Offense (25/1/12)

This week I’ve had the privilege of ministering together with my Dad for the first time.  He’s here for a two week visit from Grand Rapids, and I asked if he might teach at Moffat while he’s here.  After 40 years in ministry, from Oklahoma to Michigan, there are some areas he’s particularly passionate about in leadership and vocational ministry.  So I asked him to lead a few sessions on one of these:  the importance of forgiveness and releasing offence when people you are serving or leading offend you.

I find that forgiveness and not holding a grudge is one of those non-glamorous lessons in leadership.  Whether in the military, business, the academy, or in a church/mission setting, it doesn’t seem to headline any conferences, seminars, or bestselling NY Times books.

But after experience working in all four of those contexts, it is my observation that there are very few issues which directly affect our success in life more than this one:  learning to be a person who forgives quickly and does not stay offended long.

In each of these contexts, I’ve seen examples–CEO’s, pastors, a junior enlisted nuclear missile technician–people whose lives were negatively affected, almost controlled, by offense they had taken from something someone had done to or said about them.  Because they held onto it and did not release it, it continued to measurably impact their lives.  Being suspicious of the motives of others.  Quick to get angry over very small offenses.  Finding it hard to connect on a meaningful level with others because of filters in place which interpret normal responses as offences.  Physical, mental/emotional, and spiritual problems originating from anger and bitterness.

I have a lot of compassion for people who struggle with this, because I used to be one of them.

Sometimes we simply do not understand that in this life, on this side of Jesus’ return and the restoration of all things, people are going to say and do things which offend us regularly, usually without their intending to or being aware of it.

We know from reading the account of a follower of Jesus from two thousand years ago that Jesus understood this well, and tried to prepare his followers to respond to these offences with a forgiveness and grace which almost seemed unreasonable to them: “…it is impossible that no offences should come…” (Luke 17:1).

This topic becomes particularly important in the context of church and mission work, where we become very close to people and pour ourselves into them.  Like our family members, those close to us have the capacity to hurt us the most.

Dad taught three sessions on this topic, and it was deeply moving to watch these future pastors and chaplains respond to it.  I was unprepared for their stories, and for the decisions a few of them chose to make later in the week.

The honesty in the room during the sessions was just amazing, and some students were courageous enough to share stories of offences they had suffered which were just horrific.  I’ve been around the block a few times and seen some pretty horrific things, but some were bad enough to bring tears to my eyes and make me cringe that such a thing could happen to anyone.

The students asked for an extra session for Q&A and prayer, and so we held it the afternoon of the last day.  Their questions were deep and sometimes really painful.  We then broke them into groups to minister to and pray for each other, and it was a holy time as some of them confessed long held offences and forgave the offence and the person causing it.

One student texted me at 10p that night to tell me that he had dropped everything, and was on a matatu (minibus) headed home.  In his words, he had been angry at his father for years for something his father had done.  He decided during prayer that day that he needed to go to his father and seek his forgiveness for harbouring a grudge and judgement in his heart against him.

When he came back a few days later, I could actually see a physical change in his demeanour.  His face looked calmer, more peaceful.  He had gone to his father (who thought he had come home to ask for money for school fees) and asked for his forgiveness.  He told me, “I have never seen my father cry before.  He had tears streaming down his face, and we are now reconciled.”  The power of forgiveness and keeping short accounts in action.  I received his permission to share this story with you.

This is one story among many, and I have been reminded this week again of how powerful it is when we make a decision to not remain offended, but to forgive those who wrong us, whether or not they seek our forgiveness or even acknowledge their wrong. It can affect the whole of our lives.

I don’t spend much of my time at Moffat; most of my work is at Kijabe Hospital, but I am finding that the time I do spend with these future leaders of the church is an enormous blessing to me.

And it was just so cool to work alongside my Dad.

- A.

Koinonia (24/1/12)

Yesterday morning we received this email from our medical director:

“I received word this am that the night team rallied to help a mother in Maternity who was bleeding and needed 10 units of blood acutely overnight.  Nurses, nursing students, housekeeping and a security guard all donated blood between 1 – 4 am to get this mother through a crisis, supported at 4 am by donors from RVA.  Word is that the lab night shift was impressive, and that coverage kept things moving very smoothly.

We need to keep praying for this mother of 4 who is not out of the water yet.  But I am moved to hear of the team’s “extra mile” efforts to be the love of Christ for this family.

It is an honor to work with you all, now as much as ever.”

I love working in a place like this – where the lab has a list of the blood types of the staff and local residents, so that when the operating theatre is running on empty an SOS can be sent out.  Where the nurses and chaplains and doctors and lab techs live and work side by side, our lives (sometimes too) intertwined and interdependent, so that in the middle of the night when the new obstetrician is faced with a critical case, the not-on-call-family-practitioner who also does obstetrics goes in for most of the night to help.  Where, when it is obvious the mother will bleed to death without definitive action, another surgeon gets out of bed to do a hysterectomy.

It is a blessing and curse, living in a place where the boundaries are so blurred.  It is quite strange, your neighbours being your colleagues, your social life and your work life being often one and the same.  Your friends all have your phone number, which also means that you are by default on call 24 hours a day for your community – and they are on call for you.  It is truly astounding that, amongst these colleagues, there is no-one who rubs me the wrong  way, whose company I chafe against.   On the contrary, I have grown to enjoy and love these people, for them to have become friends and people I truly respect and admire.

I have never thought that the be-all and end-all of life was to go and live in a commune, away from the nasty evil world.  But I am appreciating living here – that amidst the loneliness of missing family and friends, with the lack of conveniences and comforts of things familiar, that we have a community that is so…  not crazy.  Supportive, normal, selfless, amusing, real.

There is a Greek word – koinonia.  It has a multitude of meanings that no single English word adequately expresses, but could be translated as “community”.  A derivative of koinos, the word for common, it signifies generous sharing through demonstrable action.  Partnership or common effort.  Shared experiences, joy and pain.  Common unity of goal and purpose.  A higher purpose or mission that benefits the greater good of the members as a whole.

I am grateful, here right now, for koinonia.

- M.

“stop doing” lists (7/1/12)

Mardi’s on call at the Hospital this weekend, and so after seeing her off this morning the kids and I went on a walk to have a bit of adventure.  Slaying dragons with paper towel cardboard rolls, collecting berries and flowers, stopping at Rich and Stacy Davis’ for coffee along the way, the usual sort of thing.

One of the trails we like to walk on goes down the mountain before meeting an old road, which we then follow along the escarpment until meeting the road down into the valley, which we follow up the mountain and back home.  Before we left I asked the kids to grab a small bag along with their ‘swords’ so they could collect treasures they find along the way…here’s what Liam showed up at the front door wearing:

Essential equipment: a backpack full of Thomas engines

Yes, that backpack is completely filled with all of his Thomas the Tank Engine trucks and engines.

I observed that an already-full backpack won’t leave much room for the super-awesome things he finds and wants to pick up along the way.  There were vigorous protests with buckets of tears.  You can still see the remnants of his accusing and suspicious “Is Daddy going to try to take my Thomases away?” look in this photo.

So walk for two hours with a backpack full of Thomas he did.  And we had a great walk, full of lots of adventure and dragon slaying.

Liam’s desire to start a treasure-hunting walk with an already full backpack reminded me a bit of what Mardi and I are doing at the moment:  an informal semi-annual habit of assessing what we spend our time on and asking, “Is there value in this?  How does what we are actually spending our time on align with our priorities?”

What we usually find is that we need to spend less time on some things, and stop others entirely.  There’s usually always something that we’ve picked up along the way in the course of several months which does not align with our priorities; perhaps we found it hard to say ‘no’ when asked to do something, and so we just picked it up and tried to make it fit along with everything else.

This last assessment has been no exception:  for me, a realisation that I need to cut one language lesson a week, drop a Bible study, do one less mentoring group, and answer the door less when I am working in the office at home.  Since I’ve made this decision I’ve felt lighter and freer than in a while…a freedom to focus on the things I feel called to do, spend time with the kids without trying to answer emails or phone calls at the same time, and be more “present” to my family and friends when I am with them, without being somewhere else mentally or emotionally.

Jim Collins calls this process making a “stop doing list” in his excellent leadership book Good to Great.  In his words, many good leaders have clearly articulated to do lists, but not many invest the same effort in intentionally cutting out those activities which distract them.

I’ve found this true in my own life…it’s not enough to focus on the things I want to be doing; the reality is that I ‘pick up’ other activities and tasks in the normal course of life, and it is these things which take time and energy away from my primary passions and priorities.  If I am not ruthless at cutting them out, I end up distracted, defocussed, and feeling a vague dissatisfaction that I don’t seem to have the kind of focus and clarity I would like.

Taking it a level deeper, a good question to ask might be, “Am I doing something I’m not called to?”  Am I doing something that the Lord has not asked me to do?  Wherever we are, there is always an endless parade of ‘good’ things to do around us.  Might I in fact be exhausted, burned out, or lost my focus because I have taken on things I’m not called to?  Am I bearing burdens that aren’t mine to bear?

As Mardi and I continue this discipline of “stop doing” in our new context of rural Africa, I continue to learn that at least part of the answer to greater focus and productivity is not found in “doing more” or working harder.  It’s found in doing less of the things that don’t matter.

But I think Liam should be able to bring as much Thomas as he can carry when slaying dragons…as long as he doesn’t ask me to carry it for him.

- A.

R is for Reptile (4/1/12)

School starts back up this week after a Christmas break.  This term, the 4 year old preschool class has 10 kids – Ella, Lydia, Lisa, Chloe and Riley, with Ethan, Marcus, Ian, Asher and Brennan.

Ethan’s mum Angela and I are teaching this month, and our curriculum is “animals”.  We looked at the lesson plan, which of 8 lessons devoted one to lions, one to monkeys, one to pets, one to Noah’s Ark… it seemed a little abstract to us.  We decided that our preschoolers are all pretty switched on and would benefit from learning the animal classes instead, and plus we were going to be bored spending 2 hours on giraffes.

Today Angela taught “C” for creation, creatures and classes – an overview of how all of creation fits together.  By the end of the class, all of the kids could tell us one sentence about mammals, reptiles, birds, fish, amphibians and “animals without a backbone” because invertebrates just seemed a little tricky.  To bring for snack time, Riley, Liam and I made gingerbread cookies with an animal shape from each class except amphibians.  What I would have given for a frog cookie cutter!

A giraffe that looks like a dinosaur, a "fish" (shhh it's a dophin), crocodile, chicken and butterfly. Close enough!

So after this we’re going to cover:

• Mammals (domestic and farm) including Mice and the letter “M”;
• Wild mammals including Wildebeest and the letter “W”;
• Reptiles and amphibians including Rattlesnakes and the letter “R”;
• Birds including Bluebirds and the letter “B”;
• Kangaroos, Koalas and other unique/unusual animals like monotremes and marsupials with the letter “K”- no prizes for guessing who is teaching that lesson  I’m mostly hoping one of the kids asks which category unicorns fit into…
• Dinosaurs and other extinct/endangered species and the letter “D”, talking about stewardship of our planet.

We’ll finish it off with a safari walk at a conservation park in Nairobi.  There will be a whole month later this year on insects (now THAT will be a cool month) and a whole month on sea creatures.  I hope they cover Nessie.

I’m not sure who’s going to have more fun this month at preschool – me or Riley.

- M.

Would you like to support a future pastor in his education? (3/1/12)

A number of you have asked us to let us know when you might be able to help with a specific need, or to help a specific person.

This might be one of those times for you.  We are starting Term 2 of the academic year at Moffat this week, and one of my first-year students has been sent home due to not having the required school fees.

Economic times are extremely difficult here in Kenya, with an unemployment rate around 40% (see here), and the cost of food and petrol sky high.  To put it into perspective, the inflation rate here was reported in October 2011 as around 20%.  The inflation rate in the USA is around -0.4%.  When you’re earning an average of around $2 USD per day, that’s a lot less maize, fruit, and vegetables you are able to buy when the cost of living goes up.

It’s also a lot less school fees you can afford when the option is food or fees, and I was told yesterday that roughly 20% of our students are in danger of not being able to continue their education due to lack of school fees.

This student has a calling on his life to be a pastor.  He would like to stay at Moffat for the next 3-4 years, completing his Diploma so that he can be ordained as a pastor.

He was my top student, tied for the highest overall score out of 19 students in the Spiritual Formation class I taught this last term.  I was proud of his efforts.

He is short about 54,000 Kenya Shillings, or around 650USD for this Term’s tuition.  He has 5 days to come up with the $ or he will have to put his education on hold.

If you are interested in supporting this student, please drop me an email, and I’ll provide you with further information.

-A

Was it worth it? (31/12/11)

Baby Michael, transferred to a private hospital for life-saving heart surgery, died on Christmas Day.

We don’t really know the details yet – the way we found out was Jennifer, on duty on Christmas morning, receiving multiple calls from their finance department asking us to cover the rest of the bill, double what they had told us for a 36 hour admission, before they would release the body of the baby for burial.  It was sad to hear that his surgery had failed in the most final of ways, but the means of notifying us seemed callous and cruel, especially on a day of celebration and joy.  Jennifer was incensed, the family was devastated, and when Jennifer graciously waited until the next day to tell me so as not to ruin Christmas for me, I was furious.  It has taken a week of phone calls and emails and negotiating for their accounts department to be satisfied enough to release his remains to the family.  What had been a journey of hope for us – partners from around the world raising the money to give him a chance – turned into a sudden dead end leaving a bitter taste in my mouth.  We still haven’t heard what went wrong.

Was it worth it?

2 year old Mercy, had a brain tumor that was skilfully and successfully removed by our neurosurgeons.  Wonderfully, it turned out to be benign with an excellent prognosis.  But she died on Thursday in ICU.  After her surgery, vomiting had caused a lung infection which had turned into the most serious of complications, ARDS (acute respiratory distress syndrome).  Her lungs failed, our ventilator reached its limits, and she lost her battle for life because of post-surgical, rather than surgical, problems.

Was it worth it?

________________________________________

I really struggle with these questions.

Part of me wants to gliss over their deaths – to say simply and easily, as many of our patients’ families and chaplains do, that this was God’s will.   Some may say that God will bring good out of this destruction – I know that He can and I pray that he does, that through the love the family has received from us here, that their grief will be lessened, that their picture of God will be broader.   Some may say that God takes to himself those he chooses, that he chose to take these children to heaven, that it was their time.

But I don’t believe in a God like that – who chooses to take children away, to leave the parents grieving and broken-hearted.

I believe that God, like me, grieves pain and illness and destruction and loss.

I believe that God, in giving us the right to choose, has given us a world that through free will and sin has turned out to be messed up and broken and isn’t always a nice place to be.

I believe that there is good, and there is also evil – and that sickness and poverty and violence cause innocents to suffer.

I believe that bad things happen to good people, and that good things happen to bad people.

I believe that there is a realm that we can’t see, that there are angels and demons, and that every day is a battle through which we are walking.

We see these battles on a small scale every day – in harsh words spoken in a moment of loss of control.  In children ravaged by the burden of AIDS thrust upon them.  In poverty and inequality and small injustices.  In children neglected and abused through generational cycles of despair.

We see these battles on a large scale throughout the course of human history.  Unspeakable death and destruction – in the name of purity of the human race with the Holocaust, in the name of Allah with suicide bombers, in the name of Christ during the Crusades.

To think that God allows or plans these things is just unthinkable to me – my God is complex, but he is good, and his purpose is life.   But his purpose is worked out through the imperfections of a fallen human race whose choices have consequences each day, and will not be ultimately fulfilled until Jesus returns and the earth is fully restored.

We lost a couple of battles this week.  I grieve the loss, but it doesn’t mean we stop fighting.  We fight with drugs, we fight with food for the hungry.  We fight with scalpels, we fight with friendship.  We fight with prayer, we fight with tiredness at 3am.  We fight with excellence, we fight with committment.  We fight with love, we fight with tears.

So even though we lost these two battles, we win others – and it is worth it.

- M.

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Previous post:  Masai Mara (30/12/11)

Masai Mara (30/12/11)

We’ve had Mardi’s parents here for a visit the last few weeks, and their Christmas present to themselves and us was a 5 day camping safari in the Masai Mara.

I’ve always dreamed of staying in a tented camp on safari.  Camping safaris conjure up images for me of Ernest Hemingway hunting in tall grass, mist rising in the morning, lions hunting outside your tent, wildebeest unsuccessfully dodging crocodiles in the Mara river..but before we could embark on realising this dream, we had to go through… *shudder* …’The Road’.

‘The Road’ was a 5 hour stretch of driving from Kijabe to our camp at the northwest corner of the Park.  The last 3ish hours is along a deeply rutted, rocky track which had been ruined by the recent rains–the guys at the camp later told us that the Masai elders in the area reckoned that the rains were the heaviest in 16 years.  Due to a planning oversight, we hadn’t specified ’4WD’ on our safari booking, and so we had a 2WD matatu (a Toyota minibus) as our mode of transport there and back.  Thankfully, for 2 out of 3 of our game drives we had a 4WD safari jeep.

The Masai Mara. Our camp was in the NW corner.

At times we were forced to crawl over the rocks in The Road at 5 km/hr, at others our able guide, John, threw in the towel and raced over the road at 60 km/hr, resulting in jarring and vibrations that made our teeth chatter and vertebra separate.  When we arrived at the camp, we rolled out of the minibus exhausted and it was some minutes before I could hear clearly until the dull roar from the road noise faded in my ears.  Aside:  I am delighted to note that we nearly destroyed the minibus on the trip to and from the camp…the brakes failed, exhaust system holed, and axles felt floppy and loose when we arrived back 5 days later…now THAT’S getting good value out of a vehicle!

Riley and Liam wildebeest-spotting at the Mara River

But then…the Mara.

Sunrise from our tent door

The solitude of the Mara is so compelling.  It is achingly beautiful; literally, so beautiful and peaceful that something inside me just…ached.  Deep calling to deep, perhaps.

Our safari jeep on the open grass savannah of the Mara

We left on our first game drive at 0630 the day after The Road, planning to have a picnic breakfast and tea in a suitable place.  At 0730 we came across a playful cheetah, basking and rolling in the glorious morning sun near a small herd of gazelles, who were not nearly as relaxed as Mr Cheetah.  They were standing ramrod straight at attention with all eyes on him, as if they were afraid that if they ran, he would somehow run them all down and make a gazelle buffet out of the entire herd.  We had our picnic breakfast about 100 metres from this delightful scene.  We learned later that about 30 minutes after we finished our breakfast and left he made a kill.

An all-you-can-eat gazelle buffet

We were fortunate to see so many animals…elephants, lions, cheetah, buffalo, wildebeest, hyena, crown cranes, aurora birds, ostrich, warthogs, Thompson’s gazelle, and about 10 different variants from the deer/gazelle/reindeer family.

I have a confession:  I am not an animal person.  They just don’t do it for me.  I don’t dislike them, they just hold little interest for me.  For me, it is the landscape, the trees, the cavernous sky that takes my breath away.  Achingly beautiful.  Most of the time I was fighting the urge to jump out of the jeep and just start walking in the grass.  Thankfully this urge was tempered by the constant presence of predators.

Solitude

Riley and Liam were troopers…you’re really rolling the dice with young kids on safaris, we had heard, and so we were pleasantly surprised that they bounded out of bed every morning at 0600 wanting to go on a morning safari…they were just so excited.  On our second morning, we heard soft footfalls outside our tent, and opened the tent door to have a peek…out of the mist, about 3 metres away stood a giraffe towering over us.  We quietly woke up the kids, and carried them bleary-eyed to the tent door where all four of us watched in wonder.  After about 30 seconds, the giraffe noticed us staring at him, jumped a little, and galloped away.  It was a magic moment.

life in the open cockpit

We saw some beautiful lions, including this majestic creature who was conveniently posing for us in front of a rainbow.  I mean, come on, that’s just ridiculous.

Why yes, that is a lion sitting in front of a rainbow

My favorite birds were the crowned cranes.  They mate for life, we were told by our guide, and if one of the pair dies, the other dies soon after.

a crown crane and elephant

The kids had a blast; how often do you learn about an animal from a Maisy book or Richard Scarry story, and then get to watch in wonder as it trundles past your open window?  Life is a pretty sweet fruit for a kid on safari.

*stunned silence*

After 5 days of rest, game drives and good food we were ready to return to Kijabe.  The smiles on our faces for this farewell shot mask the grimace of terror that is the anticipation of a return journey on ‘The Road’.

Family photo overlooking the Mara

- A.

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Next post:  Was it worth it?  (31/12/11)
Previous post: African Christmas 1.0 (28/12/11)

African Christmas 1.0 (28/12/11)

Christmas for the Steere family is usually some hybrid of either an extended Steere or Johns family tradition, as we usually split our holidays between the U.S. with Andy’s family or Adelaide, South Australia with Mardi’s.

But this year was different…here in Kijabe, thousands of miles from our ‘home bases’ we had the opportunity to ask ourselves, ‘what do we value?’ and put into place some traditions we want to carry forward that our children will remember.  This brought a ray of joy in the midst of our missing Christmas celebrations and tradition with extended family.  The silent stillness of a night snowfall, Christmas celebrations at the beach and a swim after lunch, catching up with family you haven’t seen for a year.

This year we observed the 4 weeks of Advent (via an Advent calendar with the kids and daily readings from The Divine Hours) leading up to Christmas, attended Christmas eve carols and prayers, gave gifts to children in the hospital (see below), and had a Christmas celebration that tried to be about giving gifts, rather than only receiving them. With a 3 and a 4 year old, this was simultaneously hilarious and impossible!

It also included observing a traditional Norwegian White Christmas meal with good friends the Myhres on the 23rd, which was a highlight of the season for us.

Mardi’s parents arrived from Australia for a two week Christmas visit via Egypt and Jordan, and we’ve had a lovely time catching up with them and having some good grandchild-Mama-Poppa time.

We love it when Mama reads to us!

We’ve had a lot of fun showing them around some of our favorite places.

Reading to Riley and Liam at the RVA elementary school ("Titchie") library

The daily rains we’ve had for several weeks dried up just as they got here, and Kijabe has put on a good show for them:   verdant greenery, unobstructed views of the Rift Valley, and wonderful temperatures.  Christmas day was a balmy 24C, while it was below zero in Grand Rapids and a decade high of 36C in Adelaide!

Spiderman and the Christmas Fairy on their Christmas bikes

Chris and Tom brought over some small toys to give to the children in the Hospital on Christmas Day, and so we went over to the pediatric ward Christmas morning and handed out little koalas and kangaroos to the kids and their parents.  It was a beautiful and holy time to give a kind word and gift to those kids and families on Christmas.

I bet that's the first time they received a Christmas gift from Spiderman

Merry Christmas!

Beautiful

Then it was time for Christmas lunch!  We had Erik and Amanda Hansen and their brood of 4 over for Christmas dinner and there was much laughter and celebration.  Erik is a paediatric surgeon who works with Mardi.

A Texan encounters his first Australian Christmas pudding and custard

This season of Advent and Christmas was a meaningful one for us here in Kijabe; a time of new family traditions in a new place, sadness to be far from family and friends, and joy to be with new friends and with Chris and Tom.

It was a time to acknowledge the ‘already’ of the presence of Jesus around us in his Kingdom while we look forward to the ‘not yet’ of his coming again.  As we celebrate the ‘advent’ of his birth 2000 years ago, we look forward to his coming again and bringing healing and restoration to the brokenness and injustice around us.

If you celebrate Christmas, Merry Christmas!  If that’s not your tradition, Happy Holidays and may your new year be filled with peace and joy.

- A.

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Next post:  Masai Mara (30/12/11)
Previous post:  Relationship (2/12/11)

Relationship (26/12/11)

I learned something from an African last week.

Part of my work here is to facilitate relationships with stakeholders, donors, and statutory authorities for the projects underway at the Hospital.

I had a meeting last week with the head of an organisation which funds HIV/AIDS-related programs in Kenya.  As a part of their work they fund WASH (water, sanitation, and hygiene) projects to allow those suffering from HIV/AIDS to take their antiretroviral medicine without getting sick from the water.  On paper, their goals directly aligned with the objectives of our projects, and this was very promising!  I spent a lot of time planning my approach beforehand on paper, with agenda items and key outcomes highlighted.

At 2:00p, I was greeted warmly, invited in, and offered something to drink.  The Chief Executive enquired about my family, their health, how I liked Kenya…we had a warm and friendly conversation for 25 minutes about our respective families and each other.  We then shifted gears, and he explained a bit about the corporate goals of his organisation.  It became clear that in his view, there was not alignment between their goals and our project needs.  I pushed on this a little bit, as on paper it appeared that there was.

Without telling me “no” (because he is Kenyan, and this would be culturally akin to slapping me in the face with a goat), he explained their goals in greater detail and suggested a few other avenues the Hospital might explore to look for funding.  It was clear there is not a fit between our two organisation’s needs, and I thanked him for his time.  At 2:30, we said our goodbyes.

Total meeting length:  30 minutes.

From a Kenyan perspective:  Time spent on important matters = 30 minutes.

From a Western perspective (including this outcomes-oriented project manager):  Time spent on pleasantries = 25 minutes, Time spent on important matters = 5 minutes.

Over the last few days, I have kept returning in my thoughts to the difference between our cultural approaches to this meeting.  The CEO took the relational approach deeply embedded in African culture:   politeness, honor, relationship, conversation, family.  I took the outcomes-oriented approach, and saw the first 25 minutes of the meeting as somethign to be ‘gotten through’ until we approached the ‘real work’.  As I adjust to life in Africa, these differences can be maddening at times…from the perspective of the Western business mind, on the surface it seems so much ‘productive’ time is wasted, discussing personal matters in meetings that could be ‘parked’ until after the important agenda items are dealt with in a meeting.

My recent experiences have left me wondering if the African relational approach may actually be an echo, a reflection, of how we were originally created to live and relate to each other.  Something that we in the West may have forgotten in favour of the (good) habits of productivity and hard work.  It’s not that ‘relationship’ is to be valued to the exclusion of productivity; on the contrary, both are good and I think a reflection of how we are intended to live and prosper.

They are both good.  But I notice in myself a tendency, a habit, to sacrifice relationship for outcomes and productivity when necessary.  To subject one to the other, relegating relationship to a tier below that of the ‘real work’.

Edward, our kiswahili teacher

I suspect that a specific example of this prioritisation of outcomes over relationship can be found in how we approach God in prayer.

Over the last 24 months, as we have walked through some pain and struggle in our family, and have moved to our third country in seven years, I have noticed in myself a growing lack of desire to pray.  I have prayed regularly for certain people and outcomes for years, and seen no discernible answer.  This has had the net effect of decreasing the amount of time I spend in prayer ‘asking God to do things’.

As usual, it is in what we actually do that what we believe can be found (as opposed to giving verbal assent to a list of doctrines), and as such it is clear from my prayer habits that I have developed two ‘beliefs’ in recent years:

Belief #1.  God largely stands outside his creation, and allows us to care for ourselves.  He has created us with ‘free will’, and hence we largely ‘reap what we sow’.  There certainly is a supernatural dimension to life, and God does interact with us on a additional plane from merely the natural, but by and large he does not intervene in the world.  Hence, praying for him to ‘do things’ is more often than not a waste of time.

Belief #2.  Much of prayer, at its core, is trying to get God to do something.  It is outcome-focussed.  When God doesn’t answer my prayers, I either pray more fervently (depending on how strong I feel about the outcome), or I stop praying for it.  See Belief #1.

Mind you, if you meet me on the street and ask me if I agree with these two beliefs, I will say of course not!  How could I, when I have multiple examples around me of the opposite; of a God who regularly interacts with his creation, and with whom I regularly spend time in prayer about what we are doing together.

But my actions would contrast sharply with my words.

These beliefs, especially the second one, are being challenged by the lessons I am learning in Africa.  There’s something totally absent from both of them:  relationship.

The theologian and scholar J.R. Lucas points out that in the natural world, we can usually cause the outcomes we desire to come about by following the logic of the natural world.  For example, if I want my lawn to be lush and green, I fertilise, aerate, mow, and water it.  If I wish to take good photographs, I might buy a good camera, learn how lighting affects a photo, and study how to compose a good landscape or portrait.  But Lucas points out that this ‘logic of thingly causality’ bleeds over into our relationship with God to our detriment.

“…God we may not take for granted: he is a person, not a thing…Paul’s antithesis between justification by faith and justification by works could be rendered in modern terms as the insight that salvation depended on one’s attitude and was not a matter of technique, It follows from God’s being a person….Because God is a person, we cannot hope that he can be secured by anything less than a whole-hearted approach [emphasis added].  A grudging observance of the law of nature is enough to secure domination over nature, but a grudging reception of the sacraments or a prudential obedience of some moral law will not win the love of God any more than it will the love of a human being.”

God is a person, not a thing.  Like my wife or my children, he can’t be ‘secured’ by anything less than a whole-hearted approach.

The African relational approach is teaching me that I can’t cause God to act by my own ‘logic of thingly causality’–He is a person, and wants a relationship.  He wants a whole-hearted approach, where we are talking together about the things that are important to both of us.  Hence prayer itself is a natural extension of a relationship; outcomes naturally follow from the time we spend with your friend.

This insight helps me see how bereft of relationship my two beliefs above have become…and I am deeply convicted that an outcomes-focussed approach with God widely misses the mark of what He desires, and causes us to only skim the surface of the depth of relationship that He desires to have.

And it makes me want to pray more and pray deeply.

- A.

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Next post:  African Christmas 1.0 (28/12/11)
Previous post:  A gift of hope (24/12/11)

A gift of hope (24/12/11)

A week ago I blogged about Michael, a 4 week old who needed heart surgery.  The next day, not having read our blog, a friend of ours sent us an email – his family wanted to donate $2000 to our Needy Children’s Fund.

I was astounded.  This is the first time I have really wanted to raise a large amount of money to help a single child – usually the need around us is so great that we ration out the fund in small chunks to do small things to help as many kids as possible.  But this one procedure had the potential to change a baby’s life.  So our chaplain Mercy and our team were praying that this would be a possibility for this family.

And now it is.

Mercy told his family, who were blessed beyond belief.  Through the generosity of their family and community, they were able to raise the other $500 needed for the operation, and the wheels were set into motion for his heart to be fixed.

Yesterday, we sent Michael to Mater Hospital.  And today, his procedure was done.  We don’t know the details of how it all went, but we know that it was done, that he is alive.  And this Christmas, a family has received a precious gift – a gift of hope, that their son may have a chance, through the kindness of strangers.

What a precious blessing – that on this eve of Christmas, as we celebrate the gift of love and hope that we received 2000 years ago, we have been able to be a part of our own small story of hope, through the generosity of people across the other side of the world.

And that’s what Christmas is about, isn’t it.   Participating in hope – the hope of new life, of restored creation, of God’s kingdom coming to earth – initially in the guise of a baby, now in the form of love and restoration through all of us, His partners here on earth.

What a privilege to be a part of this rich tapestry, of which so many of you are a part.
A joyous, hopeful Christmas to you all.

- M.

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Next post:  Relationship (26/12/11)
Previous post:  A tale of two hearts (16/12/11)

A Tale of Two Hearts (16/12/11)

We see a lot of babies here born with heart problems.  Usually they come to us at a few days, weeks or months of age with a puzzling lack of growth and trouble breathing.  An xray shows a heart like a balloon, and an echocardiogram shows a heart that looks like someone twisted it like a Rubik’s cube, and now none of the connections are in the right place.  We sit down with the families and tell them that these problems cannot be fixed in Kenya – and then we send the babies home to die.

But this, week, for the first time, we found heart problems that maybe, just maybe, we can do something about.

Michael (top left) is 5 weeks old.  You may remember him from my previous post about the strike - he was the 4 week old baby arriving in heart failure, with no money to pay for his care.   This week we, through people’s generous contributions to our Needy Children’s Fund, were send him to get an echocardiogram by a cardiologist in Nairobi.

His heart showed a relatively simple problem – most connections in the right place, but a severely narrowed pulmonary artery (joining the heart to the lungs).  This has meant most of his blood just goes into his heart, and takes the easy route through a sneaky little hole straight to the aorta, bypassing the lungs, and back into the body.  This is a problem – the lungs are Oxygenville, and if the train skips that station then Mr Engineer (the heart) has to work harder and harder to get at least some of the blood through the narrow artery into the lungs.  And over time, the heart just wears out.

So our cardiologist has recommended that he get a relatively simple surgery – where a balloon is inserted via a leg vein up, up, up into the heart, and then inflated and pulled through the narrow artery to widen it (pulmonary valvuloplasty).  Voila, the blood flows into the lungs and this baby has a chance at a long life.

This relatively simple surgery costs 250,000KSh – around $2500.  An astronomical sum, out of this family’s reach.  But we are starting to investigate options to try and raise the money to pay for this surgery.  In the meantime, he will stay in the hospital.  We wanted to send the family home with oxygen for him, but you can’t have oxygen in the same room as a cooking fire – and when you live in a tiny one-room home, your options are limited.

Peninah (right), is a gorgeous 9 month old who came to us 2 weeks ago.  Her devoted parents have employment, an income, a home.  But she wasn’t gaining weight well, and when she came to us we found a dangerously low oxygen level, and heart sounds that instead of going bah-DUMP bah-DUMP bah-DUMP, went SHGGGGG  SHGGGGG  SHGGGGG.  Her echocardiogram was a little more like the Rubik’s cube – instead of 2 separate ventricles pumping the blood to either the lungs or the body, she has a single chamber in which the blood all mixes and then goes its merry way.  She also has a narrow artery like Michael’s so most of the time the blood chooses to bypass the lungs and go back to the body, with just a small portion getting the oxygen it needs.

Remarkably, a surgery is available in Kenya that could help her – a Glenn shunt.  This is essentially a graft, or short hose, that will connect her heart to the lung artery, away from the narrow portion, and allow more of the blood to get oxygen.  It is a much more complex procedure, as it is actually open-heart surgery, so we were astounded to hear that Peninah’s Dad’s employer had an insurance scheme to cover it.

Or, as it turns out, some of it.  This surgery will cost 650,000-750,000 KSh ($6500-7500), and her insurance will pay for 150,000 of it.  This still leaves 500-600,000 KSh to raise – still an astronomical amount for this family who have gainful employment, but not a lot to spare.  We are also looking into options to help this family, and the family is looking into raising money through a Harambee (community fundraising celebration).  Peninah may be able to go home on oxygen next week if she is not deteriorating, and wait to see if the funds can be raised.

And that is the joy and the tragedy of medicine here.  The procedure is available – but may be financially out of reach.  If we raise the money for this operation, it will be spent at a private hospital, lining the pockets of the administration and surgeon as we try to save these two sweet hearts.

- M.

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We are grateful for Simone Anders at Help a Child in Germany, who has started to try and raise money for us to help Michael and Peninah.  You may remember Shunetra’s story, and it was through Simone that we were able to pay her hospital bill and ease some of her mother’s grief.  If you want to help Michael or Simone,  please contact Simone or let us know.

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Next post:  A gift of hope (24/12/11)
Previous post:  Celebrating Advent (13/12/11)

Celebrating Advent (13/12/11)

On Sunday night, we were invited to an Advent Celebration at the Myhres’ house.  As an extended cobbled-together family of paediatric-associated people, we got together to sing carols, meditate on this precious time of remembering Christ’s birth and the significance of his presence in our daily lives and, of course, to eat cookies.

One of the highlights was hearing Jennifer read the story of Papa Panov’s Special Day.  Originally written in 1899 in French by Reuben Saillens, translated into English by the Russian Tolstoy and then retold for children by American Mig Holder, this lovely story has travelled around the world to be retold on a chilly December night to Australians, Americans, Africans and Canadians in Kenya.

It tells the story of an old man, sad and alone, who is hoping for Jesus to visit his village on Christmas day.  As the day fades and his hopes sink, he uses his time to help needy villagers who pass by his door on a wintery day, some cold, some hungry, some lonely.  And as the evening passes and night falls, he realises that Jesus has indeed passed through his village – through his compassion and love for those who have passed by his door.

One of the scriptures that we read was a passage that has been foundational for me in this journey from Australia to Kenya – Matthew 25:37-40.

Jennifer on piano, Scott on guitar, and flanked by Leland's marvellous baritone and the dynamic worship team duo of Lillian and Bob. Who knew doctors had artistic skills?

“Then the righteous will answer him, ‘Lord, when did we see you hungry and feed you, or thirsty and give you something to drink?  When did we see you a stranger and invite you in, or needing clothes and clothe you?  When did we see you sick or in prison and go to visit you?’  The King will reply, ‘Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.’

The evening was a lovely reminder, through story, song and scripture, that as we look forward to this anniversary of God sending his son to earth, that the restoration of a broken world began 2000 years ago and continues right now.

And then, of course were cookies and treats, coffee and friends.  A celebration for so many reasons.

- M.

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Next post: A Tale of Two Hearts (16/12/11)
Previous post: Friendly Fire (9/12/11)

Friendly Fire (9/12/11)

Today is day 5 of Kenya’s doctors’ strike.  No doctor employed by the Ministry of Health in Kenya has shown up for work for this whole week, and the strain on the system is starting to show.  The private and not-for-profit hospitals are attempting to care for a country full of sick people, most of whom struggle to pay for public care, let alone slightly more expensive not-for-profit care, and the people who are suffering are the poor and the sick.

Kijabe is one of the not-for-profits.  We charge a little more than the government facilities, but a whole lot less than the private hospitals.  In order to make this sustainable, all of the doctors who are not Kenyan work for nothing.  The Kenyans who work for the hospital are paid, but a very low salary, which they do because they have a heart for serving the poor and displaced of their own country.  And the government, seeing that we provide care for people they simply do not have the resources to treat, pay for our interns to be here.

Our interns come here because they are Christian and also have a heart for the poor, the lost, the needy.  Part of their training here is practical, but it is also a wholistic training facility.  We have some excellent interns, and they are an indispensible part of our team – especially overnight and on the weekends.   Not only do we miss them – we need them.  At the best of times.  And these are not the best of times – our workload is the highest it has ever been.

One man went to ICU after 36 hours of bouncing from one non-functional hospital to another after his road traffic accident.  Many pregnant women have come here to deliver their high-risk babies after realising that their obstetric care could not be continued at Kenyatta (the state hospital in Nairobi).  The maternity service is bursting at the seems.

Peris arrived on my night on call on Wednesday.  At 3:30am I received a phone call from our clinical officer intern, a very junior PA-equivalent with no pediatric experience, with a slightly panicked phonecall that there was a “20 week baby in casualty”.  Alive?  A baby born at only 5 months?

Peris, it turned out, was born at home 16 hours earlier, suddenly, prematurely at probably closer to 30 weeks, and her twin sister didn’t survive.  Mum took her remaining daughter, this 700 gram scrap of an almost-baby, to the closest hospital in Kikuyu, which doesn’t provide care to premature babies.  And, knowing that our nursery was full, and that the neonatologists at Kenyatta are on strike, they gave her oxygen, some IV sugar, some Vitamin K and sent her to us anyway.

We had no incubators, and nowhere to send her.  This glistening pink shiny doll, however, was opening her tiny eyes and looking at me.  And breathing, all on her own.  Her face seemed to say – I have come this far, on my own.  I am a fighter.  Give me a chance.

And so we admitted her anyway.  Under a baby warming resuscitaire, with antibiotics and oxygen and IV fluids, praying that tomorrow one of the other tiny babies would be big enough to donate her incubator to give Peris a chance.  And so far, she has made it.

Today, 4 week old Michael came in.  It was immediately apparent that he was born with a heart condition, and it is getting worse.  Mum has no money, no insurance.  We don’t have a cardiologist, no way to tell what his heart problem is, and we don’t have the right drugs to stop it worsening.  The cardiologists at Kenyatta are on strike.  So he has been admitted anyway – we will try to do what we can on Tuesday, after a public holiday weekend, if he is still alive, if there are doctors working who can help him.  Or we will access our Needy Children’s Fund and pay for him to see a private cardiologist and do what we can here.

And my last patient of the day, Richard, who came in with weight loss and swollen glands, it turns out has leukemia.  Dad almost left before doing any tests because he has almost no money.  The oncologists at Kenyatta are on strike.  So we, with no oncology facilities, will admit him over the weekend, and try, on Tuesday, to talk with a private hospital in Nairobi to see if this curable cancer can be given a chance through their Benvolent Fund.

Frustration – that these innocents are caught in the middle of the tragedy of friendly fire.

- M.

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Update 11/12/11 – Sweet Peris lost her struggle in the wee hours of this morning.  Despite finding an incubator for her the next day and some strong medications, her strength just wasn’t enough to overcome a rough start in life, and her kidneys just didn’t make it.

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Next post:  Celebrating Advent (13/12/11)
Previous post:  My ridiculously heavy white coat (4/12/11)

My ridiculously heavy white coat (4/12/11)

Every day before I go to work, I don a white coat – all doctors, clinical officers and medical students wear one as our identifying uniform.  The absolute best thing about a white coat is the number of pockets – I don’t carry a bag because in my coat pockets I have hospital protocols, an otoscope/ophthalmoscope, pulse oximeter, reflex tendon hammer, patient note cards, tape measure, keep-the-TB-out face mask, thumb drive for teaching, glasses, hand gel, emergency chai money, beeper and small umbrella (because you can guarantee it will rain at some stage most days).  I could pretty much camp out for a week and survive if I got locked out of home.  Or at least set up an ad hoc clinic.

The absolute worst thing about a white coat is the number of pockets.  My white coat weighs a ton.  And as soon as I put it on in the morning, I feel weighed down.

It’s interesting, the weight I carry at work.  The weight of feeling that I’m not knowledgeable enough, that when the new ICU doctor calls me for advice on a child, I may not know the answer or I may not be skilled enough to put in a needed central IV line.  That one of my decisions may make a child worse, that my lack of understanding of Kiswahili and Somali means I may miss subtle but important cues.  That I am spending too much money doing tests on a child, that I am not doing enough.  That I am trying to do more than I am able by not referring enough children for specialist care, that I am referring too many because I should be more able to manage these conditions.

The weight of having to decide to take a brain injured 2 year old child off the ventilator right now, knowing they will probably die,  because there is a 30 year old bleeding to death in the next ward who may actually make it if this bed in ICU becomes available for her.  The weight of wondering, was the brain injured when the baby came in, or could it have been because of something we did or something we missed?

At the end of the day, it’s a real discipline to take off my white coat.  To not wear the heaviness home, to leave my coat in the laundry where it belongs.  It’s really easy for me to keep my pockets full at night, on the weekend, to forget that I can empty those out and feel the lightness of being at home, away from work, and to be fully available to my husband, kids, friends and distant family.

Tomorrow, there is a very good chance that all of our interns will be on strike as part of a national call for better wages, as well as our Kenyan doctors who are employed by the government.  This will leave us, especially overnight, overwhelmed by calls usually fielded by our junior doctors, and possibly overwhelmed by patients who come to us because we will be one of the few hospitals that still has any doctors working at all.  And over December, we are all attempting to take some leave – which means the workload for those of us remaining escalates.

The trick, our medical director has been encouraging us, will be to not make our white coats heavier.  To realise that the pockets are full already – and that we may need to be comfortable with that.  To realise that we are not capable, nor should we be, of providing 100% of what we really want to provide with the resources we have.  To realise that we need to prioritise how much of the load we are mentally shouldering, for it to be OK to say, I may need to spend less time micro-managing this child, to be prepared for some things to slip through the cracks and for it to be OK.

And then to take our white coats off at the end of the day.

- M.

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Next post: Friendly fire (9/12/11)
Previous post:  Seasons (1/11/11)

Seasons (1/12/11)

One of my joys in Kijabe is the time I spend running a few times per week…like with mountain biking, most of the trails people use to walk from town to town are also decent running trails.

Running is a Kenyan national pastime, and Kenya regularly produces the world’s best runners.  So people ‘get’ runners here (and will cheer you on as run by them)…although the high altitude and not-very-gentlemanly elevation changes in Kijabe mean runners are scarce.  When I pass a Kenyan mama on the trail with a load of sticks on her back, or carrying large formerly-enormous-vats-of-cooking-oil-and-now-contain-water jugs, I do feel slightly ridiculous.  I can hear them thinking to themselves as they shake their heads, ‘crazy mzungu, can’t just walk to work and climb 1,000 feet for his exercise like the rest of us, he has to put on those ridiculously small shorts and funny shoes.  What a strange people.’

My favorite running trail is reasonably level and follows the curve of the escarpment from Kijabe out past a nearby town called Machane towards Monkey Corner Springs, the site of Kijabe’s principal source of water.  I used to run on the dirt road, but we’ve had a spate of successful carjackings lately in that area so I stick to the trails just uphill.  The view looks out over the Rift Valley, and it is just breathtaking.  I am recharged looking out over the vista as I run, and I have been known to break into song.  Usually something by the Red Hot Chilli Peppers or U2 punctuated by staccato, ragged breathing, as I struggle to pull in oxygen at more than a mile and a half above sea level, but still a song…

As I ran this evening, I was brought short by something I hadn’t really taken notice of lately:  a complete transformation of the Valley floor.  This part of Kenya, like much of northern Kenya has been in drought for a while, and so when we arrived in April the Valley was a dry, dusty floor of various shades of brown, surrounded on either side by brown mountains.  This is what it looked like when we arrived–I took this picture while climbing Mt Longonot with Brenton Wait when he was over for a visit:

Rift Valley in June 2011

The drought broke a few weeks ago, and it’s rained almost every day for nearly a month.  This is what I saw this evening:

Rift Valley in December 2011

I was just stunned by the difference between the two Valleys.  One a lifeless, dusty, barren place.  Then, a new season with a lot of rain, and the Valley is totally transformed into an unbroken panorama of verdant garden with kaleidoscopic shades of green.

What a difference a new season makes.

I’ve been experiencing a dry season in my own life, my own “dark night of the soul” as John of the Cross referred to it, for a few years now due to a number of life events.  But I have noticed in recent months that glimmers of green are starting to appear, and it may be that I am entering a new season.  I’m not sure, but I am hopeful.

As I ran today and noticed this astonishing change in the Rift Valley, I was filled with hope that seasons aren’t permanent, their impermanence is good and natural.  Each season has a purpose, and is useful and life-giving in its own way.  Today, I am struck by how the ebb and flow of God’s good creation mirrors my own spiritual and physical journey.

- A.

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Next post: My ridiculously heavy white coat (4/12/11)
Previous post: Thanksgiving (26/11/11)

Thanksgiving (26/11/11)

Being an Australian in Kenya with a whole bunch of Americans means that we get the best of all the holidays.  And so this week, we celebrated Thanksgiving.

Actually, this whole month has been a month of Thankgiving for me.  When I sent out an email at the start of the month tentatively asking some friends if they’d like to join us for a Thanksgiving meal, there was an overwhelming “Yes!” response, and so for the last 3 weeks I have been looking forward to this meal, this excuse to take time out with dear people and say, thank you God –  I have a lot to be grateful for.

Turns out 20 people were going to be coming over for dinner and, since we’re in Kenya, it was a normal workday for me.  So we divided up the meal – every family brought 1 or 2 dishes in quantities sufficient for an army.  From Jennifer, a way-t00-delicious-to-be-healthy pumpkin, pecan and brown sugar concoction, as well as chocolate-pecan and pumpkin-pecan pies; from Amanda and Erik a salad with a never-to-be-revealed-secret-ingredients delicious dressing as well as stuffing and a heavenly apple pie;  from Wayne and Anna a vat of laboriously hand-mashed creamy mashed potatoes (as well as their dining table and chairs!); from Ruth a cheesy-gooey-home-style green bean casserole and flaky rolls.  Andy took the day to prepare a rosemary-basil-garlic infused succulent 30-pound turkey and sweet corn, and of course to arrange the furniture to my liking (I am so grateful to have married a man who doesn’t mind following a hand-drawn to-scale map of the dining room, including instructions as to how to alternate placemats….).

My contribution, with Liam’s able assistance, was a pecan pie made a couple of days in advance.  He’s crushing pecans in the photo – you can’t see the mallet because he’s hammering at the speed of light.  It came out of the oven looking delicious.  It tasted, however, kind of like goo made of sugar and nuts because, well, that’s exactly what it is.

It is such a blessing to sit down with friends, to look around at these people, none of whom we’d met a year ago, and realise how much they have come to mean to us already.  For the sense of family that we have, when we miss our Australian and American families so much.  For colleagues who are also friends who share our heart and our passion for showing God’s love to people who desperately need so much.  For their families, whose young children are friends to our kids and whose teen children give us hope that is IS possible to to turn tantruming two year olds into great human beings.

So, today I am happy to be reminded that I have so much to be thankful for each day.  For family and friends, near and far, in all their varied forms.

- M.

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Next post: Seasons (1/12/11)
Previous post:  Miracle Babies (25/11/11)

Miracle babies (25/11/11)

There are some things as a pediatrician you learn in a textbook, but see maybe once in your career.  I vividly remember as a resident in Florida hearing of 2 twin babies coming into our pediatric ICU, severely dehydrated, with sodium levels over 170.  Normal sodium levels are 135-145 – over 170 is getting pretty dangerous.  And the 2 twin babies, severely dehydrated because the new parents just didn’t realise that mum didn’t have any milk, didn’t survive.  It was once of those seminal training moments in which I somberly realised that sometimes, children can be so sick that they have passed the point of no return.

Since arriving in Kijabe, I have seen 4 babies with sodium levels of 200 or higher, and countless babies with sodium levels over 170.  In the last month alone, we have admitted 3 babies with sodium levels between 160-213.  And as the visiting anesthetist said to me with befuddlement on the Friday night we admitted one to ICU together – “that can’t be right… those numbers aren’t compatible with life!?”

Last weekend, Simon (pictured top left) went home with mum.  The sickest of all of the newborns, he spent a week in intensive care,  gradually turning from a shrivelled, dried chip of a baby to a healthy blooming, breastfeeding boy, looking around for his mother to take him home.   When I met him in the emergency department, as soon as I saw his numbers (doctor friends:  Na 213, Cr 11.9, K 8.5), I gently told mum we would do everything we could, but I was very worried he wouldn’t make it.  We prayed with mum, and we admitted him to ICU.  Under Wayne’s vigilance in ICU, he slowly recovered.  As did Charity, another week old baby whose shrivelled little face slowly returned to cherubic – she went home the day before yesterday.

These are conditions in which the textbooks give vague directions about how to help, or instructions that end up being actually dangerous – no-one has a ton of experience with this.  Jennifer, Immaculate and I have had a trial by fire over the last 7 months in managing these babies – and some babies, like sweet Vivian last week, have not made it.  But many of them have.

Our friend Mary Adam is managing a community newborn health project which is, among many other good things, helping educate community workers on how to teach new mothers what the danger signs are, so that these babies come in before they are critically unwell.  We really hope that as people in the community are trained in basic newborn care and recognition of danger signs, that we’ll stop seeing these little ones at all.  It would be really nice to be obsolete here – for the malnutrition and calcium deficiency and dehydration to be things of the past.  But until they are, we are here and happy to do everything we can to help these little ones when they do arrive.

- M.

The food that perishes (23/11/11)

In the last few months, our work on the Kijabe Water Project has continued its steady progress, with major areas of activity including finalising the design, putting in place procurement strategies, and applying for grants.

We are in the process of applying for around $600,000 USD in outside funding.

So when at 5pm Friday last week I received an email from an official at USAID asking if Kijabe Hospital was interesting in submitting a Concept Paper for the water project for potential funding opportunities, it got my attention.

The Project Team here in Kijabe, and our grantwriting team in the USA swung into action over the weekend.  After emailing nearly every hour and exchanging draft papers over the next two days, at 10pm on Sunday we walked the finished proposal to the Hospital Executive Director for signing.

I sent it by email at around 1230am Monday morning to USAID, and at 0830 I received a call.  Would I be able to come into the US Embassy in Nairobi for a meeting at 1030.  Why, I believe I could make that time, I said.

At this point, despite my experience in infrastructure projects and in the at-times-downright-maddening-fool-me-twice-shame-on-me vagaries of government funding, my hopes are well and truly up.  My adrenaline is pumping, and I am stoked; riding on a cloud.  This is it!  The answer to prayer that we have been looking for for six months!  Out of nowhere, someone sees the desperate need of Kijabe Hospital and wants to help.

I turn up for the meeting, and things go from good to better.  The official is just lovely, and an enthusiastic supporter of Kijabe Hospital.  Why haven’t you submitted an application for funding before, she asks.  Everyone in East Africa knows the Hospital does an astonishing amount of good with vanishingly small resources.  We’d love to help, and may be able to quite quickly.  Here’s what you need to do, I’ll pass this up the chain of command and have an answer for you by tonight.

As I leave the meeting, my hopes have gone from cumulus to stratospheric.  This is it, I think.  It’s done.  We’re not even going to have to apply for more grants.  USAID will fund the Water Project, and perhaps the Hospital’s entire 5 year Capital Plan too!  Hallelujah!

For the next 24 hours, my prayer life was better than it has been for weeks.  Prayers of thanksgiving, joy, and hope as I waited to hear back.  Planning for the future, meetings at the Hospital as we giddily programme cash flows and project expenditure, and joy just bubbling up everywhere and drowning out the stress and sadness of the last few months.

And then today (Wednesday).

I hear back from the official around noon.  Actually, we’re not in a position to help you immediately, you’ll have to wait until later in 2012 and apply in a competitive process with other applicants.

I am crushed.

Despite having done this before, despite having ridden the birth-life-death cycle of infrastructure projects many times, I feel like I’ve been kicked in the gut and the wind has been taken out of my sails.  I had such high hopes, we’ve had such excited conversations at the Hospital in the last 4 days…and now we’re back where we started?

Suddenly, my prayer life isn’t quite as filled with cherubim and elders bowing before thrones.  Lord, help me work through why this is affecting me as much as it is.  I am so disappointed.

I sit down for my noon Daily Office, and read this passage of Scripture under the midday office in The Divine Hours:

“So when the crowd saw that neither Jesus nor his disciples were there, they themselves got into the boats and went to Capernaum looking for Jesus.  When they found him on the other side of the sea, they said to him, “Rabbi, when did you come here?” Jesus answered them, “Very truly, I tell you, you are looking for me, not because you saw signs, but because you ate your fill of the loaves. Do not work for the food that perishes, but for the food that endures for eternal life, which the Son of Man will give you. For it is on him that God the Father has set his seal.”  (John 6:24-27)

Immediately I sense the Lord saying to me, Andy, don’t work only for the bread loaves, for outcomes, deliverables…be in this for me.  Work with me.  I am eternal, work with me and care as much about things that have eternal value as the here and now.  I am in the here and now, the earth is mine and everything in it, but I want you to put your hope in me, not solely in metrics, grants, schedules.

I still felt like I’d been kicked in the gut, but now I felt the Lord breathing life back into me.  Ahhhhh….yes, that’s it.  That’s the lesson he’s been teaching me repeatedly for ten or more years.  Work with me, watch how I do it, take my yoke and learn from me, for it’s easy and my burden is light.  (Matthew 11:29)

This weekend was a weekend of anticipation, hope, and delight.  Today has turned into…something else.  But as I sit here tonight and reflect on what has actually taken place, and the words of the Lord to me through them, I hear a gentle voice calling me to trust Him.  To not take on burdens that aren’t mine to carry, to release outcomes that aren’t mine to own, and to find rest in the One who clothes the flowers of the field and gives the birds food to eat.

And I’m not giving up on USAID.

- A.

Mission-focussed? (17/11/11)

Whew!  What a month it’s been.  Moving house, Moffat’s semester ending and final exams to administer and grade, my graduate school semester ending and papers on Augustine and grace to be written, the usual cycle of sorrow and joy at the Hospital, children who are growing and just being all-around simultaneously delightful and maddening, and normal life all mixed in with the signs of spring that are unfolding around us:  birds singing, flowers everywhere, and more rain than you can shake a stick at.

When the push is on in seasons like the one in which we’ve been, I get into a sort of “mission-focus” mode, where I unconsciously sacrifice everything else for the “mission”, whatever the that happens to be at the time.   To put it another way that sounds less grand or without military jargon, “head down, bum up”.

When I was on a submarine, it was operating a warship.  On an infrastructure project, time/cost/quality/stakeholders.  In vocational ministry/humanitarian work, the “mission” might be patients, students, mentees, or parishioners.

There are a number of pitfalls in my mission-focus mode, not least among them how one defines the “mission”.  Leaving that aside for the moment, a key flaw of this mode is the “everything else” that gets sacrificed:  rest, prayer, health, exercise, relationships, family, capacity-building.  It is a fascinating reflection exercise to consider how quickly and easily I justify sacrificing these things in the name of “productivity” or “mission”.

Mardi and I started a habit several years ago of setting aside time to evaluate our lives at quarterly or six-monthly intervals, cutting out things that are no longer priorities and highlighting important areas of focus we don’t want to sacrifice.  We find we have to do this regularly, as it is so easy to forget that when we say ‘yes’ to something, we are saying ‘no’ to something else.

Site visit to Monkey Corner Springs through a flooded road

Time is a zero-sum commodity, we have learned the hard way, and if we keep piling things into our schedule, we force ourselves to cheat in other areas.  With both of us working and myself in graduate school, if we say yes to every opportunity to serve–RVA, Moffat ministries, church, SIM, the endless parade of Hospital needs–we must say no to something else currently in our schedule.  Otherwise, we start to ‘cheat’ on the things we’re doing, and it’s usually family, health, and our spiritual lives that we start to cheat in first.

So as we wind up this season and look forward to Advent and then Christmas, a few highlights stand out as high points of joy, hilarity, and moments when the clock seemed to stand still for a while:

–Riley (4) piping up at dinner a few weeks ago and saying, ‘I’ll thank God for the food, Daddy!’

–A resident at the hospital coming to pick up the large baby crib left for him at our house by the previous family, and putting the whole thing on the back of a piki (small motorcycle), strapping it down, and driving away with it.  The size ratio was roughly that of putting a Volkswagen on the back of a mountain bike, and the whole thing was like a Mr. Bean episode.   I confess I made strong intimations that there was no way on earth he was going to pull out of our driveway with THAT on the back of his piki.  Pull out, he did, and I walked back into the house to Mardi who said, ‘You didn’t take a picture????’

–going on a site visit to the Monkey Corner Springs pump station two weeks ago, and, reflecting on the probability of being car-jacked on the notorious stretch of road it lies down, leaving my wallet and phone at home.  Up to that point in my life, I don’t think I’ve ever prepared for a site visit by removing valuables from my person, and given the recent spate of car-jackings we’ve experienced around here it probably won’t be the last.

–telling my Spiritual Formation class at Moffat that I would be their lecturer next year for their Biblical Leadership topic, and them breaking out in cheers and clapping.

–numerous mentoring sessions with the students in my Practical Ministry/Mentoring group at Moffat.  Getting to know them, their passions, and their hearts.  Some of their background stories are just horrific; almost all have lost at least one parent and many are orphans.

The Papa Bill Star Wars show!

–the Skype chat with Papa Bill in Grand Rapids a few weeks ago where he did a puppet show with “Princess Riley and Captain Liam”, using Lego Star Wars figures that Quinn and Will Brennan (Riley and Liam’s first cousins) gave him to “tell the Star Wars story to Riley and Liam”

–asking Riley to sweep under the table after dinner, and giving her the dustbuster to do it with…the look of wonder in her eyes as this magical tool made all the crumbs disappear was priceless.  She then proceeded to drain the entire battery by “sweeping” the entire house with it for the next 15 minutes.

–returning from Nairobi last week after dark, in the driving rain and fog.  Each of these three conditions we try not to drive in if we can help it, all together, it was the unholy triumvirate of craziness.  By God’s grace I got home safely.  In the final 300 metres, on the steepest part of the trip down the mountain on the dirt road I slid while in four wheel drive into the drainage ditch on the side of the road.  Luckily there was a sort of small flash flood in it from the rain, and the water pushed me down the last part of the hill onto the level road home.  I’m not sure I am supposed to have enjoyed that as much as I did!

–helping our outdoor worker, John, save some of his wages each month so that he can attend driving school in January, and get his driver’s license.  This will be a huge boost for his career prospects, as driver’s licenses are expensive in Kenya, and qualified drivers are sought after.  Every time he talks about going to driver’s ed he gets a huge smile on his face, which I compare to my attitude before driver’s ed in Albion, Michigan, which was something along the lines of, “Man, this driver’s school is taking away valuable skateboarding time!”

John, our outside worker and soon-to-be-driver-qualified gardener

–sharing life with Elizabeth, the lady who lives just up the mountain from us and comes to our door weekly selling delicious homemade cinnamon rolls.  She lost her husband to cancer a few years ago, her son to injuries sustained during a violent home invasion the following year, and has stayed away from church and God ever since.  ”How could a loving God allow this to happen to me?”, she asked me this morning.  She is a wonderful cook, and a precious lady, and we are praying that she would be able to move through this season of darkness and grief and emerge on the other side.

A few highlights amongst a “head down, bum up” season.

- A.

The language of humility (16/11/11)

There’s something about learning a new language that I just do not enjoy.

It’s more than the hard work, spread amongst an already busy schedule.  It’s more than the unfortunate graduate-school-timing coincidence that I’m learning koine Greek (the Greek that much of the Bible was first written in) at the same time.  It’s deeper…I have noticed that something about learning a new language cuts across the grain of a part of my character.

We’ve been taking Kiswahili (literally, “the Swahili language” in Swahili) lessons four times per week for six months now.  Mardi practices it at work nearly every day, watching patients’ and nurses’ eyes light up when she responds to them in one of their native languages.  She’s becoming fluent very quickly, and is already talking about starting lessons in another language from a troubled country to our north.

My practice is largely limited to my lessons, as I teach at Moffat in English, and the Engineering team at the hospital communicates mostly in English and Kikuyu (the language of the Kikuyu tribe, to which most of them belong).   My lack of opportunity for vocational practice = slow progress.

So my Kiswahili is limited to what a small child might know…basic grammar and a few nouns and verbs.  I’m getting pretty good at saying “Yesterday, I went for a run slowly.  It was difficult, but I returned.  I was chased by a lion and I stopped to eat some roasted giraffe meat on the way.”  To which Edward, our language teacher, unfailingly replies with mock surprise, “Kwelli!?”  [really!?]  He’s a hoot, and our lessons together are usually 1/3 laughter, 2/3 learning.

I realised yesterday that perhaps part of the reason I am finding language learning difficult is because I’m not used to being in the position of an elementary learner.  I’m not used to feeling like a child when I speak to someone in their own language and have to constantly repeat, “tena, tafadhali?”  [again, please?]

Edward encourages us to practice Kiswahili with everyone we meet, so that “everyone may become your teacher.”  Of course, he’s right…but I realised yesterday that I have found this challenging to do, because I simply don’t like being in the position of feeling like a child.

Mardi and I had a day off yesterday, and drove to Nairobi to have a date.  Driving up the mountain to the highway, we stopped to give a lift to an elderly woman; it’s courtesy (and culturally expected) if you have room in your car to offer a lift to someone in need.  During the 10 minutes or so she was in our car, we exchanged pleasantries in Kiswahili, and discussed the weather…or at least, Mardi and she did.  I noticed that I didn’t want to say much; I knew I would have to ask her to repeat herself, and I didn’t want to feel like a child on my day off.

Speaking to someone in their own language, with grammar skills approximating that of a 3 year old, is an extraordinarily humbling experience.    It is a great leveller.  The person I am speaking with doesn’t know or care anything about my qualifications, education, or past achievements.  I sound like a child, and I feel like a child.

And this is a shock to the way I view myself, to my self-image:  I’m used to being the expert, the person someone seeks when they want an opinion from an SME, or they want a bit of coaching.  If I’m truly honest with myself, it goes deeper than what I’m used to; something in me wants to be that person, to have it all together, to be answering questions and not having to ask them.

Like so many things in life that are painful on the surface, but are deep down really, really good for our character growth and spiritual formation, it’s very humbling.

One of the very bright spots in our time here has been the friendship we are developing with Leland and Susan Albright.  Leland is famous paediatric neurosurgeon known around the world, and Susan is an excellent nurse practitioner.  They retired last year, and moved to Kijabe in their sunset years to work 12 hour days, 5-6 days per week operating on disabled and injured children.

It is an inspiration just to be around them.  They would be very embarrassed to know I wrote this, but if you want to know what seven million hits on Google looks like, enter his name.

Leland and I were talking last week about what we have learned about God and life since we moved here, and in our conversation, the Lord opened my eyes to something, which we will no doubt learn again and again in our time here:  God is every bit as interested in the people we are becoming as he is in what we are doing with Him to further His Kingdom.

I am learning that there is a deeper value to learning Kiswahili than the quantitative value of becoming more effective in my work, or being able to communicate with people on a deeper level.  There is something qualitative, a byproduct of the process which deeply affects the person I am inside:  my character.

It is humbling, and requires ongoing, daily humility and the attitude of a learner to approach people on their own terms so that you might learn from them.

As I yield to the character-shaping process of allowing everyone to be my teacher, Paul’s words to a troubled church in Greece which have provided me so much comfort in past years come to mind again:  “though our outer nature is wasting away, our inner nature is being renewed day by day.” (2 Cor 4:16)

And I will continue to be chased by fictitious lions wakati ninakimbia pole pole (while I am running slowly).

- A.

Caleb (11/11/11)

Caleb is nearly 4 years old. The Ear Nose and Throat Clinic has sent him to see me because, in addition to his snoring and trouble sleeping because of huge adenoids, he may also be having seizures, and is really hyperactive, and doesn’t really talk. He and his mother have been waiting 2 hours to see me, because the clinic here sees people as they arrive, and I have been busy admitting children from the surgical clinic, seeing a newborn with an abnormal penis, following up children with abnormal test results on the ward. So now I have a few minutes to quickly see what Caleb’s problem is before seeing another scheduled patient and reviewing a sick boy in the emergency department.

Caleb flits around the clinic room like a mosquito – touching, grabbing, playing, snatching. In the midst of the boy-tornado, his mum tells me her story. Caleb, she says, was born after a prolonged labor, and was probably pretty stressed. He didn’t cry when he was born – mum doesn’t know for how long. She left the hospital the same day because her marriage was troubled – violence, she says. And her breast milk supply didn’t come in well. Her husband didn’t stay around for long – Caleb was a difficult baby. It has been just the two of them for most of his life.

The last few months have been very hard. Caleb is a very active boy – he runs, he yells, he bites, he scratches. Babysitters have not lasted – some have beaten him, bitten him back. And without childcare, mum has missed a lot of work as a dressmaker. And so 3 months ago they fired her – she has had no income for 3 months.

I ask how Mum is supporting herself. She has no family supports – she left home at 12. And while that alone is significant, I don’t have time to delve more into it. She tells me she has been begging. And sometimes, to get what she needs, people take advantage of her. I assume those people are men. She has just been evicted from her home and last night slept at a neighbour’s.

Caleb can’t talk – he can say one word, Mama. For everything else he gestures, he points. She knows he can hear – “Open the door” she tells him in Kikuyu – and off he goes to open the door. She knows he can feel – when she is sad, he comes to her and hugs her, pats her back.

Mum has thought about leaving him. Walking along the street, sometimes she thinks, I should just keep walking and not look back. But then she tells me – this boy is my life. I love this child.

And then, she just cries.

I would like to test his hearing, I would like to assess his brain. I would like him to have a developmental assessment, I would like him to see a speech therapist. I would like to screen him for autism, I would like to have his adenoids taken out, again, because he cannot sleep at night, ever. I would like to spend the day liaising with everyone I know to help this family, I would like to tell this mum, it is going to be OK.

Most of these things, I can’t do in Kenya. Those that I can, cost money.

I talk with mum, and explain my thoughts. I hear her need, I tell her, and in addition to seeing what I can do from a medical standpoint, I ask if I can get the chaplain to sit down with her – to talk with her, to encourage her, to be a social worker for her and see if there is anything we can do to help her situation, to pray with her.  She is not from our village, so I can’t really access our food bank and fund for needy families, but I am sure the chaplain will know what else we can do.

What can I do, as a doctor, for this desperate family, for the most benefit?

Hesitantly, I prescribe Ritalin for her son. For this not-quite-4-year-old, the only thing that I can do, today, is try to get his behaviour a little under control – so that he can be cared for, so that mum can return to work, so that she feels like there is a little light at the end of the tunnel.  She agrees to come and see me again in 2 weeks to see if this has helped at all.

I feel so impotent. I hope, and pray, that this medication will make any difference at all. I hope and pray that the chaplain has been able to help her, to direct her, to encourage her – as I leave her in his hands to do the next task on my list.

I later find out that he has given her some suggestions, and that he has arranged to see her again in 2 weeks to see what else we can do to help. I hope and pray she comes back and that when I see her we are able to access our needy children’s fund to test her son’s hearing. I hope that there is some improvement in her son, that there is some improvement in her life, that through her interactions with us she may catch more of a glimpse of a God who loves her right where she is.

- M.

Feast or famine (6/11/11)

It’s interesting working in a place staffed by volunteers.  In the last few months, we have been blessed to have some short term pediatricians helping us – Raymond helping on the ward and in nursery for a few weeks, and Wayne helping in ICU for 4 months.  Jennifer and I have had breathing space to do some admin, to upskill in anaesthesia, to go home a little early if we have been up all night on call.  It has been a feast of assistance, and we have been so grateful.

Volunteer short termers are gold.  But inevitably, they come when they are available – which may not necessarily be when we need them most.  Immaculate has teaching duties elsewhere in Kenya periodically; Jennifer and I both want to have a bit of R&R time every so often – over Christmas, to be able to attend a continuing medical education conference when there is occasionally one nearby, to be able to spend time with children during the school holidays.  And finding people to come and help us for just the week or two that we really need them can be tricky.

This week has been more of a famine week with Raymond gone.  We should have been back to normal staffing except that Immaculate also had to leave for most of this week to educate on a course.  That left the Clark Kent/Superman combo of me and Jennifer (she’s Superman) to cover what ended up being a really busy service – pediatrics, nursery, outpatients.  The days went from being manageable, with time to really think about the best plan for each patient, to chaotic.  Friday I was doing rounds from 8am-1pm, then frenetically seeing neurosurgical consultations and admitting patients from casualty or outpatients until 6pm, after which I was on call.  Jennifer has borne more of the brunt of it though as she is on call this weekend – by Saturday morning there were 40 inpatients to see, and inevitably more children being admitted.

I think the hard thing isn’t being busy – Jennifer and I are wired in similar ways and able to shoulder a lot of stress.  What is hardest is knowing that there must be things we are missing – not having time to sit down and delve into more details with a parent, to take the time to examine a baby more thoroughly and find the subtleties, not having the space to sit down with a textbook and read more on the things about which we only have a surface knowledge.  To feel like we are doing our job adequately, but maybe not well.  Having to rely on each other’s set of fresh eyes to see the things that, in our busyness and blinkeredness, we have missed.

People sometimes ask – what is the value of a short term mission trip, or a short term medical trip?  From my perspective, sometimes they can be a waste of time – like taking some paracetamol and a single round of immunisations to a village that you will never visit again – but sometimes, they can be lifesaving.  People who come to us  twice a year for two weeks at a time, with experience in third world medicine, are a breath of fresh air and a lifeline.  They give us space to be refreshed and encouraged, to teach us and relieve us.

So thank you to those of you who come and help us.  For those of you who may be thinking – I only have a week or two a year, I don’t think I can really help – you can.  Just find somewhere that has infrastructure and people there already, who need encouragement, who need a break, who need help.  And then, if you can, do it again.  And again.

It doesn’t even have to be a long way from home.  Nurses – find a family with a child with disabilities who needs a holiday, get to know them, and give them the gift of rest by doing respite care in your home.  Doctors – find a remote clinic in the outback that needs someone to come up sporadically to a place that is dirty, that is dry and will never get your name in lights.

The trick is – ask.  What do you need and when do you need it?  You may be surprised by what you find.

- M.

Choc chip cookies! (3/11/11)

The sun is out, the rain is gone, the birds are singing, the escarpment is alive with a feeling of spring.  Not that we really have spring here, it just feels that way to me.

When I am not at work, I get to hang out with my kids who are, let me just say, pretty great.  At least some of the time they’re pretty great.  So today was threading beads, playing outside in the sun, and baking choc chip cookies. Today is one of those days that it’s just nice to be a mummy.

Choc chips are a treasured commodity around here.  My friend Anna has seriously considered bartering spare choc chips for other essentials – I reckon she could make a killing.   So when we were sent choc chips – Cadbury choc chips, Nestle choc chips and GIANT choc chips from friends and family – I hid them away for when I absolutely couldn’t do without them any longer.

Look what I made!

That was about a week and a half ago, and today I caved.  So this morning we got to make choc chip cookies.  Ooey gooey molten chocolately Nestle-Tollhouse-adjusted-for-altitude choc chips cookies.  And the best part was, I thought the recipe called for 2 packs of choc chips so I halved the recipe – and when I got to the choc chip part, I realised I had misread and I only needed 1/2 a packet of choc chips, so I got to save half of them.  Brilliant.

 

 

It is amazing what can make your day over here!

Dignity (1/11/11)

So this post is mostly thoughts about allowing children to die with dignity.  I thought I’d make that clear upfront, so you can choose whether to wade through it with me, or not.

There are 2 children whose faces won’t leave my mind this week.  They both are going home from the hospital to die.  And the more I think about it, the more I think that if these children lived in Australia or the US, we would spend the next 2 years doing everything we could for them, with a lot of pain, and they would probably die anyway.

Narinoi is 9 months old.  A sweet princess whose Masaai mother brought her in because she had been having trouble breathing.  She had pneumonia, but underlying that her heart didn’t sound right, and on her chest xray it didn’t look right either.  And as her chest infection cleared, her oxygen level remained alarmingly low – and when she got upset, it would drop to the point that we couldn’t figure out how on earth she was still alive.

Narionoi's heart (courtesy of www.heartbabyhome.com)

We finally got her stable enough to send her to Nairobi for an echocardiogram.  A normal heart should look like the first picture (top left).  She came back to us with a horrible report – dextrocardia, transposition of the great arteries, AV canal with common AV valve, pulmonary stenosis and total anomalous pulmonary venous return, similar to this picture (right).  An absolute mess of blood mixing where it shouldn’t, and then being unable to get to the lungs properly.  A condition that, if surgery were even possible, would require at 2-4 operations.  Each of them hours long, on cardiac bypass, with a significant chance of complication each time – and each at enormous financial and emotional expense to the family.

There is acutually a visiting pediatric heart surgery team coming to a hospital 3 hours away from us in 2 weeks time.  So, pessimistically I called them to discuss Narinoi’s case.  In the last week, her oxygen levels have been low – in the 40′s-50′s for a lot of the time, when the normal is 90% or more, and a lot of time less than 80% with one of these conditions probably means that the brain has been injured.  And so the doctor at Tenwek told me, as I thought he would (and should) that with the limited resources they have for post-operative ICU care, there were other children who had a much better chance than she did of making it through.

And so, after long discussions with Masaai interepreters, the family has agreed with us that she would be best off at home for the rest of her probably short life.  She went home on Friday.

Ruth is a 1 year old with neuroblastoma, one of the most common childhood cancers.  She came to hospital for investigation of a large mass in her belly, and when the surgeons took a look inside, found tumour everywhere.  They cut a lot of it out – to test, to make her more comfortable, to allow her kidneys to drain.  But it will be a temporary relief.  In Australia or the US, she would probably receive months of chemotherapy, radiotherapy, possibly a bone marrow transplant.  Months of therapy, with horrible side effects and still a very low chance, with her extent of disease, of survival.

She will probably be discharged from the surgical service this week to spend her final weeks or months with her family, with the support of our palliative care team.

I wonder, as I think about these two precious children, in which country they are better off.  Is it better to stop now, to let them go home, to give their parents the news that the end is not far away?  Would it be better, in another country, to give their parents the numbers – there is around a 30% chance, or less, that your child will make it – if they do, they will live a long life, but if they don’t, their last few months will hospital-based, clinging to the edge of life as we fight this battle with them squarely in the middle.

Do we do a good enough job, in rich countries, of deciding not to do anything sometimes?  With a world of information and slim chances and maybes at parents’ fingertips on the internet, are we a little too good at trying to make sure no child ever, ever dies?

I’m a parent.  I cannot imagine it being Riley as one of these children – I think my default, as a parent and as a physician, would probably be to do whatever it takes.  Because the depth of love you feel for a child as a mother makes you very, very reluctant to face the thought of losing your precious one.

At the same time, you want your child to have joy, to have comfort, to have peace, to have security.  And sometimes maybe that means letting go.

It’s hard enough facing these questions with someone else’s child.  I am so very grateful that at this moment, I don’t have to face them with mine.

- M.

____________________

7/12/11 – Here is a great article on the importance of end-of-life discussions and of doctors being advocates for our patients: How Doctors Die.

Happy endings (30/10/11)

Sometimes medicine here is very, very different from what I used to do in the US and Australia.  And then there are some kids that look the same, no matter what country you are in.

Sera came to us with a puzzled and worried mother – she had been sick a week or so ago, but had been given an antibiotic at another hospital called septrim.  A commonly used medication around the world for many childhood infections.

But the day before yesterday her skin had started to blister, and she became very sick – so she was brought to us, and it quickly became apparent that she had one of the worst allergic reactions you can get short of anaphylaxis – toxic epidermal necrolysis.

Septrim contains a chemical called sulfamethoxazole, and when allergic reactions occur they cause anything from a mild rash to the entire skin essentially falling off.  And on the spectrum of reactions, Sera’s was severe –  30-40% of her skin was affected with blistering or sloughing, and we weren’t sure if this was the tail end or the beginning.  And that was just the skin we could see – what is worrying is that the lining of the oesophagus, intestines and mucosal surfaces of the body can be just as badly affected, only you can’t see them.

The treatment is basic – stop the bad drug.  Give IV fluids and proteins to try and stop the body losing all of its water and plasma from the open skin.  Pray – because no matter what you do, around 30% or more of these children die.

So that’s what we did.  Sera is the first child I’ve ever seen with this condition, and I was worried.  Over the weekend she was admitted, I and the anesthetist on call for ICU were constantly monitoring her vital signs, her lab work and the internet to reassure ourselves there wasn’t anything else we should have been doing for her.  We were constantly asking each other – do you think I am missing anything?  We were unable to measure central venous pressure, unable to give fluids containing protein, unable to transfuse with plasma, and drugs which may help, such as IVIG, cost over $1000 a dose and are simply unavailable here.  We just did what we could as quickly as she needed it, and prayed.

And she recovered.    Sera went home later that week, looking beautiful as you see her in the top picture.  It’s nice to be a part of a happy ending, and Sera is one of them.

- M.

Interconnectedness (26/10/11)

The last 3 weeks have been a little like Christmas for us – both at home and at the hospital.

When we moved to Kenya, we brought with us only what would fit in our luggage, as well as shipping a couple of boxes of essentials (*cough* insulated coffee plunger in with the car seats because we weren’t sure if they would be ubiquitous here).  So we have really been missing the opportunity to camp, having left our tent, sleeping bags and other outdoor accoutrements at home.  A couple of months ago our friends the Spornes, together with my parents, some friends and our church, offered to ship 2 boxes of goods over to us.  After Dad navigating the labyrinth of our storage unit to retrieve our gear and the Spornes navigating the labyrinth of shipping unaccompanied baggage to Kenya, our boxes arrived.

What a joy – sleeping bags and a tent, ready for us to take our first ever camping trip as a family to a nearby park to sleep with the zebras and giraffes (and most likely to be harrassed by greedy baboons).  Not only that, but clothes for the kids, Christmas pudding ingredients and Royal Adelaide Show paraphernalia from my mum, choc chips, Tim Tams, Charlesworth Nuts, a Veggie Tales movie and more from the Spornes and church…  including essential textbooks for Andy’s studies.  We really feel so loved and treasured, and are so grateful!

At the hospital, we have also been showered with necessary supplies.  We have had a lovely visiting pulmonary pulmonologist helping us for a month, Raymond Lyrene from Birmingham, AL.  In addition to his experience and wisdom, he brough us self-inflating resuscitation bags and masks, a new laryngoscope with blades, IO needles and more (including a Scrabble game that Andy had bought for me on Amazon, knowing that I was dying a slow death without it!).  Lesley brought from Australia more IO needles (I cannot tell you how much we need these things – they are impossible to source in Kenya and used almost daily for pediatric resuscitation), as well as central lines, a glucometer and ear curettes.  And then, quite unexpectedly, we had a suitcase sent from Germany – Holger, a pediatric intensivist with a long connection to Kijabe, pulled together a cornucopia of nursery equipment including eye shields for phototherapy, central lines, ECG monitor leads and much more.  Jennifer and I were giddy as we sorted through this unbelievable bounty – all of which we have been missing and trying to cope without.

Christmas for pediatricians: CPAP setup, IO needles, central & umbilical lines, gloves, drapes, ambubags and masks, ECG dots, nappies, 24G short IVs, phototherapy eye shields, vent circuits, laryngoscope & blades, glucometer, long O2 tubing, foley & suction catheters, O2 masks...

Friends and family in Australia, the US, Germany – without you, we simply could not be doing what we are doing.  Thank you.

- M.

Sunset, Sunrise… (24/10/11)

We’ve been a little quiet on the blog front in the last 10 days or so.  It has been quite a week and a half.

Last weekend, we had an overnight away with 2 couples who are a joy to be with, the Letchfords and the Myhres.  A just wonderful end to a busy week – a lake view, delightful dinner, and no conversation about work.  At all, I think.  Precious time of getting to know people who are our colleagues, our friends, and brothers-in-arms.

Our plan was to come back on Saturday at lunch time, pack our belongings into boxes and then move into our new house on Sunday – we have been in a hospital-furnished duplex for the last 6 months, and the time had come for us to free up the duplex for shorter-term people.  The Shirley family have just returned home to South Carolina, and we were able to buy their furniture and fully-stocked kitchen (dishes, pots, plastic ware) and move into their home just down the road from us – so moving meant mostly just clothing, toys, books and a LOT of food (we stock up for emergencies here…).  We also had a couple of couches and a desk, so some guys from the hospital housing team were going to help us cart everything to our new house on Sunday afternoon.

Except that when we got back on Saturday, it turned out that they weren’t going to be available on Sunday, and we could move NOW, or put it off for a week or more…

So we moved on Saturday – a slightly frantic throwing of things into boxes and car boots, carting hanging clothes on broom handles.  We were almost done at 4pm, but absolutely exhausted, and were carried across the finish line by the Myhres and their landrover helping  us with the remnants.  Our first night’s sleep in a new house, a bed that is ours, and hopefully the Steere home until our committment here ends.  Oh, we also now have a dog – Kuli, a 10-ish year old golden retriever that comes with this house – we are maybe her fourth or fifth family, and she has adopted us with an eager heart.  Way too eager at 3am for our liking on Saturday and Sunday, but after 2 sleepless nights we’ve figured out how to stop her from barking now…

Monday was a 7am-7pm trip into Nairobi – a rare “girls day out” for Jennifer, Immaculate, Mary (an American pediatrician working on newborn community health here) and myself.  We currently have a relieving pediatric pulmonary specialist helping us for a month, so this was our opportunity to do something together while he held the fort at the hospital.  We took the opportunity to visit a private hospital in Nairobi, and the national referral hospital, Kenyatta.  We met some wonderful, dedicated people and learned more about how we can help children here when our resources don’t quite stretch far enough.  More on that in another post…

Lesley in Hell's Gate Gorge

Tuesday was a day trip into Nairobi to shop for supplies and to pick up the lovely Lesley Woodard-Knight, a friend and colleague from Australia who is visiting us for 2 weeks to see our resource-poor setting compared with the resource-poor setting of Oak Valley, Australia.  Aboriginal health in Australia is not so different from a third world setting, and Lesley is one of many dedicated physicians who spend their time sowing into an often thankless situation.  It is lovely having her here, and it turns out that the Kijabe Guest House (about which I was a little apologetic) is superior to her usual outback accommodations.  Except when it runs out of water, as it did on Saturday, necessitating an emergency shower at our house…

Wednesday to Friday flew past in a blur of work, parenting, settling into a new home, entertaining friends.  Saturday, an all-day safari at Hell’s Gate National Park, finding wildlife, a ploughman’s lunch picnic, stunningly beautiful gorge hike with a charming Maasai guide.

It has been an everything-bagel kind of week.  A frantic and sad work week with over 20 complicated inpatients to see each morning, some requiring painful conversations with family about permanent brain damage or certain death – but ending on a higher note with 11 children going home on Friday, recovered or recovering.  A week punctuated by moments of bliss – a sunset from our porch, afternoon tea and a chat with Lesley, pizza from an outstanding pizza oven laboriously constructed over several months by the Myhres in their back yard.  A week also punctuated by somber moments – learning of Kenya’s military plans to destroy a terrorist group in our northern neighbour country after recent kidnappings from Lamu and Dadaab, trying to figure out what, if anything, that means for us.  Punctuated by moments of finding myself not dealing well with the undercurrent of life, busy-ness, fatigue, work and relationships – finding those things bubbling to the surface in less than idyllic ways.

I am tempted, in weeks like this, to just look ahead – next week will be easier.  Next week we will not be quite so busy, next week this stress will be gone.  But really, embracing what’s happening now is probably a much more mature thing to do.  To ask myself – how have I prepared myself for this week?  How was I doing in the less-crazy times – have I been investing in my family, in my marriage, in my relationship with God – so at the start of this week, could I have been a little more ready for it?  And when the stresses of this week came, how did I respond?

Because weeks like this are going to happen again.  Not in quite the same way, but weeks of feeling overwhelmed in life are part of the journey.  And if I think about that now, and build into myself space for grace for others, unconditional love, and a spiritual life that doesn’t rely on all of my ducks being in the row that I intend for them, I may respond a little better next time.

- M.

MacGyvering (10/10/11)

One of the frustrations of working in a resource-poor setting is that you don’t always have…. well, resources.  Here are a couple of ingenious solutions that folk over here have come up with to circumvent what we lack.

Insulin, an essential daily drug for diabetics, has to be kept cool.  This is tricky in hot environments without electricity.  So the principle of evaporative cooling is our friend.  Lydia, our nurse educator, instructs families of diabetics on how to get a simple bucket, put in sand and charcoal and a metallic container, and then pour water into the sand/charcoal mix.

In simplest terms, when water evaporates, it draws energy and heat away which causes a cooling effect.  As long as water is kept in the bucket, the magic of thermodynamics keeps the centre, and the insulin, cool.   (physics afficionados, click here for the equations!).  An affordable, sustainable refrigerator, whose principles are used all over the world.

We also struggle to find good spacers to use with inhalers.  Adults can become adept very quickly at learning to take inhaled medication for asthma straight from the inhaler – but children are tricky, and infants are impossible.  Spacers help children breathe in the medication rather than swallow it, and a mask can be placed over an infant’s face so they don’t need to cooperate at all.  They are sold at pharmacies in the bigger villages and in Nairobi, but they are expensive and it means we can’t teach families how to use them before they leave the hospital.

Fortunately, we didn’t need to reinvent the wheel on this one.  Studies like this one have shown that using a 500mL soda bottle distributes the drug as effectively as a trademarked super-whamodyne spacer in children who are old enough to breathe well through their mouths and don’t need a mask.  So here a hole is cut into either a drink or medication bottle for the older children.  For babies, we can get hold of oxygen masks relatively easily – so for one of our newborn babies in the nursery with chronic lung disease, this home-made spacer (pictured left) is at his bedside.

MacGyveriffic!

- M.
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p.s. If you were born after 1985 and don’t know who MacGyver is, I am sorry for you – please click here to read all about his awesomeness and then go out and rent the series.

Beauty for Ashes (8/10/11)

Some of you read my post about Emer – a diabetic girl who left the hospital before her bill was paid, without any medication, or any way to test her blood sugar.  We had the resources to cover all of her costs, but the family disappeared under cover of darkness.  I was just filled with sadness when she left.

But if I hadn’t met Emer, I don’t know if I would have met Margaret.

Margaret is 5 years old, the youngest of 11 children.  Margaret’s mother lives only a few kilometres from here in Kimende, and one of her sons was diagnosed with diabetes several years ago.  With the constraints and difficulties of parenting with few resources, Margaret’s brother’s diabetes was difficult to manage, and he died in 2009 from diabetic ketoacidosis.  So when Margaret, too, was diagnosed with diabetes last year, her mother despaired.

Margaret and Mum have been a sporadic attenders of clinic here, because it is hard for her to get here as she has so many kids, and then there are the transport costs, and then when she gets here she can’t afford the insulin or syringes or blood tests.  At their last visit in August, our nurse educator Lydia bought the insulin for Margaret out of her own pocket.  Lydia prayed together with mum that God would help them, and then assured mum that God would provide for her needs.

Monthly diabetic budget

It was one week later that I met Emer.  Through Emer’s story, we received money to help her and other diabetic children, opening the Diabetic Needy Children’s Fund here.  And when Lydia heard that, even though  Emer had left, there was still money available for diabetic children, she approached me about paying for Margaret’s ongoing costs.

Lydia wrote for me a detailed budget – ongoing costs of about $30 per month to supply Margaret’s transport to the clinic, the cost of seeing the nurse or doctor, insulin, syringes, glucometer strips for measuring her blood sugar levels.  A prohibitively large amount for a mother eking out an existence to support 10 children in rural Kenya – now in reach due to the generosity of friends overseas.

Lydia, Margaret and Mum

Margaret and her mother came to the clinic last week.  Lydia gave them their month’s worth of supplies, and her mother was overwhelmed.  Her blood test showed that her sugars had been very high at home for some time – but Lydia knows that, now we have a regular way of helping out, this will improve.  This little girl now has a hope and a future, and my heart is light.

” If we don’t know how or what to pray, it doesn’t matter. He does our praying in and for us, making prayer out of our wordless sighs, our aching groans. He knows us far better than we know ourselves, knows our pregnant condition, and keeps us present before God. That’s why we can be so sure that every detail in our lives of love for God is worked into something good.”
Romans 8:28 (The Message)

- M.

Grief (6/10/11)

I’ve been recovering from a rather enthusiastic 4 days of gastro, so instead of going for a ride a few days ago, I gave my bike a good clean.

I love cleaning my bike…there’s just something about it that brings me joy. The first thing I do is get the bike wet and soapy…besides the red African dust that seems to accumulate everywhere, sweat and grime builds up in the crevices and needs to be removed regularly. Once I’ve sprayed degreaser on the front and rear derailleurs and pivot points to clean the gunk off, I give the bike a good soapy scrub, and hose it off.

Then it’s time to remove the wheels, pull out the quick release skewers for soaking in degreaser, and give the wheels, tires, and spokes a good wash. Usually before I scrub the tires, I inspect them for embedded thorns and remove them–there is a yellow goo sealant in the tires which quickly seals a puncture if I do get one, but thorns stuck in the tires cause them to lose small amounts of air over time. They’ll eventually go flat if I don’t reinflate them.

As it was, this time I hadn’t checked the tires for thorns even after I had reassembled the bike…when I was putting new lube on the chain, I happened to look down at my front tire and saw this head of a thorn sticking out.

Hm, I thought. That’s one ginormous thorn. As you can see, the yellow goo had sealed around the thorn, preventing loss of large amounts of air…worst case, if I leave it in, I’ll just have to keep adding air every time I ride. If I pull it out, there’s a chance that the hole will be too large to seal, and I’ll have to patch or replace the tube, which is more effort than I am willing to put in today.

One thing is certain: I’ll have to take the thorn out eventually.

So I pulled the thorn…and pulled, and pulled, and finally the whole thing was in my hand, nearly 2 inches long. The hole it left behind was huge, and yellow goo and air started spewing out of it. I spun the tire to let the goo coat the inside of the tube, and after about 1 minute it sealed the hole…whew. The tire was nearly flat now, but a few strokes with the pump and she’s good as new, with a yellow goo patch.

I was reminded of The Ginormous Thorn at dinner, when Mardi and I were discussing how she works through the suffering and death that is part and parcel of her work as a pediatrician in an African hospital. The discussion turned to how I was processing my parents’ recent divorce. I was reminded of how important it is to grieve well, and mourn properly things that should be mourned.

I have been mourning my parents’ divorce for the past few months, and it has only been in the last few weeks that I started to notice that I am starting to move through my grief. I am not as filled with a gut-wrenching pain as I was a few months ago.

I think that if we don’t allow ourselves to grieve, part of the grief-causing event stays with us, like that thorn in my bike tire. It is slowly letting the air out of us if we don’t acknowledge that there is something there that needs to be pulled out into the light and identified for what it is: something awful, that should be mourned, and not ignored.

I have found in these past months that as I pull slowly pull the thorn of my grief out, I discover how big it is. I had no idea how deep my grief went. All sorts of things have come to the surface: anger, fury, humiliation, pride, shattered dreams, false images, deep sadness, confusion. And then, one day…the thorn is gone. My grief isn’t nearly as present as it was several months ago. The hole will still be there, but it’s a hole that’s been scarred over and healed now that the thorn has been pulled out.

I am reminded of all of the Psalms of lament in the Old Testament, and of Jesus’ words to an enormous crowd on a mountainside: In my kindgom, those who mourn are the happy ones (Matthew 5:4).  I remember that before there can be a resurrection, there must be a death.

And I wonder why I don’t hear more people talking about the things they are grieving. Are we afraid that other people won’t think we’re ‘spiritual’ enough? Are we afraid people will think we lack ‘faith’ that one day things will be restored and made whole again? Are we afraid of being real?  Are we afraid people won’t think we ‘have it together’?

I don’t know the answers to those questions, but I have noticed these past few months that acknowledging my grief and working through it–not trying to go around it, or leaping over it–has been simultaneously one of the most awful things I have ever experienced, and one of the most beautiful.  I am only now beginning to realise just how beautiful.

And I’m glad I pulled that thorn out.

- A.

Dadaab Part 3 – not quite Dagahaley Camp (4/10/11)

There is nothing quite like travelling over 500 kilometres and being told that you can’t do what you have come to do.  On Tuesday night, we found out that workers in the hospital at Dagahaley camp were striking and we would not be able to see children there on Wednesday morning.  There had been an altercation between some staff members which had turned violent, and the rumor was that 15 people were going to be fired, and thus they banded together to stop work.

Words cannot express our frustration.  Erik spent a good portion of the evening and the next morning on the phone – we did not want the children expecting to see us to be casualties of “friendly-fire”, as it were.

And so the next morning, we finally got word – the strike was off.  There was only one staff member who was going to be fired, and all of his colleagues actually agreed with the decision, so they resumed work.  Except, we also found out, someone had been found with a gun in the camp that morning, and so for security reasons the camp was still closed to us.

Eventually, we were able to figure out a way to see the kids.  A bus arranged to bring the waiting children from the camp to Dadaab Hospital (the hospital serving the village and the aid workers) – and so finally, late morning, with a flight scheduled to depart at 3pm, we were able to see the 20-or-so children who had been ferried to us.

Marian

There is always one child in any given week who just grabs me – whose face I can’t forget, whose story won’t leave me.  And this visit, it was Marian.

Two of our neighbouring countries have had a very violent history.  In around 2002, many civilians including a 7 year old girl got in the way.  According to Marian’s father, during a conflict, she was pushed into a fire with the motivation, he thinks, to burn her alive.

She was not burned alive, but her hands were badly, horrifically damaged.  And in a country where survival alone is difficult, optimal burn care for a little girl was nigh on impossible.  As the pain of injury faded, the skin started to heal.  Her body sent healing cells to replace the dead tissue on her fingers and hands with fresh new, collagen – but the process, without vigilance and therapy, causes irreversible stiffening and contraction of the skin.

So for 9 years, these have been Marian’s hands.  The fingers, if they were not burned away, are buried deep beneath the scar tissue.  And this beautiful girl has been unable to feed herself, dress herself, clean herself – completely dependent, as a teen who should be blossoming, on the assistance of others for absolutely everything.

So she is on our list to come back to Kijabe.  Dr Nthumba, our plastic surgeon, will have the task of answering many questions:  Are there fingers still there?  If they are there, are there still essential blood vessels and nerves that can make her fingers function again?  And if so, Marian may begin the long journey of restoration of hands that give her some semblance of independence.

I am so grateful for the persistence of Erik and the team – we were so close to not seeing Marian at all this trip.  Or this 11 year old (pictured right), who was born with a cleft lip and is now on our list.  Or Ruwetha, a 2 month old who was born with something the camp doctors had never seen before but sure didn’t look right – and turned out to have bladder exstrophy, which can be helped.  Or the two brothers we got to see whose cleft lips were  previously repaired in Kijabe, whose father’s smile said more than any followup interview ever could.

So we never got to Dagahaley Camp, which I’m sure is run by MSF with the same dedication as the other camps.  But we got to see some of those who we needed to see, and we boarded our plane in the desert grateful that this opportunity had not been lost.

What struck me most about this time in Dadaab is the number of organisations, countries and ethnicities all working together for a common goal – despite the inevitable differences in funding, priority and bureaucracy.  I love seeing God’s love and compassion in a secular setting – a part of God’s nature displayed despite the often stark lack of acknowledgement of the sacred.  I love that God shows himself in unexpected places – in the beauty of nature, an oasis in the desert, the kindness of strangers.  And my prayer is that He will be recognised – in the middle of anguish, pain, conflict and suffering, that his presence will continue make itself known in the most surprising of circumstances.

- M.

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See also:
Dadaab Part 1 – Ifo Camp
Dadaab Part 2 – Hagadera Camp 

Dadaab Part 2 – Hagadera Camp (2/10/11)

Let me introduce you to Abdi.  He is 8 years old, and has been referred to us for lumps.  On his left arm.  And under his armpit.  And another above his right collarbone.  One of the doctors in the camp recently removed one of the lumps, but we have no idea what was inside – was it pus?  Was it a decaying ball of cream cheese signifying TB?  Was it hard like a rock, worrisome for some form of cancer?

There is no paperwork to let us know.  And that, in itself is a bit of a worry to me.  Because if they found a lump as hard as a rock, the last thing you want to have up here is a piece of paper that says you may have cancer – because that means you have reached the end of the road as far as your options go.

You see, there isn’t enough money to treat cancer in the camps – no matter what kind of cancer it is.  Every dollar designated for healthcare must do as much good as possible, and unfortunately cancer treatments are incredibly expensive for an uncertain return.

And so I quickly learned on this trip to not write the words “cancer”, “tumor” or “neoplasm”.  Any of those words mean that access to healthcare is severely limited.  Instead, we write “mass for investigation”, because of course mass could mean cancer, but it could also mean infection, or foreign body, or anything else that can masquerade as a lump under the skin.

On this trip, Erik and I had the chance to sit down and chat with Ann Burton.  Anne is the current head of health for the camps with UNHCR.  A down-to-earth woman with a hybrid accent like all expats have here after a few months in a cultural melting pot, she turned out to be an Australian.  She asked me where I was from – turns out my accent has become pretty messed up too, unrecognisable by a fellow Aussie.

She explained that the UNHCR has the loaves-and-fishes task of taking a small pool of money designated for healthcare, and making it stretch, and stretch and stretch.  Sometimes the money comes to them packaged for “primary health care” – so they can’t use it for surgery, or dentistry, or ophthalmology.  Sometimes they need pharmaceuticals, desperately – but the drug company gives what they have in excess, not what the camps really need.   Sometimes they need something – like soap – and they don’t have funds that can be designated for THAT use.

She was somewhat surprised that Erik and I had approached her with some funds from SIM and BKKH and actually asked her what they needed.  And so we are going to be able to get some soap up to the camps in the next month, to be distributed with education on hygiene as malnourished children are discharged from the Stabilisation (refeeding) Centres.    We also talked about the possibility of increasing our medical assistance to the camp, in pediatric surgery, pediatrics, and general adult surgery – all areas of desperate need.

Daktari Lebbie

Back to Hakim – he’ll get a biopsy next time our team is in the camp.   I really hope we can write on his record that we have diagnosed something that has been treated, and it is gone.

The Hagadera clinic was a bastion of efficiency, and we were grateful as it made a huge difference.  I don’t know if it was a function of IRC being in charge of the camp, or just the staff being who they were, but it was like clockwork.  As soon as we had arrived, we went to the paediatric ward where the first 6 beds had patients lined up ready for minor surgeries (mostly testicles – conveniently accessible organs for surgery!).  Consents were signed, IV lines were in place, children had been weighed (I particularly liked that they couldn’t escape the basket).  Lebbie had gone straight to the operating theatre to get started.

Erik and I went from the ward to the clinic next to  the Emergency Department to start seeing children.  There was a computer printout of which child was to be seen in what order, and every parent came in bearing a card with their appointed number.

Erik and I saw around 50 children.  A 3 year old whose right arm and hand were badly burned as an infant, and whose skin has contracted as it scarred, leaving her unable to fully move her shoulder, elbow, wrist or fingers.  A 13 year old boy who was born with epispadias (where the urine comes out of the top of the penis rather that straight out the end) who has had surgery once at Kijabe already, but still needs at least another 1-2 procedures.  A 7 year old with a skin conditions that would get better by itself.

Erik and Lebbie entering the clinic - ED on the right

Too many children with orthopedic conditions – a 13 year old whose hip was dislocated 3 months ago during a football game, and has scarred into place outside of the socket.  A 6 year old girl with avascular necrosis of the femoral head – her thigh bone, right where the ball goes into the socket of the hip, lost its blood supply.  If it had been found early, maybe something could have been done, but it happened so long ago that her femur has fused with her hip and nothing can be done now until she is fully grown.  Even then it would mean a hip replacement, not exactly a primary care essential procedure out here where people use walking sticks for life after polio, poorly healed fractures, congenital deformities.

After clinic, Erik returned to the operating theatre to help Lebbie finish up the list.  I, being absolutely useless in the OR, was free to see what else the camp hospital had to offer.  The stabilisation unit is where malnourished children are brought to receive high-colorie milks through a nasogastric tube until they have enough energy to swallow milk on their own.  And then for the older children, to move onto high-calorie solid foods like Plumpy Nut, a delicious peanut butter based supplement.

I was also enamoured with the goats walking right past the front door of the maternity ward.  Because you never know, as a postpartum mother, when you’re going to need some supplemental goat’s milk or get a craving for some roast mbuzi.

- M.

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Next:  Dadaab Part 3 – Not Quite Dagahaley Camp
See also: Dadaab Part 1 – Ifo Camp 

Dadaab Part 1 – Ifo Camp (29/9/11)

Imagine, if you will, Spokane WA, or Canberra ACT – around 450,000 people.

Imagine it without paved streets, with sand and gorse as far as the eye can see.  Imagine it without a source of water – with water tanks filled by tankers and your home supplied by filling containers.  Imagine that nothing will grow there, and that when food comes your means of obtaining it is by ration card.  Imagine that you live in a tent, or in a hut you have constructed from twigs, plastic bags and cloth.

Imagine it without a dentist, a surgeon, an obstetrician, an ophthalmologist, a pediatrician.  Imagine that your health care is provided by a doctor with one year of experience after medical school, whose job description is care of every ailment due to infection, war, trauma, pregnancy, and whose abilities have come to to include appendicectomy and c-section.

You cannot leave this town to look for a better place, or a job, because you are not a resident of the country you are in.  Imagine that, if you leave this town, without paperwork specifying where and why you are going, you will be sent back to a place that is worse.  And so you stay.  Because although this place is a little bleak, it is infinitely better than what you have fled.

Welcome to Dadaab.

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*warning – the rest of this post contains medical details and words such as “penis” which some readers may find disturbing*

From Monday to Wednesday, our pediatric surgical team held its semi-monthly clinics in the 3 main camps of Dadaab – Ifo, Hagadera and Dagahaley.  GIZ, who runs Ifo camp, transports and houses the team every 2 months.  This time the team was made up of Erik (American peds surgeon), Lebbie (senior peds surgical trainee from Sierra Leone), and me.  After our 4:30am start from Kijabe, GIZ was ready for us to start at today’s camp, Ifo, when we arrived mid-morning.

The goal of these visits is simple:  see all the children who have been referred by the camp doctors for possible surgery.  Put them in a category: “now” for surgery today at the camp, “soon” on the waiting list to come to Kijabe for surgery, “next time” if their simple surgery can be done in the camp in 2 months when we return, or “no” if their surgery is something that we cannot do or if their condition doesn’t require surgery at all.  For those that need surgery in Kijabe, GIZ will provide their transport to Kijabe and BKKH will pay for their entire hospital stay from their refugee budget.  Some of the patients have already had their operation(s) at Kijabe, and are here for followup.

We have been told there are no cases on the “now” list, so we will be purely hosting a clinic today.  So we start – we set up an empty room with 2 tables, one examination bed and a few chairs.  It’s my first time here, so Lebbie and Erik each take a translator, and I sit between them, acting as a general pediatric opinion for the non-surgical things and a scribe as I learn the system by doing.

It’s immediately apparent that many of these children will be in the “soon” category – an infant whose face and scalp are covered with disfiguring blood vessel growths called hemangiomas.  These will improve rapidly just with medication, but it will need to be given IV at Kijabe hospital with close monitoring for side effects.  The sooner GIZ flies him down to Kijabe, the better – one of these growths covers his entire left eye, and development of vision in that eye won’t happen unless we are able to let light in by getting the hemangioma much smaller.  A 4 year old boy whose penis was injured by a rope as an infant – and now urine comes out of holes that shouldn’t be there – a urologist will visit Kijabe in March, and we can make sure he is scheduled for repair.  3 siblings, all with cleft lips and palates, ranging from 2-11 years old – conditions that have made them ‘different’ for years, and between 1-3 surgeries apiece will change how others see them, how they view themselves.  A girl who, for her 16 years of life, has been living with no anus, because it never formed in utero – stool has been coming out of a connection between her bowel and vagina.  This is something the surgeons can do something about.  2 little boys with minor scrotal problems that we can put on our “next time” list for operations within the camp when the team returns in November.

Some children make it to the “no” list.  Children who, since birth, have been floppy or stiff and have never sat or talked – we gently attempt to explain that their brains were probably injured at birth , or didn’t form properly, and we are sorry but surgery will not help them.  We refer them back to Handicap International who has already been helping them.

2 minute break: let me tell you about Handicap International.  This wonderful agency has rehabilitation facilities in all 3 camps -providing physiotheraphy, orthopedic-fitting workshops and other resources to refugees.  Children with club feet who need plaster, adolescents whose polio has left them with a limp, babies who are floppy – there are caring people who can help with strength, mobility, encouragement.  What a wonderful group.

Back to clinic.  There is a 2 year old who has been having seizures twice a week, and a long time ago used to be on anticonvulsant medications.  I am able to find out what medications the pharmacy has, and prescribe for her a drug that should help.  A “no” on our list, but a condition we can do something about.

2 children with one leg longer than the other.  Much longer.  The four year old’s right leg is about 30 centimetres shorter than the other – a foot shorter.  She is too young for crutches, and so she walks on the knee of her long leg, and the foot of the other.  She is a “no” – currently, our orthopedic team does not have the budget for refugee surgery.  Every patient they see here in Kijabe is charged nothing, and their budget is stretched to the limit.  We decide that we have to tell them about her anyway – surely, there must be some way we can help this beautiful little girl.

We see around 60 children and suddenly, our time is up.  Our convoy leaves for GIZ, and it is not safe to travel without an escort – we are only 75 km from the border of a nearby country from which violence and kidnappings are not uncommon.  There are still around 10 children waiting to be seen and suddenly the room feels like the trading floor on Wall Street – papers thrust into our faces by parents with loud hurried words we don’t understand, each parent desperate for their child to be added to the list.  We scribble down some details of whoever we can as we walk out the door.

Unlimited resources.  An impossible dream.  It’s rewarding and frustrating to be here, to be able to help some, to see some who will have to wait for consideration, to know there are doubtlessly other children in this camp that are not yet, or may never be, on our radar.

- M.

______________________

Coming next:
Dadaab Part 2 – Hagadera Camp
Dadaab Part 3 – Not quite Dagahaley Camp

Coming soon:
Dadaab – the movie! 

Blessed are those who mourn (23/9/11)

I preached today at the Moffat chapel service on Matthew 5:4, “Blessed are those who mourn, for they shall be comforted.”

I signed up to speak on this verse about two months ago as a part of the regular roster of staff preaching in chapel.  In the month following:

-My parents’ divorce was finalised
-There was a major fire in a Nairobi slum, with over 100 burned to death, including two cousins of a friend of ours, who both died in a hospital from their burns
- A staff member at RVA home in the USA on furlough died unexpectedly of a brain hemorrage, leaving behind 8 children.
-A good friend had a traumatic miscarriage.
-Mardi diagnosed a little girl in a refugee family with Type 1 diabetes, a generous friend donated the money to pay for her medical costs and future insulin supplies, and before this could be given to her family, her parents took her from the hospital under cover of darkness, we think to try more traditional ‘medicine’.  We don’t know if we’ll see them again.  It is certain the little girl will get very sick again quite soon.
-Numerous little children, each with their own story, promise, and grieving community, passed away in the hospital under Mardi’s care.

As I write this, Mardi is spending the night with Liam are in the Hospital (100 metres from our back door).  Liam’s had another asthma episode, and so he’s on a bit of oxygen to stabilise his oxygen levels and so he can be monitored.

Moment of reflection, American Cemetery, Normandy

This really turned into one of those “I had no idea how real this was going to become for me when I signed up for it” kind of sermons!

Amongst all this grief and mourning, there has also been an extraordinary amount of joy and blessing…but this is not a blog post about that.

It has been the so-real-you-can-touch-it grief which lent a new perspective my preparation and talk on “blessed are those who mourn…”

When Jesus says “…for they will be comforted”, the comfort he is referring to isn’t only a future comfort.  It’s not only the comfort we have in knowing that one day, in the age to come, God will set things right again in the restoration of creation.  It certainly does have a future component, in which we quite rightly place our hope.  But the grief I have experienced in the last few months has brought home to me the truth that if I only have a future hope, this too easily leads me to a worldview along the lines of “I’m just hanging in here by the skin of my teeth until one day, O glory…I’ll fly away…” (to heaven).  How can I be grounded in reality, in the inherent goodness of God’s creation and participate with his ongoing work of restoration around me right now, with that kind of outlook?

In the last few months, I’ve discovered through the tears and grief that a future-only hope just isn’t enough for me.  While it is ultimately where my hope is based, I find myself wanting more…how do I to connect with the reality of suffering around me in a genuine way, and how am I to reach out effectively to those around me who are suffering?

In the story immediately prior to the discourse in the book of Matthew we call the ‘Sermon on the Mount’, we see Jesus ‘travelling throughout Galilee, teaching, sharing the good news of the Kingdom of God, and healing everyone who was brought to him including casting out numerous demons.  As a result, huge crowds followed him wherever he went.’

Picture Jesus, surrounded by huge crowds of people, pressing in around him–and so he climbs up a hillside to sit down and teach.

In the crowd he was speaking to, directly in front of him were people who had just received ‘the good news of the Kingdom of God’ through him:  healings, exorcisms, a touch from God himself.  Jesus could point out in the crowd an individual who was “blessed” because The Kingdom Among Us had just reached out and touched them with Jesus’ heart and voice and hands.  I am struck by the fact that in the stories about Jesus we only find Jesus giving “Beatitudes” such as “Blessed are those who mourn…” from the midst of a crowd of people he had touched and healed.

These aren’t theoretical, philosophical, ivory-tower prognostications from a guru telling people about a nirvana-like existence they will have one day in the future…it’s real, earthy, personal, now.

A comrade in arms..."known but to God"

Jesus’ method of ‘show and tell’ ministry gives me a grid inside of which to align my longing for both a present comfort in the midst of present suffering, and future hope…he demonstrated the power of the Kingdom of God, and then he told the people he had just demonstrated it to how things work now that the Kingdom is at hand.

In the words of Dallas Willard,

Luke refers to them as “the weeping ones” (6:21).  But as they see the kingdom in Jesus, enter it, and learn to live in it, they find comfort, and their tears turn to laughter. Yes, they are even better off than they were before their particular disaster.  And you don’t have to wait until you’re dead. Jesus offers to all such people as these the present blessedness of the present kingdom—regardless of circumstances. The condition of life sought for by human beings through the ages is attained in the quietly transforming friendship of Jesus.  (from The Divine Conspiracy).

I find that Jesus’ words also give me a permission to mourn and freedom to be real:  his words presuppose events in this life which cause us to mourn:  hence, we are free to mourn, and to acknowledge these events as worth mourning, and not have to pretend that everything’s OK.  Jesus validates as genuine the mourning experienced by the people he was speaking to, even after he has ministered to them in power.  He doesn’t say, ‘You were mourning, but now that I’ve touched you I want you to never speak of it again.  Your daughter who died of leprosy?  Pretend it doesn’t still cause you grief, cause you’ll be in heaven one day.”

Validation, permission, to mourn.  Freedom to not sweep suffering under the rug, like an uncomfortable bit of conversation that comes up and you really don’t know what to do with it so you just avoid the topic.  ”Me?  Yeah, I’m good.  How’re you?”

This gives me great peace tonight, as I go to sleep with Riley in my bed (it took her two hours to fall asleep because she ‘wanted to go into the Hospital to see Liam’s xray and his bones and lungs’), my son and wife in Hospital, and friends whose Facebook status reads something along the lines of, ‘Lord, come quickly, and have mercy on us’.

I am learning that in some ways, we can’t properly understand life on earth now if we don’t have clarity as to the reality/validity of suffering and mourning, and yet that because of the in-breaking, present availability of the Kingdom of God, we can still be blessed in the middle of it.

For now, though, I’m going to do the dishes and go to bed.

-A

September 2011 Update

Click here to read our September update – enjoy!

Freedom (20/9/11)

Emer, our new diabetic, disappeared yesterday.

Jennifer and the team had sat down with the family in the afternoon to talk with them – they had a 20,000KSh ($200) bill, of which they were going to pay 15,000 and our Needy Children’s Fund was going to cover the rest.  And then, incredibly, a friend of ours at home who has a special place in her heart for children with diabetes had offered to pay for all of Emer’s supplies.  A glucometer, the test strips, insulin, syringes…. Immediately after reading my last blog post she & her husband had sent us enough money to cover her medications for a year or two.  Incredible generosity, that we were thrilled to share with this needy family.

And two hours later, they left.  Without paying any of the bill, without taking any means of checking or treating Emer’s sugar level.  I found out this morning.  We have not been able to contact them since then at all.

There are so many emotions warring within me.  Fear, that Emer will die – and this is realistic.  Anger, that her parents, having been offered so much, took so little, at such huge risk to their daughter.  Embarrassment, that I have had to share with my generous friend that her gift has been rejected.  Resignation, that this is neither the first time nor the last that parents have rejected my advice because they have other inputs into their decision making process.   Grief, that this little girl is yet another treatable patient that we are handicapped to help, and who will suffer.  Hope – that Emer will get just sick enough to require medical attention and that her parents will see that we helped last time, and maybe they will give us another shot at helping her.

This is free will.  This is how it works.  Every day we choose – good versus not so good versus bad.  Life versus existence versus death.  Love versus apathy versus hate.

Hardly any of our choices are black and white.  They’re usually somewhere on the spectrum – and this is how God made us.  Free to choose to join him in making this world as he intended, free to choose otherwise.  I am grateful to have this freedom.  To know that my life is not cosmically predestined, that God loves me enough to say, here is life.  Do with it the very best you can, because I love you enough to let you choose.

Today I feel like a really bad choice was made.  But if God gave me the chance to choose, he gave it to Emer’s family as well.

I just wish I could have chosen for her.

- M.

______________________________

There is always hope – click here to read about sweet Margaret, who has been helped through Emer’s story

Tea (19/9/11)

It’s my birthday in a few days and so Mardi planned a surprise outing for the family to go and have lunch and a tour at a local tea farm in Limuru, Kiambethu Tea Farm.

In a word, it was gorgeous.  More than 100 years of family tradition (English, originally) in making black tea, including building the local Anglican church which has the distinction of being the burial place of the eminent archaeologist Dr Louis Leakey and his missionary parents.

We had a ball…lovely old grounds, tea, old growth forest for a bit of a walk, lunch, discussion on how tea is made, great conversation with Fiona and Marcus, proprietors of Kiambethu (and granddaughter of the founder), and more tea.

Fiona taught us how to make a proper pot of tea, and described the tea-growing, making, and selling process to us in detail.  The area around Limuru is ideal for tea growing, apparently, as it is wet, high in elevation, and relatively cool.  It has acidic soil, which the tea plants like, and once they get the tea bushes growing (their original stock was from India), the workers hand pick new shoots from the bushes every two to three weeks, year round.

It’s a crop that is harvested all year round, with a brief interlude of a few months every few years for some serious pruning.  Talk about a reliable cash crop…Fiona told us that it’s very common here for small growers to get an acre or two of tea bushes established, which can then provide reliable income for the whole family, year round.

I found her description of the process from harvest to ready-to-drink fascinating, and surprisingly moving.

Tea stalk (2 leaves + pekoe at top)

Tea bushes take about 4-12 years to bear seed, and once a new bush is grown from seed it takes 3 or so years before harvesting can commence.  The tea bushes are carefully tended, fertilised as needed, and then picked by hand–no machines here.  The workers know to pick only the newest shoots of the tea bush, which should include the newest leafy tendril (the ‘pekoe’), and the next two leaves.  They toss the whole stalk into a basket they carry on their back, and as the basket gets full they build a pile in a shady spot under a tree.  If the tea isn’t processed immediately, it will start to oxidise, releasing tannins into the tea leaf which affects the taste.  So the day’s pickings are taken on the same day to the local tea factory.

The tea factory does stringent quality assurance on the tea brought in by each farm, and randomly inspects bags to make sure that only the pekoe + 2 leaves has been picked…any further down the stalk, (e.g. the third leaf) and the leaf is hard, oxidised, and high in tannin.

The first step in the processing is to put the tea stalks in large holding containers (think the factory scene from Attack of the Clones) with large grates in the bottom.  Over about a 24 hour period, air is blown up into the containers, and this reduces the moisture content in the tea stalks by about 30%.

View from the front verandah of the farmhouse...ideal for some good Thomas playing

Once this is done, they get put on a huge conveyor belt (again, think Attack of the Clones) that goes all around the factory, and warm air is blown onto them to further dry out the leaves.  This takes about 12 hours and gradually turns the bright green stalk yellow.

Then they get a final burst of superhot air to stop the oxidation process completely.  This is when the now-yellow tea stalk turns brown, and begins to get aromatic–in short, this is when it becomes tea.  It’s not until after this burst of superhot air that it really becomes…well, tea.

The brown stalk then goes through a series of rollers and spikes to chop up the tea, and it’s bagged up and sent to the wholesalers in Mombasa for buying by the big tea companies, and shipped around the world.

I was interested to learn that tea stalks don’t taste or smell like the tea we know until nearly at the end of the processing in the factory.  All those years in growing a new bush, tending the plants, pruning, fertilising, hand-picking new stalks, rushing them to the factory, aerating them in Attack-of-the-Clones containers, heating them on conveyors…and its not until the final step, superheating, that it becomes recognisable…”Oh, that’s tea.”

In fact, unless you were an expert, at no point in the life of a tea stalk until that final release of superhot air would you even know you were holding the potential for a cup of black tea in your hand.

Fiona, proprietress of Kiambethu Farm

I find comfort in this process…in it I find parallels to my own life, particularly my spiritual life.  For me, it’s often after a long process that I begin to see things as they really are, and what God is doing around me.  It’s not until quite late in the game, after years of fertilisation, pruning, being torn off the bush sometimes, lots of heat, that I go….”Ohhh…..I think I am beginning to understand now…”

I don’t understand, I just can’t see clearly earlier in the process what’s really going on, or where it’s all headed…let’s be honest, at times I just plain lose perspective and hope and keep moving forward only with gritted teeth and faith that God can be trusted with the things that matter most.

And then, later on (sometimes years), a superhot blast of air, and…”Oh, that’s tea.”

Riley, collecting tea seeds/nuts for planting at Kijabe!

Kiambethu Tea Farm

I am grateful to have learned that the processes of my own life are mirrored in a small way in the life of a cup of tea.

-A

Resource-poor excellence (17/9/11)

Yesterday I met a sweet 4 1/2 year old girl named Emer – 4 days ago she was a healthy little girl with no problems about 100km from here.  Then she started to get thirsty, and lose weight, and then she collapsed.

A local clinic checked her blood sugar and quickly recognised she had diabetes.  They gave her an insulin injection, some IV fluids to start to treat her dehydration, and told the parents that they needed to bring her here, IV still in place in her skinny hand.

The next day she came to us.  She had a very high blood sugar and was still very dehydrated.  You know how after exercising really hard, you cannot help but breathe hard and deeply because of the lactic acid buildup in your muscles?  That is how she was breathing – we can’t accurately check acid levels here beccause we don’t have a blood gas machine, but that alone was enough to tell me that she would need to go to ICU.

It’s a tricky thing explaining diabetes through an interpreter.  Her parents didn’t speak English or Kiswahili, but a had brought a friend with them who was able to help me – Emer’s grandfather has diabetes, so the parents had some understanding.  Finding that they were literate, I was able (through the wonders of Google) to find information about diabetes in their language.  The translator’s eyes just lit up  - “This is very good!  How did you find this?  This is so good!”  Their main question, once they understood that I was telling them their daughter has a lifelong illness was – how much is the medication?  And that, in Kenya, is a really good question.

They are poor people.  I wanted to send Emer to ICU – they asked if ICU was really necessary, knowing its expense.  I explained that it absolutely was, but that I would admit her under HDU status, a lower cost than full ICU, and that as soon as she was stable I would transfer her to the regular ward.  So after a long night on call, with hourly conversations between the nurses and myself about her blood sugars, IV fluid finagling and insulin drip finessing, by this morning she was a different little girl and we were able to transfer her to the pediatric ward.

I’ve managed diabetes before in children – in the last 5 years, I’ve stabilised them in emergency.  7 years ago I managed the sickest children in ICU.  10 years ago, I looked after the children who were stable with diabetes on the pediatric ward.  I have never managed a child from emergency through to ICU through to the ward through to finalising their discharge plan and followup.  There wasn’t a lot of sleep between those hourly calls last night, as I second-guessed all my decisions and googled management on my phone to make sure I wasn’t mis-remembering things.

So you can imagine my relief to find this morning that our hospital has an outstanding diabetic nurse educator.  I peppered her with questions about everything I could think of – how much does a glucose testing machine cost here? ($30, plus about $15 a month for the testing strips – so it’s usually only children under 6 who are strongly encouraged to get one, because they may be too young to recognise or communicate the nauseating symptoms of a low blood sugar).  How much does insulin cost? ($7 for a vial that should last for 2 months).  How much do the syringes cost, knowing she will need 2 injections a day, forever? (50c each, but we tell the parents that if they are fastidious about keeping them clean and cap both ends that they can use them for 3 days).  Can we do the blood test here to look for complications of a chronically high blood sugar level?  (Yes, we can, and we check it every 3 months in the first year of diagnosis).    What do you tell parents to do if a child has a low sugar level? (This is the main thing we teach and reinforce – what the signs of low sugar are.  Give the child 4 teaspoons of sugar – if they wake up better, get them to eat something; if they are still sleepy, give them 4 more teaspoons and get them straight to a hospital).   Are there many children with diabetes here?  (Kijabe Hospital is currently following 11 – and Emer, as of today, is the youngest by 6 months).

I am constantly amazed at the level of care we can provide here.  It is sometimes frustrating, not being able to do everything we can do in Australia or the US.  But the dedication and excellence of so many of my colleagues, and the ingenuity of some our diagnostic and treatment options makes me proud to be here.

So often in western medicine, we assume more is better.  We don’t question more cost-effective ways of doing things – especially in the US, we practice fear-of-litigation medicine, where more tests always means we are covered in a court of law.  I hated practicing that way, but I did it.

Today I liked learning how to do more with less.

-M.

_____________________________

Click here for Emer’s continuing story

Little scars (13/9/11)

For over 2 months, we have been watching baby Shunetra grow.

Although Shunetra wasn’t that premature, she was born very, very small for how long she’d been growing – under 1kg at birth.  She had a tenuous but determined hold on life – another one of our 2-steps-forward, 1.9-steps-back kind of babies.

We like babies to gain at least 20 grams a day when they’re in the nursery – Shunetra took about a month to just get back to her birth weight after losing weight.  Every time we would feed her, she’d tolerate some feeds, and vomit others.  She’d have days with no weight gain at all, and then maybe 10 grams here, 20 grams there.  She had a severe blood infection and meningitis.  And then both of her knees filled with pus, requiring our anxious anaesthetists and orthopedic surgeons to take her to the operating theatre to use tiny needles and the smallest scalpels to drain her infection, leaving teeny tiny scars on her knees.

Despite her setbacks, she has clung to life.  Slowly tolerating feeds via a tube down her nose.  Learning to swallow from a syringe.  Finally, wonderfully, breastfeeding.  Starting to interact with her dedicated mother whose hope in Shunetra has never flagged.

For the last 2 weeks, almost every other day I’ve been to visit the nursery, because Shunetra was finally approaching the home stretch.  Once a baby reaches 2kg, we celebrate the milestone by letting them go home.  And each day Shunetra has been 1800 grams, 1840, 1860…  and finally 2000 grams.  Graduation day!

Shunetra’s mum opted to stay an extra day or two, just to make sure she was 2000 grams and staying there.  This remarkable woman has been hand expressing breast milk every 2 hours, sleeping in the maternity ward as a boarder, for 2 months.  Having lost her first baby at 8 months of pregnancy, Esther has determinedly been at Shunetra’s side, noticing problems before we did, buying her own thermometer to check her temperature when she felt warm, pointing out her knees to us when the signs were still subtle.  Esther and Shunetra had become a part of our nursery, a fixture that we enjoyed but couldn’t wait to reward with a one-way ticket home.

So I went in to see Shunetra for a final goodbye last Thursday – I took my camera to take this picture of this little princess with her mum.  Her bill came to AU$3000 – insurance covered $2000, and our needy patient’s fund covered some of the remainder.  Jennifer sent out an SOS to some partners in Germany to see if they could add to our Needy Children’s Fund to cover the rest of her bill.

It’s so fulfilling to get to the end of a long, long road like this.  These mothers and babies become a stable part of our sometimes schizophrenic work days.  There is something reassuring about the daily check of “How is Shunetra today?  We are getting there!  We’re on the home strait!”   There is nothing quite like seeing the tentative half-smile of a mother as we pass in the hallway become a grin because we have made it to the end together.

______________________________________________________

The next morning I got a text from Jennifer that Shunetra was dead.

She had been sleeping next to her mum, like the 5 previous nights, and had breastfed at 10pm.  When Esther woke at 1am wondering why Shunetra hadn’t cried at the 2 hour point for her next feed, she found Shunetra next to her stiff and cold.  She ran to the nursery, but it was already too late.  She had been dead for some time.

Bewilderment.  Anger.  Complete disbelief.

I cannot imagine how Friday was for Esther.  A parade of condolences, a procession of tears.  As word spread among the doctors, nurses and chaplains who had been caring for Shunetra, all of us wanted to express to her our sympathy, to let her know we shared her pain.  I wanted to say something profound.  All I could say was “I am so sorry”.  And cry with her.  And listen to her repeat monotonically her perplexed words – “I fed her at ten.  At 1 I woke up.  She was gone.  Wasn’t I a good mother?”

We see so many children here.  Most of them get better quickly, with pretty basic medical intervention – the right tests, the right drugs and discharged home.  Those successes feel so small when a loss like this happens.   The more difficult the fight, the bigger the victory feels – and with Shunetra and Naomi, we had fought so hard and the impending victory was already a celebration in my mind.  And so the defeat just feels so much larger.

I don’t really have a nice concluding paragraph this post.  No simple lesson learned.

Just a lingering sadness that other precious children will help to heal, while a little scar on my heart remains.

- M.

Best bits (10/9/11)

Highlights of my week:

- Going to the movies as a family today – we saw Mr Popper’s Penguins.  After Liam stopped crying because the closeup of “Loudy” freaked the snot out of him, we had a wonderful time as the only people in a real, live movie theatre.  Precious.*

- Finding that the Nakumatt has, in the bakery section, honest-to-goodness sausage rolls, chicken pies and pepper steak pies.  As a kid growing up, one of the highlights of my week would be (Australian meat) pies and pasties bought from the deli on the way home from church.  We have them in the fridge ready for Sunday lunch and I am a little embarrassed how excited I am about it.  And that I didn’t make them from scratch myself.  All in good time…

- Not having to worry about babies and children in the intensive care unit during my days at work, because the wonderful Dr Wayne Ellis (midwestern Med/Peds doctor here for 3 months with his lovely family, who happen to be our new neighbours) is not scared of sick babies.

- Fresh baked choc chip cookies, containing actual chocolate chips (a coveted luxury here in Kenya), made by the aforementioned delightful Ellises.

- Reading “One Day” all by myself on a gorgeous sunny afternoon while overlooking the Rift Valley – stupid fluff romantic novel which I am reliably informed is much better than the movie (which I have no intention of seeing even though Anne Hathaway is undeniably adorable).

- Rainy evenings with crackling fire.  Bliss.  And boy do we need the rain.

- Feeling at work like I almost have my head around a lot of what I am doing, for the first time.  This has not prevented me from consulting Jennifer, Immaculate, Leland and random international dermatologists about children whose conditions completely flummox me, but I have felt like I have had a handle on a lot of things rather than almost none… (seriously though, congenital epidermolysis bullosa and infantile erythroderma in one week?)

- Home made brownies, oat encrusted cilantro mustard chicken, roast lamb with mango chutney, french toast and cadbury cashew & coconut chocolate.  OK, neither the chutney or the chocolate were home-made.  But credit for the brownies.**

- Lovely emails from Jen and Fiona which have just helped me feel connected to a world wide web of friends.

This week has had moments of sadness, difficulty and bewilderment.  I don’t quite have the heart to blog about those yet.  Lakini, leo ninafurahi.

-M.

 ** nor did I slaughter the chickens or the lamb myself.  I totally cooked the meat though.