Surgeons rebuild a face.

March 3, 2009

Twent years after being disfigured by a disease called Noma, Gadam had reconstructive surgery at the hands of a visiting team of Dutch surgeons. Gadam faces still more surgeries as he pursues his goal: “To look like other people”.

Mahosot Hospital - Vientiane, Lao Peoples Democratic Republic

In my previous journal entry, dated February 27, 2009, I described the way in which my friend Gadam was afflicted by Noma, an ulcerative condition of the mouth, sometimes described as “oro-facial gangrene”.  As promised, in this entry I will share the story of Gadam’s arrival at Mahosot Hospital in Vientiane, and how a team of surgeons worked to repair damage that he had lived with for more than twenty years.

From the age of about seven, Gadam has truly been a victim of Noma.  The disease not only disfigured him, it took control of his life.  The disease determined his level of education, his occupation, his place of residence, his choice of friends and his choice of wife.  Everyday, Noma determined how he would dress and what he could eat.  It removed from him the ability to issue a hearty laugh, or to shout in anger.  Only ten percent of untreated, childhood victims of Noma survive.  Noma left Gadam alive, to live among people, yet apart.  It demanded that he develop remarkable courage, yet left him afraid to show others his face.

For several years Dr. Leila Srour, an American doctor living in the far north of Laos and working for the non-government organization (NGO) Health Frontiers, tracked down Lao victims of Noma.  One by one she met patients, collected their life histories and documented their medical conditions.  Her research was eventually published in a medical journal and resulted in recognition that Noma exists in Laos, and that survivors of this cruel disease need help.  It was Leila who directed me to Mahaxai in 2006 to interview a young men disfigured by Noma, with the goal of adding his case history to her study.  That’s how Gadam and I became friends.

In December 2008 I was home from Laos, enjoying the holidays with my family, when I got an email from Leila asking me if I still had workmates in Khammouan Province who might assist in contacting Gadam and another young Noma victim from Mahaxai. (The other victim was Vongvilay, a 22-year-old laborer whose medical history was remarkably similar to Gadam’s).

Leila wanted to let the men know that a team of nine surgeons from the Netherlands, funded by the charity “Bridge the Gap,” would be visiting Vientiane for the purpose of evaluating, and possibly treating, patients in need of reconstructive surgery.  A window of opportunity was open, but just narrowly.  The Dutch team would be in Laos for just two weeks.  To be considered for treatment, the men had to present themselves at a particular room in a particular hospital on just one appointed day.  (No small challenge to villagers who had never been to a city as large and complex as Vientiane).  If they couldn’t find the place or arrived a day late, it might well be, “Better luck next time, if there is a next time”.

Minutes after receiving Leila’s email I dashed off an email of my own to Mike Hayes, my boss when I worked at Phoenix Clearance Limited, a bomb and landmine disposal company that has staff doing clearance work throughout Laos.  Mick’s a big hearted guy who has often approved using his company’s vehicles and staff to haul amputees or other disabled people from remote villages to Vientiane for treatment of one kind or another.  True to form, Mick dispatched a PCL employee to Mahaxai to locate the two patients and inform them about their opportunity.

Leila told us to not over promise in regard to treatment, since the decision to treat, or not, was up to the Dutch team.  But she did tell us to assure the two fellows that, whatever the team’s decision might be, a charity in Vientiane called the Woman’s International group, would reimburse them for their bus fare and would provide them with room and board while in the city.

After the PCL messenger (a capable young man named Kham) informed the men of the offer and discussed the working arrangements, I got the following email:

Dear Jim,

Yes, I found those two guys in Mahaxai.  When I told them about a doctor coming from a foreign country, they were excited and wanted to come to Vientiane.  I told them to come up on 7th January 2009.  The doctor is arriving Vientiane on 9th January 2009, right?

I said to them it would be great if they have any relative or cousin living in Vientiane so that they can stay with while waiting for the doctor.  If they don’t have anywhere to stay, they can go straight to Mahosot Hospital.  I also told them that they spend their own money to go to Vientiane first and someone will give them back for the travel expenses and food as well.

What they are worried about is that how do they know they will get the money back?  They are afraid they won’t be able to go back [home] if they don’t have enough money.  And also, once they arrive Vientiane who is going to deal with them?  Who should they contact?

Both of them really want their faces fixed up, so they will come to Vientiane in time.

Please answer to their questions so that they feel more comfortable.



And then, after sending Kham the requested information about the place to be and who to ask for, I got this optimistic email:

Good morning Jim,

Yes, the two guys are coming to VTE tomorrow (8th Jan). There will be 4 of them because they are coming with either their mothers or fathers.   As soon as they arrive, they will go straight to Mahosot hospital. They will give me a call if they have any problem so that I can direct them to the right place.



A couple of days after the scheduled evaluation I phoned Laos and learned that both Gadam and Vongvilay had made it to Vientiane, been selected for treatment and, in fact, were scheduled for surgery within hours.

When I returned to my work in Laos at the end of January, I called Leila and asked her to accompany me to the hospital so I could see the guys.  Leila welcomed my interest and said that my visit might encourage the fellows and cheer them up.  But, she cautioned me that I might not consider their current condition to be a pretty sight.

Before Leila and I entered the ward, she briefed me on all the patients that the Dutch team had treated.  I was surprised to learn that, in addition to several Noma patients, they had done reconstructive surgery on a girl recovering from an accidental gunshot wound to the face, and a boy mauled by a bear.

Of all the patients treated by the Dutch team, Gadam had required the most extensive work.  Leila told me that the doctors, prior to surgery, had informed Gadam, his wife, and his brother-in-law that there was a significant possibility that Gadam could die during the operation.

When I asked Leila whether that was a perfunctory warning meant to cover a remote possibility, she leveled a serious gaze at me, and made clear that Gadam’s two surgeries had been an ordeal for him and a challenge for his the doctors.  (During the longer of Gadam’s surgeries the team of doctors worked on him for twelve hours; he needed transfusion of seven units of blood.)

When I saw Gadam, a week after his second surgery, his face was again partially shrouded, not in his usual colorful scarf but in white medical bandages; his face looked as though it had been randomly cut apart and then sewn back together. While the holes in his cheeks were closed, his body was marked in several new places (scalp, forehead, shoulder, thigh and stomach) where doctors had harvested skin to graft over his facial wounds.

To my inexperienced eye, the most remarkable procedure performed by the doctors was the creation of a hose-like appendage that they fashioned out of Gadam’s own flesh to carry blood from his chest to the transplanted skin on his face.  This fleshy tube will remain in place, providing oxygen-rich blood to Gadam’s face, until his newly constructed right cheek becomes viable.

Still, if I looked beyond the many sutures, and the raw looking wounds from the grafts, I could recognize definite improvement.  In spite of having his frozen jaw sawn apart in two separate places, Gadam’s speech was only slightly more labored than I remembered from Mahaxai and, incredibly, his eyes looked bright  and optimistic.  He even acted happy to see me.  His warm greeting allayed my fears that he would confront me with, “What did you get me into!” hostility.

Vongvilay, had had just one surgery, and that procedure was less involved than Gadam’s.  He too was marked up badly (he could easily have been mistaken for the bear attack victim) but was well on the mend and nearly ready to be discharged.  Gadam, I was told, would need to stay in the hospital for a couple months and endure additional surgeries when the time was right.

Two weeks later, when I returned from my work in the countryside I checked on the guys again. Vongvilay was long departed for his village, but Gadam was there in the same ward where I’d left him but looking much improved. His sutures had been removed, his face was less swollen, and his color was good.  Someone who hadn’t seen Gadam before his operation, or immediately after, might not recognize improvement, but I was more optimistic than ever.

A lesson to be learned from the experience of the two fellows from Mahaxai is that, for uneducated people living in impoverished villages distant from medical care, the hope of curing them of Noma once the disease strikes, is probably a false hope.  The best course of action is to keep this opportunistic disease from occurring by helping villagers eradicate the conditions that permit it to appear in the first place.  Noma is not a tropical disease.  It once existed in America.  We didn’t conquer the disease by attacking a particular strain of bacteria, we eradicated Noma by fighting the root cause: poverty.

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