Feb 052012
 

The Balkan Airways flight left Heathrow early afternoon on a Saturday in 
mid-March, first stop Sofia. Here we had a lengthy wait before travelling 
on. The Russian aeroplane was efficient but drab. Sofia Airport transit 
lounge has a marble floor, chandelier lights, and just basic tables and 
chairs. But on the lower floor is the cheapest duty free in Europe�not much 
good if you are flying to an Arabic country. We were�via Cairo and in an 
aeroplane with steadily decreasing occupancy. We landed at Khartoum at 330 
am and all 40 of us got off. Khartoum Airport was little changed since I 
was last there in 1971 and slow. We finally reached the Acropole Hotel and 
welcome beds as it grew light. 
This trip was the first by a United Kingdom medical team to visit Eritrea. 
Two orthopaedic surgeons from Britain had been before� Peter Webb from 
Great Ormond Street and Robert Duke from Warwick, as well as a few 
orthopaedic visitors from various countries of western Europe. In March 
1987 a whole medical team was asked to visit and our travelling was funded 
by International Medical Relief. 
The Erirrean People�s Liberation Front has been engaged in a struggle for 
independence against Ethiopia since 1961, and in 1981 it set up a base 
hospital of 1200 beds at Orona. To work at Orotra was the genesis of our 
team�s visit, and arrangements via International Medical Relief were made 
by the Eritrean Relief Association. 
In Khartoum the relief association took over, dealing with police permits 
and arranging our flights to Port Sudan on the Red Sea. Woken at 430 am on 
the Tuesday we made the flight by two minutes; airline ticket arrangements 
had gone awry. Port Sudan was hot, breezy, and sandy. The association�s 
guest house was our home for the next four days. Delay in travelling on was 
caused by the second and Unity Congress of the Eritrean People�s Liberation 
Front and the Eritrean Liberation Front. (Years ago the two were in 
conflict.) This congress, attended by a worldwide audience, was in a 
specially built auditorium holding 2800 people and we could not travel into 
Eritrea until this was finished. 
We finally arrived seven days after leaving London. Three quarters of an 
hour on a fast road in a Toyota Land Cruiser to Suakim, the old Turkish 
slaving port, where a massive vehicle repair camp occupies acres of sand. 
Prom then on the �road� is sand, rock, dry river bed, and wet river bed. 
Eleven hours at an average speed of 14 km an hour, almost always in second 
or third 
gear, rarely fourth, not infrequently first, and sometimes in four wheel 
drive. The flat desert country of the eastern Sudan was enlivened by a 
small locust swarm, creatures with bodies at least 6 cm long and leaping up 
to a metre or more in front of the vehicle – It was dark when we reached 
the drivers� camp for baked bread and jam and crossed a large dry river 
bed. In moonlight the country continued like a moonscape; mice and rabbits 
crossed the track and gradually we climbed. 
Gentle questions at the �frontier� 
Starting to splash up a wet river valley we climbed more, reaching the 
Eritrean checkpoint to be gently questioned at the �frontier��name, 
country, and occupation. Orthopaedic surgeon was documented. Nurse was 
easy, but physiotherapist posed a linguistic problem, and prosthetist was I 
am sure beyond the guardsman. Then past three �camps� for Ethiopian 
prisoners of 
(1638 BRITISH MEDICAL JOURNAL VOLUME 295 19-26 DECEMBER 1987) 
war equipped with badminton nets strung across the track, and we really 
climbed�300 m or more up a massive hairpin bend �road� massively hewn out 
of rock. (It was only later that we discovered that this was done entirely 
by human muscle plus some small compressor machines. When it was hewn the 
Eritreans had no earth moving equipment.) Up at perhaps 2000 m we were 
rewarded by a splendid view of the Southern Cross. The Pole Star and the 
Plough were equally visible and there cannot be many places in the world 
where you can see both at the same time. I have done so once before in 
ICano in northern Nigeria. 
Then down to a long rocky valley and lights and at one in the morning we 
reached the medical guest house still full of folk from the congress, and 
bed was more than welcome. So here we were in Orotta�a physiotherapist, 
senior nurse, prosthetist, and orthopaedic surgeon. You will not find 
Orotta on any map. Like Eritrea (a non-country to the United Nations) it 
does not exist. In 1981 this was a barren rocky valley in the far north 
west of what had been Eritrea, uninhabited except by nomads with herds of 
goats and cows, largely waterless; flash floods come in June and July and 
there must be enough underground water to sustain numerous large acacia 
thorn trees. Spread over 5 km in this barren and rugged wilderness, where 
the schist rock valley sides rise often extremely steeply and the highest 
point in the area is up to 2800 m, is this remarkable hospital of up to 
1200 beds. Water is trucked in by tankers from a dam some distance away, 
offloaded into concrete tanks at points in the valley, and then piped to 
wherever it is needed. Electricity is from one main and several subsidiary 
generators spread up and down the valley. Light comes on at 6 o�clock in 
the evenings and continues as long as the theatres require it; otherwise it 
is torchlight. 
All the buildings are small and hidden into the hillsides, dug down and 
then in. Concrete or mud floors support drystone walling. Roofs are massive 
tree trunks, often tree trunk supported, covered with sacking and brushwood 
sufficient to be waterproof. The walls are a mixture of mud and lime, some 
plaster covered. Most of the buildings have one or more large overhanging 
thorn trees outside. From the air the buildings must be invisible; from the 
valley floor they are almost equally impossible to see unless you are very 
close. By every building is a dugout hewn down into the rock. 
High up in the valley that curves like an extended snake is the central 
pharmacy. Five hundred plastic bags with intravenous solutions are produced 
every night to be dispatched all over free Eritrea as well as to the base 
hospital. Very recently installed is the one tonne machine for antibiotic 
production, turning imported powder into pills and capsules. This, the very 
latest Italian machine�Eritrea�s 70 years under Italian colonial rule has 
left 
many reminders�was trucked up from the Sudan, the last 30 m requiring 
manhandling up a series of rollers to its present site. Now installed, one 
glass sheet has been broken, but this is not affecting its producing 
capacity. Basic antibiotics can now be 
manufactured here and distributed throughout the country. 
A series of ward blocks spread down the valley. Each department has two, 
three, or four separated buildings, all built to the same half hidden 
pattern and cleverly camouflaged. Neurosurgery and neurology have three 
wards; then there are the cardiovascular department wards, which seemed to 
do most of the general surgery. (While we were there a patient arrived all 
the way from Saudi Arabia where he had seen several medical advisers. 
Dissatisfied, he had made the long and difficult journey up to Orotta to 
have his subacute intestinal obstruction expertly relieved by the surgeon 
in charge of the department.) The orthopaedic unit has three wards, one not 
in use when we were there, plus a purpose built recovery unit, its doors 
made from old packing cases. Most of the work is the result of war injury 
from every known form of weaponry, including napalm. 
The fighters are all volunteers�unlike the Ethiopian forces, who are mainly 
conscripted�and 30% are women. In the orthopaedic unit there is no 
separation of the sexes. Most of the injured have had first aid treatment 
near the front and probably stay in one of the district hospitals before 
reaching Orotta�anything up to 10 days after injury. If a plaster change is 
needed a standard orthopaedic table sits outside the ward under a thorn 
tree, not infrequently used for spicas of both hip and shoulder. Elsewhere 
in tropical countries I have met resistance to the use of body plaster 
casts because of the heat. Here in Orotta they are accepted when needed. 
The wards are cool and there is much shade under the thorn trees. 
Passing the medical guest house, complete with separate shower and be room 
with a flush system, one comes to the x ray department, one of whose three 
machines was liberated from the enemy and still works. We then arrive at 
the theatre block. High on its dry stone wall support and with two 
windmills outside for wind power, this is a remarkable place. Thorn trees 
screen the outside and the two solar panels on the roof provide extra light 
power, these being covered with blankets�and therefore less efficient�as a 
camouflage necessity. Once in, in theatre shoes, we are in another world. 
The theatres, which would not disgrace the Western World, have mosaic 
panelling half way up the walls. This panelling was liberated when an 
Eritrean town was temporarily in Eritrean hands, along with a mass of 
military equipment. The tables are modem, as are the movable lights. In 
addition there is strip lighting from the generator. There is a separate 
recovery room, although it is easier and safer to lay the stretchers on the 
floor. Anaesthesia by nurse anaesthetists lacks anycylinders and therefore 
oxygen. For the same reason orthopaedic power tools have to be electric, 
not worked by compressed air. Much use is made of the Oxford McIntosh 
Vapouriser, ketamine, ether, halothane, and intraveous drugs. The first 
procedure we witnessed was an open anterior thoracotomy by sternotomy for a 
malignant tumour�hardly a likely scene in a valley unoccupied until six 
years ago. 
We pass the main generator, the central bakery using one and a half tonnes 
of sorghum flour each day, and around more valley bends we reach the dental 
and maxillofacial unit. The dental surgery is spick and span and the woman 
doctor, a grnduate from Sofia, not only does some excellent facial 
reconstructions but also copes with major plastic work. The maternity and 
gynaecological department has 500 deliveries a year, mostly patients with 
complications, and inevitably the most difficult gynaecological procedure 
is the vesicovaginal fistula. It is then a lengthy walk to the steep narrow 
sided valley for medicine and paediatrics. Tropical diseases are inevitably 
though not predominantly the problem, the hot dry climate and barren rocky 
valley not being conducive to many diseases. The department does have the 
longest bed in the world�a raised stone platform down each side, blanket 
covered, on each of which at least 25 can sleep. Most patients are 
convalescing and waiting to be fit enough to return to the front line. 
(Basketball on one leg) 
It is a considerable distance further on to the modern prosthetic workshop 
equipped with brand new West German machinery. There are 500 amputees in 
the hospital valley, all single amputees, as the 150 double amputees and 
those with paraplegia are in the �hospital� by the guest house in Port 
Sudan. Those folk cannot return to Eritrea until the towns and cities are 
back in Eritrean hands. A single leg amputee may be seen playing basketball 
on his single good leg, but the more severely handicapped could not cope 
with the wild country in the mountains. 
Most of the patients in the hospital, especially in the orthopaedic 
department, are war injured. Every known method of maiming is available to 
the Eritrean forces. For many months now fighting in the front line has 
been quiet and casualties have been few. Most of those we saw are from 
commando type units who operate behind the front line complete with medical 
teams and portable x ray apparatus; some of the teams carry a portable 
microscope. We saw one of these in use in the central laboratory, British 
designed, collapsible, and easily carried. What percentage of the injured 
fighters survive to reach the base hospital is unknown. The journey may 
take many days. Surgery is at best second stage or reconstrucfive. There is 
a surprising amount of modern equipment for internal fixation. Sometimes 
the leap from conservative management to modern internal fixation has been 
made too fast. Some of the implants are cast oils from western Europe. 
Fifty cm Kuntscher nails, a whole bundle of them, are no use to people of 
the stature of 
the Eritreans. They might suit the femora of the Dinkas in the southern 
Sudan. Much of the orthopaedic operating while I was there was in the hands 
of a nurse, trained as anaesthetist and in charge of the theatres, then 
trained as an orthopaedic surgeon. He obviously had considerable experience 
of operating near the front line and had acquired a remarkable knowledge of 
modern orthopaedic armamentarium. In his case this could have been only 
from others in free Eritrea or from books and journals. The inevitable gaps 
in his knowledge was one reason why an orthopaedic visitor was requested. 
Hospital valley is not short of food. Sorghum, much of it imported, is a 
major item of diet. The Italian influence yielded the macaroni and 
spaghetti. An abundance of eggs and vegetables is trucked down from other 
parts of free Eritrea, especially spinach. The beetroot, offloaded one day 
from a lorry, was the size of footballs and very edible. Certainly everyone 
in the valley was adequately fed and we understood this also applied to the 
fighters. How the majority of the seniitroglodyte population fare for diet 
was less clear. There were many children in the valley and they certainly 
seemed well nourished. 
Such then is a brief impression of a remarkable people in a remarkable 
place. They are intensely determined on independence. As they adapt to 
their barren surroundings they display determination and initiative 
combined with inventiveness and adaptability. It is a privilege to be able 
tovisit them andto work there. 
I am grateful to International Medical Relief and its medical director, Dr 
John Foran, and to the Eritrean Relief Association and to the Eritrean 
People�s Liberation Front, who looked after us so well during our visit. 
My colleagues in the team were Anne-Marie Hassenkamp, deputy head 
physiotherapist at the National Orthopaedic Hospital, London; Fiona 
Sherriffs, clinical specialist in infection control at the Royal National 
Orthopaedic Hospital; and Normaa Govan, senior lecturer at the National 
Centre for Training and Education in Prosthetics and Orthotics at the 
University of Strathclyde. 
High Wycombe, Bucks 11P15 6LJ 
H D W POWELL, MB, PRC5, consultant orthopaedic surgeon 
Correspondence to: Ravensmere, Cryers Hill, High Wycombe, Bucks HPI5 6LJ. 
Treating a snakebite with antivenom. 
Hoffa,ann external fixator on one of the fighters

 Posted by at 12:09 am