Final World Conference Report

April 25, 2012

The 6th World Conference of Friends ended today, so everyone has moved on: many to safaris, me to Western Kenya for a HROC (Healing and Reconciling Our Communities) workshop with David Zarembka's group, Liz to Nairobi for 3 days of meetings with the Central Executive Committee of FWCC.  As we were leaving the conference, many were using words like "transformative" and "life-changing" to describe their experience. 

In our final "home group" meeting yesterday (small group of about 15 who met together daily)be , we were asked to think about what we would taking home from the conference.  Here are the three I would mention:

1.         A renewed appreciation for the place of joy and gratitude in worship.  On the final night, the Kenyans had everyone singing, clapping, and dancing with their exuberant music. Why are unprogrammed Friends so somber?   

2.         A new perspective on Quaker diversity.  We often pride ourselves on our theological diversity, whereas in truth we cover only a small part of the Quaker spectrum.  At the same time, as we lament our lack of ethnic and racial diversity, the worldwide family of Friends is incredibly diverse.  

3.         A new appreciation of the work that African Quakers have done with peacemaking.  20 years ago, when I was invited to give a message at a Kenyan Friends Church, the invitation came with a caveat: "I hope you are not going to talk about the peace testimony, like every other American who visits."  Kenyans saw themselves as living in a peaceful country, and the peace testimony was something Americans, not Africans, were concerned about.  Now with Friends facing serious civil unrest, ethnic cleansing and even genocide, first in Rwanda and Burundi in 1994, and then Kenya in 2007-08, peace is an active concern for all African Quakers.  There is an amazing and inspiring variety of local initiatives springing up, especially as Kenya looks forward (or perhaps dreads) elections within the next year, and Quakers have been in the forefront of many of these.  The possibility of violence, and the urgent need for programs to prevent it, is a constant part of life for Friends in this part of the world.  It is not a matter of writing letters to your congressman, but learning to live with a neighbor who might be from a different ethnic group.   It is no longer us to teach them about peace, but them to teach us.

There is much more to ponder.

Mid-conference report

Friday, April 20, 2012

We are approaching the halfway point of the World Conference, and I wanted to send at least a brief report back.  The days have been so packed that it has been hard to do even that. 

Nearly 1000 Friends arrived on Tuesday, from 42 countries, and over a hundred different yearly meetings: the most diverse gathering of Friends ever.  Not all things have gone smoothly with logistics, so Liz her small team have been very busy at work behind the scenes to keep things going (little things like not having the number of beds and classrooms that the university had promised us, etc.).  I barely see Liz during the day.  Tonight she was the recording clerk for the first business session; minutes here must be approved as we go along (and simultaneously translated into Spanish)

Where to start?  Perhaps a suggestion to go to the web site to see pictures: www.saltandlight2012.org/  and click on “follow the conference.”

Each morning, responsibility for organizing the worship rotates between the various sections of FWCC.  The first morning, the African section chose Esther Mumbo, a professor at a Kenyan seminary, to address the theme, “Being Salt and Light: Friends Living the Kingdom of God in a Broken World.”  The second day, the Section of the Americas had a semi-programmed meeting for worship, during which Noah Baker Merrill of New England spoke out of the silence (from a prepared text) very powerfully, perhaps for me the highpoint so far (the text of his talk, as well as those of some of the other speakers, is on the web site).  This morning 3 young Friends from Asia / West Pacific addressed the conference theme (a Hindu convert from Nepal, and evangelical Friend from the Philippines, and a liberal Friend from Aoeteora/New Zealand).

The second half of the mornings, we meet in “home groups” of about 15; more than half of my group are Kenyan.  This provides a chance to get to know at least a few others in more depth. 

Afternoons have been occupied with workshops and interest groups.  My 3-day workshop (“Opening the Scriptures”) ended today, so that is a relief to have that behind me.  I also seem to have become the unofficial conference doctor, and have spent an hour or tow each day seeing patients in the infirmary (fortunately, nothing too serious).

On a lighter note: tonight at supper we had “the great termite hatch”, and so were inundated by enormous flying termites which hatch, fly for only a few minutes, and then lose their wings and crawl away.  By the end of the meal, they covered the tables and floors,  to the consternation of some (the Kenyans seemed not to notice) and the delight to the stray cats that hang around the living room, who seemed appreciative of the extra protein. 

Tomorrow, we take a break with “mid-conference excursions” to various local attractions.  Many are going to a couple of nearby small national parks; I signed up to climb up to the crater of an extinct volcano. 

April 2012: Return to Lugulu

I arrived in Nairobi April 2, and spent the next 3 days with Liz’s sister Kathy and brother-in-law Dan, mostly recovering from jet lag. I also spent a morning with Dan in Kibera (said to be the largest urban slum in Africa), touring a clinic and a girl’s primary school; paid a visit to my colleagues at the Kenya Hospice Association, and had dinner with the Buckwalters, who are leaving Kenya after four years on the family medicine faculty.

On April 6, Dan and I set out on the 8-hour journey to Western Province; although the road is much improved from 20 years ago, the truck traffic makes for a very slow trip.

We spent the first day with Ray and Jan, the couple who replaced us in Lugulu, but who have since joined the family medicine faculty at Webuye District Hospital. They have lived in East Africa for most of the last 25 years, so have an interesting perspective.

Then on to Friends Lugulu Hospital, where our family lived and worked from 1991-94, and where I have returned for 1-2 month working stints on 3 occasions since. Our old house is now the guesthouse, so I slept in the same bed as when we lived there. Grace, our housekeeper back then, now is in charge of the guest house, so it really was all very familiar, including the usual lack of running water and intermittent power outages.

The hospital is struggling. I guess I always say that, but this time it does seem that morale is the lowest I have seen it, and the finances seem precarious. I had hoped to spend my five days there just visiting, but of course there is always something to do, so I did spend some mornings making rounds and seeing patients. Mostly, though, I just listened to people’s frustrations and fears. At the end of the five days, after lengthy sessions with the head doctor, the administrator, a board member, several nurses and clinical officers, and a couple of sacked employees, I felt that I was doing some kind of “institutional therapy.” Culturally, people here are not always very direct with one another, so perhaps the presence of an outsider (though known to and hopefully trusted by many) gave them an opportunity to try to work through some of their conflicts. I do leave Lugulu with a sense of great concern about the hospital’s future, and with the extra burden of feeling this may be my last opportunity to visit.

I was able to participate in a couple of teaching sessions with the family medicine registrars at the District Hospital (basically, a family medicine training program for Kenyans, parallel to my job at LGH), so that was interesting.

I have today moved on today to Kaimosi Hospital, where I will be helping to lead a small pre-conference workshop on tropical medicine. Then we all travel to the World Conference on Tuesday the 17^th.

Liz arrived safely in Nairobi on Tuesday, and is busy there with conference preparations.

Crossing the Great Rift

I chose to take the bus… Usually people in my position are in a hurry and opt to spend the extra money and take the one hour flight from Kisumu to Nairobi. However, I had no real reason to be in Nairobi, so I opted to take the bus. I had never been on this particular route (from Kisumu through Kericho to Nakuru; usually I go through Eldoret), and Dr. Serem in Lugulu (who is from that area) had told me I “had to see” this very beautiful part of the country.

The seven hour trip is dominated by crossing the Great Rift Valley, which is one of the few places where one can see the effects of two of earth’s tectonic plates drifting apart, creating over the past several million years the geological uplift and volcanic activity that makes the Rift ever-wider and deeper. (Usually this process takes place under the sea.) Coming out of Kisumu, for twenty miles or so the land is flat, wet and fertile, but then begins the slow steady assent up to 8000 feet. At the top of the escarpment, around Kericho, there are enormous tea plantations, with rolling hills and the verdant green of the tea plants stretching as far as the eye can see. Then the long descent to the bottom of Rift Valley, usually dry and dusty, but with the recent rains, uncharacteristically green. Then the whole process in reverse, the slow climb up the eastern escarpment, with breathtaking views of Mount Longonot (a dormant volcano I had climbed with our boys in 1997), then through torrential rains down into Nairobi. Once again, crossing the Great Rift evokes a feeling of reverence; this is the place where humankind first emerged, and deep within me I experience it as a kind of homecoming.

I chose to take the bus partly to save money, but mostly because I wanted to fully experience the vastness of Kenya and the Great Rift one more time. The Great Rift Valley has come to symbolize in my mind the huge divide between rural western Kenya and the rest of my life, and so to cross slowly seems to help me make the shift from one world to the other. When we lived in Kenya in the 1990’s, we would come into Nairobi only a couple times a year, and we always said that the divide between western Kenya and Nairobi was bigger than the divide between Nairobi and home. Like the Great Rift Valley itself, that divide seems to be getting gradually deeper and wider. As I turn toward home, I find myself wondering how the readjustment will be this time. I have never found it easy; even as the intensity of this time fades and I re-enter my American routine, I will feel, as I have in the past, that part of me remains here in Kenya.

Nairobi is a city: six-lane roads and shopping malls, coffee houses and skyscrapers. To be sure, it is a third world city. The traffic is chaotic; poverty is everywhere visible alongside great wealth. At an intersection down the hill from where we are staying, as traffic slows to a crawl during rush hour, hawkers appear, walking up and down between the lines of idle cars, selling everything from bananas to puppies and TV antenna. Everyone is hustling, on the make, trying to find a way to make a little money. Capitalism in its most pure form… X-capitalism.

I don’t have much to show for my two days here. I did take two hot showers, go to an internet café, do some half-hearted looking at local crafts, read a book, and spent the morning with Liz at the National l Museum, with its magnificent collection of ancestral human fossils. Today I had lunch with my hospice colleagues at KEHPCA, debriefing last week’s training. The best part has been staying with Donald and Ruth Thomas, with leisurely meals, stimulating conversations, benefitting from their 50-year perspective on Kenya. Tonight we fly out at 11 p.m.; we will be in Philadelphia by 3 p.m. tomorrow, God (and the volcano) willing.

Good-byes

It is always difficult for me to say good-bye, especially when I am ambivalent about leaving. This is my third extended visit to Lugulu since our three year term here ended in 1994. This time, I feel better about the way I was able to take my leave. Perhaps with age and experience, we really do grow in wisdom.

The context for all this is that from about my second day here, people ask me virtually every day, “Why can’t you stay longer?” “Two months? Why not two years?” So from the very beginning, I have not been reticent in saying that I had come for as long as I could be but no longer, that each of us is called to do what we can and not what we cannot, and that I had a job to return to.

The night before I left, I met for an hour and a half with the “management team” (Kiburi, the hospital administrator; Dr. Serem, the acting MO in charge while I was here; Dr. Kesaka, the returning MO in charge, back last week from his four month study leave in Taiwan; the Matron or head nurse; and the chief financial officer). This was at their invitation, and I was touched that they valued my opinion enough to ask for the meeting. I prepared a written report in which I was able to raise some hard issues, most of which they were certainly aware of; but in the meeting they were as a team able to recognize and commit to addressing these. We part on good terms, and they all made it clear that they want my relationship with the hospital to continue in whatever way it can.

On my last morning, I gave the message at chapel one last time, and used the opportunity to formally say thank you for the hospitality and kindness extended to me, and to encourage them in their ongoing work. There was an opportunity to say goodbye individually to several special people. To the very end, many continued to voice disbelief that I was really leaving.

Then off to Webuye for the last day of the Palliative Care Training. My part of the curriculum was over, so I could enjoy the lectures on, among other things, the impact of culture and religion on issues of death and dying. I left just before the lunch break (missing the post-test and the closing ceremony; they are big on closing ceremonies here), but they granted me a few minutes to again say how the seminar came about, and to encourage them to find the commitment and passion to carry their new knowledge back to their respective institutions and implement it. In the Kenyan fashion, the chair asked for someone to respond, and my Webuye colleague Dr. Chege responded with a tribute that was truly moving to me. I donated my facilitator’s honorarium to buy sodas for everyone for lunch, which seemed to be greatly appreciated.

Then a matatu ride back to Lugulu, to pick up my luggage, share a leisurely soda with Dr. Serem at the hospital “café”, and one last meal prepared by Grace. Kennedy, one of the nurses, insisted on taking me back to the maternity ward – to meet his firstborn son, born just two hours previous. I suggested that since he is called Kennedy, he ought to name his son “Obama.” My final –and most difficult – task was to say goodbye to Grace; hers was the saddest face of the day. She sent me off with some fresh pineapple juice and fried peanuts to snack on; I left her with another contribution to the fund for a roof for her new house (which she has been working on for three years). She is certainly one of the most generous people I have ever met, so that was my way of recognizing her generosity.

The hospital driver brought me to Mabanga (about 40 minutes), to join Liz and the others on her committee at the FWCC African Section Triennial, already in session. It is a relief to be able to sit in the back and observe.

Howard Thurman, the African-American mystic and writer, once wrote, “Find the thing that makes you come alive, and go do that. Because the world needs people who are alive…” Over the last two months here, I have felt discouragement, and encouragement; loneliness, and hospitality; incompetence, and competence; frustration, and accomplishment; impatience, and patience; many times humbled, and always uplifted. But above all, I have felt Alive.

Metaphors

Usually I am not terribly fond of the idea of “illness as metaphor”, but on occasion certain patients and their illnesses seem to cry out for further reflection, to see if they might contain deeper lessons than just the everyday flux of life and death that characterizes medicine here.

I have already written about Jackson, the 76 year old who was found to have a subdural hematoma on CT scan, and subsequently underwent brain surgery here. It wouldn’t be right not to share the rest of the story, which unfolded over several weeks, and unfortunately is not as edifying as the first installment.

After surgery, he seemed to be recovering well over the first few days, which is when I first wrote. But I was then off the male ward for 2 or 3 weeks, and only heard that he had had some setbacks. I know that he had some fevers, and was treated first for malaria and then for meningitis. I kept hearing that he was finally starting to improve, but when I rotated back to male ward, I found him obtunded, barely responsive, unable to even eat or keep awake for more than a few minutes at a time. I called the surgeon and asked if he would re-evaluate, but of course his first reaction was “repeat the CT scan.” I relayed this recommendation to the family, but added my belief that it was unlikely that a second CT scan was going to find anything amenable to further treatment, and they ought to think about just taking him home. To my surprise, by the next day the family had organized to take him to Eldoret by private vehicle and get the repeat CT scan (they seem to have had more resources than any other family I have dealt with here). It showed a small amount of blood had re-accumulated, really quite minimal compared to previously. I quietly voiced my skepticism, telling them that repeat surgery was unlikely to produce a dramatic improvement. I don’t know what the surgeon’s conversation with the family was like, but within a couple of days he went back to the OR. He died on the table, too weak to survive the second surgery.

Looking back on what I first wrote, it now seems naively optimistic. I had fallen prey to what Dr. Ron Pust has called “the seduction of surgery” here in the tropics, the belief that heroic surgery is what makes the biggest difference. The end of Jackson’s story seems to be saying that even though sophisticated tests and surgery are occasionally available, we are still working in a system that does not do well with complex problems. It is as if the modern technology is just tacked on to the underlying dysfunctional system, rather than growing naturally out of it – and therefore has little ultimate effect.

The second case was this past weekend. Jacob is 47, had been on ARV medication for HIV for the past year. Ten days previously, he had been seen at a government hospital and had an x-ray because of shortness of breath. All I could glean was that he was then started on anti-TB medication, but the reason wasn’t clear. They had not brought the x-ray with them, and because it was the weekend we couldn’t get a repeat. When the next day the family finally brought in the old x-ray, it showed a complete collapse of the left lung, with the heart displaced to the right side of the chest, a so-called tension pneumothorax, normally considered a life-threatening emergency which needs immediate attention. By the time all this unfolded, his breathing had deteriorated to the point where I didn’t think he could survive the night. So late Saturday night, we put in a chest tube, getting not air (which I had expected, based on the old x-ray) but 4 liters of fluid. His breathing improved immediately, the chest tube is now out, and he should recover, although of course he still has his HIV and TB to contend with.

Just before all of this unfolded, I was informed that Derrick, a three year old whom we had admitted seven hours earlier, had died. He had a grossly swollen belly, heart failure, and extreme respiratory distress. I knew as soon as I saw him that his chances were slim. We drew off a liter of fluid from his belly, hoping that it would make his breathing easier, but in the end he succumbed, most likely to a variant of TB involving the pericardial covering of the heart.

As I finished with the chest tube, there was a call to come quickly to the pediatric ward, to evaluate a child admitted earlier in the day, with malaria and pneumonia. I had seen her two or three times over the course of the day, and although I knew she was very sick, I was cautiously optimistic that she might pull through. But it was not to be; she died before I could even get there. With both children, we had done everything within our (limited) capability, but they had both come too late to be helped.

So in the end I was struck by the contrast: here was Jacob, getting all that expensive and sophisticated HIV care (through a program generously funded by international donors). Meanwhile, the children keep dying. Of course, it is not as though there is a direct trade off between Jacob and the children (i.e., even if Jacob was not getting his HIV treatment, the children would still be dying). Rather, when one disease is lifted out of the context of the entire health system and treated separately, the wider system inevitably suffers. For instance, my friend Jan Armstrong tells me that at the District Hospital in Webuye, they can have 100 children in the pediatric ward, with only one nurse covering the night shift. She estimates that because of the nursing shortage, only half of the ordered doses of IV quinine actually are given. This right next door to a state-of-the-art HIV program, funded by international donors.

Difficult questions; it will take “the wisdom of Solomon” to sort out. But it seems that at the end of the day, what is needed are programs to improve the entire system.

Grace

"For by grace you have been saved, through faith, and this is not your own doing; it is a gift of God-- not the result of works, so that no one may boast." Ephesians 2:8

I recently re-read If Grace is True, by Phil Mulley and James Mulholland, an important and thoughtful book. The main point is that grace is the most important attribute of God, and that grace (like God) is not to be limited by our doctrines, creeds, and dogmas; that if grace is true for anyone, then it is true for everyone.

Important ideas, but the Grace I wish to discuss is a more concrete one, Grace Sokonyi, our beloved housekeeper over the years here, our friend, and in many ways our most important teacher about all things African.

Grace does indeed save me: feeds me, keeps from making cultural blunders, and helps me with the nuances of etiquette. She is truly a gift. There is no one I know whose name is more fitting; she is,well, Grace-ful.

Grace has not had an easy time, especially in recent years. She was widowed at a relatively young age about four years ago, but has managed to hold her family together, and keep all her children in school. For the last several years, she has cared for her 90-something mother-in-law in her own home (culturally, she should be living with her own children), while at the same time having responsibility for her 90-something mother, who lives a couple of miles away. All this while working very hard for the hospital, doing various cooking and cleaning jobs. And she does all of this without ever a hint of complaining or ingratitude. She bears it all with amazing grace.

On Liz's last day in Lugulu, we walked the mile or so to Grace's modest shamba, where she had spent the day preparing a lavish feast for us. She also wanted us to see her children, 4 of the 5 whom were there with her that day. It was a wonderful afternoon.

Missing was her oldest daughter Catherine, who is off in Nairobi, where she goes to school. Catherine was described as married (although the dowry is not yet paid, so the ceremony will not be until later this year) and expecting a child "sometime soon." Culturally, people don't seem to talk much about pregnancy, almost as if an excess of anticipation might bring disappointment or even bad luck. Still, it was clear Grace was excited.

Yesterday afternoon (Sunday), Grace showed up unexpectedly; she said she needed to charge her phone so she could call Catherine back. I had Grace use my phone to call Nairobi; it seems Catherinie had gone into labor, gone to one hospital and been told that "the baby is not sleeping right" and so referred to another hospital for a C-section. I know that C-sections in Nairobi are over $1000 (5x more than here) and commonly done, so there were huge financial implications to all of this. Grace is not usually very emotionally demonstrative, but she was clearly worried (as was I).

But Grace came this morning with good news: the second hospital had told Catherine everything was fine, and allowed her to labor. She gave birth early this morning to a healthy daughter, Grace's first grandchild. As Grace put it, "I am now finally a grown-up person."

On this very special day, Grace hurried and finished her work in the morning, so she could leave early, to participate in the funeral of her neighbor and friend, and her friend' s mother. Her friend had died unexpectedly last week, and at the news, her elderly mother who had been ill for sometime, died as well. So another double funeral. Such is life -- birth and death -- in Kenya.

[Liz, if you read this: I can no longer access gmail; I will see you Friday afternoon in Mabanga.]