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Third-World Surgeon

Last summer a laparoscopic surgeon from New York City named John de Csepel traveled to West Darfur, in the African nation of Sudan, to perform surgery on the war-ravaged populace there.

One day in early June, his operating room at Zalingei District Hospital was particularly chaotic. Together with his team, he repaired two obstetric fistulas, extracted a bladder stone, cut away the bad tissue from three wounds, corrected two cases of heavy vaginal bleeding and delivered two babies via emergency C-sections. He was preparing to do a hernia repair and a skin graft when the sterilizer broke down. De Csepel wrote in his journal, Having run out of clean instruments, gowns and drapes, we were forced to cancel these operations. It was at this point that three gunshot wound patients arrived.

The shotgun victims had appeared out of the dusty landscape surrounding Zalingei, a town of 40,000 that has swelled to three times that size with refugees from burned-out villages who are crowded into makeshift camps on the outskirts of town. Zalingei District Hospital is a series of one-story whitewashed buildings set in a patch of dirt. There’s no electricity, just a generator that sometimes cuts out without warning. There’s no MRI, no CT scan, no lab for blood tests. There’s no anesthesiologist. Patients get an intravenous sedative but are awake and chatting during even the most invasive operations. I am still getting used to the occasional kick during surgery, de Csepel jotted down in his journal. The nurses, when he got there, had no idea how to take vital signs or change a dressing. The one diagnostic tool at de Csepel’s disposal, other than his own senses, was an X-ray machine, but it wasn’t a very good one. Sometimes the only way to figure out what was wrong with a patient was to slice him open and poke around inside.

For the gunshot victims, nomads who had driven their flock too close to a rebel army camp, their appearance alone was sufficient for diagnosis. One man had been shot in the hand and lost a small chunk of flesh. Another had suffered a shot to the leg that shattered his femur just below the hip. The third had taken a blast to the mouth. There was a gaping hole in his cheek, and half of his lips was missing, along with most of his teeth. I almost never get grossed out anymore, but this one was hard to take.

The outcomes, however, were really pretty good. The man with the wounded hand would lose only the use of a thumb. The man with the shattered leg, who would have received a high-tech rod or plate in New York, got a rudimentary traction device using a screw in the knee, a pulley and a sandbag to draw the leg back into line. After six weeks, he might possibly begin to walk again. As for the man with the ruined mouth, he would never look pretty, but de Csepel, after multiple operations, managed to sew his lips back on his face.

Yet there were dispiriting cultural wrinkles de Csepel hadn’t counted on. The man with the shattered leg? Shortly after his operation, his friends spirited him away with the intention of handing him over to a traditional healer.

De Csepel could only shake his head; he knew the man would never walk again. Sudanese often turn first to healers, and as a result, Western-style doctors tend to see people late in their illnesses, often too late. We operated yesterday on an eight-year-old boy with late-stage osteomyelitis, an infection of the bone. His tibia was so necrotic that it came out in chunks.

Ah, Darfur. But de Csepel had asked to come. In 2005 he undertook a lengthy application process to become a volunteer with Médecins Sans Frontières, or Doctors Without Borders, a medical relief organization with a presence in seventy countries. Finally he was rewarded with a seven-week mission to one of the most fractured, hopeless places on earth. What’s happening in Darfur can’t be boiled down into a line or two. Ethnic strife has long riven this region of desert and sparse grassland the size of Texas. But open warfare began in 2003, after the Sudanese government authorized Arab militias to quell bloody tribal uprisings. (Sudan is a Muslim country, but tensions have long divided ruling Arabs and tribal Africans.) Reports of indiscriminate rape and murder followed; villages were looted and burned to the ground, and refugees fled in droves across the border to Chad or to “internally displaced persons” camps sprouting up outside the larger Darfurian towns. Colin Powell and others used the word genocide to describe the situation in Darfur. Médecins Sans Frontières, however, must sometimes put things more delicately. In the case of Darfur, MSF scrupulously avoids politically freighted terms like genocide in order to avoid giving problematic offense to its host government; getting kicked out would only multiply the suffering.

Last summer wasn’t an absolutely horrendous time to visit Darfur. One of three rebel groups had just signed a peace accord with the government in Khartoum, and hostilities went into a brief lull. (De Csepel’s surgical predecessor had had to treat rebel soldiers behind enemy lines and half-expected not to make it back alive.) Still, Darfur remained an incredibly dangerous place. Fighting, drought and disease had claimed 400,000 lives since early 2003, millions more had been displaced, and the desert outside the government-controlled towns continued to be the province of rapists and murderers (and Kalashnikov-toting children) whether one called them bandits, rebels, militia or soldiers.

De Csepel, a self-effacing man of forty-two, has short graying hair, a boyish face with dark, watchful eyes, and the fit build of an inveterate runner. As a single man with a paid-off Manhattan apartment, he implies that his relatively footloose life cleared him for his Darfurian adventure. Yet the evidence also shows a growing attraction to humanitarian work. The son of John and Lennie de Csepel, he grew up in Riverside and went to Greenwich High School. After graduating from Georgetown, he first went to work in that great East Coast Sodom, Wall Street, and then in that great West Coast Gomorrah, the entertainment industry. He doesn’t pretend that finance and show biz were beneath him, though it’s quite clear that neither was a consuming faith. His form of promiscuity ran toward the medical, and he spent his free hours volunteering in the very busy emergency room at Cedars-Sinai Medical Center in Los Angeles.

At length he discovered that surgery was his calling. By the time he applied to Médecins Sans Frontières, he was chief of minimally invasive surgery at St. Vincent’s Hospital in Manhattan. His specialty, laparoscopic surgery, entails the use of a tiny camera threaded into the body, which transmits an image to a television monitor. He’d make a small incision, insert specially designed tools and resect a colon, say, or remove a gallbladder.

That no fancy equipment would be available to him in Darfur hardly phased de Csepel. “Laparoscopic surgeons are general surgeons, and they have to be quite comfortable doing surgery open before they do it laparoscopically,” he explains. “Open meaning the old-fashioned way, where you make a large incision and put your hands inside.”

Still, the Western mind can’t help making certain assumptions. During a Paris layover, de Csepel amused the MSF staff by asking what type of electrical outlets they used in Zalingei. And on his arrival, Darfurian realities kept on taxing his New York imagination. Zalingei International Airport (as de Csepel liked to call it) was an open swath of desert with a single sad-looking tree and a tumbleweed bumping past. The MSF residence had no electricity or running water. Camels were ridden out of the mountains to market, a Biblical-scale sandstorm blotted out the sky and ripped down huts, and 100-degree days and nights oppressed every living thing, though the Sudanese kept drinking their hot tea and the French kept smoking their cigarettes.

The operating room was clean and bright, but boiling under the generator-driven lights. I drink three to four liters of water through the day, as I sweat so much in the OR that I drench my scrubs with each case. The surgical staff at his disposal, except for an improbably skillful ob/gyn named Dr. Saleh, consisted of two amiable but not quite passable Sudanese internists “who like to operate.” Early on they nearly drove de Csepel mad with frustration. One was not wearing a mask or hat. The other neglected to wear a gown and was sweating into the wound.

I repeatedly lectured them on the importance of sterile technique, but they just kept chatting in Arabic amongst themselves.

One of his first patients gave de Csepel a clear indication of his value in Darfur, where he was the only trauma surgeon for hundreds of kilometers and half a million people. De Csepel had completed the third of six surgeries scheduled for the day when a doctor helping with surgery said nonchalantly, “By the way, you might want to look at that guy — he was stabbed.” The man lay on a gurney outside the OR.

“When was he stabbed?”

“About a day ago.”

In the middle of a war zone, it isn’t easy to get to the hospital; doubtless many died before completing the journey. De Csepel peeled back the dressing to find a slash wound that had cut clear through the man’s abdominal wall. His bowels began spilling out and looping toward the floor.

“Hold off on the next patient,” de Csepel called out. “We’ll take this one in.”

He made the large midline incision necessary for a trauma exploration, expecting to find serious, possibly fatal, organ damage. “I found I could sort of retrace the path of the knife,” de Csepel recalls. “It had just missed his kidney. It had just missed his aorta. It had just missed his colon. It had just missed his pancreas. A complete miracle! I just sewed him up and we discharged him from the hospital two days later. Sometimes you get lucky.”

More often you don’t. A twenty-eight-year-old man was admitted after bullet fragments caught him in the chest, thigh and gut. The wounds looked rather unassuming, or so thought the doctor on call in the men’s ward. The results of a simple chest or abdominal X-ray would have dictated an urgent trip to the OR, but none was done.