This essay was written in response to a prompt from the Consortium of Universities for Global Health soliciting writing that could "foster a culture of self-analysis, critical reflection, and cultural humility within the global heath community." The essay did not win anything, but I appreciated the opportunity to write about a topic I have pondered over the years. I am happy to share a few of my photos, as well.
My colleague is eager to hear about our annual two-week Kenyan ENT Camp and safari. “Welcome home!” she says. “Did you get photos of the Big Five?”
Lions, leopards, cape buffalo, elephants, and rhinos are the five large African mammals that were prized by white American and European big game hunters as trophy kills in the 19th and 20th centuries. Bagging the Big Five conferred bragging rights on the hunter and earned admiration back home. I open my phone and hand it to her.
“We came close,” I say. “No leopards this year, but lots of other animals.”
As she swipes through my photos, I share how great it was to work with our Kenyan otolaryngology friends again. Over the years, we have settled into a routine of teaching, learning, and capacity building. We conclude each trip with a two-night safari. I take lots of pictures.
On the first morning of ENT Camp, the clinic hallway is always packed. Patients and families travel hours carrying handwritten notes and battered CT scans believing we have something special to offer.
Clinic is hectic. Physicians, nurses, and medical students from the US and Kenya swarm between the office and the open examination rooms. Privacy is abandoned. We hold CT scans up to the windows. We find students who speak regional dialects and press them into service as interpreters. Patients share stories of longstanding nasal and sinus disease, persistent tongue ulcers, salivary masses, facial tumors, and draining ears. We take photos, explain options, and schedule surgical cases. We work well into the evening, plowing through the list with the local ENT specialists and selecting patients on whom we have time, expertise, and the needed surgical equipment to operate.
Most people’s problems are hidden. For some, though, the reason they have traveled to see us is obvious. We spot the huge goiters from across the room or down the hall. The surgeons glance at one another and nod, anticipating the satisfaction of wresting one of these enormous masses from a patient’s neck. For us, all thyroid surgery is interesting, but removing a huge goiter offers a special kind of conquest.
In developed countries, few people have thyroids large enough to be obvious. In the US, for example, glands are most often removed to treat thyroid cancer or to relieve breathing or swallowing problems. Most thyroid nodules are the size of grapes, and it is rare to remove a thyroid simply because it is unsightly.
In East Africa, however, the lack of iodine in groundwater and cassava—a starchy vegetable and dietary staple which interferes with the body’s iodine absorption—cause widespread iodine deficiency and, in some people, thyroid enlargement. During screening clinics each year, we see and photograph several people with masses the size of cantaloupes. Most are healthy young adults with no other symptoms. They ask us to remove their goiters because of the way they look.
Offering thyroidectomies in an under-resourced setting is not straightforward. Although the procedure can be challenging because of the size of the gland, the real issue is this: the more thyroid tissue removed, the more likely the patient ends up becoming hypothyroid. In a perfect world, hypothyroid patients take a daily thyroid pill for the rest of their lives and have periodic blood tests to adjust the dosage. Although the medication is relatively inexpensive in Kenya, many cannot afford even the few pennies per day it costs. Half of the country has no access whatsoever to essential healthcare services. Untreated, severe hypothyroidism can be deadly.
When our ENT Camps began many years ago, our Kenyan hosts were not comfortable performing thyroid surgery, but they were anxious to learn the techniques. Over the years, we removed several goiters during each camp, preserving as much normal thyroid tissue as possible to minimize the risk of hypothyroidism. Eventually, we asked several patients to return for testing and discovered that almost 40% who had undergone subtotal thyroidectomies in the past were now hypothyroid. Even still, the patients believed the surgery had improved their quality of life.
As a result of the study, we became more ambivalent about performing thyroid surgery during ENT Camps. Even though patients were happy to be rid of their goiters, we worried we were performing essentially cosmetic operations that carried long-term risks. We looked to our hosts—who, by now, were safe and independent thyroid surgeons—to choose patients who could understand the need for lifetime follow-up.
I was disappointed by our study’s results. I hoped none of our patients experienced permanent harm and worried about those who did not return for follow-up. We would have to be more selective about performing this operation I love. Yet, as the Ancients taught us, primum non nocere. First, do no harm.
My American friend continues scrolling through photos on my phone. A picture from the OR pops up showing a goiter the size of a softball. “Oh, my god! she says. “That is amazing.” She cups her hands, imagining how it must have felt.
I remember the case. The young patient had come to the screening clinic with a scarf clutched tightly around her neck. The morning after her hemithyroidectomy, she smiled as our team made postoperative rounds. Her neck was still a bit swollen but now had a natural contour. “Asante sana,” she said softly. Thank you very much. She nodded as one of the Kenyan physicians reminded her to return to clinic in a few weeks.
I chuckle as my colleague hands me my phone. “Yeah,” I say. “That was one of the bigger ones.” I stare at the picture before tucking the phone in my pocket.
I once viewed each goiter as a trophy, conflating the thrill of a perfect thyroidectomy with the big game hunter’s pride in bagging a rare and beautiful creature. We each returned after the hunt with evidence of our prowess to the delight of our friends and associates.
Of course, it was never about me. I know that. I hope our patient continues to return to clinic for follow-up.
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Trophies: Chasing the Big 5 (or 6) in Africa
