Daniel D. Galat, MD, (center) and local surgeons operate on a patient at Tenwek Hospital in Kenya.
Courtesy of Daniel D. Galat, MD


Published 10/1/2016
Douglas W. Lundy, MD, MBA

Orthopaedics in Kenya: Trauma and Tea Time

An interview with a medical missionary
Many U.S. orthopaedic surgeons like myself volunteer for short-term assignments in underserved areas. But few decide to devote their lives to serving the poor of another country. One of those orthopaedic surgeons is Daniel D. Galat, MD, whom I met through mission work in Africa.

Early in his training, Dr. Galat realized a calling to work in rural Africa helping the poor. As I got to know him better, I found his story of selfless dedication to helping the underprivileged absolutely inspiring. I hope that my interview with him encourages and inspires you as well.

Dr. Lundy: Why did you choose to go to Kenya rather than work in the United States?

Dr. Galat: I started medical school with the intention of one day using my skills and knowledge overseas in a medically underserved area. As a fourth-year resident at Mayo Graduate School of Medicine, I traveled with my wife to Kenya, supported by the Mayo International Health Professions Scholarship. During that 2-week trip, we were introduced to Tenwek and Kijabe Mission Hospitals, and caught a vision of what life and work would look like overseas.

I was most struck by the incredible need for more surgeons to care for the huge volume of cases that inundated these hospitals. Back then, Kenya had about 50 orthopaedic surgeons for the entire country of 40 million people. I decided I would be more effective in this medically needy environment than in the States.

Dr. Lundy: What is Tenwek hospital like?

Dr. Galat: Tenwek hospital is in a rural area of Kenya and serves a surgical population base of more than 8 million people. The hospital has 300 beds and is always full to over-capacity. At any given time, the orthopaedic inpatient service averages 50 to 70 patients; in the outpatient clinic, we see, at times, more than 100 patients a day.

Two operating rooms [ORs] are dedicated solely to orthopaedic surgery, and 6 to 10 procedures are performed daily. Although the hospital is equipped with modern technology such as a CT scanner, C-arms, X-ray, and lab, it (along with other hospitals in developing countries) faces daily challenges, ranging from equipment breakdowns and implant acquisition to low resources in general. The most critical resource is OR space, because we often have 30 or more patients waiting for surgery.

Dr. Lundy: What are the most common procedures that you perform?

Dr. Galat: Trauma makes up about 85 percent of our caseĀ­load, mostly due to road traffic accidents, which are epidemic in developing countries. Most trauma patients are severely and/or multiply injured; many have open, pelvic ring, or acetabular fractures. We also see a large number of late-presenting malunions and nonunions, with and without infection. Tenwek also has a growing adult reconstruction practice, and we perform many hip and knee replacements on patients with severe osteoarthritis and deformity.

Dr. Lundy: What are the most unusual cases that you see?

Dr. Galat: Among the most unusual cases we see are patients with massive neglected bone tumors. These situations are sad because often, all we can offer is an amputation; limb-sparing surgery and chemotherapy are challenging in our environment.

One young man had a massive proximal humerus osteosarcoma, the size of a small watermelon. He did not seek medical care until the tumor fungated through his skin and he couldn't bear the foul smell of necrotic tissue. We performed a forequarter amputation, sent the tissue for pathology, and then referred him to a large government hospital for chemotherapy. However, many patients like him do not have the resources to afford chemotherapy, and as a result, never follow through and are often lost in follow-up.

Dr. Lundy: How do you deal with the language barrier?

Dr. Galat: Kenya has two national languages, Kiswahili and English, so we are able to communicate with staff and many patients in English. Also, we are required by our mission agency to learn Kiswahili, so I am able to communicate on a basic level with patients. However, many older patients speak only their local vernacular, so local staff workers translate. Unfortunately, many key instructions and important points are often lost in translation.

Dr. Lundy: What is the most beneficial cultural issue for you and your family?

Dr. Galat: The Kenyan people are some of the most beautiful and joyful people I have met, and it is a privilege to work with the Kenyan staff on a daily basis, learning their culture and sharing our culture with them. It seems they have learned to be content with less, unlike our culture (including myself). Yet, even with less, the Kenyan culture is one of community, giving, and sharing with others. Relationships are more important than productivity, and on my walk to the hospital every morning, I have to stop and greet each person I meet along the way.

Dr. Lundy: What is the most difficult cultural issue for you and your family?

Dr. Galat: Because relationships are more important than productivity, it is challenging to run a Western-style orthopaedic department. For instance, during tea-time (every day at 10 a.m.), I have, at times, found myself alone in the OR finishing a case while the staff is in the break room sipping a cup of chai. This highly relational culture can also take hours out of my wife's day because the people will frequently come to our door to visit or to request help. This is quite different from American culture, but it teaches us to re-evaluate our priorities and make relationships with others central.

Dr. Lundy: How do you keep up with technology advances?

Dr. Galat: We try to have the most up-to-date implant technology, but it can be difficult to obtain. Some of our implants come from local sources and others from donations from the United States. As a result, some of the equipment is older generation and not gold-standard for treating many cases. For instance, periarticular distal femur fractures are often treated with dynamic condylar screws and plates when the stock of locking plates runs low. For myself, I keep up with the latest technology by working in the United States when I am on furlough.

Dr. Lundy: What do you see is the biggest benefit for short-term orthopaedic surgeons serving in areas such as Kenya?

Dr. Galat: The biggest benefit for short-term orthopaedic visitors to our hospital is exposure to the needs in medically underserved areas. I get excited when I see short-term visitors catch the vision, and begin to think about how they may have a long-term impact in Africa. For example, they might sponsor a Kenyan trainee, help to acquire implant donations, donate to our needy patient fund, or provide teaching materials for our residents. The Kenyans say that once the red dirt of Africa gets under your skin, it is hard to wash off.

Dr. Lundy: What is the biggest need in musculoskeletal medicine/surgery in Africa at this time?

Dr. Galat: The world health community is beginning to recognize "global surgery" as a neglected public health crisis, and steps are being taken to remedy this problem in terms of funding and access to care. But without question, the biggest need in Africa right now is for more well-trained national surgeons. Tenwek started an accredited orthopaedic training program in 2014 that takes two national residents per year. My most important task is to train these surgeons well so that they can bring orthopaedic care to their own populations. National surgeons are much better equipped culturally to care for their own people than I am. But for this to happen, we not only need to train surgeons, but to train "trainers" of surgeons. In this way, our efforts will be multiplied to affect the greatest number of patients.

Douglas W. Lundy, MD, MBA, is a member of the AAOS Now editorial board.