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.]

The Heart of a Teacher

“The Lord God has given me the heart [or tongue] of a teacher,
To know the word that sustains the weary.
Morning by morning he wakens—wakens my ear
To listen as one who is being taught.”
Isaiah 50:4

The opportunities to listen and be taught have been many, but in contrast to previous visits here, I have also been given opportunities to teach. This past week has been particularly rich in that respect.

On Tuesday, I gave the weekly “Continuing Medical Education” for the hospital staff (doctors, nurses, clinical officers, but also it seems housekeepers and maintenance men). I had done that last month, both here in Lugulu and at the district hospital in Webuye, on hospice and palliative care. This month, the topic they had requested was diabetes. I have many diabetics in my practice in Lancaster, and in some small way I came to Kenya to get away from diabetes, but of course it is here as well, and increasing dramatically as diets change. The big challenge is to fashion a simple and reasonable approach from the very limited resources we have; with most of the medicines we have at home not available here, with just one available kind of insulin, and of course the logistics of keeping patients on insulin when mostly they have no refrigeration and little concept of taking medicines for an indefinite period of time.

On Wednesday morning, I gave “the message” for the staff morning devotionals, as I have about once a week since coming. The hospital chaplain has asked me to use these opportunities to “teach the staff about Quakerism” (very few on the staff are Quakers). Always a challenge, but especially when the usual model is a “shouting” and somewhat manic type of oration that is very big on the wrath of God (a recent example: from Numbers 16, where the earth opens up and swallows those who dared to oppose Moses). Not my style…

I talked about the importance of having “the heart of a servant”. I told a story about a cleaning woman in one of American hospitals, who was doing her job of mopping the corridor floor when she heard a confused and distressed elderly patient crying out for his daughter, who had long since left. She put down her mop, went quietly to his bedside, and just held his hand until he quieted down and then drifted off to sleep. And then she went back to her mopping. The question arises, would her supervisor reprimand her, because she had departed from her job description, which was only to clean the floors? I then went on to tell (not read) another story: a man was going down from Jerusalem to Jericho, and fell into the hands of robbers… The priest and the Levite who passed by on the other side evidently felt that their job description did not specify tending to the man in need; their job was to keep themselves pure and holy so they could perform the Temple sacrifices. “But go and learn what this means: I desire mercy and not sacrifice.” The Samaritan saw his job differently: to love God, and in so doing to love the neighbor, the one in need, as himself. We have the example of Jesus, who was willing to do the job of the lowliest servant by washing the feet of his disciples, and who said, “The Son of Man came not to be served but to serve…”

On Wednesday afternoon, my final session with the family medicine registrars in Webuye, I tackled an ambitious topic on clinical reasoning and cognitive errors, with I hope at least some success. For an introvert like me, teaching in front of a group is always tiring, but when doing this cross-culturally it seems to be especially exhausting.

I now need to start preparing for the three day palliative medicine training next week, which will be my last official duty here. It turns out the medical director from Nairobi will not be able to participate, so she has delegated to me the responsibility for several of the talks. The way the training has come together on short notice, with the cooperation of both hospitals, has felt like this is the most important reason I am here.

Banana Man.

"Salamia" (Greetings)

Liz, Grace, and two of her

daughters.

Another Kenya

Looking back over previous posts, I am seeing overly-long and overly-medical writings. So, a non-medical subject.

After five unbroken weeks in Lugulu / Webuye, it was time to get away. So after Saturday morning rounds, Liz and I hitched a ride with Roger Sturge (from England, a colleague of Liz's on the FWCC Central Executive Committee, whose connection to Kenya goes back all the way to the immediate post-independence era, when he was a teacher in one of the Friends Schools here), here to Kisumu, about three hours distance (over truly terrible roads). We are staying overnight with Jim and Eden Grace; Eden has been the FUM representative in Kenya for the last 5 years, and always an important source for news of Friends in Kenya.

Kisumu is the third largest city in Kenya, with a large ex-patriate community. On Saturday night, we went to a party at the home of the head of the CDC here, with real food and live jazz. Tonight we will take them to dinner at The Laughing Buddha restaurant (for Mexican food). If this side of Kenya existed fifteen years ago, we were unaware of it.

The Grace's have a real Internet connection (as opposed to the pretend one I have in Lugulu), and it seems much of the weekend the four of them (Jim, Eden, and their sons Isaiah and Jessie) are on four different computers. I am the odd person out; my LGH computer is worthless when it comes to the Internet, so I am writing this on Liz's. I was hopeful of uploading some pictures, but it appears only one actually made it. However, on a brighter note, I had an interesting exercise in cell phone use this morning. I received a text message from Jane, a retired oncologist from England who is volunteering with a small clinic further north (I had met her in conjunction with the palliative care initiative). Her colleague and pastor had been admitted to Webuye District Hospital with advanced cancer; she was asking if the family medicine team there could provide the palliative care which he needs. I forwarded her message to Jan Armstrong and Dr. Laktabai in Webuye. Laktabai texted back that he would see that it happened, and I forwarded his reply to Jane. All this from someone (me) who never has sent a text message before last month!

Back to Lugulu early tomorrow morning, for my final two weeks; Liz will travel to Nairobi to begin her FWCC work.

Tom Making rounds.