book. We have a book there,

00:34:38.160 kind of basic anesthesia book. So I bring you through the protocols. Okay. First, give some

00:34:42.000 ketamine, you knock them out with that. They go to sleep, give it a little batropine, you give

00:34:45.900 succinylcholine to paralyze them, intubate, and you give pancoronium. You have a health anesthesia,

00:34:51.960 put the tube in, blah, blah, blah, decide to intubate. I'm like, okay, okay, let's, let's do it.

00:34:55.940 So we took some of these guys back and, you know, I would go and give the drug. I had a nurse there,

00:35:01.320 kind of on child, it's okay, give the ketamine. He would push it in, push the succinylcholine.

00:35:06.680 I would intubate. And I guess I should explain for the person listening to this, because we use these

00:35:11.580 terms so commonly. So intubation is a very important step where if you screw this up, you're going to

00:35:16.960 kill a person. Literally you will kill them, but you have to put a breathing tube into the endotracheal 0.89

00:35:21.960 space. So this is now to allow a machine to breathe for someone while they're under anesthesia. And 0.95

00:35:27.720 we do these things in medical school. We did them in residency. A lot of our critical care training

00:35:33.140 required that. But I have to tell you, and I was not trained as an anesthesiologist, I never

00:35:38.460 intubated somebody without being incredibly nervous. Because it's so easy to put that tube

00:35:44.340 accidentally into the esophagus and you think you're doing it right. And all of a sudden you,

00:35:50.580 you know, you get the tube in, you hook it up to the ventilator, you think everything's going well.

00:35:54.900 And by the time you realize you're providing oxygen to their stomach instead of their lungs,

00:35:59.900 it can be too late. And then of course the panic that ensues is often what kills the patient.

00:36:06.060 Right. Because you're getting, you're getting nervous and then you can't do it. You're starting to

00:36:09.540 shake. You know, the problem is my, like I said before, my training was family practice. I did

00:36:13.360 an internal medicine internship, you know, and they finally practiced. I never intubated somebody.

00:36:17.300 I never did anesthesia rotation in medical school. That was not part of our training at all.

00:36:21.680 So I was very green with this. Anyway, by the grace of God, managed to get the patient intubated,

00:36:26.620 connected to help. We have a really primitive structure called an OMV, Oxford miniature

00:36:30.820 ventilator. It's got a set of bellows. It's like turn of the century kind of stuff,

00:36:34.880 turn of the 20th century. So, you know, intubating. So we have to, you have to do manual ventilation

00:36:39.480 for the patient.

00:36:40.880 Wait, wait, throughout the whole surgery?

00:36:42.120 Yeah, throughout the whole surgery. As long as they're paralyzed, you've got to,

00:36:44.440 you've got to ventilate manually. Usually with the Hella thing, after you manually ventilate for

00:36:48.980 about 20 minutes, they can breathe on their own. And it's a bit of an art to try to keep them under

00:36:53.820 enough where they can breathe on their own, but they're not in pain. So it's a big art to this

00:36:58.500 kind of work, but it's all manual.

00:37:00.400 I just have to go off on a tangent for a moment, which perhaps only the people listening to this who

00:37:04.220 have medical training will appreciate what you're saying. I'm guessing you don't have blood gases.

00:37:09.540 No.

00:37:10.600 Okay. So you can't measure a patient's PaO2 or PaCO2. And yet your anesthetist has to figure out

00:37:17.760 how to ventilate, which again, means how much oxygen the person needs and how much CO2 you take

00:37:24.720 off. And if you screw either of those two up, you will kill someone.

00:37:28.620 And if you told me to walk into Mass General or NYU or pick your favorite hospital and said, 0.83

00:37:37.200 Peter, we're going to do everything for you. We're going to intubate the patient. We're going

00:37:40.360 to do this. All you have to do is be the guy that manually ventilates them. I wouldn't be able to do

00:37:45.700 that. Like I would, I would overdo it or underdo it. There's no way you'd hit that sweet spot.

00:37:50.340 Yeah.

00:37:50.760 You'd cause an alkalosis, acid, you would just, and then to be able to not have the laboratory tools

00:37:56.700 to know when you're off the rails.

00:37:58.720 Right. Yeah. And in those days we didn't have a pulse ox. Now let's have a pulse oximeter,

00:38:02.160 which can measure the percent of oxygen saturation of blood. That time we had no pulse ox. Some of

00:38:07.980 this stuff, maybe ignorance is bliss because you can't measure it. So you just hope and pray that

00:38:12.340 things are going okay, but we just got the guy intubated.

00:38:14.080 I mean, you couldn't do veterinary medicine like this in the United States.

00:38:17.120 Right. Yeah. You know, it was pretty hairy. We managed to get through and

00:38:21.100 this went out. We eventually got an anesthetist to come. This was after about a month or two.

00:38:25.940 Well, and in that month or two, what types of casualties did you see?

00:38:29.600 Oh, I mean everything. Abdominal trauma, lots of leg trauma. We did a number of general anesthetics

00:38:34.460 during that time. We had a baby that came in with intussusception. This was the worst case. It was a

00:38:39.260 nine month old baby who came in, who had an intussusception, which is kind of an intestinal

00:38:43.880 obstruction.

00:38:44.240 Yeah. Explain what that looks like the telescoping part.

00:38:46.380 Right. So intussusception is when the intestine telescopes on itself and basically causes a

00:38:51.880 blockage of the intestine. And then when the longer you delay, that intestine can die and the

00:38:57.400 person will die, the baby will die from, from infection. And we made the diagnosis and I'm just

00:39:02.080 like, Oh God, you know, what are we supposed to do with this kid? You know? So anyway, we,

00:39:06.180 we take the baby to the operating. We said, we got to try something. So, uh, I mean,

00:39:10.560 intubating an adult is hard. A baby is, is really, really hard. And we managed to get the kid

00:39:15.580 intubated. So I did intubate the baby, started on the ventilated telethane, went out, scrubbed for

00:39:21.080 the case, came back. We opened the baby up, did a bowel resection, put it back together,

00:39:25.540 closed the baby up and he did great. He's a, well, how old is the baby now? He's like baby,

00:39:28.940 he's eight years old now, eight, nine years old. So he's cruising, but that's kind of one of the

00:39:33.560 many miracles, uh, we've seen bits of shrapnel are going through people. I mean, you're seeing

00:39:38.460 liver lacerations, you're seeing bowel injuries, hemo pneumothoraces, head trauma. I mean,

00:39:45.120 give me a sense of the mortality. There are some cases that obviously just can't be saved.

00:39:49.560 Right. Well, you know, I'll tell you, Peter, I think what happens sometimes people say,

00:39:52.600 why do you have so many extremity traumas?

00:39:55.240 Because they're the ones that make it in. 0.75

00:39:56.720 The ones that survive. Yeah.

00:39:57.940 So, you know, the ones that get a really terrible trapped in the chest, they bleed out in the field

00:40:02.840 because we're, you know, we're six hours. Sometimes these patients come a day. We've had people

00:40:06.480 with penetrating abdominal trauma with multiple holes in their intestines come three, four days

00:40:12.420 afterwards and survive. So imagine that you're, you're leaking, you're leaking feces into the

00:40:18.880 abdomen for three or four days. So imagine how strong these people are and they come and it's

00:40:23.460 just a mess and you open them up and, and some of them pull through, you know, anemic, dehydrated,

00:40:28.980 they haven't eaten in several days and these guys can survive. So some of it is the people are just

00:40:33.520 tough as nails, but we get a lot of penetrating. I mean, kidneys get torn to shreds, liver lax,

00:40:39.140 massive kidney trauma, liver trauma. I remember one guy had, we counted, he had 23 holes in his

00:40:46.240 intestines that we had to, you know, resect here, resect there, stitch this one. It just took forever.

00:40:52.100 How did you learn surgery?

00:40:54.140 Right. So, you know, I trained in family practice and when I went to Kenya, we're doing a lot of,

00:40:59.740 you know, tons of tropical medicine, a lot of obstetrical care, did a lot of C-sections,

00:41:04.360 but I realized a lot of the disease burden in Africa was surgically related. A lot of it. I mean,

00:41:10.200 a lot of it, of course, is tropical medicine. Okay. You do all those things and say, well,

00:41:14.620 a good, it seemed like half of what we were seeing was surgically related, either just wound care,

00:41:19.360 miscarriages, laparotomies, amputations, kind of the run of the mill kind of surgical stuff.

00:41:24.040 There's a lot of it. So I thought, I really need to learn how to do this stuff if I'm going to stay

00:41:26.720 here long-term. So luckily where I've been, both rural Kenya and Nairobi, I met up with people that

00:41:33.880 were willing to teach me things. So really it was like doing another residency. I mean, I would,

00:41:38.280 I was in Nairobi, I had a whole day in the operating room and we'd do tons of cases and

00:41:41.840 there was an American missionary doctor there named Mike Johnson. So Mike would just sit there and

00:41:45.160 teach me stuff. You know, I would, I would do the, just like he did in residency. I would do the

00:41:48.980 case. He would assist me and just kind of walk me through it. There was a Kenyan surgeon there.

00:41:53.580 Dr. Rucha was a fantastic, he was like a magician. He was not so hands-on, but if he was always,

00:41:59.820 he was there in the operating room. So he would say, go ahead and start the case.

00:42:02.420 After he had a little bit of experience, he would say, start the case, if you have problems, call me.

00:42:05.300 So I'd start, open up, look around a bit, say, okay, I'm stuck. What do I do? He'd come in,

00:42:08.860 look around, say, I'll do this, do that. I'll do this and that. And things would go ahead.

00:42:12.700 Before you know it, you're doing thyroids and laparotomies and resecting bowel and stitching

00:42:17.440 liver and taking kidneys out and doing amputations. And I mean, you know how it is, you just kind of,

00:42:21.720 once you learn a few, you have a few skills, you can add the next case, the next one, the next one.

00:42:26.820 And I mean, it took, I was there for seven and a half years in Kenya. It was like doing another

00:42:31.140 residency. I mean, at some point though, you have to be making mistakes that are harming patients

00:42:35.820 because even in our, and I say that not being critical, right? But just saying like, that's

00:42:40.140 the nature of medicine. I mean, I think of every time I hurt somebody, even, you know, I remember

00:42:45.640 once causing a hemo pneumothorax in a patient when I put a central line in them, it was my 500th

00:42:50.820 central line. So at this point you'd think I could do it blindfolded. And yet to cause that

00:42:56.440 complication, which in my case, I'm lucky enough to have an x-ray to see that I've caused this

00:43:00.840 complication. You don't even, I mean, you're missing so many of the basic tools that could act as sort of

00:43:06.580 a safety net. So what was that process like? I think what I wanted to make sure of when I was in

00:43:12.120 Kenya, I think those whole seven and a half years I was in Kenya, I always had either somebody

00:43:17.560 assisting me in the case or somebody in the room or in the next room over. So I think I was pretty

00:43:22.700 well covered during that time. And by the time I was finished seven and a half years, I felt pretty

00:43:27.160 confident I could go out on my own and do, and do surgery. I think it's this concept, you know,

00:43:31.760 better than I do about 10,000 hours, you know, and I think in residency, you have to like a thousand

00:43:36.000 cases, I suppose like a thousand cases at least, but that's like a minimum. Yeah. Maybe 1200 or

00:43:40.320 something. Yeah. So I did, you know, by the time I finished my time in Kenya, I'd done. But for you,

00:43:44.340 it's harder because you're doing a breadth of cases that like, even if you took something as

00:43:49.220 broad as general surgery, I mean, you're still doing basically orthopedic surgery as well.

00:43:55.020 And obstetrics. Right. Tons of obstetrics, a lot of urology. There's a mix. And I think maybe the

00:44:01.480 trade-off is the surgery in Africa is much broader, but less depth. Like we don't have any

00:44:07.140 laparoscopic stuff. Of course, we have many of the, these Da Vinci things and all that,

00:44:11.000 and all this high tech stuff. You trade off kind of depth of surgery for breadth. I felt after doing

00:44:18.260 around 2000 C-sections and over a thousand other major cases, I felt, okay, I think I can do

00:44:23.340 whatever we're doing in Nairobi. I can do that. I think safely in Sudan. I mean, obviously, you know,

00:44:29.060 we have complications and other problems and there are a lot of limitations in terms of going into the

00:44:33.900 case. So you tend to do more laparotomies because you, you don't have a diagnosis.

00:44:38.780 You don't have a CT scanner.

00:44:39.780 Right. No CT scanner. You don't know exactly what's going on. To get a tissue diagnosis might

00:44:43.840 take you six months. So you say, go, Hey, let's do laparotomy and see what that thing is.

00:44:48.040 That's, that's your CT scan in the end, but that's about the best you can do. So I think what I always,

00:44:53.320 what I try to do when I approach a case is, you know, the premium known, known cherry first do no harm.

00:44:59.180 So if you think you'll make the patient worse by doing this, like, okay, I'm not an expert at doing this

00:45:03.800 case. Um, and sometimes I say, I'm not going to do it. You know, I won't, I won't do it. If I think I

00:45:08.520 really cannot improve this patient's health, I think, okay, this is too much of a risk. Sometimes I look, I

00:45:13.660 just, I'm not really comfortable doing this, but usually I'll feel, I say, okay, I think it's better

00:45:18.260 if we try to do this operation. I think we can, the patient can improve and, uh, we'll go ahead and it

00:45:23.520 works. I mean, it normally works out pretty well.

00:45:25.740 I was talking with my wife and my daughter a couple of days ago and about how we were going to be speaking

00:45:30.500 today and they had so many questions, you know, we all watched the heart of new, but together. And, um, one of

00:45:36.780 the questions my wife had was how do you deal with exactly that type of situation you described, which

00:45:40.920 is what we would consider quote unquote end of life here in the United States or palliative care. What do you do

00:45:46.500 in a situation where somebody comes in and your judgment says this person is not an operative candidate, but

00:45:51.800 also by not operating, they need to be palliated. I mean, they're not going to, they're not, it's not

00:45:55.740 like, you know, they're going to walk home. How do you deal with that? And more importantly, I guess,

00:45:59.300 than medically, how you deal with that it's emotionally. And how is that communicated to the

00:46:04.480 community? Because you're still a foreigner, right? 1.00

00:46:08.480 Right. Right. I was still a foreigner and will always be one. So I would say when we first started

00:46:14.160 10 years ago, people did not trust us and it was incredibly nerve wracking, something we just got

00:46:21.760 here. People did kind of have this because they've been, these people have been traumatized and

00:46:25.700 oppressed for so many years. They're not going to trust some foreigner showing up saying he's there 1.00

00:46:29.340 to help them. So you got to prove yourself. So I'm thinking, well, you know, I got them doing these

00:46:32.820 operations. What if we have bad outcomes? You know, what happens? So it was really nerve wracking for all

00:46:38.700 of us. And, you know, thank God things went pretty well. We went ahead. So the issue with palliative

00:46:44.640 care, you know, we try to just talk to the family, talk to the patients, say, look, I think we can't

00:46:50.040 do much for you. And so if you go home, we'll take care of the pain and other things we can do.

00:46:55.060 One good thing there is the people, their expectations are extremely, are low. And I'm not

00:47:01.360 saying that in a negative way, I'm saying in a positive way. They don't expect, they don't really

00:47:04.700 expect miracles. They want to be treated as a human. They want that human touch. They want to,

00:47:10.040 they want to talk to somebody, talk to you and say, okay, what, what can we do? If you tell them,

00:47:13.580 look, we can't do much. They're not, they're not saying, they're not like demand, they're not very

00:47:18.440 demanding saying, no, you got to get, send me to Nairobi for a second opinion. They're very accepting.

00:47:23.500 I think that's just because of their lives are, are, are very hard. They're not used to good outcomes.

00:47:28.720 So I think first off, they're, they're very accepting. So when you tell them, look, I think there's not

00:47:31.900 much work we can do. We often will talk to the relatives, uh, culturally, usually the relatives

00:47:36.280 will say, well, just, you know, uh, they don't, they don't like telling the patient, which is very

00:47:40.620 different from here in the U S. So we just talk with relatives and they're usually very accepting.

00:47:44.980 They say, okay, we, you know, we see if done what you can, we'll do, we'll take them home and make

00:47:48.080 them comfortable there. They have some of their local traditional things they might try with the

00:47:53.620 person at home, but they're usually very accepting of negative outcomes or bad news. When you're

00:48:00.900 kind of at the edge of survival all the time, when you get this kind of bad news, it's not so

00:48:04.780 shocking to you. It's like, well, yeah, that's what happens. People die, you know, and people have

00:48:08.440 bad outcomes, bad things happen to you. So it's not so unusual for them. You know, in the U S we're

00:48:13.020 kind of anesthetized that everything has to be perfect and we're not supposed to die. We're supposed

00:48:17.260 to, you know, have this kind of outlook on life. It's, it's a very different way of doing things.

00:48:21.600 So they're fairly easy in that respect. They understand this stuff. You know, most people have

00:48:25.740 some level of faith, whether Christian or Muslim, they can accept this stuff in a theological sense.

00:48:30.160 It's also, it's not so difficult. When you showed up, how primitive was the extent to which people

00:48:37.040 were receiving, I don't know what, how to describe the type of care, but there must've been local

00:48:41.560 traditions and shaman and stuff like that. Right. Right. And at some point you're showing up and

00:48:47.460 you're coming from a place of science as sort of simple as you describe your work in medicine,

00:48:53.920 it is still grounded in the fundamental principles of Western medicine. And you use antibiotics,

00:48:57.800 for example, you wash your hands before you operate. What was the landscape like as far as the

00:49:04.780 other types of medicine being practiced? And are they still being practiced now?

00:49:08.580 Yeah. They're still being practiced. So their scope of medicine, you have kind of the local level in

00:49:13.920 the home and what they'll do is almost any febrile illness. So some kid's got a fever, someone's got a

00:49:19.500 fever, they burn the person. So that everybody there, my wife included, they have burn marks.

00:49:23.640 They look like cigarette burns. They're not cigarettes, but they take a round thing,

00:49:28.360 it's put in the fire and they burn on the back of the wrist, back of the neck and the elbows.

00:49:32.620 There are certain points where they burn the person to try to release the, whatever it is,

00:49:38.720 the spirit or evil humors that are causing the problem. And when they see that kind of smoke and

00:49:43.540 they see the fat underneath the skin burning, they feel relieved. Okay. The thing is gone now and better.

00:49:48.420 So they burn, they cut. A lot of people have cut marks in their arms or in the abdomens where they

00:49:52.640 think that'll also release things. They cut down to cause some blood loss. That'll relieve some of

00:49:58.280 the problem. And that's usually done in the home, usually by the father or the mother or the

00:50:04.000 grandparents will do that kind of thing. That's kind of the local treatment. That is still practiced,

00:50:08.800 less so than when we came, I would say. I mean, everybody, all of our staff have burn marks from

00:50:13.100 when they were kids. Now we still see patients come with the burn marks. Somebody comes with a

00:50:17.980 simple malaria. They've been at home four days and they've been roasting the kid. It's like,

00:50:21.900 why, you know, just give us a chance. Anyway, so burning, cutting, that's one level.

00:50:27.260 They do have some herbal remedies that don't seem that prevalent. They were there, I think,

00:50:31.380 traditionally, some people still use those. And I don't know, you know, some, they still swear by

00:50:36.260 it. If you use the neem tree or this Kala, this plant that they use for malaria, they still swear 0.78

00:50:40.400 that that thing works for that. A lot of kind of local fruits and vegetables they use for GI problems

00:50:46.740 and other things. And those seem to work okay. And the third level is the, what's called the

00:50:52.440 Kujur. Kujur is like a, kind of like a shaman. And the Kujur is like the priest for the, for the

00:50:59.020 village. The traditional legend there is ancestor, kind of ancestor worship. It's communion with the,

00:51:04.540 with the ancestors. So if you're sick, if you have a problem, whether it's physical, psychological,

00:51:09.000 whatever, you go to the Kujur, you have a little ceremony with the family, all get together.

00:51:13.620 The Kujur will talk with your ancestors and then kind of give a report back saying, well, 1.00

00:51:18.700 your kid is sick because you, your goats wandered on this guy's land and ate his crops. So you need

00:51:24.180 to make up with this guy. You need to go and give him something. And then you pay the Kujur 0.98

00:51:27.380 something. And then this thing is kind of lifted. Child should get better. Those three things were

00:51:32.180 kind of traditional treatment. The Kujur is still very, very prevalent in the society. And they still 1.00

00:51:36.740 often go to the Kujur and they still will often delay treatment when they go to the Kujur.

00:51:41.160 Sure. So how many people does your hospital serve?

00:51:46.480 Catchment area is roughly a million, anywhere from 75,000 to a million people is in our catchment

00:51:51.060 area. And the physical region is around the size of Austria, somewhere in that, in that range.

00:51:57.860 The people there, I, for example, how many of the people that you serve would understand

00:52:03.020 what you meant if you were going to New York? Like how big is their world?

00:52:10.260 Well, it's, it's interesting. You asked that. I mean, even the ones that have finished secondary

00:52:15.220 school wouldn't have an idea. Like if they ended up here or, I mean, it'd be, it would blow their mind.

00:52:21.480 Maybe I'll give you an example. My mother-in-law is probably in her seventies. So we went to talk to,

00:52:26.660 my wife was talking about writing a book. Actually, she started writing her book and we went to my

00:52:31.080 mother-in-law and we said, let's go and interview her mother as part of your book. You know, I can

00:52:34.340 write on it about her life. My wife, my wife didn't actually know a lot of facts about her mother 0.94

00:52:38.440 because they don't have that, you know, mothers and daughters there are not like buddy, buddy.

00:52:42.300 You know, the girls are, you know, once they, once they get weaned from the breast, they start 1.00

00:52:46.720 working, carrying water and firewood and everything else and cooking for the family. So we went to talk

00:52:50.380 to her mom and my wife asked her mother, uh, her mother only speaks the tribal language. She doesn't

00:52:56.420 speak Arabic or English or anything else. So we talked to her, she's talking on the tribal 0.97

00:52:59.440 language saying, do you know where Tom is from? And she said, she thought for a minute,

00:53:03.180 she says, he's from Kenya. And she said, that's the furthest place she can imagine. 1.00

00:53:08.160 Right. Because she's heard of Kenya. So in her mind, anybody who's not from Nuba mountains

00:53:13.020 must be from Kenya. It doesn't matter who you are, you know? So that's the outside world. 0.97

00:53:18.440 And we said, well, no, he's from America. You ever heard of America? No, she'd never heard

00:53:21.800 of it. Had no concept of America. Have you ever, you know what an ocean is? No concept of an ocean,

00:53:26.540 no concept of a lake, no concept of Africa. She didn't know she was in Africa. So what she knew

00:53:32.240 was her local area is just a few of the villages there. She'd been to Khartoum once. She's my wife's

00:53:37.960 mother has leprosy. We've treated her for leprosy and they've amputated. I think all of her fingers

00:53:41.640 at one point or the other, she's really quite disabled. She'd gone to Khartoum some years

00:53:46.280 previously to get treatment there and ended up not getting treated. But besides that brief trip to

00:53:51.460 Khartoum, she'd never been out of that local area. A lot of my wife's siblings have never been

00:53:57.260 out of this 15 square mile radius. You can't imagine the worldview. Presumably your wife also

00:54:03.900 hadn't experienced things outside of that until she met you. And what was the first time she left

00:54:08.600 or traveled with you or the first time, especially that you don't travel much, right? So the first

00:54:13.400 time we traveled was after we married was just this past June. We went to Armenia. So it was really

00:54:18.680 her first time out of rural Africa. She'd been, she went to nursing school, but that was in South

00:54:23.320 Sudan in a while, which is, I mean, for, for South Sudanese, they call it a city, but it's, it's a

00:54:28.760 village, you know, it's a big village. So imagine we went from, we went from, uh, EDFG camp down to

00:54:34.100 Juba, which is the capital. I mean, Juba's more or less a city, but it's really not very nice.

00:54:39.600 Then we fly from Juba to Dubai and we were in the Dubai airport. And I mean,

00:54:44.800 which, which I was just there a month ago, even for someone who's from the United States,

00:54:49.100 the Dubai airport is an overwhelming. Yeah. It's, I mean, it's, it's terrifyingly huge. It's a city.

00:54:55.040 I mean, it's a, it's a major city. So we get there and her eyes are, you know, the size of saucers.

00:55:00.200 Has she seen that much electricity in one place? No. I mean, not even close,

00:55:04.760 not even close. Has she seen fresh water to that extent? No. I mean, I'm trying to think if she'd

00:55:10.600 never seen a tap. No, we had taps in the hospital. We have a pump that pumps water up and we have

00:55:15.420 some, some, uh, taps in the hospital, but you know, flush toilets were, she never seen before

00:55:21.260 all this stuff. Elevators. Elevators. So that was one of the things we get in there. We're at the

00:55:25.700 airport. We get in this, you know, pressure button, this door opens, we get this thing and

00:55:29.220 press the button and the thing goes up and we get off. She's like, what was that? So no concept of

00:55:36.060 elevator. We've gotten the escalator and she's like falling over the place. We go to get off the

00:55:39.560 escalator. She's like, what is the house? How's this thing moving? I think when she was in there,

00:55:43.240 she's going, wow, I think they had one set of stairs. There might've been a second floor,

00:55:46.600 but just the concept of walking upstairs is something strange, let alone a moving staircase.

00:55:52.680 So all these things were very new to her. Now we get to Armenia. And I mean, just being in a city,

00:55:56.860 I mean, the air van is the capital of Armenia, not like New York, but very different experience for her.

00:56:01.680 Now she came to the U S for the first time just this past October. And I mean, she was in Times Square.

00:56:07.240 I mean, saw the ocean for the first time. She went to my brother who lives in near Boston,

00:56:11.860 on the North shore of Boston. So that was the first place she went. So first place she went to,

00:56:15.740 went to Boston and our hospital was getting an award by a group called medicines for humanity,

00:56:22.120 which supports us. And they were giving us an award for the work that our outreach team is doing.

00:56:26.680 So nobody could make it. You know, I couldn't go, my, you know, other staff couldn't go.

00:56:30.720 So my wife went to accept the award on behalf of the staff. So she lands in Boston. And the first

00:56:36.140 thing she does is goes to the Harvard club to get this ward. It's a very opulent place.

00:56:40.380 Right.

00:56:40.820 It was my brother's place. He's up in Rockport, Massachusetts. It sees the ocean for the first

00:56:44.640 time. She's a train for the first time, goes to malls, to Walmart. You know, she loved the dollar

00:56:50.920 store. And, you know, my family just went, went crazy with her. They had so much fun being with her,

00:56:57.140 you know, seeing all these things for the first time through her eyes. And, uh, I mean,

00:57:01.480 she's very, has a very kind of infectious joy to her and they really kind of tapped into that.

00:57:06.180 And, uh, it was really, and the flip side of that is we can sit here and have this discussion.

00:57:10.380 And of course, most of us would be thinking how amazing at all the things that they don't have,

00:57:15.900 but I'll, I'll share with you a story that I suspect will resonate and you will understand it.

00:57:22.540 This past Christmas, my daughter's school, each grade picks something they're going to do.

00:57:28.180 And that grade decided that they were going to buy Christmas presents for all of the kids at the

00:57:37.020 Sudanese community center in San Diego. And so they're basically all refugees. And this was very 0.99

00:57:43.460 interesting because we had already watched the heart of Nubo, which was her first time even,

00:57:48.100 she didn't know what Sudan was and she certainly didn't understand why there would be refugees leaving

00:57:53.240 this place. So on the day that we take all the presents there and the kids have done an amazing

00:57:59.800 job, right? They've bought like four or five presents for each and every kid there. And we

00:58:03.660 spend the whole day there. So we go, it's my whole family. So it's me and my wife, three kids. And our

00:58:09.400 youngest is like a year and a half old. So there's another little kid there, a Sudanese girl, who's also

00:58:15.280 about the same age. So the two of them are playing together, but you know, you feel like you got to sort of

00:58:19.400 keep an eye on them because they can fall off the stairs or hurt themselves. So there's a woman 0.99

00:58:23.940 that's holding the Sudanese girl and she's sort of keeping an eye on our son as well. And so that

00:58:29.380 gives us time to go and do these other things and see the other kids and do all the other stuff. And

00:58:32.780 about four or five hours later, when we're leaving, my wife goes over to the woman who's, has been

00:58:39.320 holding this little Sudanese girl the whole time and says, um, you know, what's your daughter's name?

00:58:44.660 Um, and she says, Oh, I don't know. This is not my daughter. I don't, I don't even know whose kid

00:58:50.660 this is basically. And, and we couldn't stop talking about that. Right. Which was talk about

00:58:56.940 a different sense of community. Yeah. Right. There was nothing odd to this woman who was probably 20

00:59:03.400 to just say, Hey, there's like this little 18 month old running around. I'm going to take care of 0.85

00:59:07.760 her. And by the way, like she's taking care of our kid too. Right. And, and so for as many things as

00:59:13.220 they lack, they have something we don't have. Right. That, that taps into Peter something you

00:59:19.720 always hear about the negative side of place like Sudan. People think of sitting, what are the

00:59:23.340 images? War, poverty, disease, starving kids. The positive side is not shown. And some things that

00:59:29.880 always stick in my mind. One is we'll have patients that will come to us that it's a seven or eight day

00:59:35.660 walk to reach us. And on the way, like they'll start their journey and start walking. Now nighttime comes

00:59:41.820 in the society there, you can stop in somebody's hut and knock, you know, just kind of knock on the

00:59:48.560 whatever, or just show up and say, look, I'm going, you know, I've got a long journey. Uh, would you

00:59:53.280 mind if I, if I kind of spend the night with you? I don't know where to stay. So that family will take

00:59:57.380 this person and total stranger, give him place to sleep, give him food, get some water for them to

01:00:02.200 wash, take care of him that night. The next day he'll continue on his journey. Next day, stop at another

01:00:06.940 total stranger's place. That stranger will take this person in, give him some food, hang out this

01:00:12.940 next day, same thing until they reach the hospital. And this is the normal way of doing things there.

01:00:17.600 The concept of community and what stuff belongs to you. What is a stranger? Totally different than

01:00:24.340 our outlook here. So when you're there like, well, geez, who's really, really has it all. You know,

01:00:30.380 who's doing the right thing, which society is on the right track. You know, it's really,

01:00:34.400 it's really mind blowing. Well, especially for you, because I guess it's one thing to

01:00:40.140 know nothing that, but, but you've seen both worlds and I've read enough about you to know,

01:00:46.000 I've seen enough interviews to know. I mean, correct me if I'm wrong, but you've described

01:00:50.560 being more at home there than anywhere else. Right. Which I have to admit, you know, Tom, when I

01:00:56.100 watch the videos of that, the first thought that comes to my mind is not, I wish I was there.

01:01:01.540 I realize that probably just speaks to me being sort of a vapid, shallow person. But

01:01:07.240 if I'm going to be brutally honest, right, I don't look at that and think I want to be there.

01:01:13.180 Right. I think I would never want to give up my family. I would never want to give up my comfort,

01:01:18.240 my safety, my whatever. You couldn't fake it. I mean, so it's obviously so genuine for you and

01:01:25.980 any, you know, the other people like John who are serving as missionaries there. I know that on some

01:01:31.000 level you'll say the answer is faith, but there must be more to it than, than simply your faith.

01:01:35.140 Well, you know, some of it, Peter, I think is just, I think everybody is kind of geared a bit

01:01:39.980 differently. So, you know, we grew up in a big family and, you know, my brothers could never,

01:01:45.880 could never be there, but at the same time I could not do what they're doing. So I think,

01:01:49.420 I think all of us are really, we're kind of wired a bit differently, even people in the same family.

01:01:53.100 So I think I'm very comfortable there, but I couldn't maybe fit working in New York,

01:01:57.760 you know, but I think the good thing is I don't attach a value to all this. Everybody has something

01:02:04.240 to contribute. I really, I really believe that it's not just kind of blowing smoke. My thing is,

01:02:08.920 is being there in the mountains, you know, it's a, it's a part of the puzzle. Somebody else might be

01:02:13.500 in New York, but you're doing a podcast. You're helping us in Nuba tremendously by getting,

01:02:20.000 helping get the message out. You know, if you're in Sudan doing the same work I'm doing,

01:02:24.760 we don't have this, you know? So I think everybody has something to offer. And if we try to get in

01:02:31.560 this thinking like, gosh, I'm not doing what he's doing. I should be doing what he's doing. I think

01:02:35.760 we missed a point. We miss out on our shared abilities. You've got unbelievable talents and a

01:02:41.900 brain twice the size of mine and you're using it in an area that you are comfortable with that is

01:02:48.420 probably maximizing your abilities. I think it's good to be aware of what's going on in the world

01:02:53.620 and everybody should think about their brothers and sisters elsewhere and contribute and do something

01:02:59.120 to help other people. At the same time, don't, don't spend too much time stressing that you're

01:03:04.720 not doing enough, you're not doing anything, do something, but it shouldn't be something which

01:03:08.360 is agonizingly painful. You know, I think just the way I'm geared, that kind of life is a pretty

01:03:13.220 comfortable fit for me, you know? So I don't see it. Yeah, it's a sacrifice. It is. And, uh,

01:03:18.020 I miss the family like crazy and I'm missing a lot and not being with my man. It's been more than

01:03:22.240 three years since I've come here. I'm missing my parents, my nieces and nephews, my brothers, my

01:03:26.820 sister. I do, I miss all that stuff, but I'm pretty comfortable in that, in that weird remote

01:03:33.600 setting in the mountains. So I learned about you through my really dear friend, Rick Gerson,

01:03:41.100 his brother, Mark Gerson, and ultimately met John. And I think they learned about you through a piece

01:03:46.660 that, uh, Nick Kristoff wrote in the New York times in 2015. How did Nick come to find you?

01:03:53.040 Because that story, we're going to link to that story. The story is amazing, right? It leads off

01:03:57.220 with about a 10 minute video that I watched over and over and over again. And I came home and I made

01:04:05.720 my family watch it and I sent it to my family back home. And there's a part in it that just

01:04:12.960 says everything about it. I mean, first of all, I think Kristoff did an amazing job

01:04:16.860 framing the story and he was there, which is in and of itself, I want to actually understand how

01:04:22.380 someone actually gets there because that's, that's, that strikes me as quite a challenge

01:04:26.840 logistically. But he ends the article with a story of a Muslim man who proclaims that you are Jesus

01:04:33.680 Christ. And I always, that's the title of the article, if I'm not mistaken, he's Jesus Christ,

01:04:38.920 which coming from a Muslim man also speaks to the religious harmony that you've described.

01:04:43.620 Right.

01:04:44.280 And for people like me who aren't especially religious, it makes you think, well, I guess

01:04:49.380 that's what religion should be about, right? It shouldn't be about most of what we think of

01:04:54.620 religion as religion has, has its taboos here. But I think the point Kristoff makes and makes it

01:05:00.540 beautifully is if you want to be critical of all of the religious hypocrisy, by all means do so,

01:05:05.780 but you can't then fail to acknowledge the times when in the name of religion, people are doing

01:05:11.740 these incredible things in the name of all religions, by the way, it's not just your religion. I mean,

01:05:15.540 as you know, it's, it's people of all faiths that are doing these things. But in many ways,

01:05:19.780 I think that story brought amazing attention to your work that it breaks my heart to think,

01:05:24.560 are there other Toms out there whose stories are not being told? So how did Kristoff find you or how

01:05:29.320 did you guys find each other? He has an interest in Sudan. I think he's had it for a number of

01:05:32.660 years. And I think for him, he saw this, what Bashir was doing as such an egregious affront to

01:05:40.380 humanity that he felt obligated to go and see firsthand what was happening. So he made a couple

01:05:44.920 of trips into the mountains. You can fly into Juba. Then he got a flight up to the refugee camp in

01:05:48.980 Ida and then managed to come into the mountains. You know, you don't come in with official permission

01:05:53.520 of the Sudan government.

01:05:54.280 So you're sneaking into the country.

01:05:55.780 Right, because he's sneaking in. You get a permit from the

01:05:57.620 rebel government and they allow you to come in. And I think he just has an interest in that,

01:06:02.620 in that part of the world and really wanted to do something that shed light on the situation there

01:06:07.380 against Bashir. And he'd been into Nuba, I think one previous time and heard about the hospital,

01:06:12.540 wanted to come and see us there and see what kind of work we were doing to see for himself

01:06:16.080 and was there for, for a few days. He's, he's a, I mean, he's a really intrepid traveler

01:06:20.520 and incredible journalist. I mean, he's unbelievable. And what I respect about him the most is he can

01:06:26.960 disagree with you, like, you know, whether, whatever, religiously, politically, not agree

01:06:30.900 with your beliefs, but he can realize what you're doing has benefit. He can look at it objectively

01:06:36.460 and say, okay, you know, I don't believe in this religion, but I see what these guys are doing and

01:06:40.660 highlight that. You know, not many people are willing to do that.

01:06:43.960 I thought it was very elegant how he framed that in, in that piece in the New York times.

01:06:47.800 And that video though, it's only about 10 minutes. That was really my first introduction

01:06:52.200 to you. Uh, God, it's about three and a half years ago now. Right. So the world's a better

01:06:56.720 place. Certainly the Nuba mountains are a better place because of Nicholas's work.

01:07:00.820 Right. And he, he tends to highlight people that are kind of not, not well-known and there are others

01:07:05.980 that are out there and it's actually part of what we're trying to do now with Aurora. Aurora's focus

01:07:10.900 is on, is on highlighting what they say is unsung heroes, but people that are kind of operating in the

01:07:16.240 weeds that nobody knows about. So shine a bit of spotlight on them, not so much for publicity,

01:07:21.120 but to help them both in their, in their work and to raise, uh, by raising their profile,

01:07:25.000 you raise the issues that they're involved with. So tell people a little bit about what the Aurora

01:07:28.980 prize is and what it means for you to now be, you're the 2018 recipient. Is that right?

01:07:35.380 2017. 2017 recipient. So what is the Aurora prize? I know it's based on, I know a few things about it.

01:07:40.960 So I'll fill in the little bits that I know. It's a prize that has a finite life, correct? It was

01:07:45.140 began in 2015 or 16 and it will run until about 2022, 23. And that duration, if I recall,

01:07:51.000 is meant to commemorate the length of the Armenian genocide in 1911 ish, 1915.

01:07:56.220 Well, it's a hundred years onward. The genocide went on for about eight years from 1915 to 1923.

01:08:01.220 So this is a hundred years. Henceforth, those eight years, that's the, those eight years of the

01:08:05.940 Aurora prize will be given out. Yes. And it's a, it's a substantial prize. You were selected.

01:08:12.240 And my understanding is, first of all, it takes an act of Congress to get you out of Nuba to be

01:08:18.480 doing this other work, but it speaks to, I think your understanding of how valuable this will be to

01:08:24.800 the broader mission that you're serving. Right. What I saw was I'm, I'm very comfortable being

01:08:29.400 in Nuba and doing the everyday medical work. And I definitely want to go back to that environment,

01:08:35.700 longer term and get involved more with teaching the local people. And when these guys, once these

01:08:40.040 guys come back from medical school that we have out there, really working with them to get their

01:08:44.340 skills up. But I thought, um, maybe using Aurora as a vehicle, it was time to come out to kind of see

01:08:51.560 what was out there with Aurora to try to expand the model that we have in Nuba mountains. So find a

01:08:58.200 way to bridge the gap between say big donors or people that have resources and small organizations,

01:09:06.460 small people on the ground that are kind of doing a lot of the grassroots work and doing it very

01:09:10.180 efficiently. Cause I think there are a lot of other people that are doing the work nobody knows about,

01:09:14.940 and there should be a way to try to connect them to resources. So through Aurora, that's one of my

01:09:20.780 main goals. I wanted to come out and try to expand what we're doing. I felt that was,

01:09:24.640 we're in Nuba doing our thing, but maybe a little bit pigeonholed. How do we expand that

01:09:28.880 and get outside of Nuba, get into South Sudan, to Central Africa Republic, to Chad, to Niger,

01:09:33.820 other places, which are really neglected parts of the world, hopefully into some conflict zones.

01:09:39.180 That was my main thinking coming out. And my time now, I've got three months out of Nuba

01:09:43.880 mountains. I'm traveling all over the place, speaking on behalf of Aurora, kind of doing some,

01:09:48.800 basically some promotion for them, but also meeting a lot of people and trying to formulate

01:09:52.980 which direction we need to go in Aurora. So I'll be physically out for these three months.

01:09:58.360 It'll be three months later in the year from September through November. Besides those two

01:10:02.760 or three month periods, I'll be back into the mountains, do my usual work at the hospital.

01:10:06.760 What does more money solve in this problem? I remember recently, Mark sent us an update about

01:10:11.820 sort of where the dollars were going. And it was sort of hard to believe that so much could be done

01:10:16.540 with so little. And I don't think the stats are, I think they're so overwhelming that it's almost

01:10:22.340 hard to put it in context, but it's worth trying. For about a million dollars as an annual budget,

01:10:29.500 what have you been able to do in the past year? A million dollars is pretty generous. That's

01:10:34.720 probably more than we'd need for the basic work, but let's say if it's a million dollars, we can

01:10:39.300 see about 130,000 outpatients. 130,000?

01:10:44.080 130,000 outpatients. Do close to 2,000 operations. See maybe 5,000, 6,000 inpatients.

01:10:51.320 I mean, vaccinate tens of thousands of children. See, I don't know, I'm not sure what numbers of

01:10:57.620 maternity, antenatal clinic patients, but a lot, several thousand maternity patients for that.

01:11:03.620 A lot of that million dollars, I mean, most of that would, gosh, I think it's, I mean, the number

01:11:07.400 that comes that I use is about 750,000, but somewhere between 750,000 a million, if I'm being

01:11:12.200 conservative. If someone gave us a million bucks, we could easily run the hospital for a year and

01:11:17.300 probably expand, expand quite a bit of what we're already doing. That'd be very, very generous

01:11:22.100 amount of money for us for one year. Which is very interesting. Anyone listening to this who

01:11:26.600 has some understanding of the economics of the US healthcare system would find everything you just

01:11:32.200 said to be sort of comical because of just the costs here are so artificial and so inflated and 0.95

01:11:37.940 so ridiculous. Now, when you think about where those dollars go, I mean, how do you get these

01:11:46.420 supplies? How, I mean, where do these things come from? I remember once asking, I knew somebody who

01:11:51.920 was, I think, on the board of Doctors Without Borders and I said, hey, how come you guys aren't

01:11:55.700 in Sudan? You know, because I remember once reading, you guys couldn't even get certain vaccines and

01:12:00.240 antibiotics. You just physically couldn't get the supplies. Right.

01:12:03.240 So you're really doing the work that nobody else can do here.

01:12:06.840 Yeah. It's tricky. I mean, our number one problem, when people say, what's your biggest

01:12:11.560 problem there? I always say logistics. It's the hardest thing because-

01:12:15.380 You don't have infrastructure.

01:12:16.660 Infrastructure is not there. And if we want anything, you want chemotherapy drugs,

01:12:21.280 you want antibiotics, you want a roll of gauze, you've got to buy that in Nairobi. Nairobi is two

01:12:25.720 countries away. It's South Sudan and Kenya. So it's got to come from Nairobi. Like this past

01:12:31.380 shipment of drugs came from Nairobi by truck up to, actually through Uganda, up to the border

01:12:36.960 with South Sudan, where they just harassed the heck out of the drivers and all kinds of paperwork.

01:12:42.420 You have to bribe the guards?

01:12:43.660 You've got to bribe the guards and they give you a hard time and they don't want you going

01:12:47.220 through. And they say, no, they're always changing the rules. You know, there's a duty.

01:12:51.660 You've got to have all this paperwork. I mean, just reams of paperwork to get this stuff through.

01:12:55.440 So we've got some people that are in Juba that don't actually work for us, but work for the

01:13:00.740 church that help us through all this process to get this truck through. Now, from there,

01:13:05.840 there are, I don't know, 30 or 40 checkpoints from the border of Uganda and South Sudan up to the

01:13:11.300 refugee camp in Ida. And it takes a few weeks. It takes about three weeks to get up there just

01:13:15.540 because of the checkpoints and the delays and everything else. It can take three weeks to get

01:13:18.920 up to this refugee camp in Ida. Then from there, it's offloaded. We've got to go and pick it up. 1.00

01:13:24.520 We've got to find a way to get it from Ida up to our place.

01:13:27.640 Not you personally.

01:13:29.120 No, not me personally, but we've got to get some trucks or something to go down there and pick

01:13:33.600 it up or find someone that can carry it up, carry it for us. And that's about six hours. It's not

01:13:41.520 really a road. It's a dirt track. I mean, there aren't roads there, these terrible dirt tracks you

01:13:46.100 get from Ida up to where we are. That's about six hours and the best day, just during the dry season.

01:13:50.640 It's a rainy season, which runs from about June through October. You can't go with the trucks.

01:13:57.380 You can't really even go with a, um, like a land cruiser. Usually we don't, we don't move at all.

01:14:02.360 If you really had to get in or out at that time, you've got to go with a quad bike and that can

01:14:06.260 usually get you in or out. But sometimes even then, if it's a flash, if it was a heavy rainfall,

01:14:09.820 you have a flash flooding, these, um, dry riverbeds that fills up with water. You got to wait,

01:14:14.780 maybe it's the way today, a few hours. So in the hospital on any given day, how much do you have

01:14:22.280 in terms of IV fluids, gauze, antibiotics, soap? Right. I mean, things that we just, we can't even

01:14:29.500 imagine not taking for granted in an American hospital. Right. I mean, if we have, if this

01:14:34.280 truck makes it through, cause we make our order and we make a fairly generous order just cause we

01:14:38.000 know it's so difficult to get stuff out there. If that stuff makes it all through, we're in pretty

01:14:41.840 good shape for how long for a year. So we try to make it one full year on that supply that gets

01:14:46.880 sent in. And the problem comes cause sometimes you order stuff in Nairobi and it's not in stock and

01:14:52.380 you know, you just can't, you can't order one-off things. There's no, there's no system to get stuff

01:14:56.660 up to us. So it's really hard. If you can't load everything on that truck for this one go,

01:15:01.480 we're a bit stuck and we've got to really be creative trying to get these other smaller things up.

01:15:06.960 Is there like a chief logistics officer that is in charge of the ordering and the

01:15:11.780 procurement and the management of this product? Cause that sounds like a, I mean, that's a,

01:15:16.260 that's a bottleneck, right? Yeah. It's a, it's a terrible job. So John Fielder through F

01:15:20.420 commission healthcare has a woman who's in his, he's gotten off a small office in Nairobi. They

01:15:24.260 got a few staff. So she did all of our procurement. So we sent her the list of things we needed. I mean,

01:15:29.260 it's, it's, it's a lot of items, um, a lot. So she has to go out and source all this stuff and get

01:15:34.380 it in Nairobi from a few different vendors, get the trucks or less stuff, get it through. Uh, we've got a

01:15:40.760 couple of people in Juba that help us with logistics that are not employees of ours, but

01:15:44.360 they're just kind of, they're helping us out just kind of random people and they can help shepherd

01:15:48.300 that stuff through. But it's, it's, it's really, really difficult. It's a lot of work for those

01:15:53.160 people. What does the pattern of mortality look like in Nuba? My guess is infant mortality must 0.99

01:16:01.380 still be quite high, right? How much of that is due to challenges with prenatal care versus the

01:16:08.900 actual deliveries and postnatal care? I think a lot of the neonatal deaths are just from

01:16:14.760 difficult deliveries. You know, they're, they're maybe gets asphyxiated, maybe he's born and dies.

01:16:20.160 There is a stillborn or dies soon after birth. And there are very few deliveries done. I mean,

01:16:27.100 99% of women there still live at home to deliver in a clinic with maybe a traditional birth attendant 0.92

01:16:32.740 is rare, let alone in a hospital. So I think a lot of it is just due to, you know, most of those

01:16:38.920 people probably would end up in a C with a C-section if they were at a hospital in the U S or even in

01:16:42.360 Kenya, if they had access to care or they would have the C-section years, you know, we have one

01:16:46.000 place to in C-sections or actually two now that do C-sections. How many, how many babies do you

01:16:49.600 deliver in a typical year? I think there are maybe three or 400 in our hospital, somewhere around

01:16:54.720 there. I became the exact number. So it's, it's, you know, it's really, it's not, it's a very small

01:17:01.380 number compared to the number of deliveries. So most, the vast majority of women still deliver at 1.00

01:17:06.440 home. And, but you're doing presumably more of the high risk ones. I mean, if, if, if a child is

01:17:12.200 breached, is there, can you deliver a breach baby at home? That's the risk would be enormous, right?

01:17:18.660 Some make it out, but a lot of those babies are going to die because they just get, they get stuck,

01:17:22.540 they get asphyxiated and maybe dies. So, I mean, when we do our antenatal clinic, you know,

01:17:27.540 these women will come and they, the midwife there fills the cart out for them. It's okay. They've

01:17:31.660 had 10 deliveries and four living children. You know, this one died at birth. This one died at

01:17:36.280 birth. This one died from diarrhea. This one died from fever, you know, this kind of thing. So it's a

01:17:39.760 lot of, and what about the mothers? What, what, what is the maternal mortality like? I don't know.

01:17:44.180 And that's something I really wish I could have a grip on because you hear occasionally,

01:17:47.940 you know, we don't, it's not, it's not that often we hear about it, but once I hear,

01:17:50.980 oh yeah, this woman died from, she bled to death, you know, after giving birth to the baby

01:17:54.280 at some remote village, there's not really, it's so remote and people are so spread out.

01:17:59.500 There's not really a system to collect that kind of information. So I don't really know. It's got to

01:18:03.820 be, it's got to happen because, you know, we have a lot of women that we ended up doing C-sections 1.00

01:18:07.980 on that would have died without that. Yeah. You know, they've, you know, how many times the baby is

01:18:12.600 stuck? Well, there's already septic and, you know, we have to do a C-section or something.

01:18:17.040 And this says nothing of preeclampsia and all of the other things that would just show up even

01:18:21.660 under the most normal, you know, circumstance. Right. And getting women with eclampsia is not 0.81

01:18:25.720 uncommon. So if you get eclampsia at home, especially young, you know, most of our primates

01:18:30.380 that are very young, they're not going to survive when they start convulsing. And to get to us is a

01:18:34.760 chore. I mean, it's really hard to reach us. What are the patterns of diseases like there? I mean,

01:18:40.040 when we're watching, and again, I keep mentioning this because it's just such an important

01:18:44.340 film, The Heart of Nuba, you see these things that you're doing, Tom, that just, I mean,

01:18:50.820 they blow my mind. And maybe because I know enough about medicine that I can watch what you're doing

01:18:56.080 and appreciate, you know, the partial nephrectomies you're doing on kids with, you know, tumors in

01:19:01.160 their kidneys. And like, how did you even learn to do that operation? Even within the realm of

01:19:06.500 surgery, that's not a trivial operation to do on a child that size. Yeah. I'd done some nephrectomies

01:19:12.320 before total nephrectomies on for tumors or for trauma or for whatever. So meaning remove the

01:19:17.200 whole kidney, the whole kidney. So I wasn't so worried about that, but I was worried about was

01:19:20.500 the other, the other kidney. It's harder to take part of the kidney out because you have to be able

01:19:23.800 to preserve the blood flow to the part that remains. Right. And you, you know, the kid can

01:19:27.460 bleed in that. So if it, if it was just say a tumor was partially involved in the kidney and say

01:19:30.680 you're doing the operation and you can't stop the bleeding, your backup is just take the whole

01:19:34.660 thing out. But you couldn't do that in this case. Because this child had one kidney that had to

01:19:38.620 fully come out and then there was a partial. So you basically, this kid would die if you couldn't

01:19:43.760 save half of the remaining kidney. Right. Exactly. So it was a lower, the tumor was in the lower

01:19:48.400 pole of the kidney. So we had to take out half the, half the kidney. So there was a visiting,

01:19:52.840 actually a visiting as a friend of mine who was visiting, he's a family practice doctor,

01:19:55.880 Corey Chapman was there. And we were talking about this case and going back and forth. And he said,

01:19:59.420 let's look on YouTube if there's something, cause I read, reading about it and everything I was

01:20:03.220 reading was talking about all these fancy things. You know, there's some kind of a slush, 1.00

01:20:08.160 like an ice slush that you have to bathe the kidney in to get the metabolism weighed down so

01:20:12.960 you can do the operation. Just different things we didn't have. So we looked on YouTube and I'm just,

01:20:19.140 when I think about it now, I wonder how we did it because normally we can't watch YouTube there

01:20:22.440 because we have internet, we have a satellite dish and internet, but the speed is very, very slow.

01:20:26.580 So normally we can't watch any videos cause it's just too, it's just too slow. But for some reason,

01:20:30.780 we were able to see this video and it was this group of Polish surgeons that were doing the partial

01:20:36.060 nephrectomy and with a fairly low tech approach. So we watched that. We said, okay, I think,

01:20:41.080 I think I can do it following what these guys are advising. We kind of followed their system,

01:20:45.740 managed to put these, um, sort of buttresses like on the, on the lower pole, the kidney to kind of

01:20:50.700 staunch the bleeding. And it worked and the child did very well. That was helped by YouTube. I mean,

01:20:56.260 I think that really helped us out in that case.

01:20:57.900 Like the Khan Academy of Surgery. That's right. How long do you just spend rounding? I mean,

01:21:03.400 how many inpatient beds do you have in this hospital?

01:21:05.900 Yeah, it's 435 beds.

01:21:07.880 And what's your typical capacity? I mean, your typical utilization, how many patients are in there?

01:21:12.480 I mean, it's, it's about a hundred percent occupancy. It's, it's a bit less now than it was

01:21:16.460 say the peak of the fighting. And the peak of the fighting, it was crazy. It'd be five,

01:21:19.440 500 people there, 550. So there were several children's war, several to a bed.

01:21:23.980 We have wounded all over the place. I mean, not even in beds, just wherever we could, we could fit

01:21:29.580 them. It looks like when you see movies in war zones and you see the tents that are serving as,

01:21:36.900 you know, hospitals and you just see amputation, nose completely missing, you know, sort of the most

01:21:45.280 gruesome things. That's what it looks like you're in. I mean, you are literally in a war zone.

01:21:50.440 Right. I'm thinking back to residency. If we had to round on 20 patients in the morning,

01:21:56.320 we were moaning and groaning like it was going to be the end of the, oh my God,

01:22:01.040 I'm not going to have time for breakfast today before the OR. I've got to round on 24 patients.

01:22:06.640 Yeah.

01:22:07.220 So you're rounding on 300 patients. I mean, I don't even know how you do that.

01:22:11.440 Now probably 300. Those days was more. I mean, I remember one time we had this measles

01:22:15.040 epidemic and just on children's ward, we had 225 patients. So a hundred normal cases,

01:22:21.700 malarious, bowel obstructions.

01:22:23.220 You don't have vaccines, I'm guessing. Is that the reason the kids all get the measles?

01:22:26.500 With the first three years of the fighting, we didn't have them. So the usual provider

01:22:30.020 stopped providing them. The usual big organization that provides them stopped providing the vaccines.

01:22:34.680 Why? Just logistically couldn't get them in?

01:22:37.260 Logistically. And they, we were in rebel held territory. And a lot of these people,

01:22:41.600 like big organizations don't want to violate the sovereignty of the, of the host government

01:22:46.900 by providing something as simple as vaccines. This is just how it is, which really shocked me.

01:22:51.880 The sovereignty of a government that kills its own people. It needs to be respected.

01:22:55.420 It's the theater of the absurd. It's crazy. So yeah, I mean, runs were just,

01:23:01.280 they would take hours and we started at seven 30 in the morning and two o'clock I'd be finishing up

01:23:05.160 and just try to get through all those people. But then you're, aren't you being interrupted every

01:23:09.100 hour by some trauma that comes in? Cause right. There's stuff coming in. There's stuff,

01:23:13.740 there's other emergencies. I mean, the other stuff was still coming. I mean, somebody comes in,

01:23:17.660 a woman comes in who's having a miscarriage, is bleeding. We have to break into a C-section

01:23:20.980 on somebody who can't deliver. So all this stuff was still going on. It was, it was pretty crazy.

01:23:26.220 I mean, it was, you really had to just go as fast as you could. And it was a lot of just putting

01:23:31.600 out fires and we weren't, we weren't able to spend a lot of time with these patients. Obviously it was

01:23:34.800 really got to go pretty rapid fire through all those cases. It was exhausting. Psychologically

01:23:40.060 it was, it was rough. One of the other questions my daughter wanted me to ask you is what's the

01:23:45.900 most afraid you've ever been there? You know, she was sort of taken aback and we told her before the

01:23:51.400 movie, I said, look, Olivia, this is a, this isn't a Disney movie. You're going to see people getting

01:23:57.320 killed. You're going to see bombs dropping on innocent people and it's not a movie. It's real.

01:24:01.940 Right. So are there times when you are just afraid for your own safety?

01:24:07.160 Yeah. You know, I think every time they bombed the hospital twice and they bombed our local region

01:24:12.000 kind of within a half kilometer, several times. So the first time the area was bombed or we were at

01:24:17.500 church and the church was just outdoors. It's not really a church. It's kind of outdoors thing. And

01:24:21.740 we're finishing up and the, the catechist was up there talking to people and we heard the airplane

01:24:25.840 overhead. We were used to it because every day the airplane came overhead, but we'd never been,

01:24:30.040 our immediate vicinity had never been, had never been bombed. So we just got all the airplanes

01:24:33.000 overhead. It's going to bomb somewhere.

01:24:34.360 And is that because you had this belief that said, even these people as wicked as they are,

01:24:40.300 wouldn't actually bomb a hospital? Is there some sort of view of, we'll respect at least one

01:24:45.980 sanctity of life?

01:24:47.220 Yeah. So that was, that was the bit in the back of our minds and we hadn't been bombed yet. This was,

01:24:50.480 this was a couple of years into it. All right. We hadn't been bombed directly.

01:24:53.940 There weren't commercial flights. So anytime you heard an airplane, it was going to bomb

01:24:56.780 somewhere. And then we heard the, we heard the airplane. Then invariably a few hours later,

01:25:01.560 wounded would show up. They bombed somewhere and people were wounded and wounded show up.

01:25:05.520 This day it was a bit different. We heard the airplane overhead and the mass was over. We're

01:25:09.620 kind of standing there. All of a sudden, somebody says, everybody get down. So we, we just dive on

01:25:16.280 the ground. It was lying flat. And I heard the airplane drone overhead, you know, this Antonov sound.

01:25:20.340 Then I heard the pitch change. It's sort of high pitched, like a whirring sound,

01:25:24.060 almost like a jet engine noise. And then boom, this incredibly loud explosion. It felt like it

01:25:29.920 was two feet away. I mean, it was like half a kilometer away. It wasn't right. But it was so

01:25:33.900 loud. And it circled again. Then I realized that what that whirring sound was, was a sound of the

01:25:40.100 bomb falling through the air. So then I, now, so now I know what that sounds like. Then it's happened

01:25:46.100 six, it bombed six times. You kept hearing this thing, comes around again, bombs. And you're lying there.

01:25:54.060 So terrified thinking, you just, you feel like you want to burrow yourself into the ground and

01:25:58.660 disappear. You know, just lying flat, exposed. Thinking what, you know, what happens? And the

01:26:04.160 thinking is not even so much being killed, but what if, what if my, you know, what if my leg is blown

01:26:09.040 off or my arm gets blown off? You have no control over this. You're totally at the, at the mercy of

01:26:13.760 these people. And you feel like you're, you feel like you're just an, like a hunted animal. That's the,

01:26:18.860 that's what I felt like. I felt like I'm, I'm a hunted animal. And at that time, since we hadn't been

01:26:23.040 bombed, we didn't have the, the foxholes dug around. So immediately after that, we went and

01:26:29.560 we dug foxholes all over the hospital grounds. And that's what you see in the film. There's

01:26:34.040 actually one point when you're being interviewed and the bombs start coming in, you guys have to

01:26:37.540 jump into these foxholes. Right. Right. And then another time we were bombed. I was in the hospital

01:26:41.340 and just down on the, on the floor of the hospital, you know, and you're thinking, well,

01:26:46.820 you know, you're just, you're just thinking this, this might be it. This thing might,

01:26:50.680 cause you can't tell where it's going to fall. You hear that whirring sound and we hear that

01:26:55.000 whirring sound. You don't know if that's going to fall on top of you. If it's going to fall right

01:26:57.760 next to you and, and, and just then shatter your body. You have no idea. So it's really, it's,

01:27:04.380 it's really terrifying. I mean, there's no other way to describe it. And I mean, you know,

01:27:08.620 when you see this stuff that's happened in Syria, people living in these cities, I mean, you can,

01:27:12.420 you can imagine what that is like. And the kids that are in that situation, that's something

01:27:17.920 you'll never, never outgrow that fear. And that feeling of, of being bombed. You really,

01:27:22.440 you feel like you're a hunted animal. I think it's the closest thing I can, not that I've ever been

01:27:27.300 hunted or I'm an animal, but you just feel like, I remember thinking to myself, we were down,

01:27:33.840 this is after, this is a few bombings later, we're down in the foxhole and there was a Sukhoi 24 jet

01:27:40.480 going overhead. A Sukhoi 24 is a supersonic jet bomber, you know, bombing villages, you know,

01:27:45.620 huts. And thinking, what are these people doing? And we're thinking to these guys, I say, how can

01:27:51.840 they bomb us? Don't they know there are people down here? That's what I felt. You know, like it was

01:27:55.720 some exercise where they made a mistake. And of course they knew exactly there are people down

01:27:59.880 there. That's why they're bombing, you know? But I, I really hope someday I will meet these pilots.

01:28:06.620 Not that I don't even feel any animosity towards them. The feeling is never as strange. You don't feel

01:28:10.320 anger. You don't feel animosity towards these people. Just kind of wonderment, like,

01:28:14.560 what are they doing? Like, why are they doing this? So I would love to meet these guys someday

01:28:19.840 and say, what, what were you thinking? You know, what, what'd they tell you before you did your

01:28:23.600 mission? You know, I was a flight surgeon in the Navy. So I know you have a briefing before the

01:28:27.860 pilots fly out. They discussed the mission. Today we're going to fly here. We're going to bomb this

01:28:32.560 target. This is our objective. What were you told in the briefing room? They say, okay, today you guys 0.99

01:28:38.540 are going to bomb a hospital. There are a bunch of civilians there. I mean, presumably if you're,

01:28:42.940 if you're trying to put your psychology hat on, you have to believe that they are being told

01:28:48.260 that the people that they are bombing are somehow a threat to them or their sovereignty or supporting

01:28:54.940 rebel. I mean, you, you'd have to concoct a story that's so orthogonal to the truth.

01:29:00.620 Right. Maybe that might be it. Because I mean, after one of the times the hospital was bombed,

01:29:04.320 one of our staff heard a, a radio broadcast from El Abed, which is a city in the North.

01:29:10.880 And, um, the way they portrayed it on this radio was they admitted they bombed a hospital. They

01:29:16.040 said, we bombed an American church hospital in Cauda, which is the kind of capital of the rebel

01:29:20.940 held territory hospital, taking care of the rebel soldiers. That's how it's portrayed. So you're an

01:29:28.300 American hospital and America, of course, is a great enemy is a Christian hospital. Therefore, 1.00

01:29:33.140 they're no good. And it's, they're taking care of rebels, taking care of rebels. So you're,

01:29:37.420 you're justified in this, in this act. And my guess would be, that's what these guys were fed.

01:29:43.480 Who knows that the pilots were true believers. I know, worked with a lot of pilots in the U S

01:29:47.600 military and they would, they would not go along with the mission that they said, you're going to

01:29:51.440 the mama hospital with civilians. They wouldn't do it. I would say, look, man, we're not doing this. 1.00

01:29:55.440 I know these guys, they were not, uh, these guys, they love to fly and they love the country,

01:29:59.180 but they were not interested in killing civilians. And, uh, I still hope someday I can meet these

01:30:04.720 guys and just have a talk with them and, uh, just to know what they were thinking and what,

01:30:09.520 what went on in their brains. Like, whether they know this, how they feel about it. I'm just

01:30:13.740 interested in what they would, what they would say.

01:30:16.000 How do you cope with what I could only imagine is stress and anxiety aren't the right words,

01:30:24.380 but just sort of the gravity of it. Like, you know, when you describe a day in your life,

01:30:28.280 you know, getting up at five 30 in the morning, making rounds at seven operating. If you said,

01:30:34.600 Peter, you got to go do this for a month. I mean, first of all, I could provide no assistance to you.

01:30:39.960 That's the unfortunate reality. Despite my medical training, I would, I mean, I could,

01:30:44.720 you know, put IVs in patients and that's about, I mean, I, I don't think I could provide any benefit,

01:30:49.720 but let's assume I could even magically provide benefit. I can't imagine how physically, but more

01:30:57.740 so emotionally exhausted I would be at the end of 30 days. Right. Even thinking back to my training

01:31:05.000 where, you know, you'd have every other night call, but on one of the nights in between, you didn't get

01:31:10.260 to go home. And so you've been in the hospital for three and a half days and it's been one

01:31:14.620 trauma after another. Like even that feeling is just, as physically tired as you are, there's

01:31:20.120 something different going on, which is just an emotional depletion. Right. So to imagine that

01:31:26.480 you're now eight, no more, you're coming up to 11 years into this, and this is just in Sudan.

01:31:33.660 Right. I don't understand how you can do that. I think it hit the nail on the head. I think probably

01:31:39.020 the emotional trauma and upset is probably worse than the physical degradation your body takes by

01:31:44.920 just always being on call. And just, even when you're not called at night, it's hard to sleep.

01:31:49.280 You know, always, there's a lot of kind of fear and worry about things, but there's always that

01:31:53.960 less so now, cause you're not bombing, but there's always that sense of worry about being physical

01:31:58.760 danger. But even when you're out of that, when the physical, the risk of physical danger is not

01:32:02.640 there. It's just the, the psychological thought of always being responsible for the, for the

01:32:08.140 patients and not having a psychological rest. Like I can't refer these people somewhere.

01:32:13.020 There aren't other colleagues we can talk to or get an advice on or have somebody else see these

01:32:17.580 patients. It is very draining. And, um, I don't know. I just, you know, a couple of things is one,

01:32:24.460 of course, is I do draw on my faith all the time. And I think that does help me keep centered a lot.

01:32:31.520 You know, I go to church every day and that's, I think helps put things in a bit of perspective.

01:32:35.820 That's just how it is. And besides that, I think you see the people there,

01:32:40.780 they see the strength and resilience of the Nuba people. You say, well, okay, if they can

01:32:45.820 put up with this environment and keep functioning, keep going ahead, let me just try to keep

01:32:49.800 taking care of them as best I can. So I definitely get a lot of strength from the people there and

01:32:56.060 their attitudes. And they've been in this for their whole lives and they're, they're not giving up.

01:33:00.340 They're pushing ahead with things. So let me see if I can also just keep going. It's not easy by any

01:33:05.800 stretch, both physically and mentally and emotionally. It's, it's, it's very, very draining,

01:33:09.980 but I don't know. It's weird. I mean, you get up in the morning and you, you know, had this huge

01:33:15.920 number of patients to get through and you kind of say, man, I'm sure if I can. So I'm tired already.

01:33:20.860 Like I kind of see the first few and then you, before you know it, you're finished with the

01:33:24.440 children's ward, take a deep breath. Okay. I got through all the children. Now we go to the female 1.00

01:33:28.200 ward, you get through there, you pick up pace a bit, you get to the male ward, you go through them,

01:33:32.780 see the maternity patients. Now it's one o'clock. You're okay. I finished the rounds. We go to clinic,

01:33:38.580 go to clinic. And there's a big line of people. How many patients would you see in clinic typically?

01:33:43.280 Uh, maybe 40, 50. Again, I don't even know what that means. I mean, I think most U S physicians

01:33:50.060 would have a hard time seeing that many patients in a week in clinic. Do you have any blood

01:33:54.180 tests you can do? Can you do CBCs or UAs even? I mean, what, what's the extent to your diagnostic

01:34:00.320 toolkit? So until recently you had nothing. I mean, now you have an ultrasound, right? We've

01:34:05.260 had the ultrasound from the, from the beginning. Okay. So we've had that the whole time. That's

01:34:08.460 been hugely helpful. You don't have an x-ray machine. X-ray we do now. Okay. So we just got

01:34:12.680 that about a year ago. So you can do a chest x-ray at least if you want some assistance with,

01:34:16.700 does this person have pneumonia or a pneumothorax or something like that? Right. So prior to a year ago,

01:34:21.260 we didn't have the x-ray, now we do. It's, it's been a help. Lab has been difficult. We can do a

01:34:26.560 urine. We can check a stool. We can do a hemoglobin. Sometimes we can do a CBC, but the machine always

01:34:32.660 seems to be broken. You know, we'll get in the machine, work it for a while, then it just stops

01:34:35.980 working. Can't do a CBC chemistry tests. We can sometimes do a creatinine, but then the machine

01:34:42.480 breaks and you know, you can't do a creatinine. Sometimes you can do ALT, ST machine breaks, can't do

01:34:48.400 anything. But would those things matter? In other words, if, if, if, if someone's listening to this

01:34:52.480 and says, well, gosh, if it's $50,000 to buy a new lab piece of laboratory equipment, can we have one

01:34:59.400 of those, you know, brought in with next year's supplies? Would that change? Would that make life

01:35:03.940 easier for the care you guys provide? It would help. And you know, like there's a, just saw this

01:35:10.660 chemistry analyzer, it's called a piccolo, which is supposed to be kind of built for these remote

01:35:14.880 locations. It's pretty doctor proof. I mean, you kind of have this thing that's pretty hardy. You

01:35:18.240 slip in a disc, you put a drop of blood on it and it gives you results. So our guys in the lab could

01:35:22.500 do that. Not our lives, our guys in the lab can do the other tests, but the machines are just very

01:35:26.060 sensitive. Yeah. It's less about the human. It's more about the, you need a robust machine.

01:35:30.380 You need a very robust machine. So this is kind of a thing and that's about 14 grand. If we had one

01:35:35.420 of those and some of the discs, which have the reagents kind of embedded in them. So if you had a year's

01:35:41.260 supply of, of test strips or reagent discs and then the machine, right. You could do a CBC and a

01:35:47.480 chem seven or a metabolic panel of some sort. Right. That would, yeah, that would definitely

01:35:52.200 help. We're pretty limited. We can do a peripheral blood film. So taking blood, you know, guys can do

01:35:56.760 the film. We can look at that. So you're a pathologist now too. Yeah. And a very hematologist.

01:36:01.520 I'm terrible at it, but I can pick up like a chronic leukemia, chronic myelogist, chronic

01:36:05.680 lymphocytic or an acute leukemia. Those are, if it's pretty obvious, we can pick those up. But a lot

01:36:10.180 of blood films I'm baffled. And when you have a child that has leukemia, I assume you send them to Kenya. 0.99

01:36:14.700 Yeah. It's impossible. Why? It's too far. It's too expensive. It's too difficult. Like just

01:36:20.480 the administrative stuff to get them there. And the chance in Kenya of them being, I mean, 0.99

01:36:26.020 maybe at a higher ed hospital, they could get decent care, but there's just, we just can't do it.

01:36:30.260 So what do you, can you treat with chemotherapy, a child?

01:36:33.780 Not with leukemia. If a child has leukemia, we often will give steroids to try to, you know,

01:36:38.360 palliative care. Yeah. For leukemias, for chronic leukemias, these are again, are usually adults.

01:36:43.920 If it's a chronic lymphocytic leukemia, we'll treat them with cyclophosphamide. We don't have

01:36:47.940 tablets, we'll give periodic injections and that can kind of whitelium a bit. CML, chronic myelocytic

01:36:52.820 leukemia, we don't have treatment for. I would like to have at least some hydroxyurea, which is kind

01:36:59.320 of an older drug for it. You know this drug Gleevec? Yeah. I was just about to say Gleevec would cure

01:37:03.700 most cases of CML. Right. I mean, it's a very expensive drug in the United States, of course.

01:37:07.560 That's the problem. So with Gleevec, I was so excited like a month or two ago,

01:37:11.200 I'm reading that Gleevec is now in generic. Oh my God, maybe we can buy Gleevec because we get a

01:37:16.020 few a year. We don't get a huge number of CML patients. We need a few. I think, man, we wouldn't

01:37:20.360 need a huge amount, you know? So I look it up and it's okay. Gleevec's gone on generic. So the price

01:37:26.040 went from 8,000 a month to 7,000 a month. Yeah. This is another one of these ridiculous

01:37:31.220 systems, you know, problems, which is a lot of times when drugs go from being branded to generic, 0.88

01:37:38.240 there's virtually no change in price. Right. We just can't do that. You know,

01:37:42.200 there are a lot of things that are just beyond our scope of being able to pay for it.

01:37:45.400 That's something that to me is, it's really difficult to consider. I mean, if, you know,

01:37:50.220 we can be as critical as we want of the U.S. healthcare system for all of its buffoonery, 0.85

01:37:54.220 but in large part, it's because we can be buffoons, right? It's because we have infinite

01:37:59.960 resources, though we don't, right? But in the short term, we have infinite resources. And so we never

01:38:05.960 have to ask the question of what are we optimizing for and how do we triage expenses? On the other

01:38:13.080 hand, you're faced with that decision every single day. Right. So you would look at a patient with CML

01:38:19.660 and say, we're not going to spend $80,000 a year to save this person's life because as much as we

01:38:26.480 believe every life is equal, we sort of know that $80,000 can save a hundred lives in another way. And

01:38:32.780 are you the one that has to make that decision by yourself? Yeah. It's agonizing. It's absolutely

01:38:38.540 agonizing. That's just one example of many. I've got a woman that comes all the time with CML and 1.00

01:38:43.820 she's got a huge spleen that hurts. She's anemic and she's got a bunch of kids. I got to talk to

01:38:50.040 her in clinic and try to figure something out with her. And she walks, I don't know how long,

01:38:54.780 how far she walks to reach us. I mean, it's absolutely agonizing. I cannot send her anywhere.

01:39:00.500 It's just, it's totally impossible. You just can't do it. So if we had, we wouldn't need

01:39:06.860 mountains of Gleevec. I mean, a small amount would be enough to at least get her through a year.

01:39:12.020 There are a few people that have CML. It's a few, it's not a huge number.

01:39:15.180 If someone's listening to this and they say, I'm going to tell you a story in a moment called the

01:39:18.940 starfish story, but I want to save one starfish. That's, that's, I'll tell you the story.

01:39:23.300 Logistically, would it even be possible for someone to provide one year's worth of Gleevec to a

01:39:27.340 patient in your hospital? Is that something that they could do through the American, 0.56

01:39:31.060 the African mission? How would someone even logistically go about providing specific or

01:39:36.440 project-based funding to your mission? If they could get the drug, say they had access to the

01:39:42.600 physical drug here in the U S maybe if they sent it to say the Catholic medical mission board,

01:39:47.160 which is my sponsoring lay sending agency. And they also help us a lot with logistics and with

01:39:52.720 the overall managing the hospital, they might be able to find a way to get it down to us,

01:39:57.500 at least get it to Juba. And then we could figure out a way to get it up to us.

01:40:00.720 If they could get the physical drug. There was a program when I was in Armenia, the time before last,

01:40:05.880 we met some guys and there's supposedly some Gleevec program that you can register. Like the patient

01:40:10.480 can register and they can get drugs at either low cost or no cost. So we went through all this

01:40:14.100 thing, contacted the person. She said, okay, all you have to do is take, fill out these forms,

01:40:17.580 have the patient go to Khartoum, get the drugs. That's absolutely impossible. We can't get to

01:40:24.020 Khartoum. That's on the other side of the enemy lines. And, uh, you just can't reach there.

01:40:28.360 So it gets back to your point of providing the money is half the battle, but the logistics of

01:40:34.700 actually getting it in there. And I mean, just spit balling, you can't have these things airdropped

01:40:39.660 or airlifted in because the enemy fighters will obliterate anything that's trying to, it's not like

01:40:44.780 you can fly the Cessna in there to get this stuff in there. There's been no non-bombing aircraft in

01:40:49.880 our airspace for, it's been since November, 2011. So, so even foundations like the Gates

01:40:55.080 foundations, which do a ton of great stuff in Africa. I mean, Sudan's basically off limits. 0.83

01:40:59.440 You know, so they were able to provide money for a bunch of Gleevec. One of the problems and one of

01:41:05.040 the problems I've, I've decided to go with Aurora is a lot of these funds are kind of unassailable.

01:41:10.120 If you're like, I'm an individual or even a small organization that's trying to apply to

01:41:15.520 one of these big organizations that just get through that application process to get funds

01:41:20.620 and then to account for it and do monitoring evaluation and follow-up. It's a very daunting

01:41:25.640 task. You need, you need people who are trained in this area of writing proposals and monitoring

01:41:33.140 evaluation, all this sort of stuff to really follow through with all this. It's very difficult

01:41:37.760 to access some of these big funds and big organizations. You know, a lot of these bigger

01:41:42.580 groups are set up to do that kind of work and their administrative size has grown exponentially

01:41:47.780 because in order to get these, this funding, you need a big administrative staff to apply for the

01:41:52.920 funds and follow-up and accountability and accounting and all that kind of stuff.

01:41:55.760 Right. And you, I mean, you've got tons of extra time, I'm sure, to do that, right?

01:41:59.960 I just can't, I just can't do it. I just can't do it unless it can be made fairly simple

01:42:04.180 where someone's okay. If I got the drug, I'll send it to Catholic Medical Mission Board and

01:42:09.100 then Catholic Medical Mission Board will send it down and we get the drug, you know, at least as

01:42:12.940 far as Juba and we can try to figure out a way to get it out. But it's just, it's really, there's

01:42:17.600 a problem with access and just getting through the administrative things you have to do to get

01:42:21.580 some of this stuff. There's, um, so there, there, there are several kind of different levels of,

01:42:27.700 of difficulty.

01:42:28.540 So going back to the sort of state of diseases you see, if a person makes it out of their sort

01:42:35.000 of their, the young life, right? If a person's sort of your age or my age, what are they going

01:42:40.660 to die from?

01:42:41.600 Middle-aged people, we have a lot of cirrhosis, liver cancers, and that's, there's a huge-

01:42:47.400 Is it hepatitis-based?

01:42:48.380 Hepatitis B. Yeah, huge. Like we do, we screen all of our pregnant women for hep B.

01:42:52.720 Do you guys have a hep B vaccination program?

01:42:54.940 We do. We do. Um, the reason we started screening the, the pregnant women is just to get an idea 1.00

01:42:59.060 about the basic rate and it's about close to 20%. Hepatitis B positive, just in general

01:43:04.460 populations are people who are not sick. They're pregnant with children. So what we're doing

01:43:08.680 is we encourage a mother when the baby's born, we give the baby hepatitis B vaccine immediately 1.00

01:43:13.900 after birth. And we hope with that, that we'll stop, prevent this baby from getting hepatitis

01:43:18.540 B as they get older and prevent all the complications from that. We haven't really scaled up to the

01:43:23.240 point where we have so many happy, positive people.

01:43:26.500 And can you only vaccinate the women who are coming in for deliveries or are you able to 0.99

01:43:30.700 get the vaccine into the community for the women who are still delivering at home?

01:43:36.120 No, we haven't, we haven't reached that point yet.

01:43:38.360 So you're only scratching the surface then because the majority of these births are outside

01:43:42.260 of your hospital.

01:43:43.260 Right, exactly. I mean, eventually we'd like to have kind of minimize these places and have

01:43:47.200 the testing capability to test all these people for hepatitis B. Or if people deliver it in these

01:43:52.620 clinics, you say, look, we can't do the testing, but we just give the vaccine. We'll assume the kid

01:43:56.600 has hepatitis B, you get the vaccine because they have to get hep B anyway. It's part of the

01:43:59.640 pentavalent series. So after that first shot, we continue with pentavalent, which is DPT, diphtheria,

01:44:05.600 pertussis, tetanus, hepatitis B, and a marvelous influenza B.

01:44:08.680 I've heard that kids actually can get diphtheria in Africa.

01:44:12.400 Yeah.

01:44:12.560 Has there been a case of diphtheria in the United States since the forties?

01:44:16.360 No, I think that, I think.

01:44:17.820 I don't even know what diphtheria is. I mean, like, it sounds stupid to say that, but I remember 0.86

01:44:22.040 learning about it in medical school and I know we all get the vaccine for it. What, what is the 0.61

01:44:25.640 disease? What is, how does it manifest?

01:44:27.500 We've only had, from what I remember, one case, and I think she had diphtheria as well as it was in

01:44:31.900 an adult, but it's a coronibacterium diphtheriae and it's a bacterial infection. It affects the

01:44:37.260 throat and the, like a, it looks almost like a thick scab that forms in the throat.

01:44:43.340 They kind of die from airway problems. You know, just think it's thick and they can't,

01:44:48.020 they swallow, they can't really breathe well and they can die from airway problems. It's a horrible,

01:44:51.840 really a terrible disease.

01:44:53.360 And you mentioned your mother-in-law has leprosy. 0.89

01:44:55.640 Right.

01:44:56.240 Again, I've never seen that in my life. It's a bacteria as well. It's,

01:45:00.420 is it in the tuberculosis family or something like that?

01:45:02.400 Exactly. It's mycobacterium leprae. It's a mycobacterium and it's transmitted by

01:45:08.640 respiratory droplets.

01:45:09.960 Oh, it's not by touch. I thought leprosy was sort of contagious through touch.

01:45:14.480 Yeah. That's, that's...

01:45:15.520 Is that a wife's tale? 0.97

01:45:16.540 Yeah. It's really transmitted by respiratory droplets and it should be prolonged close

01:45:20.800 contact. So some of the TB, it's not a real, it's a very slow growing organism, but prolonged

01:45:26.180 close contact, respiratory droplets, you can affect it. It affects the nerves and the skin.

01:45:31.200 And by that nerve infection, people lose sensation. They, they get cuts or wounds. They don't take

01:45:37.520 care of things. They burn themselves. They don't pay attention to what gets infected. Bone gets

01:45:41.020 infected and you have to amputate the digit.

01:45:43.260 Are these people prior to your arrival that were kind of outcast and they would be not touched or

01:45:49.220 anything like that?

01:45:50.180 Yeah. There was definitely discrimination against them. They didn't have like separate places where

01:45:55.560 they would make them outcast, but people would kind of avoid them. Like my mother-in-law still,

01:46:00.440 and I think a lot of it was that people themselves would kind of withdraw due to shame and due to the

01:46:06.080 fear of, of us giving it to somebody else. Like my mother-in-law kind of withdrew. She stays by

01:46:10.340 herself. She doesn't eat with the other family. They keep telling her, look, come and eat with us.

01:46:14.240 It's okay. But she will not come and eat with other people. She always insists to kind of eat by

01:46:18.200 herself. She does it herself. She's kind of a self-isolation from society. She's pulled herself out.

01:46:24.020 So she'll talk to you and chat, interact with you. But then with eating and with more social

01:46:27.900 interactions, she'll kind of pull back and eat by herself.

01:46:31.100 And how prevalent is tuberculosis?

01:46:33.220 Very, very prevalent. And for our place, our HIV rate is quite low.

01:46:36.800 Which is what?

01:46:37.860 It's less than, much less than 1%.

01:46:40.380 Oh, wow.

01:46:41.100 Point something, maybe 0.1%.

01:46:43.460 And is that an artifact of where you are geographically, or is that as part of the benefit

01:46:49.900 of some of the aid relief that made its way in the early part of 2000s?

01:46:54.560 Yeah. I think the main reason is our isolation.

01:46:57.240 Is there drug use there? Prostitution? I mean, which I assume would be the two most dominant

01:47:01.300 modes of transmission.

01:47:02.600 No, prostitution is not really part of that society. IV drug use is unheard of. It's all

01:47:07.860 through, like with most of Africa, is through heterosexual transmission. And I think just the, 1.00

01:47:13.620 it's starting to get a little bit of a toehold in Nuba, but still our rate is very low.

01:47:17.400 I'm worried that if peace comes and the place opens up and you've got more movement of people in

01:47:22.840 and out, the rate's going to skyrocket. That's what happened in South Sudan. The nidus is there 1.00

01:47:27.380 because we have a lot of STDs. Gonorrhea is very common. Syphilis, I mean, we-

01:47:32.160 Do you see tertiary syphilis in really advanced cases or-

01:47:35.980 I don't think so, but maybe some of the stuff we're seeing is just undiagnosed tertiary syphilis.

01:47:39.720 I don't know. I don't think we see it. What I see is syphilis is we have, we do VDRL tests and

01:47:44.300 we have a lot of VDRL positives, which are not, you know, it's not a very accurate test.

01:47:48.000 We have a lot of false positives. We have a lot of VDRL or RPR positive people. We do that screening.

01:47:54.940 We're just screening now with the pregnant mothers for VDRL and we have a lot of positivity.

01:47:59.120 We don't see the chancres or the secondary syphilis. That's really, really rare,

01:48:04.020 but the VDRL positives are very common.

01:48:06.220 So we talked about liver cancer. Do you see heart disease?

01:48:10.180 No, heart failure. So in the older population, we'll see a fair bit of heart failure. Somebody

01:48:15.620 maybe in their 60s, 70s, that's in heart failure.

01:48:18.020 And it's like bacterial or I remember there was some bacteria like Chagas something or other that

01:48:23.460 would weaken the heart muscle. Is it that type of a heart failure?

01:48:26.160 Yeah. No, we don't have Chagas disease in our area. It's just old age.

01:48:30.120 But do you think it's atherosclerotic in origin?

01:48:32.420 I don't think so. I've never seen anybody that could say, I think this person had an MI.

01:48:36.560 Just not a single one in 10 and a half years. Some is hypertension, just kind of untreated

01:48:41.360 hypertension. And we'll let people come in with a pressure of 250 over 180.

01:48:46.520 Really?

01:48:47.060 Yeah.

01:48:47.620 How prevalent is obesity, overweight, type 2 diabetes?

01:48:51.880 Obesity, about 0.0001%, almost non-existent. An occasional person is a bit overweight, but

01:48:59.300 really, really rare.

01:49:01.500 And how often do you see type 2 diabetes?

01:49:04.020 We'll see it. Not so prevalent, but it's definitely there. Some of you see older people

01:49:08.860 come in and just new diagnosis of diabetes. Maybe someone who's 40s or 50s.

01:49:13.520 Do you ever see fatty liver? Like when you're operating on a patient, do you ever

01:49:16.840 see that the liver is fatty? No. No, I think, no, never. I can't remember a single case when

01:49:23.540 I've seen fatty liver.

01:49:25.120 What kind of cancers, I mean, you do so much cancer surgery, especially in children, but

01:49:30.760 they're cancers we don't see that much here.

01:49:32.960 Right.

01:49:33.500 What types of cancers do the people in Nuba get versus basically not get? I mean, in the

01:49:38.920 United States, of course, you'd have lung, breast, colon, prostate are the lion's share

01:49:44.280 of cancers, followed by pancreas. So those are the big five. How prevalent are those cancers

01:49:49.620 in Nuba?

01:49:51.140 Not so. I mean, like if we go to kids first, our Burkitt's lymphoma is fairly common.

01:49:56.580 That's an EBV related, if I recall, right? Epstein-Barr virus is...

01:50:00.480 Epstein-Barr virus. And you really just see that in larioholoendemic regions. So we're in

01:50:05.660 that, it's called a Burkitt zone. And that's a great cancer because it's curable with just

01:50:10.140 cyclophosphamide. Six courses, cyclophosphamide, and you cure a cancer. It's great. Very satisfying.

01:50:16.200 But it's rare to have a cancer you can cure, obviously. For adults, liver cancer is probably

01:50:21.720 the most common. And that's, I think, all...

01:50:25.140 Hepatocellular carcinoma?

01:50:26.080 Hepatocellular carcinoma. And probably all related to hepatitis B positivity. They drink

01:50:30.420 a fair bit. There's a local beer they make from sorghum. But the alcohol content is not

01:50:35.120 very, very high. It's fully weak. So hep B related cancer of the liver, we have a fair

01:50:40.580 bit of cancer of the cervix. So for females, probably cancer of the cervix is the most common. 1.00

01:50:45.240 And can you screen for HPV? You're the local gynecologist as well.

01:50:49.500 Right.

01:50:50.020 Can you do a pap smear?

01:50:51.580 No. Pap smear would be a little bit impractical because we have to do the swab and get that

01:50:56.300 sent off and do it high level. You know, get it off to a pathologist or...

01:50:59.780 Is there any... I mean, again, if someone were listening to this and said, oh my God, like if

01:51:03.320 I could have an impact on eradicating cervical cancer for these women, is that even feasible 1.00

01:51:09.120 to have the equipment there to, after you do the swab, assess for HPV?

01:51:14.620 No. For cancer of cervix, two approaches. One would be this Gardasil, the HPV vaccine,

01:51:22.300 were made available either at very low cost or just giving us part of... I think it's... I actually

01:51:27.720 just heard today as part of the WHO package. So they can be integrated into the system where HPV is

01:51:33.120 given to young girls, even young boys. But then we're back to the logistics problem.

01:51:37.100 Right.

01:51:37.360 Is how do you... Even if the WHO or any of the foundations came along and said,

01:51:42.060 we want to provide HPV vaccination en masse to Africa, you're still somewhat excluded, right?

01:51:47.820 We give other vaccines.

01:51:49.060 If they can be lumped into your annual supplies.

01:51:52.300 Right. And just do it to get stuff out there. But if you do it in one big push,

01:51:55.660 get it out there. It's got to be all cold chain. It's really hard, but it's doable.

01:51:59.960 Get this stuff out there. One big push. That would make a huge difference. We'll start with that.

01:52:05.500 To treat cancer of the cervix, treat earlier versions, they call it a see and treat technique.

01:52:10.960 I've not done it, but it's not...

01:52:12.700 There's probably a YouTube video on it.

01:52:14.700 There probably is, I think. I think there is actually. You paint the cervix with something.

01:52:18.160 I can't remember if it's iodine or some substance. And you look for irregularities in the cervix.

01:52:21.800 And then you freeze it. You have the little liquid nitrogen cylinder with some probes.

01:52:27.840 Put that in the cervix and you freeze it. Make a nice ball of the cervix.

01:52:31.240 Then you kill those precancerous cells. And hopefully those people will not go on to develop 0.99

01:52:35.520 invasive cancer to the cervix. You would need some personnel for that because that would be

01:52:40.460 pretty labor intensive. That's more of a preventive medicine thing. We come in, examine them.

01:52:44.760 Because you're not treating people with the cancers. You want to get the precancerous lesions.

01:52:48.040 Because you have to screen them and do a lot of these screening things. We paint the cervix with

01:52:51.680 some substance. Look and see. Propellinger, you don't even need a colposcope. It's something

01:52:57.800 even more simple than that. I know they're doing it in Uganda and they have this equipment.

01:53:03.580 So that might be kind of an in-between thing before Gardasil becomes available. At least we do a

01:53:07.660 screening of young women, check the cervix, see what it looks like when you paint this stuff and then 0.95

01:53:13.200 treat with liquid nitrogen. We don't have the equipment. None of that stuff is there.

01:53:16.160 Nor the knowledge to do it. What about breast cancer? How prevalent is that?

01:53:21.860 It's definitely there. The problem with breast cancer is by the time we diagnose it, 0.99

01:53:26.520 we only diagnose it when you can feel a lump. No one's getting a mammogram.

01:53:29.640 Right. No mammograms or we don't do other stuff to diagnose it, memorize whatever you have.

01:53:34.320 So women present with a palpable mass that they're feeling and they show up. 1.00

01:53:38.660 Right. So usually they come with a palpable mass and they already have a nose and axilla.

01:53:43.140 So in that situation, you still do modified radical mastectomies?

01:53:47.960 We do. We usually do a modified radical mastectomy and then follow with adriomycin,

01:53:51.920 sycophosphamide chemo and do that sort of every month for about six cycles. And I mean,

01:53:57.760 it's still, the results are pretty dismal. I mean, usually they get a couple of years,

01:54:02.180 but two years on, two and a half years on, they come back and they've got another lump.

01:54:05.360 They got a lump in the axilla. There's another tumor in the chest.

01:54:08.440 So the chemotherapy almost assuredly isn't helping, is it?

01:54:11.620 No, I really don't think it's doing much. So it's, it's really frustrating.

01:54:16.800 Would getting a mammogram machine add value? I mean, of course there's all the futility and

01:54:21.420 the controversy around mammography per se, but I'm just sort of thinking of like,

01:54:25.240 what are some finite resources that could be added to, I mean, you're serving a million people

01:54:31.640 basically that live in a world we can't even imagine as far as even the simplest acts of

01:54:38.300 prevention.

01:54:39.400 Right. The problem with that to, to do the screening, the scale up to that level.

01:54:43.180 Yeah. You need a whole new staff to get people through.

01:54:45.860 Right. And the same thing with cancer surface screening, it's maybe possible. So it's not

01:54:49.960 just a matter of supplying the machine. You need the radio, you need someone who's dedicated to

01:54:54.120 reading mammograms all day long. Or I mean, I guess the other option is, I mean, AI should

01:54:59.180 actually make mammography. This is probably one of the most important applications of machine

01:55:03.800 learning is actually reading x-rays and you don't need, you wouldn't even need a radiologist at some

01:55:08.920 point. You know, there will be a day when you could run a million women through a mammogram in a year 0.94

01:55:13.840 and there's a machine that's reading it and basically giving you the answer. And then now you

01:55:17.780 still need the logistics of a person taking the patients through the machine and operating the

01:55:22.220 machine. But anyway, we've got to think big, Tom. We've got to, we've got to think of these other

01:55:25.960 ideas. I think these are areas where technology and medicine and developing where there's not

01:55:31.120 always a good marriage, but there are some areas where you have technological leaps. Like for

01:55:35.600 instance, our x-ray machine, part of the reason we waited eight years to get one, first of all,

01:55:41.640 they were expensive as heck. How much does it, I don't even know how much an x-ray machine would

01:55:46.200 cost. This one costs 33,000. Which of course in the United States, that's the cost of like

01:55:51.620 getting your gallbladder removed. Right. I mean, literally that's about the cost of a

01:55:55.600 cholecystectomy. Yeah. So it was, I mean, for us it was a big expense, but we do quite a few

01:56:00.320 x-rays now. Our operating, the guys actually taken, our x-ray techs are the operating room guys,

01:56:05.340 but the guys in the operating room, my lab, my assistants in the operating room are the ones

01:56:08.720 we taught how to take x-rays and they did a pretty good job. We waited that long because we wanted a

01:56:13.440 model that we could use. It was very small, lightweight, simple, where you didn't have to use the

01:56:18.880 chemicals and developers and all that sort of stuff. And we just waited. Now we have a model

01:56:22.700 where, is it digital? It's digital. So it's a tiny little device mounted on this little thing.

01:56:30.100 And gosh, it's like the size of a small, like a tiny box that has the x-ray tube in it. And it's

01:56:36.060 a laptop and the screen is a, operates by Bluetooth between x-ray machine and the computer, take the x-ray

01:56:43.120 that shows up on the computer screen and it's all there. And you can take that x-ray

01:56:48.060 and adjust it. You can darken it, lighten it. You can focus in on certain areas. I mean,

01:56:52.560 it's, it takes a beautiful x-ray and you can just play around with it. So you really get a nice

01:56:55.720 picture. And there's very little variable cost at this point. It's like it's, it's all a fixed cost

01:57:00.380 that you've covered. And now you can, the more you use it, the better you're getting more.

01:57:03.700 Right. Absolutely. And it's, you know, the, the power is also the other thing was the power

01:57:08.280 needed because we're on a hundred percent on solar. We've got a backup generator. It's 12 and a half

01:57:13.240 kilowatts. How long does 12 and a half kilowatts last the hospital? If the panels were to go out,

01:57:19.140 we could run things on it. The problem with the rate limiting factor there is the fuel.

01:57:22.420 Like right now, I think we, I think we're left with maybe. Oh, so you, if you have enough fuel for

01:57:27.900 the generator, you could run indefinitely off it if you needed to. Yeah. But I mean, we have to give

01:57:32.960 probably big breaks of time. You know, it's, it's a pretty, it's a fairly good size thing.

01:57:36.820 And the hospital is the only thing that has electricity, but you don't have electricity in your home.

01:57:41.180 No, there's no grid. So it's just, just the hospital has power. That's, you know, we, we run on the

01:57:47.940 solar. I mean, pretty much 24 seven. We really don't need the, as long as the batteries are there

01:57:52.320 and everything's functioning, we don't need the generator at all. And we try to, we try to find

01:57:57.000 the time when it's, these batteries are going to order a new set and new panels, wherever we need to

01:58:00.880 re-up that. So we're, I think three years into this set of batteries. What about colon cancer? Do you see

01:58:05.960 that? Pretty rare. We've had what may be two or three cases in 10 years. I mean, it's really,

01:58:10.980 really rare. The folks who are the, the most elderly within the community live to what age?

01:58:16.420 I mean, what is considered old? They're, you know, nobody there knows their age. You know,

01:58:20.600 they don't have any birth records. Even my wife doesn't know her age. She's somewhere in her

01:58:24.780 thirties probably. So they don't really know their exact age, but I would guess they're probably an

01:58:29.380 older person there would probably be in the seventies and his or her seventies. I don't think they,

01:58:33.580 they live much beyond that. And do you see cognitive impairment in that population?

01:58:37.640 Really rare. You rarely get somebody who say, I think this person has Alzheimer's really,

01:58:43.340 really rare to see that. I mean, I think they should die of something else before they reach 0.53

01:58:47.600 that stage. You just don't see it. The point you just made that reminds me,

01:58:52.260 there's a new movie, which you may have seen. It's, I think it's called a good lie.

01:58:56.220 Yes.

01:58:56.640 It stars Reese Witherspoon. It's a beautiful story.

01:58:59.200 Yes.

01:58:59.480 After we saw the heart of Nubo, we watched that because I wanted my daughter to sort of

01:59:03.980 understand the history of the Sudanese refugees. And that that's one of the points from the movie

01:59:09.960 that I remember being very sort of moved by. They were all assigned the same birthday because

01:59:15.820 nobody knew their birthday. Like even something like that, that we would take for granted.

01:59:19.820 Do they celebrate birthdays?

01:59:21.600 No, nobody does. I mean, you know, my wife, we kind of invented a birthday or she invented one

01:59:26.180 of November 21st. So when that day comes around, we'll usually do something. And she's always

01:59:31.160 surprised. She's like, what, what are you doing? Oh, okay. So she doesn't give me a hard time for

01:59:37.340 not buying flowers if we could buy flowers. So it's pretty, it's, it's pretty easy to be married

01:59:43.640 to a new lady. It's, you know, she doesn't, the expectations are very low.

01:59:47.200 How has your life changed since you've been married? I mean, do you have a greater sense of

01:59:52.660 obligation to not die, to put it bluntly? Yeah, I would say, yeah, definitely. So I'm like,

01:59:58.360 you know, you can't be so heavily with things because I've got a wife and I wanted to kind of

02:00:03.440 look after her and make sure she's okay. There's been a little bit of a change in perspective with

02:00:07.820 that. And I think if, and when we get children, I think that'll change another degree up for sure.

02:00:13.320 Do you think you could do what you do if you had children?

02:00:15.640 I think we could stay there. And if things aren't really hairy, we'd have to see how to proceed.

02:00:20.800 But just in terms of, I mean, your wife is a nurse, so you have the luxury of working together. So

02:00:27.040 as focused as you are on your work, she is there with you.

02:00:31.100 Right.

02:00:31.580 When you have children, they will not work with you for quite some time. I just wonder,

02:00:36.740 would it be challenging to sort of now be torn between two obligations that for many years will

02:00:43.140 not overlap at all?

02:00:44.540 It'll be difficult. You know, I think one thing, and one thing I remind my wife of is that,

02:00:49.220 you know, I finish work late and I'm always, you know, often preoccupied with things and things

02:00:54.340 with the hospital and all that sort of stuff. But at least I'm there every evening. The weekends,

02:00:59.360 we have a little bit of time on a Sunday to be together. And even though the work is very much

02:01:04.840 all encompassing, there's no commute and there are no distractions. You know, we don't have,

02:01:09.460 there's no TV, there's no radio. We don't have other things that kind of occupy our minds. So when we,

02:01:14.140 when we're together at home, we really can be present to each other. And I would hope that if

02:01:20.800 we have children, I'll be able to use that to really spend time with the kids and not be always

02:01:24.960 in work. You know, if life continues like that in Nuba, there's not any travel involved. I'm just

02:01:29.440 there. You know, I'm a stone's throw.

02:01:30.840 You know, it's funny when you say it that way, it's actually, you may actually spend more time

02:01:35.220 with your kids than many of us do here because of our distractions and our travel and our this and

02:01:42.900 our that. Yeah. Life here is, is much more hectic. I mean, it's, it seems almost ironic to say that.

02:01:48.280 Do you feel out of place here, even though you grew up here? I mean, when you walk down Park Avenue

02:01:53.580 or Madison Avenue, are you sort of like, what in the hell is this place? I do. I do feel a bit out

02:01:59.560 of place. In a sense, I do enjoy it. Like I've never, even when I was like, grew up in upstate New

02:02:03.600 York, I'd never spent time in New York city. So this is really kind of, it's, it's exciting.

02:02:07.560 I like it, but I don't think I could, I could stay long-term. I mean, a lot of people I'm sure

02:02:11.280 say that about New York, but I do feel much more at home in the mountains where it's, it's very

02:02:16.000 quiet and kind of sedate and your time is your own when you're off. What possessions do you value?

02:02:22.520 I mean, I, I, I know you have some textbooks and things, but I mean, your home is very modest,

02:02:27.260 obviously by the standards of someone living in the United States, it would not really,

02:02:31.840 you wouldn't even really call it a home in the same way, but you don't give the impression that

02:02:36.880 you're wanting. No, I really don't. I think that was my character since I was a kid. I'm, I'm very

02:02:42.680 much, I think I'm very much a minimalist since I was born. All these clothes you see me wearing

02:02:46.780 from the, well, the socks, the trousers, both these shirts I bought when I came out of Nuba last month.

02:02:54.600 So I have scrubs. I had scrubs. I had one pair of trousers. I had a suit, a few t-shirts and that

02:03:01.780 was it. And they're like, Hey, look, you got to go and meet people. You can't be wearing your scrubs

02:03:06.300 around. So I had to buy all this crap when I came out. It was painful for me to buy clothes. Like I 0.99

02:03:10.840 don't, I just don't like it. When I go back, I said, look, when I go back to mountains, all this

02:03:15.040 is winter coats and this stuff. I'm not taking this stuff back with me. I'll keep it in Armenia. 1.00

02:03:18.880 Let's be someone there. Use it. I don't know. I don't want it. My suit. I do have one suit

02:03:23.020 that I wore to the ceremony in Armenia, the world prize ceremony, but I bought that suit in 1985.

02:03:29.820 So I haven't bought one since then. Probably when you were interviewing for medical school or

02:03:35.180 something. Well, I was interviewing for jobs, like for engineering jobs. That's the reason I bought it.

02:03:39.220 So it was when I, same one I used for interviewing for, for medical school. And then, uh, I've used it

02:03:44.100 when I come out for this world prize ceremony, I'll, I'll take it out and wear that suit with a blue shirt. 0.67

02:03:48.640 Then a tie, but a bottle of crap in 1985. And I know that you, it's absolutely against your nature 0.78

02:03:54.180 to sort of be critical of anyone, but do you spend any time thinking about the way the world works

02:04:01.120 here and how most of us are somewhat attached to our possessions and the more possessions we have,

02:04:10.000 the more complicated our lives get. I mean, you certainly hear people talk about minimalism.

02:04:14.120 Few people can apply it to the extent that you can, of course, but I mean, what have you learned

02:04:21.760 about this and how, how could you speak to somebody like me who, you know, loves his possessions as

02:04:28.020 much as the next person and can't imagine giving up these comforts? I mean, help me understand

02:04:33.340 because you don't look like you're miserable and you look even happier in these videos in Nuba. I'm sure

02:04:41.200 that this is about the hardest thing you've had to do all year. Yeah, it is. To schlep around New York

02:04:45.940 and talk to idiots like me. No, I, you know, I'll tell you, Peter, I really do believe that the more 1.00

02:04:51.720 detached you become, not like in this Buddhist kind of Nirvana sense, but the more detached you are from,

02:04:56.500 from things, the easier life is, it just simplifies your life. I mean, for me, I look at all, at a lot

02:05:02.660 of possessions and things and attachments as just adding more complications, you know, life becomes

02:05:07.420 so complicated. It's much harder here in the U S you know, I see my sister and how she's interacting

02:05:12.360 with the kids. You know, there's a reason why advertisers are good at what they do. You know,

02:05:17.640 what they want to do is convince you to buy something you really don't need. And they're very

02:05:21.120 good at it. Why does Madison Avenue exist? Why is there huge buildings in Madison Avenue? These guys are

02:05:25.760 very good at what they do. They're convincing. They've managed to convince all of us to get things

02:05:30.600 we really don't need and convince us that we'll be only happy and fulfilled and satisfied if we

02:05:35.500 have those things. So you've got all this tsunami pushing against you. For me, I think just because

02:05:41.720 I'm in a place where you can't have anything that kind of realized, well, geez, I don't have any of

02:05:46.940 this stuff. And I kind of like it. It's, it just makes things much easier for me. I've always been a bit

02:05:51.800 of a minimalist even when I was, when I was younger, but I've come to kind of feel that

02:05:56.200 that's really, I do feel better with less. And I think everybody is looking for some kind of

02:06:03.040 meaning in life. You know, uh, this book, this man's search for meaning, this, uh, Victor Frank,

02:06:07.080 that was something that was one of my, is one of my favorite books. And this idea of logotherapy,

02:06:12.140 but we all really do need a sense of meaning in our lives. That's extremely important for our

02:06:17.660 psychiatric makeup. Whatever that is, it's different for each person, whether it's kids,

02:06:22.380 whether it's your pets, whether it's your job, but to try to get something in your life

02:06:27.220 that's meaningful. And if you're looking for it, this is me philosophizing, but certainly

02:06:31.140 I think if you're looking for immaterial possessions, I don't think you'll find it there.

02:06:35.000 So if I can make a bit of an aside, something I talked about earlier with a talk with the Catholic

02:06:41.000 Medical Mission Board volunteers, my favorite Bible passage, I can't remember the book and the

02:06:46.480 verses, but the basic story is there's a guy, the guy's a very wealthy young man and he goes to

02:06:52.180 Jesus. They says, to try to justify himself and says, look, what do I have to do to get eternal

02:06:57.620 life? And Jesus says, well, follow the prophets. You've got all this stuff there. Follow the

02:07:01.720 10 commandments, follow the laws of the prophets and you'll, you'll be okay. And the guy says,

02:07:06.160 well, I do all those things. What do I need to do to really become perfect? And Christ said,

02:07:12.140 you know, sell everything you have, pick up your cross and follow me. 0.99

02:07:16.560 And it says something very, which I think is very beautiful. It says the man went away

02:07:20.740 very sad because he had many possessions. He couldn't do it. He couldn't, he wanted to,

02:07:26.660 I think he wanted to justify himself. Say, I'm doing, I'm good. I'm doing all the things I need

02:07:29.840 to do. I should be okay. And Christ kind of turned that on his head and said, okay, if you want to be

02:07:35.160 perfect, sell everything you have and come and follow me. And I think, I think what he's saying

02:07:40.820 is, look, if you really want to be perfect, really want to be happy, you know, get rid of, I mean,

02:07:46.780 I'm, it's a bit of pie in the sky stuff in a way and not practical for, for people, but in some way

02:07:52.920 get rid of your baggage and come and follow. 0.99

02:07:55.040 Yeah. Because it could be metaphorically, get rid of your stuff, right? I don't think it's

02:07:58.340 necessarily literal, right?

02:07:59.280 Right. It doesn't mean throw your couches out, but it's going to be,

02:08:01.380 it means don't be wed to these things the way that I think we are.

02:08:04.040 Exactly. And the theological meaning is exactly that. It's not that you can't have things,

02:08:08.960 but what's your attachment to those things? You know, is this thing where you put your values,

02:08:13.680 you know, is your value in the car you drive and the, what kind of beer you drink or whatever,

02:08:18.620 or is your value more in people and what you're doing and how you're helping people? There is a

02:08:23.540 bit of values in that. And I think, I'm sure some people can do it very well. They're very wealthy.

02:08:27.740 They have a lot of stuff, but they're, they do have a sense of detachment from that. I just think

02:08:31.000 it's more difficult. You know, it talks about this passage about it's more difficult for a rich

02:08:36.960 man to enter the kingdom of heaven than it is for a camel to go through the eye of the needle.

02:08:39.940 That's kind of something you say, well, eye of the needle, it's supposedly where the camels were

02:08:43.000 and to keep them out of the, out of the city. They had a thing that looked like an eye of a needle

02:08:46.340 and the camel couldn't go through there. It's not saying being rich is bad or rich people are bad

02:08:51.640 people. That's totally, that's nothing that's missing the point. It's just very difficult because

02:08:55.200 it's very difficult to be detached from things when you have a lot of possessions. You know,

02:08:59.300 I'm trying to say that without coming across as being judgmental. I don't mean that, but certainly

02:09:04.620 for me, I feel much better having less. I really, I really think that.

02:09:09.020 Well, it's funny at the outset, you talked about this idea that even in college, you were sort of

02:09:13.380 struck by this idea of you wanted to be a missionary and you even said something to the effect of

02:09:16.560 whatever that meant. And it's sort of funny. Like if you say to me, Peter, picture a missionary,

02:09:22.280 I don't actually picture you. I picture someone going into a remote part of the world and hitting

02:09:29.640 people with Bibles, right? Like that's sort of the image we have of a missionary. But in the reality of

02:09:35.580 it, I think what you're doing is far more aligned with, in as much as one believes in, in sort of

02:09:42.700 religious values, I guess, I think what people like you do that is, regardless of one's religious

02:09:49.860 views, they can't help but respect it is you're not preaching it to anybody. You're not hitting

02:09:54.480 anybody over the head with a Bible. You're just sort of saying, look, I'm here to serve you.

02:09:57.740 And your example is what's actually doing the talking as opposed to your words. Whereas I think

02:10:02.460 most of us, myself included, are far too quick to use our words to speak as opposed to our actions.

02:10:09.360 Well, you're tapping into my favorite quote, which has been attributed to St. Francis. I don't know

02:10:14.480 if St. Francis is like many people, he's my favorite saint.

02:10:17.160 And a friend of Assisi who lived in the early 1200s, he said, preach always and sometimes use

02:10:23.900 words. And I think that's exactly what I think we try to do in a mission. Show the love of Christ

02:10:31.460 by who you are and what you're doing, Colossus. And don't get too wrapped around the axle about how

02:10:38.080 it's going to play out. Remember, if you're there as a missionary, you know, God is the one that

02:10:42.280 changes hearts. Not, not me. I'm not smart enough to do that. I don't have the, I'm not a guy that's

02:10:47.800 going to have just the right thing to say and to, you know, school somebody on something. I can't do

02:10:51.660 that, you know, but I can do my best to show the love of Christ to these people. And that's what I

02:10:59.000 feel comfortable with. You know, if you ask me why I'm a Christian, I can, I can talk to you about it.

02:11:03.360 And my, even my words might be a bit jumbled and goofy, but preach always sometimes use words.

02:11:10.320 Are there any cases of suicide in Nuba?

02:11:12.880 We had one guy who's the husband of one of our staff and, uh, yeah, he shot himself and that

02:11:18.980 really shocked everybody. He, he seemed to have some kind of a psychiatric problem. He was

02:11:24.940 kind of acting a bit strange a few days. They didn't tell us, but he, he'd been in one of the,

02:11:28.880 in one of the refugee camps was acting a bit odd. There came back to Nuba and was

02:11:33.240 acting a bit odd at home. And then the night he was acting a bit odd, he went and he shot himself.

02:11:37.620 That's the only case I know of. It's, it's extremely rare, extremely rare.

02:11:42.020 I mean, to me, there are so many amazing contrasts between Nuba and America, right? I mean, 0.93

02:11:50.340 they're so obvious. They're not worth stating. It's these subtle ones that to me are interesting,

02:11:54.520 right? There must be a different sense of fulfillment, contentment, happiness, sense of purpose

02:12:00.680 there versus here. I mean, as you know, I'm sure you're not paying close attention to statistics

02:12:05.220 in the United States, but suicide is among the top 10 causes of death in every, I may be incorrect on

02:12:11.380 this, but I'm not far off in every age demographic except for zero to 10. So once you get above, you

02:12:17.900 know, 10 to 20, 20 to 30, suicide is always in the top 10 as a cause of a disease. And that doesn't

02:12:23.200 include, that's what we call fast suicide. Right.

02:12:26.600 When you kill yourself immediately with a clear, but then you have all the slow suicide. So the 0.84

02:12:31.040 alcohol related, you know, basically people that kill themselves with alcohol and drugs.

02:12:35.660 Yeah. So when you include all of those, I've heard analyses that would suggest that self-harm

02:12:42.160 would be sort of top five causes of death across the board. What does that say to you, given that

02:12:47.800 you're, you live in a world that has one, one thousandth of the privilege and for all intents and

02:12:54.400 purposes, like, shouldn't everybody be killing themselves in Nuba? So to avoid being a, you 1.00

02:13:00.320 know, ripped apart by shrapnel.

02:13:02.000 Yeah. It's very interesting. And, you know, my, the initial thought that comes to me is

02:13:06.080 the people are, when you're really gripped in this struggle to survive. So your, your life is based on,

02:13:13.700 you know, every day is you're, you're just trying to survive. When you have that sort of primal

02:13:18.880 instinct of survival, you don't, your mind doesn't drift off to the things you don't think about

02:13:23.880 so much about your life is hard. Your life is this, your life is miserable. So I think you become

02:13:28.140 less inward looking. Suicide is so inward looking, so focused on your own misery that you can't come

02:13:35.780 out of it. I mean, it's such a miserable thing. I mean, it breaks my heart when I hear about these

02:13:40.280 things. It really does. Because I think, man, to get to that point when you just, life is so

02:13:46.700 miserable for you and you are so miserable, you kill yourself. It for me is heartbreaking. 0.79

02:13:50.560 Does that break your heart more than the tragedy that you see every day? I mean,

02:13:55.100 not to compare miseries, but like what you see breaks my heart. Maybe I'm numb. I mean,

02:14:00.380 and it's not to say that I'm not heartbroken by anybody who hurts themselves, but what you see

02:14:06.220 is so staggering. Do you see this as an even greater source of tragedy?

02:14:10.280 For me, I would, I would equate that with the five-year-old girl who's got the shrapnel

02:14:14.840 ripping her arm off. Yeah, I would. I would see, I would feel the same sense of pain and heartbreak

02:14:21.800 with that. Suicide has a similar effect where, you know, if a child dies from this kind of thing,

02:14:26.100 the effect you have on the whole family is devastating. The grief, suicide, the grief you

02:14:31.100 leave behind, I think that's really tough. And that really, really breaks my heart. Not only for

02:14:36.140 the person who was so miserable that they decided to take their own life, but for the people.

02:14:39.840 The ripple effect. Oh gosh. And that's terrible, man. I would just never wish that on anybody.

02:14:45.260 And yet it's almost impossible in the United States to not have your life touched by suicide.

02:14:50.560 I think it would be very rare that someone listening to this in America wouldn't know

02:14:55.520 somebody first or second hand who hasn't taken their life either clearly and deliberately or sort

02:15:01.240 of slowly and maybe less deliberately. Yeah. I think it's wrapped up in that struggle for survival.

02:15:06.320 There is a will, you know, a natural will to survive. And when you're in this kind of daily

02:15:10.640 grip, even when there's, when there's not fighting just to survive there, the amount of work it takes

02:15:15.760 to get up in the morning, to, you know, make food, to cultivate crops, to keep the animals out of your

02:15:21.940 garden. I mean, it's, it's a, it's a tremendous struggle. There's a book, I think the book is called

02:15:25.840 Tribe, Sebastian Younger. Have you heard of it? Yes, I have heard of it. Yeah. I can give you a copy

02:15:29.980 actually. I have a copy here, so I'll give it to you as one more possession to have. Right. But he writes

02:15:34.900 about how post nine 11 suicide rates went down in New York and he talks much more eloquently about

02:15:41.600 this than I ever could, but I guess it speaks to what you're saying, which is when there's a real

02:15:47.940 struggle, when there's something and something that can bring people together in a common goal or

02:15:53.300 there's something that unites people, it can presumably distract from some of that pain that

02:15:57.240 can otherwise hurt us. Right. And it's interesting because I've fairly recently was hearing about this

02:16:02.880 PTSD and, and I mean, how many veterans have killed themselves? It's, it's, that's another

02:16:08.900 heartbreaking thing. Somebody's fighting in Iraq or Afghanistan. They survive all that. They come

02:16:13.480 back home, they get despondent, they kill themselves. What kept them alive during the fighting was a sense

02:16:18.600 of camaraderie, togetherness, fighting for, you know, for a common goal. I mean, no matter what you

02:16:23.320 think about warfare and the horrible things that happen in warfare, at least they have some kind of a

02:16:27.420 common bond. They come back home to the U S and people are indifferent to them. Nobody pays

02:16:31.580 attention to them. They've lost their, the common bond with their, with their comrades and friends.

02:16:37.460 And what ensues is despondency. And before you know it, we had this huge rate of suicide amongst

02:16:42.620 veterans that come back, not so much from the trauma they had during the fighting. You know,

02:16:47.220 it wasn't like flashbacks to horrible things that happened there, but the sense of loss of any bonds,

02:16:52.320 that human contact with other people, that sense of purpose is gone. So I found that quite

02:16:58.000 interesting that, that thought. That's what, it just makes you wonder if there was, if there is a

02:17:02.240 way to, you know, we have these dating apps here in the United States, right? You probably don't

02:17:06.080 have a lot of them in Nuba. Well, dating, dating is, is totally illegal there. The word dating doesn't

02:17:11.240 even exist. And then how did you meet your wife? Well, we have what she calls secret love. That's not

02:17:16.800 like in a, in a scandalous sense for anybody, but you know, there you can't openly date somebody,

02:17:20.980 you know, if, if somebody like I could never be alone with her somewhere, like just chatting out in the

02:17:26.040 public, people would tell her brothers, Hey, this guy is talking to your sister. What are you going

02:17:29.540 to do about it? They come and they beat me up. They'll beat her up. And then this big scandal and 0.94

02:17:33.780 they say, Oh, co, you know, either you guys can get married or what's going on here. You just can't, 0.93

02:17:37.180 you can't be doing this. So you have to do it. We did it very quietly. You know, it's got the,

02:17:41.240 it's, it's difficult. We got to know each other kind of on the side. And our marriage is normally

02:17:45.380 arranged. Is that why this dating process is unnecessary? Yeah. Traditionally they were arranged. Now

02:17:51.160 they're not so much arranged, but the families will meet together. Somebody, you know,

02:17:54.080 someone might show interest in somebody else. Then they have to approach the family,

02:17:57.080 but there's not really a dating, they can't go through a public dating thing. If you,

02:18:02.020 if you're interested in marrying a girl, you've got to go and approach the family right away and say, 0.95

02:18:06.480 look, I want to marry this woman. Then they have to start negotiations with dowry and all that sort 0.91

02:18:10.020 of stuff. You can't be seen together in the public sphere. It's just, it's just totally not allowed.

02:18:15.560 So not so much arranged. There's, there's some attraction between the two, but they have to really

02:18:20.140 make the move fairly early. So they don't, you know, one of the problems, you don't really get to know the

02:18:23.860 other person very well. It's really difficult. You know, they're good and they're bad points

02:18:27.280 because you, you're not really allowed to go through that, that, that process of dating if

02:18:31.440 they know somebody and all that sort of thing and know the family.

02:18:33.640 All right. So there's definitely no Nuba version of Tinder. Um, so, so I think where I was going 0.99

02:18:39.980 with that was in the same way that we have these dating apps, it's all, which are basically trying

02:18:44.260 to pair people, right? Similar interests at a meta level. It's, it would be interesting if,

02:18:49.680 if there would be a way to pair a void that exists here in this country and, and for much

02:18:55.760 of the civilized world, right? The avoid of purpose with a part of the world where purpose

02:19:01.460 is not lacking, but resources are lacking. And in many ways, I think that's what philanthropy

02:19:05.340 sort of tries to do. But of course the question is, it's more than just that, right? I mean,

02:19:10.260 I don't think it's just giving. I think there's more to it, right? I mean, I, I, and I was

02:19:15.960 sort of thinking about this, knowing we were going to speak today that, cause my daughter

02:19:19.880 asked me another question. She said, you know, she said, well, can you ask Dr. Tom, like what

02:19:24.520 could a 10 year old girl in San Diego do to help a 10 year old girl in Nuba? And I thought,

02:19:31.740 and I thought, and I thought, and I was like, I don't know. Cause it's not like you going there

02:19:37.840 is going to, you know, be a practical solution and, or even provide value. I mean, even me,

02:19:42.560 even if I decided, Tom, please, I'm going to come for a year and work at your side,

02:19:46.440 I would slow you down. I mean, I would be a waste of like, you'd spend a year just teaching

02:19:50.940 me how to get out of my own way. So how can people help? I mean, giving is of course the

02:19:57.740 most obvious you've, you've outlined so many clear, tangible examples of where even modest

02:20:04.700 resources by the standards of our healthcare system would have profound step function changes

02:20:09.580 there. Is there something else people can do to help?

02:20:13.580 Yeah. First of all, never underestimate the value of a donation to, to someone you trust

02:20:18.740 or a group you trust or an organization you trust. The amount, the impact that has is tremendous.

02:20:22.820 We can't do anything in our work without financial resources. Beyond that, I think one is just

02:20:29.720 becoming aware of the situations somehow in this environment, trying to understand how these

02:20:36.560 people, how they live, what their lives are like, that these really are individuals that

02:20:41.380 have their own thoughts and aspirations and everything else, trying to get it into their

02:20:46.200 skulls a bit and understand what their life is like and who they are. If you have kind of 0.99

02:20:50.600 a knack for advocacy or work through governments and this kind of thing, be aware of the political

02:20:55.660 situations there. Advocate on behalf of some of these people that are oppressed or having

02:21:00.900 difficult lives, whether it's working in issues of poverty or poor health, poor education, I think

02:21:07.280 people have a, have a voice to offer and people do have an influence over governments. So government

02:21:14.700 policies, government funding is a reflection of the constituents. And I just came to realize this

02:21:21.440 full well in this trip, because some of these people say, well, the government funding, a lot of these

02:21:26.780 administrative requirements, these beneficiary organizations have become more stringent and

02:21:31.740 more difficult because governments require these things because they're accountable to their

02:21:35.760 constituents. Their constituents are saying, why are you sending so much money to Africa? They're

02:21:38.820 wasting it or it's a waste of money. So to give the money out, the constituents are holding the

02:21:44.320 politicians' feet to the fire. If the constituents were a little more open and said, look, let's help out, 0.99

02:21:49.840 let's, let's be aware of what's going on and try to help some of these people get out of their misery so

02:21:54.420 they can eventually help themselves through education, better health, all these sorts of

02:21:58.540 things that would free the politicians up a bit to allow more resources to go out and to more,

02:22:04.220 more aid and other things, more benefit to give them. I mean, the goal in all this stuff is eventually

02:22:08.660 let these people who are beneficiaries now stand in their own two feet, maybe in the next generation,

02:22:13.460 next go around. This cycle of aid, I mean, everybody knows a cycle of aid and dependency is, is,

02:22:18.600 is a bad thing. Great. But how do you get out of that? So what are some creative ways we can do that?

02:22:23.400 But you can't do anything without some help at this point, but geared towards getting these

02:22:29.080 people to stand in their own two feet. Talk to me about food. I heard a funny story once that,

02:22:33.640 is there a word for food in Huba? Like it, it's like it.

02:22:39.380 Gumo. So, you know, Nuba has, uh, I don't know, like 99 different languages amongst the Nuba people.

02:22:46.360 So does everybody speak Arabic?

02:22:47.980 Pretty much. Most will speak Arabic.

02:22:49.360 And you speak Arabic?

02:22:50.020 Yeah. I speak, I mean, Shwaya. Yeah. Shwaya, Shwaya, Shwaya. The thought of my wife's language

02:22:55.400 is Tira. And this came from her. The local word for food is Gumo. And I would say, what did you

02:23:01.740 have for supper last night? And she said, well, I had food. I said, what kind of food? She said,

02:23:06.460 no food. What, what are you talking about? I had food. I said, what kind? I said, well,

02:23:09.520 I had Acida, you know? Acida is the kind of the, it's like a cake made out of sorghum,

02:23:13.940 kind of ground sorghum boiled. I mean, just totally tasteless. She loves it. You know,

02:23:18.180 say, oh, I have to have my, my Acida. So for them, the word food and, and this Acida is synonymous.

02:23:24.720 There's so little variety.

02:23:26.260 So little variety of foods.

02:23:28.180 So what do you eat?

02:23:29.540 First of all, what did you weigh? Cause you were a nose guard in college.

02:23:33.320 Right.

02:23:33.500 I've seen pictures of you. You were huge. What did you weigh in college?

02:23:39.360 In college, I was two 30 and this was 1985. I weighed two 30.

02:23:44.700 And what did you, yeah. What did you weigh when you arrived in Kenya in 2000?

02:23:49.460 Probably around one 90, I would guess.

02:23:52.560 And what did you weigh by the time you got to Nuba?

02:23:55.580 Oh God.

02:23:56.220 In 08.

02:23:56.860 Then maybe 170. And I got down, I was down about 150 up until recently. Now when I've come out for the

02:24:03.080 past month, I think I've gained about 20 pounds. I was down to about 150.

02:24:06.200 You've gained 20 pounds in the United States in a month.

02:24:08.780 Yeah.

02:24:09.100 So you were down to 150 pounds a month ago.

02:24:11.560 Yeah.

02:24:12.140 Talk to me about what you eat.

02:24:13.760 Well, that's the thing. I, I, I eat, but my wife makes the food there. So is this food.

02:24:18.480 This is the, what did you eat before you got married?

02:24:21.340 Then I was living on the hospital compound. So we'd have a lot of, um, they would send them

02:24:25.380 food in from Kenya normally, like once a year they'd send food in. So usually rice, uh,

02:24:30.220 kidney beans, some kind of lentils. So we'd have that every day. Once I'd have chicken,

02:24:34.980 but usually it was just kind of rice and beans kind of stuff. So now when I got married and

02:24:38.740 moved off the compound, my wife makes a sassita and she has some sauce on top of it. So the

02:24:44.620 main sauce is this okra. Okra grows pretty well. They take okra, they dry it and they pulverize

02:24:50.100 it in the powder. They mix that in with water and some other stuff. And it makes like a really

02:24:54.340 slimy sauce that you pour over the sorghum paste and it tastes about as good as it sounds. I mean,

02:25:00.700 it's really pretty bland. Where's the protein?

02:25:05.420 You know, I think the sorghum actually has a high protein level. I think it's a grain.

02:25:09.540 And I'm saying that because the people are, are pretty, are pretty muscular. Like that's what they

02:25:15.680 eat. They eat that and they'll have maybe some sorghum porridge in the morning. And that's pretty

02:25:20.340 much it for the day. And I mean, a few peanuts, they have peanuts too, but not huge numbers of

02:25:24.380 peanuts. What about fruits or other vegetables? For fruits, there are seasonal. So you can get

02:25:30.100 mangoes for maybe two or three months out of the year. You know, a mango season is there. There are

02:25:35.260 tons of mangoes. Then they, when they're gone, they're gone. You don't see a mango for several

02:25:38.860 more months. Then there's two seasons for mangoes usually, but it varies quite a bit year to year.

02:25:44.080 So mangoes are there periodically. Lemons you can get for fruits. That's about it.

02:25:50.560 Oranges are not there. You know, pineapples. Are there tomatoes and tomatoes are there for

02:25:55.720 a couple of months, sort of towards the end of the rainy season. You can get tomatoes and you get

02:26:00.320 some, some greens. They grow a few kind of greens there and they'll put that on top of it. Like

02:26:04.620 even the tomatoes will kind of cook up a bit and then make the, uh, okra slime to it and put that

02:26:09.900 over the, the seed up. That's not bad actually. We'll have that quite a bit. Or the other thing we'll

02:26:15.340 have during the rainy season is milk. Also milk is only there for a couple of months.

02:26:19.320 The cows will only give birth during the rainy season and that therefore they're only lactating

02:26:25.060 during the rainy season. So they'll get milk sort of towards the end of the rainy season,

02:26:28.340 those last couple of months. And since there's no refrigeration, most times we'll have it sour,

02:26:34.800 sour milk. So we'll get the, get milk out, let it sit for a while and become sour. And that'll

02:26:38.860 also decontaminate it a bit. There's a lot of brucellosis there. And you take the sour milk,

02:26:44.180 which is kind of curdled and, you know, I think people have had sour milk before and you pour that

02:26:48.140 over the aceta, over the sorghum paste. It just doesn't sound tasty. It's not very good. It's

02:26:54.340 really, it's, you kind of eat it and you're like, oh man, you know, the problem is you eat it, you're

02:26:58.280 kind of hungry a bit, but there's no way you're going back for seconds. Like, it's like, okay,

02:27:01.920 that was enough. It's kind of go to bed, you know, or go back to work. It's like, okay,

02:27:06.780 because I'm finished. My wife really, she does a great job cooking with what limited resources we 1.00

02:27:12.200 have, but it's pretty stark. Is there a food that you particularly looked forward to having when you

02:27:17.840 knew you were coming to the United States? Yeah. Like you're Italian, right? Yeah. So pizza, 0.54

02:27:23.220 eggplant parmesan is my favorite food in the world. So my sister made that when I was down there.

02:27:27.780 Hamburgers, I just crave cheeseburgers, like just a good sandwich, you know, with some chicken

02:27:31.980 sandwich or something. Is this really nice with a good bread? You know, this kind of stuff.

02:27:37.320 You've been sick when you're there. I mean, how many times have you had malaria?

02:27:41.620 Well, I've been there 10 and a half years, so I've gotten malaria every year, except for 2018.

02:27:46.440 How bad is malaria? It sounds awful. It's pretty bad. I mean, you, sometimes you're wishing somebody

02:27:51.220 comes in and just shoots you and puts you out of your misery. It's, it's, you're, you're pretty sick 1.00

02:27:54.220 with it. It's worse than influenza, right? Yeah. And influenza, anybody who's actually had the flu

02:27:59.900 will attest, that's 10 days of really bad living. Yeah. Larry's pretty miserable. I mean,

02:28:06.080 real bad headache, nausea, vomiting, you can't sleep, just high fevers, body aches,

02:28:11.520 terrible body aches. And sometimes you get a bit lucky, you take medicine, you're, you're over it

02:28:15.740 in a few days, but you know, a lot of times it'll drag on for a month. But you don't take prophylaxis

02:28:21.040 throughout the year, just, or during the rainy season, which I'm assuming is when it's endemic.

02:28:24.780 Right. I don't, I don't take prophylaxis. Just because of the cost and.

02:28:28.180 Um, yeah, I just don't want to take the drug. I just want to say, okay, let me just not take

02:28:31.580 it. Take it once you get it. Right. Once I get it, sometimes it'll drag on a bit longer. I mean,

02:28:36.300 sometimes you get it just for a month. You take the medicine, you feel a bit better for a couple

02:28:39.440 of days. Then next evening you start feeling the chills and shaking and the headache comes again.

02:28:44.360 And it's like, oh gosh, still with me. It can really drag on for a long time.

02:28:48.720 So every year you've got it. Every year. That was in a coma a few years ago.

02:28:52.360 So just, uh, God, it was a strange night or I started feeling sick the night before. It's

02:28:58.700 on a Tuesday night. And I started taking, I took some oral drugs. I think I caught them,

02:29:03.400 which is, um, seen in derivative. Took that at night. I went to bed, just kind of had a kind

02:29:08.780 of fitful sleep. And then I woke up the next morning and all these staff were in my room.

02:29:13.060 And I have an IV in my arm and I'm an IV quinine. Like what, what's going on here?

02:29:17.740 The doctor needed treatment. That's right. But I was really out of it. That was like 11 o'clock

02:29:22.980 when I woke up and I was really, you know, they tried to get me up in the morning. Some of the

02:29:26.040 staff, cause I was in the operating room day on Wednesday. And, uh, our guy, that's our assistant

02:29:30.700 there. I didn't show up. I, you know, for the, I was on there by seven 30 and I didn't show up.

02:29:35.840 So he came up to the room. He tried to wake me up and I couldn't get up. Like I didn't respond to him.

02:29:39.960 So he thought I was dead. He was like, Hey, people can't run in. Anyway, I didn't die. So

02:29:45.380 I just, uh, I was out of it for quite a while, but then I recovered pretty quickly.

02:29:49.500 I can't even imagine. I just, I can't, when you think back, Tom, about all of the people you've

02:29:55.140 taken care of in the last 10 or 11 years. So just even just limiting it to, to the time in Nuba,

02:30:01.720 is there any one particular patient that just stays with you, that haunts you one case,

02:30:07.780 one story, one child, one adult. I mean, I have those stories. I've got one or two,

02:30:13.240 three, probably three stories that have stayed with me from my training.

02:30:17.180 Right.

02:30:17.560 That if I even think about these patients, I'll tear up. I mean, just, you know,

02:30:21.280 they're unfortunately they're all bad outcomes is the ones that, but they're also, they're not like

02:30:27.140 the only bad outcomes I've seen, but there's just some, there was some emotional connection

02:30:30.220 that happened. And then it's maybe it's sometimes you're projecting what's happening there onto your

02:30:35.160 own life or something. But do you have those cases?

02:30:37.300 Yeah. Probably like you, the ones you really remember are the ones that have bad outcomes

02:30:40.780 or ones that didn't go well. Gosh, we had one kid. I remember he, he came in on a Sunday morning

02:30:47.100 and he had been the Antonov bombed in the shrapnel and went in his face and just tore his face to

02:30:53.120 shreds. And he went to some clinic somewhere and they, they put a few stitches in it, like chromic 0.98

02:30:57.120 stitches. And it came a couple of days after that and his face was just mangled. So we took the

02:31:03.220 stitches out and it was all just pus and dirt coming out. I mean, just, they didn't clean

02:31:06.620 the wound out. So we took all these stitches out, cleaned the wound out. Well, put them

02:31:09.680 on some antibiotics. A couple of days later, we go in, he's got high fever and he can't

02:31:14.780 swallow. I'm like, no crap. He's got, he's got tetanus. So we kick his tetanus. I remember 0.92

02:31:19.120 the day before then, I remember the Antonov came overhead. The Antonov is the airplane that

02:31:23.640 bombs. And we saw the kid, he was like a, maybe 10 years old. He was standing against the

02:31:28.340 wall, just shivering when he heard the airplane, just shaking. He was so traumatized.

02:31:31.360 He was so traumatized. He was shaking like this. Then like the next day, he gets a real

02:31:35.600 high fever. He can't swallow. He put him in isolation, put an NG tube down to feed him.

02:31:39.580 And he just died from tetanus. Like overnight, he died from tetanus. And I remember this kid's

02:31:44.340 face and how, and I said, what the heck? It was a 10 year old kid with this thing.

02:31:49.440 We had another kid, this was a few years ago. He was, he was bombed, he and his aunt, and

02:31:54.920 it was an incendiary bomb from the Antonov. And I don't know what they had, napalm or whatever,

02:31:59.580 but it bombed him. It just, he had, I don't know, he had third degree burns on probably

02:32:04.200 60, 70% of his body.

02:32:05.980 And he lived.

02:32:06.260 Is that even survivable?

02:32:07.900 No. He lived like two months with this and both he and his aunt were the same. And I mean,

02:32:12.000 we tried everything with these kids. The amount of work the nurses did every day just to try

02:32:17.820 to address him and the agony he went through before he died. I remember, you know, this,

02:32:22.520 his aunt would have these scabs. And I remember there were, there were, her eye was,

02:32:26.860 was burned with this thing. And I remember there were maggots coming out of her eye, 0.98

02:32:31.000 you know, I think, what, what the heck are we doing? You know, this is crazy. What, what,

02:32:36.820 who are these? These are civilians. Burned to death. You know, there were other, six other

02:32:42.140 kids that were in an area that was being shelled. So they would shelled their village like all 1.00

02:32:48.760 night and then they would bomb during the day. So they were at nighttime, they would sleep

02:32:52.740 in the foxholes for protection. So right next to them was a straw racuba, kind of a straw little 1.00

02:32:58.400 structure. So the artillery shell fired and hit the racuba thing burst. It was just like a kind

02:33:03.960 of lean to with made of grass and wood. It set this thing on fire and it fell into the foxhole.

02:33:10.760 And there were, I think, nine people in the foxhole all sleeping. Three were burned to death

02:33:15.000 immediately. Six of them came to the hospital with varied degrees of, of burns. I mean, a couple

02:33:21.660 were just like 80% full thickness burns. I mean, just, they lived for quite a while before they

02:33:26.600 died. Two of them, one girl started improving. They developed tetanus and died from the tetanus.

02:33:33.380 So these are ones that really kind of stick out. Maybe one of the soldiers I remember best is a guy

02:33:37.980 that he was a guy that I told you before he had 23 or four holes in his intestines. We opened him up

02:33:43.160 and we just, I mean, hours we operated in this guy. Post-op, he was doing great. I mean, he was

02:33:49.040 cruising, started feeding him. He was set up in bed. The next time I'm called down to see him, he's

02:33:53.040 changed condition, as they say. And I went down there, he's already dead. He was a, he was a, he was a

02:33:57.960 Darfur. He was fighting with the Rebels. And I just remember thinking, you know, what, what would

02:34:03.580 this like for his, like, this guy's got a family, you know, he's fighting in this place. His family's

02:34:08.480 somewhere in Darfur. What's happening? Do they have any idea what's happening here?

02:34:13.160 So many terrible things. You know, there was young, one young kid, he was about 16 and he,

02:34:19.620 the Sudan army was encroaching on our area. So the rebels ran out there to kind of repulse them.

02:34:25.300 And then people just kind of jumped on the vehicles to go out and fight, you know? So this kid just

02:34:29.960 jumped on the vehicle. He didn't have a gun, any weapon, anything. It was just a, he was a civilian.

02:34:33.380 He goes out there, he gets shot in the head with, with, you know, machine gun or something. He comes in

02:34:39.260 with, with, you know, part of his skull missing and his brain tissue kind of pulsating out.

02:34:44.480 I mean, he survived for two or three weeks like that. You know, he had steroids and different

02:34:48.380 things, antibiotics, try to count things down and ended up just kind of going south and dying.

02:34:52.640 So these are all, all people I'll never forget. And there are many, many, many beyond that.

02:34:58.120 If people want to get involved in any way, shape or form, where would you recommend they,

02:35:02.920 they look to as, as a resource?

02:35:05.100 I think like an African-American healthcare foundation, there was something on their website

02:35:09.180 about the hospital. That's one source to go to.

02:35:12.360 And their website is sort of...

02:35:13.900 It's amhf.us.

02:35:16.000 Yeah.

02:35:16.220 www.amhf.us.

02:35:18.540 So that's a pretty good source to start.

02:35:20.280 There's a group called Take Heart Foundation, which was set up to kind of, to harness the,

02:35:28.020 whatever support to be through the Heart of Nuba movie, which was made by my friend, Ken Carlson.

02:35:32.620 Which I recommend everybody watch it. I think it's a, um, I'm sure it was done on a shoestring

02:35:37.640 budget, but it's so well done. Yeah.

02:35:39.760 You know, it just sort of speaks for itself.

02:35:41.380 So anything raised through them goes to African-American healthcare, which comes to us without 0.93

02:35:45.340 anything taken out. Catholic Medical Mission Board is another good source.

02:35:48.960 That's my, they're my sponsoring organization. They're here in New York. They've been here for,

02:35:53.540 I think, over a hundred years. And their cmmb.org, I think is their website. These are probably the

02:35:59.480 main sources for our work at Nuba.

02:36:01.440 You know, I'll close with a story, Tom, that I think in many ways kind of defines you.

02:36:05.520 I remember, um, when I decided I wanted to go to medical school, I was applying for this

02:36:11.580 scholarship. And in the end, I didn't get the scholarship, but I remember during the interview,

02:36:15.260 this guy asked me a question. He said, you know, what do you want to be? And at the time,

02:36:18.940 when I went to medical school, I wanted to be a pediatric oncologist. And, uh, I know what the

02:36:23.760 guy was doing in retrospect. I mean, I think he was just trying to push me. And he basically said,

02:36:29.560 like, why would you want to do that? You can't possibly make a difference, you know, without

02:36:34.760 dedicating your life to research, you're not going to have a difference saving one kid's life at a

02:36:40.160 time, et cetera, et cetera. And, you know, I remember thinking of a story after, which in

02:36:45.040 many ways exemplifies you to an extent that probably no one else, which is, you know, in

02:36:50.040 medicine, you can do two things, right? You can, you can do something very scalable through research.

02:36:55.440 You know, you can devote yourself to, to working on, you know, treatments for cancer or developing a

02:37:01.720 new drug to treat this disease or that disease, or you can be on the front lines trying to save one

02:37:07.360 life at a time. So the story is there's these two guys walking down the beach and it's after really

02:37:12.720 high tide and the beach is covered in starfish and the starfish are going to die pretty soon if they

02:37:17.820 don't get back in the water, which means they're pretty much all going to die. The two guys are

02:37:21.280 walking and every few steps, one of the guys bends down as he picks up a starfish and he throws it back

02:37:26.280 in the water. Five steps later, he does it again and again and again. After like the 10th one, the one

02:37:31.480 guy says to me, he goes, what are you doing? And he says, well, you know, if these starfish don't get

02:37:35.580 back in the water, you know, they're going to die. And he goes, have you looked and seen how many of

02:37:40.700 them there are? You can't possibly make a difference. And he throws another one in the

02:37:45.640 water and he says, well, it made a difference to that one. Right. And I think for doctors that

02:37:50.900 don't have the privilege of being able to affect the larger through research or policy changes,

02:37:57.400 whatever, for people on the front lines, I don't think there's a human being on this planet who

02:38:01.400 throws more starfish back in the water than you. In the end, medicine is individual. It's the beauty

02:38:08.040 of our profession. And it's a huge privilege to have the, the opportunity to affect one person.

02:38:15.800 And in the end, you close the door and it's you and the patient, whether you're in Nuba mountains,

02:38:20.380 whether you're here in New York, and that's an incredible privilege. And I think if we keep that

02:38:25.040 focus, just one person at a time, I think people can kind of relax a bit. You can see that what

02:38:32.020 you're doing for that one person, you know, I think people look at Africa and say, you know,

02:38:35.380 what you're doing is a drop in the ocean. I really liked that story because when you're there,

02:38:39.980 you don't see a drop in the ocean. You see a person, you see a life, you see a life and you see

02:38:44.320 somebody that, that can laugh and can cry and can play and can, you know, has aspirations and is a

02:38:51.200 living, breathing human being. I think, man, we helped this one person. That's a huge thing,

02:38:56.200 you know? And I think that helps to stave off some of the burnout and the cynicism.

02:39:01.660 The fact that you are, this is a very individual thing. So one person is really a big deal. It's

02:39:07.380 everything to that one person, that one person's family. And, uh, I think we really have to keep

02:39:13.900 that in mind, especially with this growing realm of cynicism and sort of negativity that we see now.

02:39:19.860 Tom, I have been wanting to meet you for three years. I didn't know that I'd ever get a chance

02:39:25.680 to. So it's, it's sort of beyond a privilege. And I know that for you being outside of Nuba is

02:39:33.040 the toughest thing imaginable, which is of course the irony sitting here in the plush New York city.

02:39:39.400 And yet all you're doing is pining to go back to a place where your own life is in danger.

02:39:45.200 But, you know, I remember thinking, God, I really just, I'd love to be able to interview Tom. And I

02:39:48.920 remember thinking there's no way he could justify making the time to do this when his time in the

02:39:54.040 U S is so short. So when I asked Rick and Mark and John, and they said that Tom would be happy to sit

02:40:00.220 down. I just, I couldn't believe it. And I might make the case that of all the interviews I've ever

02:40:04.760 done or will do, this is the one I feel most privileged to. So thank you. Thank you so much.

02:40:09.280 Yeah. Thanks, Peter. This has been a real privilege for me to be here with you. And thanks for

02:40:13.460 giving us the platform to spread the word a bit. Thank you so much.

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The Peter Attia Drive - February 11, 2019

#40 - Tom Catena, M.D.： The world's most important doctor – to nearly a million patients – saving countless lives in the war-torn and remote villages of Sudan

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