2024 | Volume 25 | Issue 3
Heart of Darkness1 , by Joseph Conrad describes Marlow’s journey up river to find an ivory trader named Kurtz who had gone rogue. Marlow found a place of pure evil, indiscriminate violence and death. This was Rwanda 30 years ago, my first deployment and the most challenging.
The story of the Rwandan genocide in 1994 is well known. Nearly 800,000 people were killed in 100 days before a UN peacekeeping force was deployed. Australia provided a medical support force including a small hospital2 . I deployed in 1995, not long after the Kibeho massacre. Indiscriminate killing and landmine explosions were still common.
My first day in Kigali, the capital of Rwanda, was instructive. Our specialist team met the outgoing team in the brew room, which was fortified with sandbags and barbed wire. Rwandan Patriotic Army troops jogged outside singing African songs. It sounded quite beautiful. I asked what they were singing.
“We will cut off the heads of our enemies”. Not quite what I was expecting.
Soon after, a young boy arrived having stood on a landmine. Both teams worked together amputating both his legs below the knee. I repaired his face and removed one eye. Rwanda was littered with landmines and anecdotally an Italian company made both land mines and protheses. They had the market sewn up.
Around midnight I operated on a perforated duodenal ulcer (DU). I performed a traditional operation, truncal vagotomy and pyloroplasty. There was no chance of follow up in Rwanda. Surgery had to be curative, or not at all.
Almost 40 per cent of all operations were done on children, including all the burns cases. Children were statistically more likely to suffer war injuries than adults. Women working in the fields with their child on their back were especially vulnerable to landmines. We did nearly 90 cases in 42 days. I assisted the orthopod, and he assisted me. Sometimes you took a leap of faith and operated despite your lack of experience. One case comes to mind.
A teenager presented in cardiac tamponade after being bayoneted and left for dead in a ditch. He needed sternotomy. This was ’see one, do one‘ territory. I had seen one cardiac repair and been a cardiothoracic Senior Resident Medical Officer. I had only done one sternotomy in an elective case, in a teaching hospital, with an electric sternotomy saw, under supervision. Glancing at a phone I wondered if I should call the boss, then realised I was the boss.
Using a bone chisel for the sternotomy I opened the pericardium as I had seen previously. I found a freely bleeding small left ventricular laceration, a moving target that I oversewed with nylon and pledgets. I copied the technique from a general surgeon in Albury.
After the drains were removed, the teenager absconded, staples in situ. Patients had been killed in their beds during the genocide. He wasn’t hanging around to be next.
Nuns asked me to see a 14-year-old disabled orphan with abdominal pain and distension. She was pregnant. Soldiers passing through the orphanage had raped many children. Heart of Darkness indeed.
My overall feeling in Rwanda was one of dread. I was constantly on edge. Wearing the UN blue beret offered little protection. Many Australian Defence Force colleagues had a far worse time of it. Some risked their own lives to save others. Some still suffer. Seeing slaughter on an industrial scale can do that to a person. Man’s inhumanity to man3 was on full display. Ancient grievances and tribal hatreds still drive wars today.
As Joseph Conrad’s Kurtz lay dying, he whispered to Marlow, “The horror. The horror.” Rwanda in a nutshell.
References:
[1] Joseph Conrad “Heart of Darkness” (1899) ISBN:014356644X, Penguin Press.
[2] Farrow GB, Rosenfeld JV, Crozier JA, Wheatley P, Warfe P. Military surgery in Rwanda. Aust N Z J Surg. 1997 Oct;67(10):696-702. doi: 10.1111/j.1445-2197. 1997.tb 07112.x. PMID: 9322719.
[3] Robert Burns "Selected Poems: Man Was Made to Mourn" (1784) ISBN: 0140423826 Penguin Classics