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
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
(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
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
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
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
The Balkan Airways flight left Heathrow early afternoon on a Saturday in